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Department of Cardiovascular and Thoracic Surgery, Arizona Heart Institute, 2632 N 20th St, Phoenix, AZ 85006
(Email: gwheatley{at}azheart.com).
One of the last surgical domains yet to be addressed in a less invasive fashion is repair of the aortic arch. This is significant because surgical repair of aortic arch disease involves cardiopulmonary bypass and hypothermic circulatory arrest. Although surgical outcomes for aortic arch replacement have improved consistently, many patients are not surgical candidates secondary to multiple medical comorbidities that frequently accompany aortic arch disease. Therefore newer surgical alternatives that incorporate emerging endovascular techniques have the potential to transform the way we address the aortic arch.
In this study, Weigang and colleagues [1] describe their innovative approach to hybrid arch repair using surgical debranching of the great vessels, followed by endovascular repair. This is not the first report of this technique; however, their report contains important technical details that better elucidate critical aspects of their procedure, such as placing a radiopaque marker at the proximal anastomosis in the ascending aorta, which can better ensure success and should be widely adopted. Because the current generation of aortic stent grafts do not have side branches to accommodate perfusion to the great vessels, surgical bypasses of the great vessels must be performed before endovascular repair of the aortic arch. This technique avoids many of the complications associated with surgical repair, although long-term durability is unknown.
In their series of 26 patients, the authors concluded that the hybrid technique has lower morbidity and mortality rates compared with standard surgical repair of aortic arch disease. Of note, their patient cohort consisted of 15 patients with arch aneurysms and 6 patients with a history of a chronic dissection and subsequent aneurysm formation of the false lumen. This is an important point, because these patients generally have a higher atherosclerotic disease burden that can translate into a higher stroke rate using surgical repair. The hybrid technique minimizes this because the great vessels are directly bypassed and ligated at their origin, which would essentially eliminate the chance for embolic stroke during endovascular repair of the arch.
The hybrid technique certainly has a role in patients with anatomy that is favorable to endovascular repair; however, little is known about its long-term success. Of concern would be progressive dilation of the proximal or distal seal zones of the stent graft and whether progressive expansion of the aorta might lead to lack of apposition and subsequent perfusion of the excluded aneurysm sac. This is purely speculation, but additional studies are needed. Nevertheless, this article helps bring to the forefront a new and innovative approach to the aortic arch that offers the potential of treating arch disease in a safer manner and possibly allowing "nonsurgical" candidates to undergo aortic arch repair in a less invasive fashion.
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