Debranching with thoracic endovascular aortic repair for treating aortic arch lesions: a retrospective single-center experience

Introduction

Aortic arch lesions, including aneurysms, dissections, penetrating aortic ulcers (PAUs), and intramural hematomas (IMHs), present unique challenges due to their anatomical and pathological complexity. Traditional open aortic arch replacement surgery involves replacing the ascending aorta and aortic arch under deep hypothermia and cardiopulmonary bypass, with employing the “elephant trunk” technique. Despite its efficacy, this approach entails significant trauma and high perioperative mortality and morbidity rates (1-3). Thoracic endovascular aortic repair (TEVAR) is widely accepted for treating Stanford type B aortic dissections but is less suitable for complex lesions involving the aortic arch, where proximal anchoring is often inadequate (4). Total endovascular techniques, such as chimney grafts, branched stents, and fenestration stents, have emerged as alternatives, yet these are limited by high rates of stent displacement, endoleaks, and variable outcomes (2,5,6). Hybrid debranching combined with TEVAR offers a less invasive solution compared to conventional open arch replacement by first reconstructing the aortic branches to create a proximal anchoring zone, followed by stent graft placement, which has the advantages of minimal trauma, fewer complications, stable and reliable blood flow, and definite therapeutic effects. This technique achieves lower morbidity and comparable short- and medium-term outcomes to open surgery, but its long-term efficacy remains under-reported (7-9). It is important to note that the invasiveness of the hybrid approach is substantially influenced by the extent of debranching. Total arch debranching performed through median sternotomy constitutes a significantly more invasive procedure compared to extrathoracic bypass configurations such as carotid-carotid or carotid-subclavian bypass. This study retrospectively evaluates the long-term outcomes of hybrid debranching and TEVAR for aortic arch lesions at our center. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1073/rc).

Methods

The study was approved by the Institutional Review Board of China-Japan Friendship Hospital (No. 2024-KY-011). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The requirement for individual patient consent was waived by the ethics committee due to the retrospective nature of the study, which involved minimal risk to participants. All patient data were anonymized and maintained with strict confidentiality.

Patient selection

This retrospective study included 41 patients treated with hybrid debranching and TEVAR for aortic arch lesions from January 2010 to January 2021. Patients were included in our study if they had an aortic arch lesion or an inadequate proximal descending aortic landing zone for TEVAR due to one of the following: thoracic aortic aneurysm, acute type A aortic dissection, chronic type B aortic dissection, PAU, or IMH. We excluded patients with aortic arch lesions who were treated with full open repair, pure endovascular procedures (such as total endovascular arch repair with chimney techniques or branched arch endografts), or the frozen elephant trunk technique. The patient selection flowchart is presented in Figure 1. The study comprised 34 men and 7 women, with a mean age of 56.9±14.6 years (range, 26–83 years). Diagnoses included aortic aneurysm (n=17), aortic dissection (Stanford type A, n=7; type B, n=14), PAU (n=2), and IMH (n=1). Comorbidities included hypertension (n=32), coronary artery disease (n=9), renal insufficiency (n=6), and cerebrovascular disease (n=5). The majority of cases in our cohort were elective procedures, and seven patients with type A aortic dissection were treated as emergency cases. For detailed patient characteristics, see Table 1.

Figure 1 Patient selection flowchart.

The aortic arch was divided into five zones (zones 0–4) based on the Ishimaru classification system (10). Zones 0–2 were selected as the proximal anchoring areas for stent placement in this study’s patients (zone 0: 8 patients; zone 1: 12 patients; zone 2: 21 patients). Preoperative evaluations included computed tomography angiography (CTA) with three-dimensional reconstruction to identify the lesion’s location and characteristics. Surgical strategies were determined based on these findings. All procedures were performed under general anesthesia in a hybrid operating room, with bypass plans tailored to the anchoring zone and the surgeon’s preferences.

Surgical methods

Complete debranching surgery (anchoring zone 0)

For patients requiring anchoring in zone 0, complete debranching surgery was performed. After a median sternotomy, the brachiocephalic trunk, left common carotid artery (LCCA), and left subclavian artery (LSCA) were mobilized. Systemic heparinization was initiated, and the ascending aorta was occluded using a side-biting clamp. The Dacron prosthetic grafts were anastomosed to the ascending aorta, and its branches were sequentially connected to the LSCA, LCCA, and brachiocephalic trunk. Complete debranching surgery was performed in eight patients, with representative cases illustrated in Figures 2,3.

Figure 2 Representative case of complete debranching for a zone 0 lesion (Stanford type A aortic dissection). (A) The preoperative three-dimensional reconstruction CTA revealed a Stanford type A aortic dissection with the anchoring zone located in zone 0. (B) DSA confirms a definitive diagnosis of Stanford type A aortic dissection. (C) We performed a Y-shaped Dacron prosthetic graft bypass from the ascending aorta to the right brachiocephalic artery and LCCA, followed by embolization of the LSCA. Final intraoperative DSA confirmed patent bypass grafts without endoleak. CTA, computed tomography angiography; DSA, digital subtraction angiography; LCCA, left common carotid artery; LSCA, left subclavian artery.

Figure 3 Representative case of complete debranching for a zone 0 lesion (aortic arch aneurysm with complex anatomical variants). (A) The preoperative three-dimensional CTA demonstrated an aortic arch aneurysm with zone 0 anchoring, complicated by a right-sided aortic arch and right descending aorta anomaly, along with anomalous origins of all supra-aortic vessels: the LCCA originated directly from the ascending aorta, while the RCCA and RSCA originated as separate branches from the aortic arch. (B) We performed Y-shaped prosthetic graft bypass from the ascending aorta to the RCCA and RSCA, along with left carotid-subclavian bypass. Final intraoperative DSA confirmed patent bypass grafts without endoleak. (C) During the procedure, an aortically anomalous anatomical configuration was observed. (D) After completion of the Dacron prosthetic graft anastomosis, the surgically reconstructed aortic arch was visualized. CTA, computed tomography angiography; DSA, digital subtraction angiography; LCCA, left common carotid artery; RCCA, right common carotid artery; RSCA, right subclavian artery.

Partial debranching surgery (anchoring zones 1 and 2)

For patients requiring anchoring in zone 1, the LCCA, LSCA, or axillary artery (AA) was exposed through incisions at the anterior edge of the sternocleidomastoid muscle or at the clavicle. Subcutaneous tunnels were created, and Dacron prosthetic grafts were used for bypass procedures. The procedures included right common carotid artery (RCCA)-LCCA-LSCA bypass or LCCA-bilateral AA bypass surgeries.

Similarly, for patients with anchoring in zone 2, the LCCA and LSCA were exposed via a left supraclavicular incision, and the bilateral AA were accessed through subclavian incisions. Dacron prosthetic grafts were used to perform LCCA-LSCA bypass or right AA-left AA bypass surgeries.

TEVAR and final assessment

The stent graft landing zones were determined by the location and extent of the aortic pathology, which in turn dictated the requisite bypass strategy. Following the completion of bypass surgery, digital subtraction angiography (DSA) was performed to confirm bypass patency, as well as the location and extent of the lesion. TEVAR was conducted after satisfactory results were obtained. To minimize postoperative endoleak risk, stent grafts (Medtronic Valiant, Minneapolis, MN, USA; and Gore TAG, Newark, NJ, USA) were deployed based on the landing zone: (I) complete debranching surgery: stents were deployed at the proximal opening of the brachiocephalic trunk; (II) RCCA-LCCA-LSCA or LCCA-bilateral AA bypass: stents were deployed at the distal opening of the brachiocephalic trunk; and (III) LCCA-LSCA or right AA-left AA bypass: stents were deployed at the distal opening of the LCCA. Stent-graft sizing was determined by the underlying pathology: a 15–20% oversizing was applied for aortic aneurysms, while a 10–15% oversizing was used for dissections, both based on the proximal aortic diameter.

Final intraoperative angiography was repeated to confirm bypass patency, proper stent positioning, and the absence of endoleaks. Type I endoleaks were addressed by post-dilation. During open debranching procedures, the native origins of revascularized vessels (specifically the innominate artery and LCCA) were routinely suture-ligated. In scenarios where revascularization was not indicated, preemptive coil embolization of the target vessel (primarily the LSCA) was employed by interlock coils (Boston Scientific, Natick, MA, USA). This consistent strategy of proximal occlusion, whether achieved surgically or endovascularly, was implemented to definitively prevent type II endoleaks.

All patients were maintained on single antiplatelet therapy with aspirin (100 mg daily) postoperatively, unless specific indications (e.g., atrial fibrillation or mechanical prosthetic valves) required long-term anticoagulation. All patients in our study received routine postoperative pulmonary care, including chest physiotherapy, incentive spirometry, and breathing exercises, as part of our standard protocol to minimize pulmonary complications.

Management strategy of the LCSA

Revascularization of the LSCA was selectively performed based on anatomical and clinical criteria. Indications for revascularization included planned coverage of the LSCA origin to achieve an adequate proximal landing zone, particularly in patients with any of the following: a patent left internal mammary artery coronary graft, a dominant left vertebral artery, or compromised posterior cerebral circulation. This selective strategy is consistent with contemporary clinical practice guidelines. In cases where LSCA revascularization was not indicated, coil embolization of the LSCA was performed to prevent type II endoleaks.

Definition of end points

We defined the primary endpoints of this study as the occurrence of major adverse events—specifically, all-cause mortality, stroke, reoperation, endoleak (types I–V), and postoperative complications [such as spinal cord ischemia (SCI), vascular graft occlusion, pneumonia, or incisional hematoma] within the first 30 postoperative days. Technical success was defined as the completion of the procedure with patent bypass grafts, absence of intraoperative mortality, and no evidence of endoleak on final angiography. The secondary endpoints of the study included survival, freedom from re-intervention, and major complications during follow-up.

Definition of complications

Endoleak classification followed established criteria per the European Society of Cardiology (ESC) guidelines on aortic diseases (11). Stroke was defined as a new focal or global neurological deficit of cerebrovascular origin that persisted for >24 hours or was confirmed by neuroimaging, in accordance with the Valve Academic Research Consortium-2 (VARC-2) criteria. SCI was defined as any new motor or sensory deficit in the lower extremities not attributable to other causes, with confirmation by spinal or brain imaging where indicated. Pneumonia was diagnosed based on the Centers for Disease Control and Prevention (CDC) criteria, requiring radiographic evidence of infiltration plus clinical signs (e.g., fever, leukocytosis, or purulent sputum). Graft occlusion was defined as the absence of flow within the bypass graft, confirmed by duplex ultrasound or CTA. Incisional hematoma was defined as a postoperative wound collection requiring surgical evacuation or resulting in delayed healing, in alignment with the Society for Vascular Surgery (SVS) reporting standards.

Follow-up

All patients underwent CTA at 1 and 6 months postoperatively and annually thereafter. Follow-ups were conducted via outpatient visits or telephone consultations. For patients with equivocal or potentially suspicious findings on the 1-month baseline scan—such as subtle endoleaks, peri-graft hematoma, or suboptimal aortic remodeling—or for those who developed new-onset symptoms during the follow-up period, we performed CTA at 3 months postoperatively. CTA imaging could be performed at external facilities, but was reviewed by two physicians at our center.

Statistical analysis

Continuous variables were shown as mean ± standard deviation (SD) or median (interquartile range) according to different distributions, while categorical variables were expressed as frequencies and percentages. Statistical analyses were performed using univariate methods to assess perioperative and short-term outcomes. Continuous variables were compared using the Wilcoxon rank-sum test, categorical variables with the likelihood-ratio χ² test (or Fisher’s exact test where appropriate), and time-to-event data with the log-rank test. For multivariable assessment of outcomes across the three surgical approaches, Cox proportional hazards regression was employed. A competing-risks analysis based on the Cox model was applied to evaluate graft patency and mortality as competing events. All statistical analyses were conducted in R software, version 3.6.2. All statistical analyses were two-tailed, and P<0.05 was considered statistically significant.

Results

A total of 41 patients underwent hybrid aortic arch repair and were stratified by proximal landing zone: zone 0 (n=8), zone 1 (n=12), and zone 2 (n=21). The distribution of aortic pathologies differed significantly across groups (P<0.001), with type A aortic dissection predominating in zone 0 (87.5%), while aneurysm and type B aortic dissection were more common in zones 1 and 2. Surgical approaches varied accordingly, with complete debranching exclusively performed in zone 0 cases, while extra-anatomical bypass configurations were utilized in zones 1 and 2 (P<0.001).

Technical success was achieved in all cases (100%). Significant differences were observed in operative parameters: zone 0 procedures required substantially longer operative times (median, 296.5 minutes) compared to zone 1 (231.0 minutes) and zone 2 (186.0 minutes, P=0.03). Similarly, intraoperative blood loss was significantly higher in zone 0 cases (median, 1,000 mL) versus zone 1 (200 mL) and zone 2 (150 mL, P=0.043).

Postoperative intensive care unit (ICU) admission rates were significantly higher in zone 0 (100%) compared to zone 1 (41.7%) and zone 2 (38.1%, P=0.007). The incidence of perioperative complications was comparable across groups (P=0.60), with pneumonia being the most frequent complication in zone 0 (25.0%). Two endoleaks (9.5%) occurred exclusively in zone 2 patients. The single 30-day mortality occurred in a zone 0 patient with type A aortic dissection who underwent complete debranching. No significant differences were observed in postoperative hospital stay or most specific complication rates. For detailed perioperative data of hybrid arch repair, see Table 2.

Postoperative complications included 2 patients (4.8%) who developed type I endoleaks. No immediate endoleaks were detected postoperatively in DSA. The 1-month follow-up CTA revealed minor endoleaks, which resolved spontaneously by the 3-month follow-up with conservative management. Severe pneumonia was reported in 6 patients (14.6%), with 2 of these patients developing respiratory failure. These individuals required ventilator support for more than 48 hours and showed improvement after anti-infection therapy. One patient experienced a postoperative cerebral infarction but recovered without sequelae following conservative treatment. Postoperative incision hematoma occurred in 4 patients (9.8%). No patients required surgical re-exploration for hematoma. The mentioned hematomas were managed conservatively with close monitoring and resolved without further intervention. A single mortality (2.4%, 1/41) occurred at primary endpoint, accounting for a patient with type A aortic dissection who underwent complete debranching and subsequently died from myocardial infarction. No other significant complications, such as postoperative paralysis, bypass vessel occlusion, or stent-related issues, were observed at primary endpoint.

Among the 41 patients, 39 (95.1%) completed follow-up evaluations, with a mean follow-up duration of 62.6±31.1 months (range, 24–124 months). Bypass vessel occlusion was reported in 5 patients during the follow-up period, affecting the AA (n=4) and the LSCA (n=1). As none of these patients exhibited symptoms of upper limb or cerebral ischemia, they were managed conservatively. For detailed long-term outcomes of hybrid arch repair, see Table 3.

No new endoleaks were detected during follow-up. However, 5 patients (12.8%) died during the follow-up period. Causes of death included myocardial infarction (n=2), lung cancer (n=1), stroke (n=1), and pneumonia (n=1). The postoperative survival rates at 1, 3, and 5 years were 94.9%, 92.3%, and 84.6%, respectively. Kaplan-Meier survival plots were performed for patient survival and graft patency, which revealed no statistically significant differences in either long-term survival (log-rank P=0.72) or graft patency rates (log-rank P=0.74) among patients stratified by proximal landing zone (see Figures 4,5). Although the zone 0 cohort (complete debranching via sternotomy) showed a numerically lower survival probability in the early postoperative period, all three survival curves converged over time, suggesting comparable long-term outcomes across the different surgical extents of hybrid arch repair. Although the zone 0 cohort (complete debranching via sternotomy) demonstrated a numerically lower early survival probability, all three groups showed converging survival curves and consistently excellent graft patency during follow-up.

Figure 4 Kaplan-Meier survival estimation curve. All presented results were within a standard error of 10%.

Figure 5 Kaplan-Meier graft patency estimation curve. All presented results were within a standard error of 10%.

These findings indicate that despite variations in procedural invasiveness, all hybrid approaches achieved comparable long-term survival and graft patency outcomes. This supports the technical durability and clinical applicability of different hybrid arch repair strategies when tailored to individual anatomical requirements.

Discussion

Currently, the surgical strategies for treating aortic arch lesions include open surgery, total endovascular repair, and hybrid surgery combining debranching techniques with TEVAR. Total or partial arch replacement using extracorporeal circulation is a traditional approach for treating aortic arch diseases. However, this method is associated with significant surgical trauma and a high risk of complications. Studies have reported a mortality rate of approximately 20% for this strategy, with perioperative mortality and complication rates being particularly high among elderly, high-risk patients with multiple comorbidities (12,13).

To mitigate surgical risks, Buth et al. first introduced a hybrid strategy in 1998 that combined bypass vessel creation with endovascular repair for managing high-risk aortic arch aneurysms (14). Compared with traditional open surgery, the hybrid approach of debranching combined with TEVAR offers advantages such as reduced trauma and the elimination of the need for extracorporeal circulation. For elderly and high-risk patients, the efficacy of this hybrid surgery has been shown to surpass that of traditional surgery (15,16). In recent years, total endovascular repair techniques, such as the chimney grafts, branched stents, and fenestration stents, have also been developed for treating aortic arch lesions. However, these techniques lack robust evidence supporting their long-term efficacy and reliability (17). Furthermore, compared with total endovascular repair, hybrid surgery significantly reduces the incidence of type I endoleaks. As such, hybrid surgery combining debranching techniques with TEVAR remains the primary treatment method for aortic arch lesions until total endovascular repair techniques become more established.

In this study, all 41 patients successfully underwent the operation. One patient died on the third postoperative day, likely due to postoperative myocardial infarction, while another experienced a postoperative cerebral infarction but recovered with conservative treatment. No severe complications, such as paraplegia or bypass vessel occlusion, were observed. These findings confirm the effectiveness and safety of the hybrid debranching technique combined with TEVAR for treating aortic arch lesions. However, notable postoperative complications included severe pneumonia (14.6%) and incision hematoma (9.8%), which may be related to patients’ pre-existing comorbidities and the use of postoperative anticoagulant therapy. Severe pneumonia occurred more frequently after complete debranching (via median sternotomy), while incision site hematomas were more common following extra-thoracic bypass procedures.

The long-term patency rate of bypass vessels is a crucial measure of the efficacy of hybrid surgery. In this study, the 10-year patency rate of bypass vessels was 87.8%. Most occlusions occurred in AA bypass vessels (80%, 4/5 cases), likely due to the longer bypass pathway and inconsistent use of antiplatelet therapy postoperatively.

While long-term data on hybrid arch repair remain limited compared to conventional approaches, our survival rates align with contemporary series (7,18). The comparable outcomes between zone 0 (complete debranching) and zones 1–2 highlight the versatility of hybrid techniques. Compared to total endovascular solutions (19), our approach demonstrated lower endoleak rates, though with higher invasiveness. Our selective LSCA management strategy—combining revascularization and coil embolization—effectively balanced procedural complexity with clinical safety.

Conclusions

In summary, the findings of this study indicate that hybrid surgery combining debranching techniques with TEVAR yields excellent mid- and long-term outcomes for high-risk patients with advanced age and multiple comorbidities. The incidence of complications such as endoleaks, stroke, paraplegia, nerve injury, lymphatic fistula, and stent-related issues was low. Additionally, this study highlighted the relatively low long-term patency rate of AA bypasses. Therefore, RCCA-LCCA-LSCA bypass or LCCA-LSCA bypass is recommended when anatomical conditions permit.

It is important to note that this study was a single-center retrospective analysis with a limited sample size, introducing potential biases. Moreover, this study did not compare the hybrid surgery strategy with traditional surgery or total endovascular repair. Further multicenter prospective studies are required to rigorously assess the long-term efficacy and safety of these three surgical strategies for managing aortic arch lesions.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1073/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1073/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1073/prf

Funding: This work was supported by grants from the Elite Medical Professionals Project of China-Japan Friendship Hospital (No. ZRJY2024-QM01) and the National High Level Hospital Clinical Research Funding (No. 2023-NHLHCRF-PY-11).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1073/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Institutional Review Board of China-Japan Friendship Hospital (No. 2024-KY-011). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The requirement for individual patient consent was waived by the ethics committee due to the retrospective nature of the study, which involved minimal risk to participants. All patient data were anonymized and maintained with strict confidentiality.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Dhanekula AS, Sweet MP, Desai N, et al. Aortic arch stenting: current strategies, new technologies and future directions. Heart 2021;107:1199-205. [Crossref] [PubMed]
2. Tsilimparis N, Debus ES, von Kodolitsch Y, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg 2016;64:592-9. [Crossref] [PubMed]
3. Seike Y, Fukuda T, Yokawa K, et al. Differences of mid-term outcomes in debranching thoracic endovascular aortic repair between zone 0 and zone 1-2 landing. Gen Thorac Cardiovasc Surg 2023;71:59-66. [Crossref] [PubMed]
4. Lin H, Du Y, Yu C, et al. Single Stage Hybrid Repair for DeBakey Type I Aortic Dissection in High Risk Patients. Eur J Vasc Endovasc Surg 2018;56:363-72. [Crossref] [PubMed]
5. Kudo T, Kuratani T, Shimamura K, et al. Determining the Optimal Proximal Landing Zone for TEVAR in the Aortic Arch: Comparing the Occurrence of the Bird-Beak Phenomenon in Zone 0 vs Zones 1 and 2. J Endovasc Ther 2020;27:368-76. [Crossref] [PubMed]
6. Hoshina K, Kato M, Ishimaru S, et al. Effect of the urgency and landing zone on rates of in-hospital death, stroke, and paraplegia after thoracic endovascular aortic repair in Japan. J Vasc Surg 2021;74:556-568.e2. [Crossref] [PubMed]
7. Konstantinou N, Kölbel T, Debus ES, et al. Fenestrated versus debranching thoracic endovascular aortic repair for endovascular treatment of distal aortic arch and descending aortic lesions. J Vasc Surg 2021;73:1915-24. [Crossref] [PubMed]
8. Konstantinou N, Debus ES, Vermeulen CFW, et al. Cervical Debranching in the Endovascular Era: A Single Centre Experience. Eur J Vasc Endovasc Surg 2019;58:34-40. [Crossref] [PubMed]
9. Oztas DM, Ugurlucan M, Beyaz MO, et al. Follow-up results of aortic arch cervical debranching performed with the help of a temporary crossover external carotid artery bypass for cerebral protection followed by endovascular thoracic aortic aneurysm repair. Interact Cardiovasc Thorac Surg 2020;30:724-31. [Crossref] [PubMed]
10. Fillinger MF, Greenberg RK, McKinsey JF, et al. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg 2010;52:1022-33, 1033.e15.
11. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873-926. [Crossref] [PubMed]
12. Cao P, De Rango P, Czerny M, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012;144:1286-300, 1300.e1-2.
13. Soares TR, Melo R, Amorim P, et al. Clinical outcomes of aortic arch hybrid repair in a real-world single-center experience. J Vasc Surg 2020;72:813-21. [Crossref] [PubMed]
14. Buth J, Penn O, Tielbeek A, et al. Combined approach to stent-graft treatment of an aortic arch aneurysm. J Endovasc Surg 1998;5:329-32. [Crossref] [PubMed]
15. Sood V, Patel HJ, Williams DM, et al. Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm. J Vasc Surg 2014;60:57-63. [Crossref] [PubMed]
16. Elhelali A, Hynes N, Devane D, et al. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2021;6:CD012923. [Crossref] [PubMed]
17. Brown JA, Arnaoutakis GJ, Szeto WY, et al. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021;36:4292-300. [Crossref] [PubMed]
18. Gu JJ, Tian XC, Bu JQ, et al. Clinical effects of hybrid debranching technique for acute Stanford type A aortic dissection. J Cardiothorac Surg 2024;19:577. [Crossref] [PubMed]
19. Cui D, Li X, Liang Z, et al. Mid-term outcomes of the fenestration, branched stent-graft, and hybrid techniques in the treatment of thoracic aortic pathologies involving the left subclavian artery. Vascular 2026;34:50-60. [Crossref]