The best approach to aortic arch pathology remains debatable, since robust evidence favoring one solution instead of the others is still missing. Open surgical approach is still considered the gold standard, yet hybrid solutions are wide spreading over recent years . Aim of the present study was to evaluate efficacy, safety and long term outcomes of hybrid interventions expecting cervical debranching and thoracic endovascular repair (TEVAR) in the treatment of aortic arch pathologies in a single center experience.

All the patients treated with standard thoracic endografts needing proximal landing in Ishimaru zone 0, 1 and 2 and receiving supra-aortic vessel debranching in a single center during the period 2005-2021 were included in the study population. Patients undergoing TEVAR procedure without the need for epiaortic vessel debranching were excluded. Patients' data were entered into a prospective database and evaluated retrospectively. Surgical indications were atherosclerotic and post-dissection aortic aneurysms, post-traumatic vessel injuries, acute aortic dissection, Penetrating Aortic Ulcers (PAU) and aberrant subclavian dilatations. Primary outcomes were procedural technical success, mortality rate and rate of neurological events in the perioperative and long-term period. Follow-up evaluations were performed at 1, 6 and 12 months and subsequently annually by clinical exam, ultrasound, and computed tomography angiography.

Ninety-three consecutive high surgical risk patients underwent hybrid aortic arch repair during the period February 2005 - August 2021. A total of 28 cases were treated for aortic dissection and 4 patients were treated for ruptured aneurysm. Twenty-one procedures were performed in urgent setting. Eleven patients underwent total arch debranching needing a zone 0 proximal landing. The remaining 81 patients underwent single or multiple debranching with extra-anatomical bypasses or transpositions. In two cases the proximal landing zone was extended beyond the origin of the surgical debranching exploiting the Chimney technique. Short Term Result. Intra-procedural technical success was 92.5% (86/93). One patient died after the first operative debranching step and there were 6 cases of type I endoleak (5 type Ia, 1 type 1b) at the end of the procedure. Perioperative mortality rate was 13.9%. Perioperative mortalities stratified by sealing zone did not show statistically significant differences. There were 6 cases of perioperative stroke, 2 cases of transient ischemic attack and 2 cases of paraplegia upon awakening. Long Term Result. Mean Follow Up was 56.0 ± 51.7 months. Fifty-five deaths were recorded during the observational perios, with four cases of aneurysmal-related deaths. Survival analysis rate using the Kaplan-Meier curve estimated a cumulative survival rate of 70.2% at 2 years, of 49.5% at 5 years and of 27.6% at 10 years. Only 6 patients needed reintervention

hybrid treatment of the aortic arch should be carefully considered in high risk subjects based on the patient's anatomical characteristics and comorbidities. While perioperative mortality is non-negligible, the hybrid treatment presents a low risk-rate of aneurysm related mortality and re-intervention in the long run. Despite the limitations, the study highlights how hybrid treatment could still be considered a viable alternative even in the era of customized devices for the aortic arch