1. (1) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching versus Elephant Trunk Procedures for Hybrid Repair of Proximal Thoracic Aortic Pathologies CW Lee 1, PJ Hess 2, TD Martin 2, TM Beaver 2, CT Klodell 2, RJ Feezor 1 and WA Lee 1 Divisions of Vascular Surgery and Endovascular Therapy 1 and Thoracic and Cardiovascular Surgery 2 University of Florida, Gainesville

2. (2) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Disclosure WAL: – Cook Medical: Grants, consultant – Medtronic Endovascular: Consultant Off-label use of a commercial device

3. (3) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Background Hybrid (1 st stage: open surgical + 2 nd stage: endovascular) repairs of complex arch diseases are feasible and effective Optimal technique (elephant trunk vs. arch debranching) for creation of a suitable proximal landing zone for endovascular repair remains undecided

4. (4) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Elephant Trunk Advantages: – Long, prosthetic proximal landing zone – Single stage option Disadvantages: – Mobile, unsupported structure – Difficult to access – Uncertain long-term stability

5. (5) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching Advantages: – Long, native proximal landing zone – Single stage option Disadvantages: – A short, dilated ascending aorta may require ascending replacement and/or trans- valvular insertion – 3-vessel debranching can be challenging – Risk of ascending dissection

6. (6) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Objective & Methods + Endovascular Stent Graft Retrospective review of consecutive patients with proximal thoracic aortic pathologies Prospective database, imaging, medical records Categorical variables were compared using Fisher’s exact test. Continuous variables with nonparametric distribution were compared using the Mann-Whitney U test. A p-value <0.05 was considered significant. Arch Debranching vs. Elephant Trunk

7. (7) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Demographics ET (n=21)AD (n=37)p Gender, M(%)13(62)23(62)1.0 Age (yrs)68±1163±150.24 Comorbidities, n (%) HTN19(91)31(84)0.70 Smoking15(71)27(73)1.0 CAD11(52)23(62)0.58 Hyperlipidemia8(38)16(43)0.79 CRI3(14)5(14)1.0 Stroke/TIA2(10)5(14)1.0 Diabetes2(10)8(22)0.30

8. (8) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Preoperative ET (n=21)AD (n=37)p ASA, n (%) II02(5)0.53 III3(14)6(16)1.0 ≥ IV18(86)23(62)0.08 Urgency, n (%) Elective19(91)33(89)1.0 Emergent2(10)4(11)1.0

9. (9) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Indications for Treatment ET (n=21)AD (n=37)p Aneurysm, n (%)21(100)34(92)0.55 Dissection, n (%)03(8)0.55

10. (10) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Concomitant Surgeries (1 st Stage) ET (n=21) AD (n=37) Valve repair, n (%)6 (29)11 (30) Root replacement, n (%)3 (14)3 (8) Ascending replacement, n (%)-17 (46) Arch replacement, n (%)-16 (43) CABG, n (%)5 (24)11 (30) Brachiocephalic reconstruction, n (%)4 (19)-

11. (11) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta 1 st Stage (Open Surgical) Intraoperative ET (n=21) AD (n=37) p Cardiopulmonary bypass, n (%)21(100)25(68)<0.01 Cardiopulmonary bypass median time (min) 2022260.74 Circulatory arrest, n (%)18(86)10(27)<0.01 Circulatory arrest median time (min)43250.36

12. (12) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Perioperative Data ET (n=21) AD (n=37) p Median duration between stages (days)54290.16 Aortic complications between stages, n (%)1(5)1(3)1.0 Failure to complete 2 nd stage, n (%)5(24)9(24)1.0 Median combined LOS (days)25190.04

13. (13) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Outcomes ET (n=21) AD (n=37) p 30-day mortality, n (%)4(19)6(16)1.0 Spinal cord ischemia (n)001.0 CVA, n (%)2(10)4(11)1.0 Type 1a endoleak at 1 mo., n (%)2(10)1(3)0.54 Late secondary procedures, n (%)3(14)9(24)0.51

14. (14) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Conclusions Arch debranching was associated with: – Less frequent need for CPB/circulatory arrest – Shorter overall LOS – Earlier 2 nd stage completion – One-third the incidence of proximal endoleaks