1. The assessment of the new hybrid procedure for extensive aortic aneurysms compared with the conventional open surgery Department of Cardiovascular surgery, Osaka University Graduate School of Medicine, Osaka,Japan #1 Department of Cardiovascular surgery, Osaka General Medical Center #2 Depertment of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital #3 Keiwa Kin #1, Toru Kuratani #1, Yukitoshi Shirakawa #1, Kei Torikai #1, Kazuo Shimamura #1, Hiroshi Takano #2, Hisashi Satoh #3, Yoshiki Sawa #1

2. Procedure for extensive thoracic aortic aneurysm Second stage repair with left thoracotomy Second stage repair was not done in 43 (35.9%) of 117 patients who completed first-stage elephant trunk procedures Among these patients, within an average period of 3.4 years, 13 of 43 (30.2%) died, 4 of 13 (30.8%) as the result of rupture. Safi.H.J.et.al Circulation. 2001 Dec 11;104(24):2938-42. Our result with elephant trunk procedure (~2000) 11 cases Three cases died from aneurysm rupture during the interval between operation Two-stage repair with TEVAR (~2002) less invasive procedure Trying for less invasive procedure Bilateral anterior thoracotomy Mechanical ventilator support for more than 72h was required in 50% of the operative survivors, and 13% a tracheostomy was necessary. Kouchoukos.J.et.al Ann Thorac Surg. 2007 83;811-4.

3. 1 days after Two-stage TEVAR (minimum overlap length 5cm) New hybrid procedure for extensive aortic arch aneurysm Stent graft Under DHCA Insertion of stent graft to the descending aorta Insertion of stent graft to the descending aorta Open distal anastomosis Open distal anastomosis

4. Objective We elucidate the efficacy of this “hybrid procedure” to compare with a conventional single-stage repair.

5. n% Age (y)66.9± 12.2 Male/female96/35 Pathology degenerative / dissection 77/54 Comorbidity Hypertension8661 Ischemic heart disease2721 Diabetes2721 Renal dysfunction (Cr>1.5)1310 Pulmonary dysfunction1713 2000.1~2011.10 Elective patients with extended aortic arch aneurysm 131cases Patient s

6. 2000.1~2011.10 Elective patients with extended aortic arch aneurysm 131cases Patient s  Hybrid procedure with TEVAR (H-group)  Single-stage procedure with cram-shell approach (S-group) 63 cases 68 cases

7. H-groupS-group Number6368n.s. Age (y)66.7±10.470.5±10.4n.s. Male/female50/1346/22n.s. Pathology degenerative / dissection 37/2640/28n.s. Comorbidity Hypertension4244n.s. Ischemic heart disease1314n.s. Diabetes1215n.s. Renal dysfunction (Cr>1.5)76n.s. Pulmonary dysfunction107n.s. Patient s Demographics

8. Hospital mortality Complication Stroke Paraplesia Acute renal failure Tracheostomy H-group N=63 1 (1.6%) 2 (3.2%) 1 (1.6%) 3 (4.8%) S-group N=68 10 (15%) 3 (4.4%) 2 (2.9%) 14 (21%) Short-term RESULTS Short-term RESULTS 0.0068 0.7119 0.6048 0.0071

9. Mid-term RESULT ~mortality~ ~mortality~ Follow-up: 32.0month (1-121) Follow-up completion: 97.1% 0.2.4.6.8 1 020406080100120140 Number at risk Over-all 131 57 23 11 5 H-group 63 36 13 7 3 S-group 68 21 10 4 2 Free from aneurysm-related mortality (4 years; 86% H-group vs 71% S-group P=.0262)

10. Conclusion Hybrid procedure with frozen elephant trunk and TEVAR gave excellent early and long-term results compared with a conventional single-stage repair. This hybrid procedure may be alternative to the conventional sigle-stage.