The treatment of aortic arch pathologies is becoming progressively more complex and multidisciplinary. Despite progresses in open surgical techniques, the high rate of surgical morbidity and mortality, especially in frail and elderly patients, has led to the development of alternative treatment options to conventional open surgery such as hybrid and endovascular procedures. Our purpose is to summarize the advantages and disadvantages of the different approaches and investigate the role of a dedicated aortic team in the choice of the most appropriate treatment for each patient.

OBJECTIVE: Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers.
METHODS: Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5 mm, graft migration and supra-aortic trunks (SAT) patency.
RESULTS: In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341 min, p = 0.01), median ICU stay (1 vs 4.5 days, p < 0.01) and median length of stay (8 vs 17.5 days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed.
CONCLUSIONS: Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.