Hybrid repair of proximal aortic arch pathologies in high-risk surgical patients with extra-anatomic carotid bypass and zone 0 thoracic branched endograft

Objective: To demonstrate perioperative outcomes and short-term follow-up from a single-center experience using extra-anatomic carotid bypass and subsequent thoracic endovascular aortic repair using the Gore TAG thoracic branched endoprosthesis for the repair of proximal aortic arch pathologies with a zone 0 landing. Methods: This retrospective single-center case series reviews consecutive patients with zone 0 aortic pathology treated between October 2023 and December 2025. Patients were determined to be high risk for open intervention by a multidisciplinary board of cardiovascular and vascular surgeons who reviewed each case independently. All patients underwent a staged hybrid approach consisting of extra-anatomic carotid bypass followed by zone 0 thoracic endovascular aortic repair using the Gore TAG thoracic branched endoprosthesis. The primary outcome was technical success, defined as complete exclusion of aortic pathology with patent bypass grafts. Secondary outcomes included 30-day mortality, major adverse events, and early reintervention. Results: Twenty-two consecutive patients (mean age, 66.7 years; 72.7% male) were treated. Indications included residual type A dissection after earlier open repair (50%), aortic arch aneurysm (27.3%), acute dissection (18.2%), and pseudoaneurysm (4.5%). Technical success was achieved in 100% of cases. Thirty-day mortality was 9.1% (2/22). Major adverse events included stroke in one patient (4.5%) and respiratory failure in two patients (9.1%). Dysphagia occurred in 27.3% and was self-limited in most cases. Early endoleaks were identified in 22.7%, with one requiring reintervention. Conclusions: A staged hybrid approach using extra-anatomic bypass and zone 0 thoracic branched endograft repair is feasible and reproducible in high-risk patients, with favorable short-term outcomes and acceptable morbidity.