Hybrid intraperitoneal onlay mesh repair for incisional hernias: a systematic review and meta-analysis.

INTRODUCTION: Laparoscopic IPOM is technically challenging, especially regarding fascial closure. Hybrid repair has been proposed as a simpler approach. We aimed to compare hybrid and laparoscopic intraperitoneal onlay mesh repair (IPOM) in patients undergoing ventral hernia repair (VHR). METHODS: We performed a systematic review of Cochrane, Scopus, and MEDLINE databases to identify studies comparing hybrid versus laparoscopic IPOM VHR reporting the outcomes of recurrence, mortality, seroma, postoperative complications, reoperation, surgical site infection, and operative time. Statistical analysis was performed using RStudio 4.1.2 using a random-effects model. RESULTS: We screened 2,896 articles and fully reviewed 22 of them. A total of five studies, encompassing 664 patients were included. Among them, 337 (50.8%) underwent laparoscopic IPOM. All patients had incisional hernias, with a mean diameter varying from 3 to 12.7 cm, 60% were women, with a mean BMI varying from 29.5 to 38. The hybrid approach had a lower rate of seroma when compared to the laparoscopic (OR 0.22; 95% CI 0.05 to 0.92; p = 0.038; I²=78%). We found no difference in recurrence, mortality, postoperative complications, reoperation, surgical site infection, and operative time between groups. CONCLUSION: Hybrid IPOM is a safe and effective method for incisional hernia repair. Moreover, it facilitates fascial defect closure and decreases postoperative seromas.

Hybrid Technique for Abdominal Wall Hernia Repair: Description and Early Results.

Objective Ventral hernia repair is a widely practiced surgical procedure worldwide. The objective of this paper is to evaluate and analyze the results of a hybrid approach for treating ventral hernias. Methods All patients with clinically and radiologically proven ventral hernia underwent hybrid laparoscopic ventral hernia repair at Princess Royal University Hospital, London, United Kingdom using a retrospective approach with the same surgical team. Large defects >10 cm, inguinal hernia, para-stomal hernia, incarcerated patients, and spigelian hernia were excluded. We utilized the laparoscopic approach for the dissection and isolation of the sac and used the port site for the delivery of mesh into the abdominal cavity. Results Our study comprises 67 patients, with 39 males (58.2%) and 28 females (41.8%). The median age in our study group was 41 years (range: 18-65 years). The median BMI was 38 kg/m2 (range: 24-52 kg/m2). The majority of the cases were umbilical or paraumbilical hernias (n = 46). The median defect size in our study was 5.4 cm (range: 2-10 cm). The median operative time was 67 minutes. We have not encountered any recurrences in this group. Conclusion This hybrid approach combines the advantages of both the open and laparoscopic approaches.

[Surgical treatment of a patient with syphilitic aortitis]. / Khirurgicheskoe lechenie patsienta s sifiliticheskim aortitom.

Syphilitic aortitis is a rare disease caused by Treponema pallidum affecting the aorta and leading to inflammation. Syphilitic aortitis is one of the causes of aortic aneurysms. This article presents surgical treatment of a patient with syphilitic aortitis and thoracic aortic aneurysm. This clinical case confirms the difficulties of surgical treatment.

Open thrombectomy, patch angioplasty, and retrograde stenting for isolated superior mesenteric artery dissection.

Isolated superior mesenteric artery dissection without aortic involvement is an exceptionally rare event. Nonoperative management remains the first-line therapy. However, surgical interventions can be indicated in the event of bowel ischemia. In the present report, we describe a case of complicated isolated superior mesenteric artery dissection treated with a hybrid approach.

A hybrid approach to complex bilateral common iliac artery and internal iliac artery aneurysm repair.

A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, with bilateral stent grafts deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. One week later, an open infrarenal aorto-bi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair.

PURPOSE: Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers. MATERIALS AND 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.

Surgical, endovascular, and hybrid treatment of deep femoral artery aneurysm: Three case reports.

Key Clinical Message: Deep femoral artery aneurysms (DFAA) are extremely rare. We treated four DFAAs with different procedures including surgical, endovascular, and hybrid surgery. The best treatment should be selected for each individual case. Abstract: We report three cases of deep femoral artery aneurysms treated with different techniques. Case 1: A 69-year-old man with a huge deep femoral artery aneurysm underwent open reconstruction using a 6 mm expanded polytetrafluoroethylen graft. Case 2: A 67-year-old man presented with bilateral deep femoral artery aneurysms. The right-sided rupture was treated with hybrid embolization, while the left aneurysm was treated by endovascular stent-grafts deployment. Case 3: A 87-year-old man with a large deep femoral artery aneurysm underwent simply surgical aneurysmectomy. As there are many treatment options for deep femoral artery aneurysms, a comprehensive preoperative assessment is essential, encompassing an evaluation of symptoms, anatomy, and comorbidities.

Hybrid Repair of Complicated Type B Aortic Dissection Aneurysm With Dissected Kommerell Diverticulum Without Thoracotomy.

PURPOSE: The coincidence of aberrant right subclavian artery (ARSA) and Kommerell diverticulum (KD) with type B aortic dissection (TBAD) is a rare but dangerous disease. Currently, there are no well-established guidelines for treatment. Most authors seem to agree that surgical treatment is warranted. However, a hybrid repair technique as we performed is flexible, and a promising approach should be considered. CASE REPORT: Here, we summarized a case report of successful single-stage hybrid repair of a complicated TBAD combined with ARSA and KD without thoracotomy. CONCLUSION: Hybrid repair is a flexible and promising technique that has the potential to replace most open operation procedures in the future with a developed technique and more evidence-based medicine. CLINICAL IMPACT: As for ARSA and KD with TBAD patients, open surgical repair has been historically the treatment of choice; however, hybrid repair without thoracotomy means less invasion, simpler operation and faster recovery, which provides a flexible and promising technique that has the potential to replace most open operation procedures in the future with more evidence-based medicine.

Kommerell's Diverticulum in a Right-Sided Aortic Arch With an Aberrant Left Subclavian Artery Hybrid Repair.

BACKGROUND: Kommerell's diverticulum (KD) with a right aortic arch (RAA) and aberrant left subclavian artery (aLSCA) is a rare congenital anomaly of the aortic arch. Treatment is not well defined due to its uncommon presentation, with rupture and dissection risk rates of up to 53%. CASE SUMMARY: A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred. CONCLUSION: We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.

Successful hybrid repair of a giant coronary artery aneurysm after previous coronary artery bypass grafting.

A 64-year-old woman had undergone coronary artery bypass grafting (CABG) for right coronary occlusion and the Dor procedure for a left ventricular apex aneurysm 10 years previously. A follow-up computed tomography scan showed the evolution of a giant coronary artery aneurysm (CAA) located on the proximal left circumflex artery (CX). It also revealed a previous saphenous vein graft (SVG) that was patent and located on the midline. Surgical exclusion was regarded as invasive, and isolated percutaneous intervention was unsuitable for a wide-necked CAA. Thus, a hybrid approach was planned. First, CABG (SVG-CX) via left thoracotomy was performed. Following the surgery, stent-assisted coil embolization was performed. A coronary angiogram revealed complete CAA exclusion. Learning objective: Many authors have reported successful repair for coronary artery aneurysm (CAA) with a percutaneous approach or surgery. Although there is no consensus for giant CAA repair, surgical repair including resection, ligation, and coronary artery bypass grafting have been recommended in previous reports. However, every decision should be tailored to suit each condition. In this case with the history of previous cardiovascular surgery, our hybrid approach was thought to be less invasive and feasible than isolated surgical or percutaneous repair.

Staged hybrid repair for a patient with chronic type B aortic dissection.

Vascular prosthesis replacement and thoracic endovascular repair (TEVAR) are used to treat patients with enlarged chronic type B aortic dissection. A case in which thrombosis of the false lumen was achieved by the staged combination of these two methods is presented. A 41-year-old woman with a thoracoabdominal aortic aneurysm (maximum short diameter 44 mm) identified 5 years earlier was being monitored as an outpatient in our department when she presented with back pain. Computed tomography (CT) showed acute type B aortic dissection (DeBakey type IIIa), which was managed conservatively. When CT showed an aortic dissection with a patent false lumen immediately below the left subclavian artery bifurcation, one-debranching TEVAR was performed to close the entry, along with right axillary artery to left axillary artery bypass surgery. Outpatient CT at 3 months postoperatively showed rapid enlargement in the vicinity of the celiac artery. Thoracoabdominal aortic replacement to prevent rupture was performed, and the patient was then monitored as an outpatient. CT at age 43 years showed enlargement of the residual false lumen. Additional TEVAR was successfully performed. Thus, three-stage treatment was conducted to enlarge the residual false lumen, causing successful thrombosis of the false lumen.

The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection.

OBJECTIVES: A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition. METHODS: From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups. RESULTS: Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly. CONCLUSIONS: Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.

Reintervention of Residual Aortic Dissection after Type A Aortic Repair: Results of a Prospective Follow-Up at 5 Years.

Background After a type A aortic dissection repair, a patent false lumen in the descending aorta is the most common situation encountered, and is a well-known risk factor for aortic growth, reinterventions and mortality. The aim of this study was to analyze the long-term results of residual aortic dissection (RAD) at a high-volume aortic center with prospective follow-up. Methods In this prospective single-center study, all patients operated for type A aortic dissection between January 2017 and December 2022 were included. Patients without postoperative computed tomography scans or during follow-up at our center, and patients without RAD were excluded. The primary endpoint was all-cause mortality during follow-up for patients with RAD. The secondary endpoints were perioperative mortality, rate of distal aneurysmal evolution, location of distal aneurysmal evolution, rate of distal reinterventions, outcomes of distal reinterventions, and aortic-related death during follow-up. Results In total, 200 survivors of RAD comprised the study group. After a mean follow-up of 27.2 months (1-66), eight patients (4.0%) died and 107 (53.5%) had an aneurysmal progression. The rate of distal reintervention was 19.5% (39/200), for malperfusion syndrome in seven cases (3.5%) and aneurysmal evolution in 32 cases (16.0%). Most reinterventions occurred during the first 2 years (82.1%). Twenty-seven patients were treated for an aneurysmal evolution of RAD including aortic arch with hybrid repair in 21 cases and branched aortic arch endoprosthesis in six cases. In the hybrid repair group, there was no death, and the rate of morbidity was 28.6% (6/21) (one minor stroke, one pulmonary complication, one recurrent paralysis with complete recovery and three major bleeding events). In the branched endograft group, there was no death, no stroke, and no paraplegia. There was one case (16.7%) of carotid dissection. Complete aortic remodeling or complete FL thrombosis on the thoracic aorta was found in 18 cases (85.7%) and in five cases (83.3%) in the hybrid and branched endograft groups, respectively. Conclusions: Despite a critical course in most cases of RAD, with a high rate of aneurysmal evolution and reintervention, the long-term mortality rate remains low with a close follow-up and a multidisciplinary management in an expert center.

An early single-center experience with the Relay double inner-branch arch endograft.

Background: Open surgery remains the gold standard technique for the treatment of aortic arch pathologies, although endovascular techniques offer a new opportunity for patients deemed unfit for open repair. This paper assesses the early outcomes of patients treated with a double inner-branched arch endograft in a single, tertiary-care institution. Methods: All consecutive cases of elective endovascular arch repair from 2016 to 2022 were included in a prospective database. All procedures were performed using the custom-made Relay® (Terumo Aortic-Bolton Medical Inc., Sunrise, FL, USA) double inner-branched endograft; an extra-anatomical bypass was associated in all cases to preserve the patency of supra-aortic trunks. Comorbidities, periprocedural data, immediate results and follow-up complications were analyzed. Results: Twelve patients were treated during the study period [mean age 74±7 years, 100% male, 58% American Society of Anesthesiologists (ASA) risk ≥3]. Treated conditions included aneurysms (n=9), one pseudoaneurysm, one aortic ulcer and a type IA endoleak. The technical success rate was 100%. Early complications included respiratory insufficiency (n=3; 25%), stroke (n=1; 8.3%), acute coronary syndrome needing coronary stenting (n=1; 8.3%), and one perioperative death (n=1; 8.3%) secondary to an intracranial bleeding after coronary stenting. One patient required early reintervention due to retroperitoneal iliac access bleeding (n=1; 8.3%). During a median follow-up of 15.5 (range, 0-44) months, four patients suffered neurological events (two of them of cardioembolic origin), one reintervention was needed (subclavian anastomosis pseudoaneurysm), and a type IB endoleak was diagnosed. Overall mortality was of 17% (n=2), with an 83% overall survival at 2 years. The aortic-related death-free survival was 100%. Conclusions: Endovascular treatment of aortic arch pathology is feasible and shows promising early mortality and stroke rates in high-risk candidates. The main short and midterm goal should be minimizing neurological complications. A longer follow-up is mandatory to determine the effectiveness of the technique and to detect device related complications.

The technique of balloon occlusion-assisted repair of a pseudoaneurysm originated from the side branch of an ascending aortic prosthetic graft via mini-thoracotomy.

A 69-year-old woman underwent aortic root reimplantation and graft replacement of the ascending aorta 12 years ago. A pseudoaneurysm (2.5 cm × 3 cm) arising from the side branch of the ascending aortic prosthetic graft was incidentally detected on contrast-enhanced computed tomography. After endovascular balloon occlusion of the side branch through the left subclavian artery, the side branch was exposed via right mini-thoracotomy in the third intercostal space. After circumferential dissection, the side branch was ligated uneventfully. The patient was discharged home on postoperative day 7 without any complications.

Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial.

OBJECTIVE: In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta. METHODS: For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality. RESULTS: In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group. CONCLUSIONS: One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.

MIS retromuscular repair of lateral incisional hernia: technological deliberations and short-term outcome.

BACKGROUND: Lateral abdominal wall hernias (LAWH) constitute about 1-4% of hernia surgical procedures. They represent a unique surgical challenge on account of their potential for anatomical complexity and consequent operative technical demand. Furthermore, LAWH repairs are currently not standardized, and remain contentious, despite a variety of approaches. These repairs are attendant with not insignificant morbidity and recurrence rates. We profile here our endoscopic and hybrid surgical approach to the management of LAWH and early therapeutic outcomes. METHODS: A retrospective review of our hernia clinical database between March 2018 and December 2020 was performed to extract all LAWH (with and without an associated midline component) patients, who underwent an enhanced-view totally extra peritoneal (eTEP) hernia repair with a transversus abdominis release (TAR), or a hybrid repair. Initial outcome data (6-month follow-up) is profiled here. The primary outcome measures were hernia recurrence and hernia-site bulging. The secondary measures were surgical site occurrence (SSO) and hernia-related quality of life (QoL). RESULTS: A total of 33 LAWH patients underwent an eTEP TAR or hybrid hernia repair. 11 patients had an associated midline defect and 12 were recurrent hernias. The mean hernia defect area was 84.2 ± 49 cm2 and mean mesh size was 859.6 ± 263 cm2. There was no hernia recurrence at initial follow-up of 24 months. The SSO rate was 12%. The CCS QoL scores were 34.6 ± 2 pre-operatively, and improved to 27.2 ± 4 at 6 months. CONCLUSIONS: Our endoscopic and hybrid technique is a safe, reproducible, and technically promising approach for the repair of LAWH. Thorough knowledge of the surgical anatomy of the lateral abdominal wall and advanced endosurgical skills are imperative for good outcomes. We await the long-term results of our LAWH cohort to confirm the findings.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections.

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Complex Hybrid Repair of a Secondary Aortoenteric Fistula.

Background: Secondary aortoenteric fistula is a rare, highly morbid and often difficult to diagnose, cause of gastrointestinal bleeding. It is associated with prior aortic surgery or placement of a synthetic aortic graft. Our case features staged hybrid endovascular stent-grafting, graft excision, aortoplasty using a bovine pericardial patch, extra-anatomical bypass and complex bowel repair. Case Report: An 82-year-old man presented with gastrointestinal bleeding and Streptococcus Anginosus bacteraemia, with previous aorto-bi-iliac bypass surgery for left common iliac occlusive disease 15 years ago. Computed tomography angiography (CTA), gastroscopy, colonoscopy, capsule endoscopy and enteroscopy identified no bleeding source. Repeat CTA showed gas locules and stranding around the graft and the third part of the duodenum, concerning for fistulous communication. On the next day, a Zenith TX2 thoracic 28x80mm stent-graft was deployed into the infrarenal aorta. On laparotomy, a fistula was present between the Dacron graft and fourth part of the duodenum. The Dacron graft was excised, followed by aortic patching with bovine pericardium. A right-to-left femoral-femoral crossover graft was constructed. CT at one-month post-laparotomy showed no signs of perigraft endoleak and interval resolution of gas locules. He was transferred to a rehabilitation facility on the 34th post-operative day with a multidisciplinary follow-up arranged. Discussion: Aortoduodenal fistula is a challenging entity to diagnose and should be suspected in patients with GI bleeding and prior aortic surgery. Endovascular repair alone is a less invasive option but with higher re-infection and late failure rates. Liberal use of appropriate imaging modalities, a judicious repair strategy, long-term follow-up and multidisciplinary approach are critical for its management.

Single-staged hybrid repair of extent II thoracoabdominal aortic aneurysm with infrarenal abdominal aortic occlusion.

Thoracoabdominal aortic aneurysm repair has been associated with a high risk of postoperative mortality, spinal cord ischemia, and renal failure. Endovascular repair combined with open repair in a two-staged hybrid approach has had a lower incidence of postoperative morbidity and mortality compared with open repair. In the present report, we have described single-stage hybrid repair of a complex chronic type B aortic dissection with a Crawford extent II thoracoabdominal aortic aneurysm in a patient with extensive prior aortic reconstruction.