Refining Proximal Landing Zone Identification in Hybrid Arch Repair: A Novel Approach for Enhancing Accuracy and Safety

Background: Hybrid aortic arch repair combining open surgical debranching of the supra-aortic vessels with thoracic endovascular aneurysm repair (TEVAR) has emerged as an effective alternative to conventional open surgery, particularly for high-risk patients. However, achieving accurate stent graft deployment in zone 0 remains a major challenge due to the complex anatomy and proximity to critical branches, where misplacement can lead to severe complications. Objective: This study aims to evaluate the efficacy of a novel technique using surgical clips as fluoroscopic markers for precise identification of the proximal landing zone (PLZ) during zone 0 TEVAR following triple vessel debranching. Methods: A prospective and retrospective study was performed on 19 patients who underwent hybrid aortic arch repair with triple vessel debranching and zone 0 TEVAR. Surgical clips were placed at the distal anastomotic site during debranching to serve as visible fluoroscopic markers for the PLZ during stent graft deployment. Results: A total of 19 patients were included in the study. The use of surgical clips allowed for accurate PLZ identification in 100% of cases, with no incidences of proximal endoleaks or proximal malpositioning. The technique also contributed to reduced fluoroscopy time, contrast use, and radiation exposure compared to conventional imaging techniques. Conclusion: The use of surgical clips as fluoroscopic marker is a simple, cost-effective, and highly accurate method for identifying the PLZ in zone 0 TEVAR. This novel technique enhances the precision and safety of hybrid aortic arch repairs, particularly in complex zone 0 procedures. The technique also contributed to reduced fluoroscopy time, contrast use, and radiation exposure compared to conventional imaging techniques.