‘If you want to kill your dog, accuse him of having rabies.’ (French proverb)

In the article titled ‘Is total debranching a safe procedure for extensive aortic arch disease? A single experience on 27 cases’ and published in the present issue of the Journal, Ferrero and colleagues raise an essential question through the report of their experience with this hybrid technique [1]. This new therapeutic method, indeed, seems to not only become more and more popular but also be considered by some surgeons as a good alternative to the traditional ‘anatomical’ replacement of the arch.

It is, however, noteworthy that the same arguments in favour of this method are regularly put in the forefront by its upholders and continuously repeated throughout their articles.

We would like to take the opportunity of this publication to analyse the accuracy and the relevance of those arguments.

The design of the study itself is somewhat intriguing. The authors state that: ‘The primary endpoint was to evaluate the clinical and technical success rate. Clinical success was defined by the absence of perioperative aneurysm-related death and aneurysm expansion or rupture. Technical success was defined by no angiographic evidence of endoleaks, graft infection or thrombosis and no surgical conversion within 24 h postoperatively. The secondary endpoint was to assess the morbidity/mortality and the complications/re-interventions rates at 30 days.’

The notion of immediate ‘technical’ success, actually the proper placement of the stent, which has been developed by the interventional community, represents a weird feature. What is its meaning if it is isolated from the only valid and acceptable ‘success’ that is the clinical and physiological one and what is its significance in the first 24 postoperative hours?

Furthermore, what is the meaning of a ‘clinical success’ at 30 days postoperatively?

Traditionally and statistically, surgical techniques are assessed through the hospital, mid- and long-term mortality and morbidity rates (in general 1, 5 and 10 years of follow- up). Only such data can allow stating that a technique is legitimate and may constitute a therapeutic method of choice or, at least, an alternative to a previous validated method.

‘… hybrid aortic arch repair is reserved for high-risk surgical patients, unsuitable for conventional treatment …’

How the patients' risk is assessed and what is a ‘risky patient’? This major question is very seldom addressed. In the present study, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) or the Society of Thoracic Surgeons (STS) score or any other score does not appear. By the way, it is to note that, in most articles dealing with this matter, when one of these scores is calculated, it is not worse than for patients undergoing conventional surgery, on the one hand, and that the threshold beyond which the patients are considered ‘non-amenable to open surgery’ is never objectively defined, on the other hand. So, should we infer that the risk estimation is mostly left to the surgeons' appreciation only?

‘Hybrid procedures are generally considered as minimally invasive, but in many cases the procedures still involve large incisions’

Indeed, it is interesting to observe that many patients who are supposed to be in too bad a condition to undergo conventional surgery have to undergo a median sternotomy, a side bite cross-clamping of the ascending aorta (probably one of the major factors of strokes!), the implantation of a vascular prosthesis before the sequential interruption and reimplantation of the brachio-cephalic vessels and, ultİmately, the placement in the arch of an endo-prosthesis with all its possible drawbacks and complications. This was the case in almost 50% of the patients of the present study. Is such a procedure really less invasive and more appropriate than a straightforward conventional replacement of the aortic arch?

‘Conventional surgical repair still carries a substantial rate of mortality and morbidity’. ‘The hybrid treatment of aneurysms and dissections involving the aortic arch has proven to reduce the morbidity and mortality rate if compared to a full open surgical approach.’

Such statements (or similar ones) are found in all articles dealing with the hybrid or stent-grafting procedures. Are they well founded?

In general, the references of conventional open surgery quoted to support such statements consist in articles from the 1990s, which include a large proportion of acute type A dissections. During the last two decades, elective conventional surgery of the aortic arch has achieved dramatic improvements. Obviously, the results reported here do not show any improvement as compared to the contemporary results. The immediate mortality rate of 11% and the overall short-term (about 18 months) mortality rate of 26% are obviously superior to the rates of hospital mortality and permanent neurologic accidents as low as or even lower than 5%, regularly published with conventional techniques nowadays [2–8].

Finally, how not to allude to the inevitable and determining question of the cost of those techniques, since it has been demonstrated that the cost of hybrid procedures is about one-third higher than the cost of conventional surgery [9]?

To be fair, we must acknowledge that the authors of the present article are aware of all these issues and that their discussion analyses in a balanced way the advantages and drawbacks of the hybrid technique. Moreover, their conclusion is sound and wise as they write ‘No long-term data exist to ascertain the durability of this method. The hybrid repair for aortic arch aneurysms continues to evolve and only increasing experience might reduce morbid- mortality, but the results must be measured against the ones achieved through open surgical techniques. Data remain limited and we must be cautious in our enthusiastic embrace of this new technology.’ We could not say better and they certainly must be congratulated for this moderate and accurate statement.