The role of visceral debranching in hybrid thoracoabdominal aortic aneurysm repair: A narrative review of indications, techniques, and outcomes.

Thoracoabdominal aortic aneurysm (TAAA) repair remains associated with significant morbidity and mortality, especially in elderly and comorbid patients. Although total endovascular repair using fenestrated or branched endografts has broadened therapeutic options, anatomical limitations, patient frailty, and logistical constraints still prevent a purely endovascular approach in many cases. For this subset, hybrid repair with visceral debranching has emerged as an alternative strategy, though its role remains controversial. This narrative review explores the rationale, indications, technical approaches, perioperative management, and outcomes of visceral debranching in hybrid TAAA repair. Particular attention is given to frailty assessment, anatomical complexity, staging strategies, and quantitative outcome data, with the goal of defining the position of hybrid repair within current algorithms compared with open and fully endovascular techniques. Hybrid repair is mainly used in high-risk patients who are unsuitable for open surgery and anatomically unfit for total endovascular reconstruction. Reported early mortality varies widely from 5% to over 20%, reflecting heterogeneity in aneurysm extent, operative strategies, and patient selection; elective series from experienced centres more commonly report mortality between 5% and 10%. Long-term bypass durability is generally good, with overall graft patency around 85%-90% at 5 years. Superior mesenteric artery grafts show the highest durability, while renal bypasses - particularly right-sided - have lower patency rates. Acute kidney injury occurs in 20%-40% of patients, with permanent dialysis dependence in 5%-15%. Mesenteric ischaemia is uncommon but highly lethal, while spinal cord injury occurs in 5%-15%, with permanent deficits in 3%-10%. Staged hybrid approaches may reduce physiological burden and neurological risk but require careful surveillance due to interval risks. Overall, visceral debranching remains a relevant and durable option when applied selectively, particularly in patients with hostile anatomy or prior aortic interventions. Optimal outcomes depend on careful patient selection, meticulous technique, appropriate staging, and structured long-term follow-up.