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Open Arch Reconstruction in the Endovascular Era: Analysis of 721 Patients Over 17 Years
Study Questions:
What are the long-term outcomes of open surgical aortic arch repair?
Methods:
Since the inception of a thoracic endovascular aortic repair program in 1993, 721 patients (mean age of 59.3 years, 68.9% male) have undergone median sternotomy and open arch reconstruction with hypothermic circulatory arrest. Extended arch repair was performed in 42.7%, with construction of bypasses to the innominate (296 patients), left carotid (216 patients), and subclavian (75 patients) arteries; or elephant trunk procedures (42 patients). Concomitant aortic valve or aortic root replacement was required in 403 patients, and root reconstruction was required in 222 patients. Retrograde (641 patients) or antegrade (400 patients) cerebral perfusion was used for neuroprotection during hypothermic circulatory arrest. The operative procedure was urgent or emergency in 316 patients (43.8%) and included repair of type A dissection in 284 patients (39.3%). A total of 111 patients (15.4%) had undergone prior cardiac surgery. Primary outcomes were early and late mortality. Follow-up was 100% complete (mean 52.6 months).
Results:
Morbidity at 30 days included death (36 patients [5%]), stroke (34 patients [4.7%]), and permanent dialysis (14 patients [1.9%]). Independent predictors of early mortality included advancing age, prolonged bypass times, and impaired ejection fraction (all p < 0.05). Actuarial survival at 10 years was 65%. Independent predictors of late mortality included advancing age, prolonged lower body circulatory arrest times, and increasing creatinine (all p < 0.05). By Kaplan-Meier analysis, 10-year survival was significantly lower after operative procedures for type A dissection (non–type A 69.1% vs. type A 58%, p = 0.003). Freedom from aortic reoperation (any segment) was 72.6% at 10 years.
Conclusions:
The authors concluded that open aortic arch repair can be accomplished with excellent early and late results. These outcomes provide objective data for comparison and suggest that newer endovascular therapies should be evaluated first in high-risk groups, such as those with advanced age or impaired renal function, before broader application in all patients.
Perspective:
Historically, surgical aortic arch repair is a high-risk procedure, with associated mortality and morbidity especially related to neurologic complications. Although arch repair surgery remains highly specialized, progressive evolution of operative techniques––notably including the use of deep hypothermic circulatory arrest––has altered the associated perioperative risks. More recently, endovascular aortic repair, originally applied to degenerative aneurysms of the abdominal aorta and descending thoracic aorta, have begun to be applied to the aortic arch (utilizing branched endografts or hybrid debranching/thoracic endovascular techniques). This contemporary review of surgical outcomes at a single specialized aortic surgical program provides important long-term outcome data for comparative analysis of newer therapies.
Keywords: Renal Dialysis, Renal Insufficiency, Endovascular Procedures, Follow-Up Studies, Circulatory Arrest, Deep Hypothermia Induced
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