Surgical Aortic Arch Intervention at the time of Extended Ascending
Aortic Replacement is Associated with Increased Mortality
Abstract
Objective: To compare outcomes of hemiarch versus total arch repair
during extended ascending aortic replacement. Methods: Between 2004 and
2017, 261 patients underwent hemiarch (n=149, 57%) or total arch repair
(aortic debranching or Carrell patch technique, n=112, 43%) in the
setting of extended replacement of the ascending aorta. Median follow-up
was 17.2 (IQR 4.2–39.1) months. Multivariable models considering
preoperative and intraoperative factors associated with mortality and
aortic reintervention were constructed. Results: Survival was 89.0,
81.3, and 73.5% vs. 76.4, 69.5, and 61.7% at 1, 3, and 5 years in the
hemiarch versus total arch groups, respectively (log-rank p=0.010).
After adjustment for preoperative and intraoperative factors, the
presence of a total arch repair (adjusted HR 2.53, 95% CI 1.39 – 4.62,
p=0.003), and increasing age (adjusted HR per 10 years of age, 1.76,
95% CI 1.37 – 2.28, p<0.001) were associated with increased
mortality. The cumulative incidence of aortic reintervention with death
as a competing outcome was 2.6, 2.6, and 4.4% and 5.0, 10.3, and 11.9%
in the hemiarch and total arch groups, respectively. After adjustment,
the presence of a total arch repair was significantly associated with
need for aortic reintervention (SHR 3.21, 95% CI 1.01 – 10.2,
p=0.047). Conclusions: Overall survival after aortic arch repair in the
setting of extended ascending aortic replacement is excellent, however,
total arch repair and increasing age are associated with higher
mortality and reintervention rates. A conservative approach to aortic
arch repair can be prudent, especially in those of advanced age.