The New York experience of open arch surgery

Aortic arch repair has undergone constant evolution since its inception with improving outcomes. A sizeable number of competing techniques and strategies have been described, with no single optimal method endorsed by the surgical community. We describe our experience with open aortic arch repair in a high-volume center.

We queried our aortic database for consecutive patients undergoing aortic arch repair from 1997-2021. Those undergoing hemiarch repair were compared to those undergoing total arch repair. Outcomes were compared using multivariate analysis.

Of 1308 patients undergoing aortic arch repair, 953 underwent hemiarch repair and 355 underwent total arch repair. The median age was 69 (interquartile ratio 58-76) and 61.7% were men. Hemiarch patients more frequently hade aortic dissection (28.5 vs. 11.8%, P<0.001) and urgent or emergent procedure status (45.1 vs. 30.4%, P<0.001). Overall operative mortality was 2.7% and significantly higher in the hemiarch group (3.5 vs. 0.6%, P=0.007). No difference in the incidence of major adverse events (MAE) including myocardial infarction, cerebrovascular accident, new need for dialysis, re-exploration for bleeding, and tracheostomy was found between the two groups. Multivariate analysis found diabetes, urgent or emergent procedure status, preoperative renal dysfunction, New York Heart Association class III/IV symptoms, and connective tissue disease to be independent predictors of MAE.

Retrograde cerebral perfusion with deep hypothermic circulatory arrest is safe and effective, with no appreciable difference in neurologic outcomes when comparing hemiarch to total arch strategies. Rates of mortality and MAE compare favorably with strategies utilizing antegrade cerebral perfusion.