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Branch-first aortic arch replacement strategy decreases perioperative mortality
Brittany G Abt1, Markian Bojko1, Ramsey S Elsayed1
1Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif.
Insights
The branch-first technique for total arch replacement significantly lowers 30-day mortality compared to traditional methods. This approach offers a safer alternative for patients undergoing complex aortic arch surgery.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Limited evidence exists on the superiority of the branch-first technique for total arch replacement (TAR) with antegrade cerebral perfusion (ACP).
- Conventional TAR techniques have associated morbidity and mortality risks that necessitate evaluation of alternative approaches.
Purpose of the Study:
- To compare the perioperative outcomes of traditional TAR versus branch-first TAR.
- To assess the impact of the branch-first technique on 30-day mortality and adverse events.
Main Methods:
- Retrospective review of 144 patients undergoing TAR between January 2017 and December 2021.
- Patients were divided into traditional TAR and branch-first TAR groups.
- Comparison of primary endpoints (30-day mortality, adverse events) using statistical tests and logistic regression.
Main Results:
- The branch-first TAR cohort (76 patients) exhibited significantly lower 30-day mortality (4% vs. 19%, P=0.004) compared to the traditional TAR cohort (68 patients).
- Shorter median ACP times were observed in the branch-first TAR group (P=0.001).
- After multivariable adjustment, branch-first TAR was associated with a 93% reduction in the odds of 30-day mortality (OR, 0.07; P=0.007).
Conclusions:
- Branch-first total arch replacement is associated with significantly reduced 30-day mortality compared to traditional total arch replacement.
- The branch-first technique represents a potentially safer and more effective approach for aortic arch surgery.
Objective:
Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement.
Methods:
We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality.
Results:
A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007).
Conclusions:
We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.
