Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm

Objective: Repair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort. Methods: Of 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n=93), hybrid (n=11), or TEVAR (n=33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n=53) or fusiform (n=30) aneurysms or dissection (n=15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n=30), arch (n=40), descending (n=24), or abdominal (n=9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias. Results: Early mortality was seen in nine patients (7%). Morbidity included stroke (n=9), paraplegia (n=1), and need for dialysis (n=5) or tracheostomy (n=10). A composite outcome of death and stroke was independently predicted by advancing age (P=. 055) andperformanceof a hybrid procedure (P=. 012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P <.05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P=. 018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P=. 017) and an endovascular or hybrid procedure (P=.001) independently predicted late aortic rupture or need for reintervention. Conclusions: Isolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches.