Aortic arch repair outcomes held acceptable

CHICAGO – Repair of the isolated nontraumatic aortic arch aneurysm can be performed with acceptable early and late results, based on a 20-year review of 137 patients.

Early mortality was seen in nine patients (6.6%), and was similarly split between endovascular and open repair (7.3% vs. 6.5%, respectively).

Patrice Wendling/IMNG Medical Media

Five-year survival did not differ between the endovascular- and open-repair groups (86% vs. 70%; P = .57), although the risk of reintervention was significantly higher with an endovascular strategy (94% vs. 77.5%; P = .02).

"These data support ongoing efforts to develop branched endografts specifically tailored for complex and difficult-to-treat pathology to potentially reduce the morbidity of therapy for this population," Dr. Himanshu J. Patel said at the annual meeting of the Midwestern Vascular Surgical Society.

Marginal landing zones and the need for complex arch debranching procedures to extend landing zones and facilitate repair can hinder endovascular repair, though open aortic repair is challenged by the frequent need for hypothermic circulatory arrest. Early and late results with either option are ill defined for this pathology, observed Dr. Patel, with the Cardiovascular Center, University of Michigan, Ann Arbor.

To investigate these outcomes, the authors evaluated data from 1993 to 2013 for 137 patients with nontraumatic aortic aneurysms located between the left and right pulmonary artery; 93 patients underwent open repair and 44 had an endovascular or hybrid repair.

The pathology was saccular in 39%, dissection in 11%, pseudoaneurysm in 18%, and anomalous arch in 11%. Rupture was identified in 14%. The average patient age was 59 years, and 46% were male.

Courtesy Dr. Himanshu Patel

In the open-repair group, 84 patients underwent a posterolateral thoracotomy and 9 had a median sternotomy. Extracorporeal perfusion was used in all, and 80 required deep hypothermic arrest.

In the endovascular group, the proximal extent of surgery was classified as Ishimaru zone 0 in 10 patients, zone 1 in 1, and zone 2 in 33. Treatment included full arch debranching and stent graft repair for zone 0 and zone 2 patients, respectively. A chimney stent of the carotid artery and left subclavian arterial bypass was used for the zone 1 patient.

Although the institutional preference is to utilize left subclavian artery (LSCA) revascularization for all, 76% of endovascular patients requiring LSCA coverage underwent preoperative bypass, Dr. Patel observed.

Significant differences existed at baseline between the two groups, with the endovascular group almost a full decade older than the open group (65 vs. 56 years). The endovascular group was also more likely to have saccular pathology (57% vs. 30%), and less likely to have a history of tobacco use (12% vs. 84%) or prior arch repair (16% vs. 36%).

Early morbidity included stroke in 6.6%, spinal cord ischemia in 0.7%, need for dialysis in 3.6%, and tracheostomy in 7.2%, Dr. Patel said.

The composite endpoint of stroke or early mortality was independently predicted by increasing age (odds ratio, 1.05; P = .055) and use of a hybrid procedure (OR, 6.4; P = .01).

Two-year freedom from aortic rupture or reintervention was 78% in the open group and 94% in the endovascular group (P = .02).

After a mean follow-up of 66 months, four patients had died of stroke, two from myocardial infarction, one from a proximal anastomosis disruption/rupture, and one from a type A dissection/rupture, Dr. Patel said.

The average survival was 145 months and 5-year survival rate was 59%.

Independent predictors of late mortality were increasing age (hazard ratio, 1.06; P = .001), peripheral vascular disease (HR, 2.4; P = .024), postoperative stroke (HR, 6.4; P less than .001), and postoperative dialysis (HR, 11.4; P less than .001). Notably, repair type was not predictive (P = .22), Dr. Patel said.

He cautioned the audience, however, that "cerebrovascular accidents remain an important cause of early and late mortality."

Dr. Patel reported consulting fees from W.L. Gore and Terumo.

pwendling@frontlinemedcom.com

CHICAGO – Repair of the isolated nontraumatic aortic arch aneurysm can be performed with acceptable early and late results, based on a 20-year review of 137 patients.

Early mortality was seen in nine patients (6.6%), and was similarly split between endovascular and open repair (7.3% vs. 6.5%, respectively).

Patrice Wendling/IMNG Medical Media

Five-year survival did not differ between the endovascular- and open-repair groups (86% vs. 70%; P = .57), although the risk of reintervention was significantly higher with an endovascular strategy (94% vs. 77.5%; P = .02).

"These data support ongoing efforts to develop branched endografts specifically tailored for complex and difficult-to-treat pathology to potentially reduce the morbidity of therapy for this population," Dr. Himanshu J. Patel said at the annual meeting of the Midwestern Vascular Surgical Society.

Marginal landing zones and the need for complex arch debranching procedures to extend landing zones and facilitate repair can hinder endovascular repair, though open aortic repair is challenged by the frequent need for hypothermic circulatory arrest. Early and late results with either option are ill defined for this pathology, observed Dr. Patel, with the Cardiovascular Center, University of Michigan, Ann Arbor.

To investigate these outcomes, the authors evaluated data from 1993 to 2013 for 137 patients with nontraumatic aortic aneurysms located between the left and right pulmonary artery; 93 patients underwent open repair and 44 had an endovascular or hybrid repair.

The pathology was saccular in 39%, dissection in 11%, pseudoaneurysm in 18%, and anomalous arch in 11%. Rupture was identified in 14%. The average patient age was 59 years, and 46% were male.

Courtesy Dr. Himanshu Patel

In the open-repair group, 84 patients underwent a posterolateral thoracotomy and 9 had a median sternotomy. Extracorporeal perfusion was used in all, and 80 required deep hypothermic arrest.

In the endovascular group, the proximal extent of surgery was classified as Ishimaru zone 0 in 10 patients, zone 1 in 1, and zone 2 in 33. Treatment included full arch debranching and stent graft repair for zone 0 and zone 2 patients, respectively. A chimney stent of the carotid artery and left subclavian arterial bypass was used for the zone 1 patient.

Although the institutional preference is to utilize left subclavian artery (LSCA) revascularization for all, 76% of endovascular patients requiring LSCA coverage underwent preoperative bypass, Dr. Patel observed.

Significant differences existed at baseline between the two groups, with the endovascular group almost a full decade older than the open group (65 vs. 56 years). The endovascular group was also more likely to have saccular pathology (57% vs. 30%), and less likely to have a history of tobacco use (12% vs. 84%) or prior arch repair (16% vs. 36%).

Early morbidity included stroke in 6.6%, spinal cord ischemia in 0.7%, need for dialysis in 3.6%, and tracheostomy in 7.2%, Dr. Patel said.

The composite endpoint of stroke or early mortality was independently predicted by increasing age (odds ratio, 1.05; P = .055) and use of a hybrid procedure (OR, 6.4; P = .01).

Two-year freedom from aortic rupture or reintervention was 78% in the open group and 94% in the endovascular group (P = .02).

After a mean follow-up of 66 months, four patients had died of stroke, two from myocardial infarction, one from a proximal anastomosis disruption/rupture, and one from a type A dissection/rupture, Dr. Patel said.

The average survival was 145 months and 5-year survival rate was 59%.

Independent predictors of late mortality were increasing age (hazard ratio, 1.06; P = .001), peripheral vascular disease (HR, 2.4; P = .024), postoperative stroke (HR, 6.4; P less than .001), and postoperative dialysis (HR, 11.4; P less than .001). Notably, repair type was not predictive (P = .22), Dr. Patel said.

He cautioned the audience, however, that "cerebrovascular accidents remain an important cause of early and late mortality."

Dr. Patel reported consulting fees from W.L. Gore and Terumo.

pwendling@frontlinemedcom.com

CHICAGO – Repair of the isolated nontraumatic aortic arch aneurysm can be performed with acceptable early and late results, based on a 20-year review of 137 patients.

Early mortality was seen in nine patients (6.6%), and was similarly split between endovascular and open repair (7.3% vs. 6.5%, respectively).

Patrice Wendling/IMNG Medical Media

Five-year survival did not differ between the endovascular- and open-repair groups (86% vs. 70%; P = .57), although the risk of reintervention was significantly higher with an endovascular strategy (94% vs. 77.5%; P = .02).

"These data support ongoing efforts to develop branched endografts specifically tailored for complex and difficult-to-treat pathology to potentially reduce the morbidity of therapy for this population," Dr. Himanshu J. Patel said at the annual meeting of the Midwestern Vascular Surgical Society.

Marginal landing zones and the need for complex arch debranching procedures to extend landing zones and facilitate repair can hinder endovascular repair, though open aortic repair is challenged by the frequent need for hypothermic circulatory arrest. Early and late results with either option are ill defined for this pathology, observed Dr. Patel, with the Cardiovascular Center, University of Michigan, Ann Arbor.

To investigate these outcomes, the authors evaluated data from 1993 to 2013 for 137 patients with nontraumatic aortic aneurysms located between the left and right pulmonary artery; 93 patients underwent open repair and 44 had an endovascular or hybrid repair.

The pathology was saccular in 39%, dissection in 11%, pseudoaneurysm in 18%, and anomalous arch in 11%. Rupture was identified in 14%. The average patient age was 59 years, and 46% were male.

Courtesy Dr. Himanshu Patel

In the open-repair group, 84 patients underwent a posterolateral thoracotomy and 9 had a median sternotomy. Extracorporeal perfusion was used in all, and 80 required deep hypothermic arrest.

In the endovascular group, the proximal extent of surgery was classified as Ishimaru zone 0 in 10 patients, zone 1 in 1, and zone 2 in 33. Treatment included full arch debranching and stent graft repair for zone 0 and zone 2 patients, respectively. A chimney stent of the carotid artery and left subclavian arterial bypass was used for the zone 1 patient.

Although the institutional preference is to utilize left subclavian artery (LSCA) revascularization for all, 76% of endovascular patients requiring LSCA coverage underwent preoperative bypass, Dr. Patel observed.

Significant differences existed at baseline between the two groups, with the endovascular group almost a full decade older than the open group (65 vs. 56 years). The endovascular group was also more likely to have saccular pathology (57% vs. 30%), and less likely to have a history of tobacco use (12% vs. 84%) or prior arch repair (16% vs. 36%).

Early morbidity included stroke in 6.6%, spinal cord ischemia in 0.7%, need for dialysis in 3.6%, and tracheostomy in 7.2%, Dr. Patel said.

The composite endpoint of stroke or early mortality was independently predicted by increasing age (odds ratio, 1.05; P = .055) and use of a hybrid procedure (OR, 6.4; P = .01).

Two-year freedom from aortic rupture or reintervention was 78% in the open group and 94% in the endovascular group (P = .02).

After a mean follow-up of 66 months, four patients had died of stroke, two from myocardial infarction, one from a proximal anastomosis disruption/rupture, and one from a type A dissection/rupture, Dr. Patel said.

The average survival was 145 months and 5-year survival rate was 59%.

Independent predictors of late mortality were increasing age (hazard ratio, 1.06; P = .001), peripheral vascular disease (HR, 2.4; P = .024), postoperative stroke (HR, 6.4; P less than .001), and postoperative dialysis (HR, 11.4; P less than .001). Notably, repair type was not predictive (P = .22), Dr. Patel said.

He cautioned the audience, however, that "cerebrovascular accidents remain an important cause of early and late mortality."

Dr. Patel reported consulting fees from W.L. Gore and Terumo.

pwendling@frontlinemedcom.com