Outcomes of Arch Debranching: An 18-Year Single Center Experience
Hunter M Ray, Paul G Haddad, Harleen K Sandhu, Charles C Miller, III, Naveed U Saqib, Ali Azizzadeh, Hazim J Safi, Kristofer M Charlton-Ouw
The University of Texas Health Science Center at Houston (UT Health), McGovern Medical School, Houston, TX
Arch debranching (AD) was initially performed for atherosclerotic occlusive disease, however in the endovascular era these procedures are now commonly performed to obtain an optimal proximal landing zone during thoracic endovascular aortic repair (TEVAR). Here we detail our 18-year experience with AD performed for varying indications and utilizing various techniques including direct access via median sternotomy, extraanatomic bypass and endovascular methods.
All patients who underwent AD at our institution from May 2001 through July 2018 were included in the study. Review included a search of hospital records, clinical charts, pertinent imaging as well as the social security death index (SSDI). Details of the patients debranching including method of revascularization, indication and concomitant as well as future procedures were recorded and analyzed. The bypasses were split into three groups: (A) those performed for indications without TEVAR, (B) those bypasses performed at or before the time of TEVAR, and (C) those performed after TEVAR. A composite outcome of complication was defined as those with permanent lower extremity neurologic deficit (LEND), cerebrovascular accident (CVA), myocardial infarction (MI) and/or in-hospital mortality, given the low event rate. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS v 9.4 (SAS Institute, Cary, NC).
During the study period, 106 patients presented to our institution and underwent AD. Mean age was 63.1±15.1 years with 34.3% female. Group A was comprised of 10 bypasses, no LEND or paraplegia, no CVA, no in-hospital mortality and zero composite complication rate. Group B consisted of 78 bypasses with 1.3% (1/78) having permanent LEND, however no permanent paraplegia. Group C had 18 bypasses with 33.3% (6/18) experiencing any LEND which was significantly higher than groups A or B (p<0.01), however this effect disappeared when comparing permanent neurologic deficit at only 11.1% (2/18) with p=0.07. This appears to demonstrate that subclavian revascularization in those with neurologic deficit who did not have prophylactic revascularization are largely returned to baseline function with only 1 case (0.95%) of permanent paraplegia noted in the cohort and without significant difference between the groups (p>0.08). There was no significant difference in CVA between groups A, B and C with 0%, 8.97%, and 5.56%, respectively (p=0.56). Incidence of myocardial infarction (MI) was low with 1 case (0.95%) in the cohort. In-hospital mortality was 4.72%, with no difference noted between groups (p=0.76). No difference was noted in overall complication rates between groups A and B at 16.7%, p=0.31. Sex (p=0.15), diabetes mellitus (p<0.1) and presence of aortic dissection (p<0.45) failed to significantly predict complication. Age ≥70 years persisted as the only predictor of complication (OR 3.48; p<0.02). Overall survival was independent of timing and indication for AD (p<0.22).
Outcomes after AD are acceptable with rare events of permanent paraplegia (0.95%), MI (0.95%), and CVA (7.55%). Prompt subclavian revascularization in patients with LEND after TEVAR without prophylactic revascularization appears effective in restoring neurologic function in the majority of patients. Septuagenarians (OR 3.48; p<0.02) are at highest risk for complications.
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