10-Year Outcomes for Hybrid Aortic Arch Repair
Andrew M Vekstein, E. Hope Weissler, Christopher W. Jensen, Lillian Kang, Ryan P Plichta, Jeffrey G Gaca, Chandler A Long, G. Chad Hughes, IV
Duke University Medical Center, Durham, NC
Objective: Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from novel approach to well-established treatment modality for aortic arch pathology in appropriately selected patients. Despite this nearly 20-year history of use, long-term results of HAR remain to be determined. As such, objectives of this study are to detail long-term survival and re-intervention outcomes for HAR.
Methods:From 7/2005 to 4/2021, 149 consecutive patients underwent HAR at a single referral institution. Operative approach was selected according to a previously published institutional algorithm and included Zone 0/1 HAR in 26% (N=39), Type I HAR in 36% (N=53) and Type II/III HAR in 38% (N=57). Specific Zone 0/1 technique was Zone 1 HAR in 28 (19%), Zone 0 with innominate snorkel in 7 (5%) and Zone 0 with single side-branch endograft in 1 (1%). Open and endovascular components were performed in a single stage in 55% (N=82) and two stages in 45% (N=67). All data was obtained from a prospectively maintained aortic surgery database supplemented with chart review.
Results:Mean age was 63±12 years and almost half of patients (48%, n=71) had prior sternotomy. Indications for surgery included degenerative aneurysm in 52% (n=77), residual dissection after prior type A repair in 39% (n=58), and chronic type B dissection in 9% (n=14). Operative outcomes included 9% (n=14) 30-day and 5% (n=8) in-hospital mortality, 5% (n=7) stroke, 2% (n=3) new dialysis, and 2% (n=3) permanent paraparesis/plegia. Median follow up was 30 [IQR 7-67] months. Overall survival was 77%, 54%, and 41% at one, five, and ten years, respectively, while aortic specific survival was 88%, 83%, and 81% at the same time points (Figure). One, five, and 10-year freedom from major re-intervention was 98%, 91%, and 89%, respectively. Institutional experience had a significant impact on both early and late outcomes: comparing the first (2005-2011) and second (2012-2021) halves of the series, 30-day mortality dropped from 15% to 3% (p=0.036) and stroke from 6% to 3% (p=0.640, Table). Improved operative outcomes were accompanied by improved late survival, including 85% and 71% overall survival at one and five years for patients undergoing surgery in the latter era (Table).
Conclusions:HAR is associated with excellent operative outcomes, as well as sustained protection from adverse aortic events as evidenced by high 10-year aorta-specific survival and freedom from reintervention. However, surgeon and institutional experience appear to play a major role in achieving these superior outcomes, with a 5-fold decrease in operative mortality and 2-fold decrease in stroke rate in the latter half of the series. These long-term results expand on prior mid-term data and continue to support use of HAR for properly selected patients with arch disease.
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