Outcomes of Total-Arch Replacement in the Setting of Previous Aortic Surgery
D. G. Ergi1, N. Saran2, G. Bagameri1, H. V. Schaff1, J. Dearani1, J. Crestanello1, K. L.. Greason3, A. Todd1, A. Pochettino1 1Mayo Clinic, Rochester, Minnesota 2Mayo Clinic, Eau Claire, Wisconsin 3Mayo Medical Center, Rochester, Minnesota
Defne G. Ergi, MD: No financial relationships to disclose
Purpose: Operations involving arch reconstruction and head vessels reimplantation in the setting of repeat cardiac operation can be challenging with considerable risks, as such there are limited data(1,2). We investigated our experience with redo total-arch replacement and evaluated the early and long-term outcomes. Methods: From 1/1993 through 12/2022, a total of 529 patients with history of previous aortic surgery underwent aortic arch operations. We excluded patients who underwent endovascular repair (n=6) and hemiarch replacement (n=335). Final cohort consisted of 188 patients (median age, 61.8 years (InterQuartile Range [IQR] 52.1-69.7) with 136 males, 72.3%) who underwent redo total-arch replacement (TAR). Previous operations in this cohort included ascending aorta surgery in 176 (93.6 %) patients, root replacement in 68 (36.1%), hemiarch replacement in 47 (25.0%), descending aorta surgery in 11 (5.9%) and total-arch replacement in 4(2.1%). The most common indication for reoperation was dissecting aneurysm in 101 (53.7 %) patients, followed by aneurysmal degeneration in 75 (39.8%), arch dissection in 10 (5.3%) and pseudoaneurysm in 2 (1.0%). Early and late outcomes were analyzed. Results: Over the years there has been a significant increase in patients undergoing redo TAR, more so in the last decade (p < 0.001) (Figure 1). The most common concomitant procedure performed was frozen elephant trunk(FET) in 147(78.2%) patients followed by ascending aorta replacement in 68(36.1%) patients, and root replacement in 61(32.4%). All 3 head vessels were replaced in 143(76.1%) patients, while 2-vessel reimplantation was done in 37(19.7%) and single vessel reimplantation in 8(4.3%) patients. Deep hypothermia was utilized in 185(98.4%) patients. The combined initial retrograde (RCP) followed by selective antegrade cerebral perfusion (ACP) (n=129,68.6%) was the most common cerebral perfusion technique used, followed by ACP alone (n=45,23.9%), and RCP alone (n=9,4.7%). Early mortality was 8.0%(n=15). Incidence of postoperative stroke was 5.6%(n=10) with no difference between different cerebral perfusion strategies (p=0.171), although it was higher in the earlier years of the study (p < 0.001). A total of 60 deaths occurred over a median follow-up of 5.4 years (IQR:2.7-9.0). Survival at 5 and 10 years were 74.1% (95%CI,67.3%,81.5%) and 58.3%(95%CI,48.8%,69.7%), respectively (Figure 2). Multivariable analysis identified advancing age as the only significant predictor of long-term mortality (HR:1.05,95%CI:1.03-1.08), while concomitant FET (HR:1.11,95%CI:0.58-2.10), previous surgery type (HR:1.17,95%CI:0.59-2.30), and indication for reoperation (HR:1.06, 95%CI:0.62-1.82) were not. Conclusion: TAR can be performed safely with satisfactory early and late outcomes in patients with previous aortic surgery. While patients undergoing TAR have increased over time, incidence of stroke has decreased; likely due to improved perioperative management. Since age is a predictor of late mortality, an earlier diagnosis/intervention may be considered.
Identify the source of the funding for this research project: No funding was received for this project.
