Low Risk Open Arch Replacement To Establish A Proximal Landing Zone For TEVAR
Arjune Satya Dhanekula, MD, Sara Zettervall, MD, MPH, Scott DeRoo, MD, Matthew P. Sweet, MD, MS, Sherene Shalhub, MD, MPH, Christopher R. Burke, MD.
University of Washington, Seattle, WA, USA.
OBJECTIVES: Establishment of an adequate proximal landing zone for TEVAR in patients with aortic aneurysmal disease extending to the distal arch continues to pose a significant challenge. Open arch replacement is one solution: it can provide at least 3 cm of parallel Dacron for future TEAVR, and technical improvements have made open replacement more feasible and reproducible. However, limited data exists to assess contemporary rates of morbidity and mortality. Therefore, we aim to evaluate current outcomes for patients who underwent open aortic arch replacement.
METHODS:All patients who underwent open arch replacement at a single academic institution from January 2019 through December 2021 were assessed. Patients with acute type A dissection were excluded. Patient demographics and operative characteristics were evaluated, and the frequency of TEVAR was noted. Mortality and major morbidity were then assessed.
RESULTS:80 patients underwent open treatment of the aortic arch: 68 (85%) underwent zone 2 arch replacement, 7 (8.8%) zone 1 arch replacement, 4 (5.0%) total arch/zone 3 arch replacement, and 1 underwent a zone 0 replacement with debranching. Technical success was 100%. Average bypass time was 184 minutes, cross-clamp time was 125 minutes, and circulatory arrest time was 36 minutes. 44 patients (54%) required re-operative sternotomies, and 53 (61.3%) had a concomitant antegrade TEVAR (frozen elephant trunk). 30-day mortality was 2.7%. Spinal cord ischemia (SCI) occurred in 3.8%; however, all patients had complete recovery. Stroke occurred in 6.3% of patients. 4 patients (5.0%) required initiation of dialysis. 9 patients (11.3%) suffered vocal cord injury. Average ICU length of stay was 6.6 days, and average hospital length of stay was 16 days. 36 patients (45%) went on to have subsequent TEVAR extension.
CONCLUSIONS:
Open arch replacement can be performed with low morbidity and mortality, including in patients requiring re-do sternotomy. This safe and effective option for the treatment of aortic pathology provides a durable solution for patients without sufficient healthy parallel aorta for standard TEVAR. Cardiac and vascular surgeons should consider increased utilization of this approach when aortic pathology extends into the distal arch, or when an ectatic arch precludes a durable repair with TEVAR alone. 
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