title: Aortic arch debranching and thoracic endovascular repair.
abstract: OBJECTIVE
  Currently, the best approach to the aortic arch remains unsupported by robust evidence. Most of the available data rely on small sample numbers, heterogeneous settings, and limited follow-up. The objective of this study was to evaluate early and midterm results of arch debranching and endovascular procedures.
  
  
  METHODS
  From 2005 through 2013, 104 consecutive patients underwent elective arch treatment with debranching and thoracic endovascular aortic repair. Rates of perioperative (30-day) mortality and neurological complications, and mortality, endoleak, supra-aortic vessel patency, and arch diameter changes at 5 years were analyzed.
  
  
  RESULTS
  Patients' mean age was 69.8 years, and 90 were males. Twenty arches were repaired for dissection. Nineteen patients required total debranching for diseases extended to zone 0. In 59, debranching and thoracic endovascular aortic repair procedures were staged. At 30 days, death, stroke, and spinal cord ischemia occurred in six, four, and three patients, respectively. Extension to ascending aorta (zone 0 landing) was the only multivariate independent predictor for perioperative mortality (odds ratio, 9.6; 95% confidence interval, 1.54-59.90; P = .015), but not for stroke. Four retrograde dissections, two fatal, occurred during the perioperative period. At 1, 3, and 5 years, Kaplan-Meier survival rates were 89.0%, 82.8%, and 70.9%, and freedom from persistent endoleak rates were 96.1%, 92.5%, and 88.3%, respectively. Over 5-year follow-up, 34 aneurysms shrank ≥ 5 mm, and four grew. Five reinterventions were required. Two supra-aortic vessel occlusions and no late aorta-related mortalities were recorded.
  
  
  CONCLUSIONS
  Despite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than one-third of the aneurysms' diameters decrease over 5 years as a measure of the long-term efficacy of treatment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required.
authors.affiliation: Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy. Electronic address: plderango@gmail.com.
authors.forename: Paola
authors.initials: P
authors.lastname: De Rango
authors.affiliation: Unit of Vascular and Endovascular Surgery, Department of Cardiosciences, Hospital S. Camillo - Forlanini, Rome, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Cao
authors.affiliation: Unit of Vascular and Endovascular Surgery, Department of Cardiosciences, Hospital S. Camillo - Forlanini, Rome, Italy.
authors.forename: Ciro
authors.initials: C
authors.lastname: Ferrer
authors.affiliation: Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy.
authors.forename: Gioele
authors.initials: G
authors.lastname: Simonte
authors.affiliation: Unit of Vascular and Endovascular Surgery, Department of Cardiosciences, Hospital S. Camillo - Forlanini, Rome, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Coscarella
authors.affiliation: Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Cieri
authors.affiliation: Unit of Vascular and Endovascular Surgery, Department of Cardiosciences, Hospital S. Camillo - Forlanini, Rome, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Pogany
authors.affiliation: Unit of Vascular and Endovascular Surgery, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Verzini
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome