title: Contemporary comparison of aortic arch repair by endovascular and open surgical reconstructions.
abstract: OBJECTIVE
  This study analyzed total aortic arch reconstruction in a contemporary comparison of current open and endovascular repair.
  
  
  METHODS
  Endovascular (group 1) and open arch procedures (group 2) performed during 2007 to 2013 were entered in a prospective database and retrospectively analyzed. Endovascular repair (proximal landing zones 0-1), with or without a hybrid adjunct, was selected for patients with a high comorbidity profile and fit anatomy. Operations involving coverage of left subclavian artery only (zone 2 proximal landing: n = 41) and open hemiarch replacement (n = 434) were excluded. Early and midterm mortality and major complications were assessed.
  
  
  RESULTS
  Overall, 100 (78 men; mean age, 68 years) consecutive procedures were analyzed: 29 patients in group 2 and 71 in group 1. Seven group 1 patients were treated with branched or chimney stent graft, and 64 with partial or total debranching and straight stent graft. The 29 patients in group 2 were younger (mean age, 61.9 vs 70.3; P = .005), more frequently females (48.2% vs 11.3; P < .001) with less cardiac (6.9% vs 38.2%; P = .001), hypertensive (58.5% vs 88.4%; P = .002), and peripheral artery (0% vs 16.2%; P = .031) disease. At 30 days, there were six deaths in group 1 and four in group 2 (8.5% vs 13.8%; odds ratio, 1.7; 95% confidence interval, 0.45-6.66; P = .47), and four strokes in group 1 and one in group 2 (odds ratio, 0.59; 95% confidence interval, 0.06-5.59; P = 1). Spinal cord ischemia occurred in two group 1 patients and in no group 2 patients. Three retrograde dissections (1 fatal) were detected in group 1. During a mean follow-up of 26.2 months, two type I endoleaks and three reinterventions were recorded in group 1 (all for persistent endoleak), and one reintervention was performed in group 2. According to Kaplan Meier estimates, survival at 4 years was 79.8% in group 1 and 69.8% in group 2 (P = .62), and freedom from late reintervention was 94.6% and 95.5%, respectively (P = .82).
  
  
  CONCLUSIONS
  Despite the older age and a higher comorbidity profile in patients with challenging aortic arch disease suitable and selected for endovascular arch repair, no significant differences were detected in perioperative and 4-year outcomes compared with the younger patients undergoing open arch total repair. An endovascular approach might also be a valid alternative to open surgery in average-risk patients with aortic arch diseases requiring 0 to 1 landing zones, when morphologically feasible. However, larger concurrent comparison and longer follow-up are needed to confirm this hypothesis.
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 Surgery, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Ciro
authors.initials: C
authors.lastname: Ferrer
authors.affiliation: Unit of Vascular Surgery, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Coscarella
authors.affiliation: Unit of Cardiac Surgery, Department of Cardiosciences, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Musumeci
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
authors.affiliation: Unit of Vascular Surgery, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Pogany
authors.affiliation: Unit of Cardiac Surgery, Department of Cardiosciences, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Montalto
authors.affiliation: Unit of Vascular Surgery, Hospital S. Camillo-Forlanini, Rome, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Cao
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011474:Prosthesis Design; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome