title: Open aortic arch replacement in high-risk patients: the gold standard.
abstract: OBJECTIVE
  Open total aortic arch replacement (TAR) in high-risk patients is considered by some to be associated with a prohibitively perioperative risk. Recent reports describe hybrid techniques to treat this group. We reviewed our outcomes of open surgery in a 'high-risk' group of patients.
  
  
  METHODS
  All patients who underwent open TAR between 2000 and 2013 were identified from our prospectively maintained database. Patients comparable with the ones who underwent hybrid repair in previous studies (logistic EuroSCORE between 20 and 60 without intervention on the aortic root or on the mitral/tricuspid valve) were selected for analysis.
  
  
  RESULTS
  Fifty-eight patients were identified. Median logistic EuroSCORE was 27.4 (range 20-57) and median age was 76 years (34.5% male). There were 11 resternotomies (18.9%) and 20 procedures were urgent/emergency (34.5%). Preoperative comorbidities included chronic obstructive pulmonary disease (31%), coronary artery disease (22.4%), peripheral vascular disease (48.3%), previous stroke (5.2%), previous myocardial infarction (3.4%) and left ventricular dysfunction (12%). Concomitant procedures included aortic valve replacement/resuspension (58.7%), coronary artery bypass grafting (22.4%), open descending aorta replacement (10.3%) and frozen elephant trunk (19%). Overall in-hospital mortality, permanent stroke and spinal cord injury rate were 6.9, 1.7 and 0%, respectively. There were no deaths or stroke in the elective group. One-year, 5-year and 10-year estimates of survival were 82.7, 70.0 and 37.8%, respectively.
  
  
  CONCLUSIONS
  Open TAR can be performed with low mortality and morbidity and excellent long-term results even in high-risk patients. Total endovascular repair may represent an option for patients not suitable for open surgery.
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK.
authors.forename: Mauro
authors.initials: M
authors.lastname: Iafrancesco
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK.
authors.forename: Aaron M
authors.initials: AM
authors.lastname: Ranasinghe
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK.
authors.forename: Vamsidhar
authors.initials: V
authors.lastname: Dronavalli
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK.
authors.forename: Donald J
authors.initials: DJ
authors.lastname: Adam
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK Vascular Surgery Department/Thoracic Aortic Multidisciplinary Team, Heart of England NHS Foundation Trust, Birmingham, UK.
authors.forename: Martin W
authors.initials: MW
authors.lastname: Claridge
authors.affiliation: Department of Interventional Radiology/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Riley
authors.affiliation: Department of Interventional Radiology/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: McCafferty
authors.affiliation: Department of Cardiothoracic Surgery/Thoracic Aortic Multidisciplinary Team, Queen Elizabeth University Hospital NHS Foundation Trust, Birmingham, UK jorge.mascaro@uhb.nhs.uk.
authors.forename: Jorge G
authors.initials: JG
authors.lastname: Mascaro
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012306:Risk; D016896:Treatment Outcome
keywords: Aortic arch; Hybrid repair; Total arch replacement