Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm: what indicates a high-risk patient for arch repair in octogenarians?

OBJECTIVES: This study aimed to reveal the differences in intermediate outcomes between TAR and d-TEVAR in octogenarians and to identify risk factors for adverse events after aortic arch repair in octogenarians.

METHODS: We reviewed medical records of 125 patients aged > 80 years who underwent surgical intervention for aortic aneurysm between 2008 and 2016. Of these, 60 underwent conventional TAR (43 men; age, 82 ± 2.2 years) and 65 underwent d-TEVAR (49 men; age, 84 ± 3.4 years).

RESULTS: Freedom from all causes of mortality at 2 and 4 years was similar (80 and 66% in TAR, 80 and 51% in d-TEVAR, p = 0.17). Freedom from aortic death at 2 and 4 years was similar (88 and 88% in TAR, 87 and 76% in d-TEVAR, p = 0.86). Using Cox regression analysis, chronic obstructive pulmonary disease (COPD) [hazard ratio (HR), 6.0; p = 0.008], malignancy (HR, 8.8; p = 0.004), previous cardiac and thoracic aortic surgery (required median sternotomy) (HR, 65.9; p = 0.012), perioperative stroke (HR, 12.6; p = 0.012), and postoperative pneumonia (HR, 5.8; p = 0.026) were identified as independent positive predictors of overall postoperative mortality for TAR, whereas neurological dysfunction (HR, 3.0; p = 0.016) and perioperative stroke (HR, 12.1; p = 0.023) were identified for d-TEVAR.

CONCLUSIONS: TAR in octogenarians with COPD and/or malignancy showed higher mortality rates; d-TEVAR is more appropriate in these situations. The prevention of perioperative stroke, which is related with poor prognosis in both the groups, is critical.