Aortic arch disease poses significant challenges due to its anatomical complexity and the associated risks of treatment. Open repair has traditionally been the technique of choice despite being more invasive. Endovascular techniques have gained popularity as a minimally invasive option, although they present specific complications, such as endoleaks or residual aneurysm filling. This study aims to shed light on which strategy offers superior results.

The study design was retrospective and multicenter. It included 1052 patients treated between 2008 and 2019. Exclusions were made for cases with aortic root disease, acute and chronic type A dissections, annuloaortic ectasia, or extensive thoracic aneurysms distal to the tracheal carina. A propensity score matching method was applied to balance patient characteristics across both groups. Key comparisons included mortality rates, complications, and the need for additional treatments.

The results indicated that in-hospital mortality was similar between both techniques (6.8% for endovascular vs. 6.2% for open repair). However, long-term survival favored open repair; for instance, at five years, survival was 81.5% with open repair versus 71% with endovascular treatment. Patients treated with endovascular approaches were older on average (mean age 75 years). Consequently, this approach may be more suitable for patients who are not candidates for conventional surgery due to age, comorbidities, or frailty.

While pulmonary complications and transfusion requirements were more common in open repair, aortic-related complications were generally more frequent with endovascular techniques. This study underscores the utility of open repair as the reference technique due to its effectiveness in reducing long-term mortality. Nevertheless, it also highlights the role of endovascular/hybrid repair in high-risk patients or those with favorable anatomy.

The analysis of the study groups proved essential in understanding the outcomes. Within the endovascular group, various subgroups emerged based on the landing zone, ranging from zone 0 to zone 2 of the aortic arch. These subgroups included patients treated solely with branched or fenestrated endografts as well as those managed using hybrid approaches with debranching or bypass procedures in addition to endovascular stent placement. The variability within the endovascular group was greater than that of the open repair group, where surgical techniques remained more consistent across centers.

The chosen open repair technique predominantly utilized the elephant trunk method, either conventional or frozen. Additionally, the mean follow-up period was relatively short, averaging only five years, meaning the results could vary further if the observation period were extended.

COMMENTARY:

The literature offers limited evidence, emphasizing the importance of studies like the one analyzed, particularly due to the large cohort presented.

In comparing open and endovascular repair with landing zones 0/1, a higher in-hospital mortality rate was observed in the latter group (9.4% for endovascular vs. 6.4% for open repair). Open surgery was associated with a lower risk of both all-cause mortality and aorta-related mortality.

However, in the subgroup of endovascular repair with landing in zone 2, lower in-hospital mortality was noted (4.1% for endovascular vs. 7.8% for open repair), along with a lower incidence of stroke (8.8% for endovascular vs. 15.6% for open repair). No significant differences were observed during follow-up in terms of aorta-related mortality or additional procedures. These findings suggest that, with further supporting studies, a standardized approach to hybrid or purely endovascular repairs meeting these criteria might be warranted.

Additionally, ongoing advancements in endovascular surgery, including new fenestrated and branched devices for the aortic arch, raise questions about the viability of purely endovascular procedures. These techniques could potentially outperform hybrid approaches in patients for whom even debranching or bypass poses a high surgical risk. Treatment decisions should be centralized in high-volume aortic centers capable of ensuring quality and consistency. Successful outcomes have been reported in institutions with integrated aortic teams comprising cardiac and vascular surgeons, interventional cardiologists, and radiologists.

Although the analyzed study’s results are promising, it raises further questions regarding the broader standardization of these techniques. The research is novel in offering a detailed analysis of a large multicenter cohort. However, longer follow-up studies are required to confirm these conclusions and better adapt techniques to individual patient needs.

REFERENCE:

Sakamoto K, Shimamoto T, Esaki J, Komiya T, Ohno N, Nakayama S, et al. Comparison of open and hybrid endovascular repair for aortic arch: a multicenter study of 1052 adult patients. Eur J Cardiothorac Surg. 2024;66(5):ezae377. doi:10.1093/ejcts/ezae377.