Moving the Aortic Arch: Long Term Outcome for Extraanatomic Arch Reconstruction. An Analysis of 137 Procedures

R Clement Darling III, MD, Sean P. Roddy, MD, Manish Mehta, MD, Philip S.K. Paty, MD, Paul B. Kreienberg, MD, Benjamin B. Chang, MD, Kathleen J. Ozsvath, MD, Yaron Sternbach, MD and Dhiraj M. Shah, MD
Albany Medical College, Albany, NY

Purpose: With the FDA approval of thoracic endografts, extraanatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extraanatomic reconstruction of the carotid and subclavian vessels.
Methods: 137 procedures were performed for extraanatomic carotid and subclavian reconstruction. 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses and 30 were subclavian carotid reconstructions. 55 (40%) were male, 20 (15%) were diabetic, and 62 (46%) were current smokers. Mean age was 63 (range: 28 - 87). Indication for surgery was primarily for occlusive or embolic disease (97%). Prosthetic (PTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency.
Results: Of the 137 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%.
Conclusion: Extraanatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require “moving the arch” when performed for endovascular thoracic aortic aneurysm repair.