Supra-aortic transposition for combined vascular and endovascular repair of aortic arch pathology.

Background: Supra-aortic transpositions in various extents followed by endovascular stent graft placement are now an established tool in the treatment of various pathologies affecting the aortic arch. Results remain to be determined.

Methods: From 1996 through 2007, 73 patients (median age, 71 years) presented with aortic arch pathology (atherosclerotic aneurysms, n = 42; type B dissections, n = 9; penetrating ulcers, n = 17; traumatic lesions, n = 2; aneurysms based on prior surgery for aortic coarctation, n = 3). Strategy for distal arch disease was subclavian-to-carotid transposition (n = 24) or autologous double-vessel transposition through upper hemisternotomy (n = 36). For entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n = 13). Endovascular stent graft placement was performed metachronously.

Results: In-hospital mortality was 6.8% (n = 5). Persistent early type I and III endoleak rate was 9.6%. Persistent late type I and III endoleak rate was 5.5%. Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. Mean follow-up is 37 months (range, 1 to 120). Early and late endoleak formation was independently predicted by the number of prostheses (early odds ratio [OR] 0.210, p = 0.0003; late OR 0.216, p = 0.012), whereas logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) reached borderline significance regarding late endoleaks (OR 2.1, p = 0.095). An earlier year of implantation reached borderline significance predicting survival (OR 1.9, p = 0.062). Furthermore, survival was independently predicted by higher logistic EuroSCORE levels (OR 1.8, p = 0.020). Interestingly, type of arch rerouting did not influence endoleak formation and survival (OR 0.9, p = 0.812).

Conclusions: Results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for the treatment of various pathology affecting the aortic arch are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Each type of arch rerouting, irrespective of extent, has turned out to be effective. Therefore, extended applications of these combined treatment strategies substantially augment the therapeutic options.