P074. Can Less Be More?: Zone 2 Versus Zone 3 Arch Replacement
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
NewYork- Presbyterian/Columbia University Medical Center
NY
United States - Contact Me
Megan M. Chung is a resident in the Integrated Cardiothoracic Surgery Program at Columbia University. She has been conducting research on outcomes in aortic surgery with Hiroo Takayama, MD, PhD at NewYork-Presbyterian Columbia.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objectives: To address disease of the aortic arch or proximal descending aorta, total arch replacement (TAR or zone 3 arch replacement) remains a challenging procedure. With advances in endovascular therapy, Zone 2 Arch Replacement (Z2R) may be increasingly utilized to treat arch pathologies. Herein we compare outcomes between patients undergoing Z2R and TAR at our institution.
Methods: This is a retrospective study of patients undergoing Z2R and TAR from 2006 to 2023 at a single institution. Propensity score matching was used to compare in-hospital outcomes, long-term survival, and the cumulative incidence of aortic reintervention between groups. Long-term survival was analyzed by the method of Kaplan and Meier and compared using the log rank test. Competing risks regression and multivariable Fine-Gray analysis identified factors associated with distal aortic reintervention for disease progression.
Results: Of 218 patients, 46.3% (n=101) underwent Z2R and 53.7% (n=117) underwent TAR. There were no differences in baseline characteristics. Median [IQR] age was 63 [53, 70] years, 67.4% were male, and 13.3% (n=29) had a connective tissue disorder. The most common surgical indication was chronic dissection in 42.7% (n=93), followed by aneurysm (30.7%, n=67) and acute dissection (26.6%, n=58). Aortic cannulation was more common in Z2R, and axillary was more common in TAR (p<0.001); other intraoperative details including procedure times and blood products were similar. Propensity score matching created well-matched groups of 86 patients each. There were no differences in operative mortality (Z2R: n=3, 3.5%; TAR: n=7, 8.1%; p=0.33), stroke (Z2R: n=11, 12.8%; TAR: n=13, 15.1%, p=0.83) or any other postoperative complication rates. Survival at 10 years was 57.6% (95% CI 41.4%-80.1%) after Z2R and 71.6% (61.4%-83.4%) after TAR (log-rank p=0.91) (Figure 1A). The cumulative incidence of at least one distal aortic intervention, including staged and endovascular procedures, was 64.4% (45.2%-63.8%) after Z2R and 39.1% (24.9%-53.4%) after TAR at 10 years (p=0.03) (Figure 1B). When excluding staged procedures, the cumulative incidence of at least one distal aortic reintervention for disease progression was 22.2% (0%-57.1%) after Z2R and 17.8% (2.5%-33.1%) after TAR (p=0.41) (Figure 1C). In all patients, acute (HR 2.69, 95% CI 1.04-6.99; p=0.04) and chronic dissection (HR 3.53; 95% CI 1.38-9.05, p=0.009) were associated with distal aortic reinterventions due to disease progression. Staged aortic reinterventions were well-tolerated, particularly when endovascular with a 2.1% operative mortality rate (1/47) and 4.2% in-hospital complication rate (2/47).
Conclusion: Z2R resulted in comparable operative and 10-year survival when compared to TAR. Z2R had higher rates of distal reinterventions when including staged and endovascular procedures; staged reinterventions were well tolerated. There was no difference in long-term reintervention rate for distal disease progression when excluding staged procedures. For aortic arch disease, Z2R is a viable alternative to TAR.
Authors
Megan Chung (1), Patra Childress (1), Michael Salna (1), David Blitzer (1), Adedeji Adeniyi (1), Yanling Zhao (1), Dov Levine (1), Yu Hohri (1), Christian Pearsall (1), Thomas O'Donnell (1), Paul Kurlansky, MD (1), Virendra Patel (1), Hiroo Takayama (1)
Institutions
(1) Columbia University Irving Medical Center, New York, NY
Methods: This is a retrospective study of patients undergoing Z2R and TAR from 2006 to 2023 at a single institution. Propensity score matching was used to compare in-hospital outcomes, long-term survival, and the cumulative incidence of aortic reintervention between groups. Long-term survival was analyzed by the method of Kaplan and Meier and compared using the log rank test. Competing risks regression and multivariable Fine-Gray analysis identified factors associated with distal aortic reintervention for disease progression.
Results: Of 218 patients, 46.3% (n=101) underwent Z2R and 53.7% (n=117) underwent TAR. There were no differences in baseline characteristics. Median [IQR] age was 63 [53, 70] years, 67.4% were male, and 13.3% (n=29) had a connective tissue disorder. The most common surgical indication was chronic dissection in 42.7% (n=93), followed by aneurysm (30.7%, n=67) and acute dissection (26.6%, n=58). Aortic cannulation was more common in Z2R, and axillary was more common in TAR (p<0.001); other intraoperative details including procedure times and blood products were similar. Propensity score matching created well-matched groups of 86 patients each. There were no differences in operative mortality (Z2R: n=3, 3.5%; TAR: n=7, 8.1%; p=0.33), stroke (Z2R: n=11, 12.8%; TAR: n=13, 15.1%, p=0.83) or any other postoperative complication rates. Survival at 10 years was 57.6% (95% CI 41.4%-80.1%) after Z2R and 71.6% (61.4%-83.4%) after TAR (log-rank p=0.91) (Figure 1A). The cumulative incidence of at least one distal aortic intervention, including staged and endovascular procedures, was 64.4% (45.2%-63.8%) after Z2R and 39.1% (24.9%-53.4%) after TAR at 10 years (p=0.03) (Figure 1B). When excluding staged procedures, the cumulative incidence of at least one distal aortic reintervention for disease progression was 22.2% (0%-57.1%) after Z2R and 17.8% (2.5%-33.1%) after TAR (p=0.41) (Figure 1C). In all patients, acute (HR 2.69, 95% CI 1.04-6.99; p=0.04) and chronic dissection (HR 3.53; 95% CI 1.38-9.05, p=0.009) were associated with distal aortic reinterventions due to disease progression. Staged aortic reinterventions were well-tolerated, particularly when endovascular with a 2.1% operative mortality rate (1/47) and 4.2% in-hospital complication rate (2/47).
Conclusion: Z2R resulted in comparable operative and 10-year survival when compared to TAR. Z2R had higher rates of distal reinterventions when including staged and endovascular procedures; staged reinterventions were well tolerated. There was no difference in long-term reintervention rate for distal disease progression when excluding staged procedures. For aortic arch disease, Z2R is a viable alternative to TAR.
Authors
Megan Chung (1), Patra Childress (1), Michael Salna (1), David Blitzer (1), Adedeji Adeniyi (1), Yanling Zhao (1), Dov Levine (1), Yu Hohri (1), Christian Pearsall (1), Thomas O'Donnell (1), Paul Kurlansky, MD (1), Virendra Patel (1), Hiroo Takayama (1)
Institutions
(1) Columbia University Irving Medical Center, New York, NY
Presentation Duration
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