Outcomes following staged versus synchronous cervical debranching to optimize proximal landing zones for thoracic endovascular aortic repair of the aortic arch

Abstract

Objective: Cervical debranching was traditionally performed for occlusive disease of the proximal cervical branches of the aortic arch. However, as endovascular technology has evolved, cervical debranching is more commonly performed to optimize proximal landing zones for thoracic endovascular aortic repair (TEVAR). Cervical debranching and TEVAR can be performed in either a staged or synchronous fashion with little-to-no data regarding the optimal treatment strategy. Therefore, the purpose of this study was to evaluate outcomes of patients undergoing cervical debranching and TEVAR in a staged vs synchronous fashion.

Methods: This was a retrospective single-center review of patients undergoing cervical debranching to optimize proximal landing zones for TEVAR from 2010 to 2023. Patients were excluded if they had a salvage cervical debranching following an aortic intervention or had an open aortic repair following cervical debranching. Patients were stratified on whether the cervical debranching and TEVAR were staged or synchronous. Cervical debranching was defined as a bypass or transposition of the vessels of the aortic arch (including vertebral artery). The primary outcome was major adverse events (MAEs), which was a composite variable consisting any of the following: 30-day mortality, myocardial infarction, respiratory failure, cerebrovascular accident, hematoma/bleeding, complications, nerve injury, chyle leaks, and acute kidney injury.

Results: A total of 148 patients met study criteria, with 162 cervical debranching procedures performed. There were 112 staged (75.7%) and 36 synchronous (24.3%) patients. There were three patients (2.7%) in the staged cohort that were intended to be staged but did not undergo TEVAR due to complications of their cervical debranching procedure. Synchronous patients were more likely to have non-elective repairs (44.4% vs 18.8%; P = .004) and zone 0 TEVAR deployments (5.5% vs 0%; P = .042) than staged repairs. The overall rate of MAEs for the cohort was 35.8% (n = 53). There were no differences in MAEs between staged and synchronous patients (34.8% vs 38.9%; P = .692). Although not statistically significant, there were lower rates of myocardial infarctions (2.7% vs 8.3%; P = .155), respiratory complications (16.1% vs 30.6%; P = .089), cerebrovascular accidents (11.6% vs 22.2%; P = .167), and bleeding complications (10.7% vs 22.2%; P = .095) in the staged group. The rate of nerve injury for the total cohort was 5.4%, with no differences between the staged and synchronous cohorts (4.5% vs 8.3%; P = .403). The overall technical success rate for cervical debranching procedures was 99.4% (n = 161) with no differences between staged and synchronous procedures (99.1% vs 100%; P = .998). There were no differences in primary, primary-assisted, and secondary patency of the cervical debranching procedures over 5 years between staged and synchronous procedures.

Conclusions: Staged and synchronous cervical debranching and TEVAR had statistically similar perioperative outcomes despite synchronous procedures being performed more often in the non-elective setting. However, there were clinically relevant trends toward better outcomes with staging. Cervical debranching can be performed with a high technical success rate with excellent mid-term patency. Currently, both staged and synchronous strategies appear to be safe and should be tailored towards patients' clinical presentations.

Keywords: Aortic aneurysm; Aortic arch; Cervical debranching; Thoracic aorta; Thoracic endovascular aortic repair.