The Modified Arch Landing Areas Nomenclature predicts proximal endograft failure after thoracic endovascular aortic repair

OBJECTIVES: Our goal was to assess the value of the Modified Arch Landing Areas Nomenclature (MALAN) for thoracic endovascular aortic repair (TEVAR), in which each landing area (LA) is identified by a proximal landing zone and the type of arch (e.g. 0/I), as predictors of postoperative proximal endograft performance. METHODS: A multicentre retrospective analysis was performed of patients treated with arch TEVAR (i.e. proximal landing zone 0-3) for various indications between 2007 and 2017. Patients were stratified by the MALAN classification into hostile LAs (i.e. 2/III and 3/III) and favourable LAs (i.e. 0/I-III, 1/I-III, 2/I-II and 3/I-II). Outcome criteria included composite proximal endograft failure (including type Ia endoleak, persistent false lumen perfusion at the level of the most proximal communication between the lumina in aortic dissections, endograft migration and retrograde dissection) and deaths from all causes. Competing risk analyses were performed. RESULTS: A total of 359 patients (hostile LAs 133; favourable LAs 226) were identified. The median age was 71.0 (62.0-77.0); 78.3% were men. Proximal endograft failure occurred in 28/133 patients (21.1%) in the hostile LA group and in 12/226 (5.3%) in the favourable LA group. On multivariate analysis, hostile LAs were independently associated with proximal endograft failure (P<0.0001). There was no other independent risk factor. Favourable LAs were associated with an increased mortality rate (P=0.006), which could be attributed to the proximal LA subgroup (i.e. 0/I-III and 1/I-III) (P<0.0001), in addition to age (P<0.0001). CONCLUSIONS: The MALAN classification identifies hostile proximal landing zones for TEVAR, namely 2/III and 3/III LAs, which are associated with dismal proximal endograft performance. The MALAN appears to be an intuitive and valuable tool to improve the preoperative decision-making process.