Supra-aortic interventions for endovascular exclusion of the entire aortic arch

Objective: Our aim was to analyze the outcomes of endovascular exclusion of the entire aortic arch (proximal landing in zone 0, distal landing in zone III or beyond, after Ishimaru) in which complete surgical debranching of the supra-aortic vessels (I), endovascular supra-aortic revascularization (chimney, fenestrated, or branched grafts) with partial surgical debranching (II), or total endovascular supra-aortic revascularization (III) was additionally performed. Methods: Publications describing endovascular repair of the aortic arch (2000-2016) were systematically searched and reviewed. Results: From a total of 53 relevant studies including 1853 patients, only 1021 patients undergoing 35 different total aortic arch procedures were found eligible for further evaluation and included in group I, II, or III (429, 190, and 402 patients, respectively). Overall early mortality was higher in group I vs groups II and III (P =.001; 1 - beta = 95.6%) but exceeded in group III (18.6%) and group II (14.0%) vs group I (8.0%; P =.044; 1 - beta = 57.4%) for diseases involving zone 0. Mortality was higher in all subgroups treated for zone 0 disease compared with corresponding subgroups treated for zone I to zone III disease. The incidence of cerebral ischemic events was increased in groups I and II vs group III (7.5% and 11% vs 1.7%; P =.0001) and correlated with early mortality (R-2 =.20; P =.033). The incidence of type II endoleaks and endovascular reintervention was similar between groups and correlated with each other (R-2 =.37; P =.004). Type Ia endoleak occurred more often in groups II and III than in group I (7.1% and 12.1% vs 5.8%; P =.023) and correlated with midterm mortality (R-2 =.53; P =.005). Retrograde type A dissection was low in all groups, whereas aneurysm growth was higher in group III (2.6%, 4.2%, 10.7%; P =.002), correlating with midterm mortality (R-2 =.311; P =.009). Surgical revision slightly correlated with surgical complications (R-2 =.18; P =.044) but not with mortality (R-2 =.10; P =.214). Conclusions: Because early mortality was significantly higher in patients receiving endovascular treatment for proximal aortic disease, endovascular-based approaches proved to be feasible alternatives to hybrid surgical procedures, especially when they were performed for aneurysms located in the distal aortic arch. Whereas cerebral ischemia accompanies both surgical and endovascular involvement of the supra-aortic vessels, endoleaks and aneurysm growth remain hallmarks of endovascular supra-aortic repair. Because surgical revision had no impact on mortality, complete surgical debranching may become the option of choice for patients with good life expectancy suffering from proximal aortic arch disease, whereas total endovascular procedures could be particularly advantageous in patients with short life expectancy and distal aortic arch disease.