Real-world outcomes of the Gore thoracic branch endoprosthesis in aortic arch zones 0 to 2, with a zone 2 comparison to thoracic endovascular aortic repair with carotid-subclavian bypass.

Abstract

This study reports real-world outcomes of zone 0 and 1 thoracic branch endoprosthesis (TBE) after US Food and Drug Administration approval and compares zone 2 TBE with thoracic endovascular aortic repair (TEVAR) with left subclavian artery bypass (LSAB). We retrospectively reviewed consecutive patients undergoing zone 0 to 2 TBE at a single center. Additionally, we performed a sub-analysis comparison with zone 2 TEVAR + LSAB. Outcomes were assessed using multivariate regression and Cox proportional hazards models adjusting for intervention type, indication, urgency, prior aortic surgery, number of zones covered, and proximal device diameter. We included75 patients (median age, 69.5 years; 71.1% male) who underwent zone 0 to 2 TBE. Of these, 50 patients (66.7%) were performed for zone 2, 13.3% zone 1, and 20% zone 0, with 28% performed in an urgent/emergent fashion; 37.3% had prior ascending/arch repair and 13.3% prior TEVAR. Indications were 16% aneurysm, 66.7% dissection, and 17.3% penetrating aortic ulcer or intramural hematoma. Approximately one-half (51.4%) used the 12-mm portal configuration, and 48.6% used the 8-mm portal configuration. Proximal cuffs were needed in 14.7%. The 30-day outcomes showed a significantly higher incidence of permanent cerebrovascular accident in zone 0 (20%) and higher myocardial ischemia in zone 1 (20%) compared with the other zones. One-year outcomes showed an 80.4% overall survival rate, 1.3% type IA endoleak, 60% sac regression, 100% false lumen thrombosis at 1 year, and 100% branch patency. When focusing on the zone 2 TBE only (n = 50) and comparing on multivariate-adjusted outcomes with zone 2 TEVAR + LSAB performed at the same institution (n = 94), zone 2 TBE was associated with lower rates of postoperative acute kidney injury (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.04-0.99; P = .048) and myocardial ischemia (OR, 0.12; 95% CI, 0.01-0.98), shorter length of stay (β -1.7 days; 95% CI, -2.4 to -1.1; P < .001), reduced procedure time (β-54 minutes; 95% CI, -71 to -38; P = .001) and less contrast use (β-42 mL; 95% CI, -61 to -23 mL; P < .001), and greater 1-year sac regression (OR, 7.48; 95% CI, 1.43-12.27; P = .02). Adjusted Cox analysis showed TBE had greater freedom from reintervention (hazard ratio, 0.26; 95% CI, 0.6-0.92; P = .015). TBE in the real world is safe and effective for zone 0 to 2 repairs with low mid-term morbidity. Compared with TEVAR + LSAB, zone 2 TBE in particular results in shorter hospitalizations, fewer complications, and lower reintervention rates, supporting its use as the preferred strategy in suitable anatomy. Further comparative studies are needed for zones 0 and 1 treatment.