Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality

Abstract

OBJECTIVES The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30 day and 1 year mortality after total arch replacement for aortic aneurysm. METHODS This was an international two-center study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS The median age of patients was 65.4 years [IQR: 55.1, 71.1] and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year [81%, 95% CI: 78–85%] survival probability compared to 30 day [92%, 95% CI: 90–95%]. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke (HR: 2.54, 95% CI: [1.16–5.58]), renal failure (HR: 3.59 [1.78–7.25]), respiratory failure (HR: 3.65 [1.79–7.42]), and reoperation for bleeding (HR: 2.97 [1.36–6.46]) were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS There is increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short-term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.