Short- and long-term results of total arch replacement: Comparison between island and debranching techniques

Objective: The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. Methods: The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. Results: The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P =.001), had undergone more previous cardiac operations (54.5% vs 27.4%, P <.001), and had more connective tissue disorder (20.3% vs 4.6%, P <.001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P <.001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P <.001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P =.018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P =.486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P =.897). Ten-year survival was 80% (78% vs 80.9%, log-rank P =.356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P =.495). Conclusions: Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.