Surgical explantation for a rapid deployment valve: the 'shave-and-hook technique'.

An 80-year-old female patient underwent redo aortic valve replacement for haemolysis caused by moderate paravalvular leakage 1 year after a 21-mm Intuity Elite valve implantation. The elevatorium passed at the segment with paravalvular leakage. The frame was then bent inward using a hook and the peel around the sawing ring was shaved by an elevatorium. After explantation of the Intuity Elite valve, endoscopic examination showed no sign of annular or sub-annular damage. Conventional aortic valve replacement using a biological valve was performed. We introduce a safe alternative technique for explantation of a rapid deployed valve.

Type A aortic dissection with left coronary malperfusion.

Left coronary artery malperfusion is a fatal complication of acute type A aortic dissection. However, effective treatment strategies have not yet been established. Herein, we report two cases of left coronary artery malperfusion successfully treated with different preoperative catheter interventions, followed by a central aortic repair. Preoperative coronary intervention ensuring the blood flow to the left coronary artery might be essential if a coronary angiogram was performed prior to the diagnosis and treatment.

Open thoracoabdominal aortic aneurysm repair in a patient with myasthenia gravis.

Myasthenia gravis (MG) is an autoimmune neuromuscular junction disorder and rarely coexists with aortic aneurysms requiring open repair. A 66-year-old patient with MG underwent extended thoraco-abdominal aortic aneurysm (TAAA) repair 16 years after onset of type-B acute aortic dissection. At 62 years, the patient was diagnosed with MG (MGFA class IIIa) from positive anti-acetylcholine receptor antibody without thymoma. Preoperatively, MG was well-controlled by prednisolone, cyclosporin and pyridostigmine. Extent II TAAA repair was performed under general anaesthesia maintained by total intravenous anaesthesia. Transcranial motor-evoked potential and somatosensory-evoked potential were applied to monitor intraoperative spinal cord ischaemia and muscle weakness. Amplitudes of motor-evoked potential and somatosensory-evoked potential attenuated intraoperatively but normalized after reperfusion from the reconstructed tube graft. Perioperative steroid coverage was given against surgical stress. The patient was weaned from mechanical ventilatory support on postoperative day 7. No signs of spinal cord ischaemia or muscle weakness were seen.

The impact of vascularized tissue flap coverage on aortic graft infection with and without infected graft excision.

OBJECTIVES: Aortic graft infection (AGI) is a serious condition associated with a high mortality rate. However, optimal surgical options have not been identified. Therefore, we retrospectively reviewed AGI cases, including those in the thoracic and abdominal regions, with or without fistula formation, to investigate the various options for better outcomes. METHODS: We reviewed 50 patients who underwent surgical interventions for AGI out of 97 patients with arterial infective disease. The mean patient age was 67 ± 17 years. Fourteen patients (28%) had a fistula with the gastrointestinal tract or lung. A combination of graft excision and vascularized tissue flap coverage was performed in 25 cases (50%). Tissue flap alone, graft excision alone and cleansing alone were performed in 9 (18%), 10 (20%), and 6 cases (12%), respectively. RESULTS: Total in-hospital mortality rate was 32% (n = 16). In-hospital mortalities in patients with and without fistulas were 43% (6/14) and 28% (10/36), respectively (P = 0.33). Subgroup analysis among patients without fistula demonstrated that the in-hospital mortality rate of the patients with vascularized tissue flap (3/21, 14%) was significantly lower than that of the patients without vascularized tissue flap (7/14, 50%, P = 0.026). Overall 1- and 5-year survival rates were 66% and 46%, respectively. In multivariable analysis, an independent factor associated with in-hospital mortality was vascularized tissue flap (odds ratio 0.20, P = 0.024). CONCLUSIONS: Vascularized tissue flaps could provide better outcomes for AGI. Graft preservation with vascularized tissue flaps could be a useful option for AGI without fistula.

Open anatomical repair for primary coarctation of the aorta in adults.

OBJECTIVES: Although endovascular repair has become an alternative treatment for coarctation of the aorta (CoA) in adults, open repair provides concomitant repair of other cardiac complications, including post-stenotic aneurysm, ascending aortic aneurysm, and intracardiac diseases. We evaluated open anatomical repair for CoA repair in adults. METHODS: Eleven patients (6 men, age range 21-63 years) underwent primary CoA repair. Complicating conditions included post-stenotic aortic aneurysm in the descending aorta in 5 patients (45.5%) and ascending aortic aneurysm in 3 (27.3%). Two patients (18.2%) had a bicuspid aortic valve, and one (9.1%) had a quadricuspid aortic valve. Ventricular septal defect was detected in 1 patient (9.1%). Eight patients (72.7%) underwent descending aorta replacement through a left thoracotomy, comprising partial cardiopulmonary bypass in 4 and deep hypothermic circulatory arrest in 4. Of those, the left subclavian artery was reconstructed in 4 patients. The remaining 3 patients (27.3%) underwent total arch replacement, through a median sternotomy in 1 and using a combination of median sternotomy and thoracotomy in 2. RESULTS: No in-hospital mortality was observed. No spinal cord ischemia or neurological events were encountered, but 1 patient (9.1%) who underwent CoA repair via median sternotomy and thoracotomy required prolonged ventilatory support for more than 48 h. During the follow-up of 90 months (interquartile range 65-124 months), no patient died or required reintervention for the repaired segment. CONCLUSIONS: CoA in adults could be anatomically repaired with graft replacement both through the median sternotomy, the left thoracotomy, and the combination of both approaches, according to the complicated aortic or intracardiac lesions.

[Fight with Neurological Complication in Total Arch Replacement].

The surgical outcomes of total arch replacement in patients both with atherosclerotic aneurysm and Stanford type A acute aortic dissection have been improved. The development of brain protection contributed to excellent results in aortic arch surgery. Total arch replacement with four branched vascular graft using antegrade selective cerebral perfusion under mild hypothermia has been standardized in Japan, resulting in lower operative mortality and perioperative cerebral complications. However, severely atherosclerotic aorta with diffuse ulcers, "shaggy aorta", still has a potential high-risk for neurological deficits. Herein, the strategies to prevent neurological complications in total arch replacement, including preoperative images, cannulation/cerebral perfusion, temperature, monitoring systems are discussed. Finally, surgical approaches to shaggy aorta are reviewed. The combination of each step can lead to satisfactory surgical outcomes.

Severe intraluminal atheroma and iliac artery access affect spinal cord ischemia after thoracic endovascular aortic repair for degenerative descending aortic aneurysm.

OBJECTIVES: This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA). METHODS: The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI. RESULTS: SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001). CONCLUSION: Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI.

Surgical outcomes of acute type A aortic dissection in patients undergoing cardiopulmonary resuscitation.

OBJECTIVES: The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary resuscitation (CPR) were evaluated. METHODS: Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events. RESULTS: The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 [61.8%]), followed by coronary malperfusion (n = 12 [35.3%]) and acute aortic valve regurgitation (n = 3 [8.8%]). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P = .039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P = .045). Although the duration from onset or arrival to the operating room was similar (P = .35 and P = .49, respectively), overall duration of CPR was shorter in survivors (10 minutes [range, 7.5-16 minutes] vs 16.5 minutes [range, 15-20 minutes]; P = .044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P = .0040). CONCLUSIONS: CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy.

Preoperative renal function affects outcomes of surgery for aortic arch aneurysm in the elderly.

OBJECTIVES: This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function. METHODS: The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group. RESULTS: Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60 mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548). CONCLUSION: In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Efficacy of entry exclusion strategy for DeBakey type III retrograde Stanford type A acute aortic dissection.

OBJECTIVES: Resection of a primary entry tear is essential for the treatment of Stanford type A acute aortic dissection (AAAD). In DeBakey type III retrograde AAAD (DBIII-RAAAD), resection of the primary entry tear in the descending aorta is sometimes difficult. The frozen elephant trunk technique and thoracic endovascular aortic repair (TEVAR) enable the closure of the primary entry in the descending aorta. The aim of this study was to investigate the efficacy of resection or closure of primary entry, i.e. entry exclusion, in patients with DeBakey type III retrograde-AAAD. METHODS: The medical records of 654 patients with AAAD who underwent emergency surgery between January 2000 and March 2019 were retrospectively reviewed, and 80 eligible patients with DeBakey type III retrograde-AAAD were divided into the excluded (n = 50; age, 62 ± 12 years) and residual (n = 30; age, 66 ± 14 years) groups according to postoperative computed tomography angiographic data of the false lumen around the primary entry. The excluded group was defined as having a postoperative false lumen at the level of the elephant trunk or thrombosis of the endograft including primary entry. Patients with early false lumen enhancement around the elephant trunk or an unresected primary entry tear after isolated hemiarch replacement were included in the residual group. The early and long-term surgical outcomes were compared between the groups. RESULTS: The in-hospital mortality rate was 8% (6/80), with no significant difference observed between the excluded and the residual groups (10% and 7%, respectively; P > 0.99). Ninety-five percentage of the patients (20/21) achieved entry exclusion with stent grafts including the frozen elephant trunk procedure and TEVAR. Spinal cord ischaemia was not observed in either group. The cumulative overall survival at 5 years was comparable between the 2 groups (76% and 81% in the excluded and residual groups, respectively; P = 0.93). The 5-year freedom from distal aortic reoperation rate was significantly higher in the excluded group (97%) than in the residual group (97% vs 66%; P = 0.008). CONCLUSIONS: Not only resection but also closure using the entry exclusion approach for DeBakey type III retrograde-AAAD utilizing new technologies including the frozen elephant trunk technique and TEVAR might mitigate dissection-related reoperations.

Thoracic endovascular repair for retrograde acute type A aortic dissection as an alternative choice.

OBJECTIVE: The purpose of this study was to determine the clinical outcomes of thoracic endovascular aortic repair in 8 patients with acute type A aortic dissection with an entry tear in the descending aorta. SUBJECTS AND METHODS: From January 2016 to December 2018, eight patients (mean age 76 years; range 54-92 years) were treated by thoracic endovascular aortic repair due to high operative risk for conventional open repair. All patients had significant comorbidities, and two had critical organ malperfusion due to aortic dissection. Surgical outcomes were retrospectively reviewed. RESULTS: All procedures were technically successful with complete coverage of the entry tear. The proximal landing zone was Zone 1 in 2, Zone 2 in 1, Zone 3 in 4, and Zone 4 in 1 patient. Patients requiring Zone 1 and 2 thoracic endovascular aortic repair underwent aortic arch bypass simultaneously. Mean operation time was 132 min. There were no hospital deaths and no serious complications, including stroke and spinal cord ischemic injury. All patients had complete thrombosis and shrinkage of the false lumen in the ascending aorta before discharge. During up to 36-month follow-up (mean 20 ± 12 months), there were no adverse aortic events except one who died due to ischemic colitis 4 months after the procedure. CONCLUSION: Thoracic endovascular aortic repair could be a useful alternative surgical option for patients with retrograde acute type A aortic dissection with an entry in the descending aorta who are not suitable for conventional open surgery. Careful follow-up of such patients is mandatory.

Preoperative Neck Angulation is Associated with Aneurysm Sac Growth Due to Persistent Type Ia Endoleak after Endovascular Abdominal Aortic Aneurysm Repair.

Objective: This study aims to determine how instructions for use affect the occurrence of aneurysm sac growth and endoleaks after an endovascular aneurysm repair (EVAR). Materials and Methods: We reviewed 302 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013, and we were able to enroll 159 patients (74% men, mean age 78±7 years) with adequate data (mean follow-up; 48±20 months). Results: The angle of the proximal landing zone (LZ) (hazard ratio: 1.02, 95% confidence interval: 1.00-1.03, p=0.01) was recognized as an independent risk factor of sac growth (≥5 mm). The receiver operating characteristics curve (area under the curve: 0.72) showed a cutoff value of 47° of the minimum angle of the proximal LZ to predict sac growth. Freedom rates for persistent type Ia endoleaks were also found to be lower in the angulated group than those in the other groups (p=0.0095, log-rank). Conclusion: The angle of the proximal LZ was identified as an independent risk factor for sac growth post-EVAR. The incidence of persistent type Ia endoleaks was significantly higher in the angulated group.

Results of Surgical Repair of Hilar Renal Artery Aneurysm to Preserve Renal Blood Flow.

Objective: Surgical indications and procedures for hilar renal artery aneurysm (HRAA) are controversial in terms of invasiveness and feasibility. Catheter treatment is minimally invasive but leads to renal dysfunction due to renal infarction. This study aims to investigate the results of surgical repair of HRAA. Method: Fourteen patients (58.7±11.6 years old, 7 male) who underwent surgical repair of HRAA were retrospectively reviewed. Nine patients (64%) developed HRAA in the right renal artery, and the mean maximum aneurysmal diameter was 25.9±10.3 mm. HRAA was exposed via the extraperitoneal approach. HRAA was resected completely, and reconstruction of renal arteries was performed by direct closure in two, direct anastomosis in nine, and interposition of saphenous vein graft in three patients. Results: The average operation and renal ischemic times were 186±49 and 35±16 min, respectively. No operative death occurred, and postoperative renal function at the time of discharge had not deteriorated (creatinine, 0.74±0.15 mg/dl). During the follow-up periods (4.7±5.1 years), there was no death, no new introduction of hemodialysis, and no recurrence of renal artery aneurysm. Conclusion: Surgical repair of HRAA remains a valid option because of its operative safety, preservation of renal function, and long-term feasibility and patency.

Replacement of the descending thoracic aortic aneurysm with partial cardiopulmonary bypass in the era of endovascular repair.

OBJECTIVES: Although the advent of thoracic endovascular aortic repair (TEVAR) has provided an alternative treatment option for descending thoracic aortic aneurysm (DTAA), open repair still plays a crucial role in DTAA repair. The purpose of this study was to re-evaluate the operative and long-term outcomes of open repair with partial cardiopulmonary bypass, compared to the results of TEVAR with a proximal landing zone of 3 or 4. METHODS: Between 2007 and 2017, open repair was performed for 44 patients and TEVAR for 282 patients. Acute aortic dissection and open proximal anastomosis under circulatory arrest were excluded. Perioperative and long-term follow-up data were analyzed. RESULTS: In-hospital mortality rate (4.5% vs 3.2%, p = 0.42), and frequencies of spinal cord injury and neurological deficit showed no significant differences between the open repair and TEVAR groups (p = 0.41, 0.25, respectively). The propensity score-matched analysis showed similar cumulative survival (p = 0.23), but significantly higher reintervention rates for the repaired segment in the TEVAR group than in the open repair group (p = 0.0054). Twenty-two (7.8%) TEVAR patients required re-interventions for the repaired segment. Of those, 17 patients underwent additional TEVAR and 5 patients needed open conversion surgery with partial cardiopulmonary bypass. Reintervention rates for the repaired segment were significantly higher in the TEVAR group than in the open repair group (p = 0.012). CONCLUSIONS: Open repair DTAA using partial cardiopulmonary bypass showed operative outcomes comparable to TEVAR and lower reintervention rates, and thus remains an acceptable procedure for selected patients in this era of endovascular repair.

Does Endovascular Abdominal Aortic Repair Change Psoas Muscle Volume?

BACKGROUND: Because endovascular abdominal aortic repair (EVAR) lowers the lumbar arterial blood flow, we hypothesized that the volume of the psoas muscle decreases after surgery. When internal iliac artery (IIA) embolization is performed, the lumbar arterial blood flow further decreases; therefore, we also hypothesized that the decrease in the volume of the psoas muscle becomes more significant. This study was performed to assess the volume change in the psoas muscle after EVAR. METHODS: Fifty-three consecutive patients who underwent EVAR from January 2016 to December 2016 were included. The psoas muscle volume was measured by preoperative and postoperative computed tomography (CT). Postoperative CT scans were performed 6-12 months after EVAR. Axial CT images with a 2-mm slice thickness were used to measure the psoas muscle volume. Data were transferred to a 3-dimensional workstation, and the psoas muscle volume was measured. RESULTS: In the EVAR group, the volume of the psoas muscle decreased by an average of 5.8 mL (4.6%) from 114.8 ± 32.0 mL preoperatively to 109.0 ± 30.3 mL postoperatively (P < 0.01). There was a significant difference in the change in the psoas muscle volume between patients with and without IIA embolization (embolization group: preoperative 118.1 ± 31.0 mL, postoperative 107.5 ± 29.2 mL, mean volume change rate -8.8%; nonembolization group: preoperative 114.0 ± 32.3 mL, postoperative 109.4 ± 30.7 mL, mean volume change rate -3.6%; P < 0.05). CONCLUSIONS: The psoas muscle volume is reduced with EVAR. Moreover, when the IIA is embolized, the psoas muscle volume is further reduced.

Type IIIB endoleak from stent suture lines of a thoracic endograft.

We report a case of a patient with type IIIB endoleak after thoracic endovascular aortic repair that remained undetected by computed tomography and was first diagnosed during open conversion surgery. The aneurysm enlarged gradually from 60 to 78 mm without type I and type II endoleaks during 3 to 6 years after thoracic endovascular aortic repair. Type IIIB endoleaks from nitinol stent suture lines were detected, and the endograft was then explanted and replaced by a vascular graft.

Comparative study of the frozen elephant trunk and classical elephant trunk techniques to supplement total arch replacement for acute type A aortic dissection†.

OBJECTIVES: In patients with acute type A aortic dissection, the use of the frozen elephant trunk (FET) procedure with total arch replacement (TAR) has been indicated for emergency operations to obtain thrombosis of the distal false lumen (FL). However, data comparing the FET and the classical elephant trunk (CET) procedures, including the incidences of mortality, morbidity, spinal cord injury and aortic remodelling, have not yet been reported. The goal of this study was to compare the early outcomes of TAR with the FET and the CET procedures. METHODS: The past 7 years of medical records of 323 patients with type A aortic dissection who underwent emergency surgery were reviewed retrospectively, and 148 patients who underwent TAR were shortlisted for the study. First, the patients were divided into 2 groups, the CET group (n = 115; age 65 ± 12 years) and FET group (n = 33; 67 ± 11 years), to compare the early operative outcomes, including mortality and morbidity. Second, 86 patients (CET 56; FET 30) fulfilling the inclusive criteria (inserted length of elephant trunk ≥5 cm, involvement of dissection at the descending aorta and sufficient computed tomographic evaluation at ≥6 months after the operation) were compared to evaluate the patency and diameter of the FL at each segment of the downstream aorta. RESULTS: The in-hospital mortality rate was 8.1% (12/148), without significant differences between the 2 groups (CET 8.7% vs FET 6.1%; P = 1). No spinal cord ischaemia was encountered in either group. The incidence of postoperative FL patency at the level of the left lower pulmonary vein was 30% in the FET group, which was significantly lower than that in the preoperative state (73%) and in the CET group (77%). The downsizing of the aortic diameter at the distal edge of the CET or the FET, the left lower pulmonary vein and the coeliac axis was significant in the FET group 6 months after TAR. CONCLUSIONS: According to our initial experience, the FET compared to the CET procedure showed comparable early complications and an advantage concerning FL thrombosis and aortic remodelling at early follow-up examinations.

Surgical Outcome of Abdominal Aortic Aneurysm Replacement in Patients with Connective Tissue Disorders under 30 Years of Age.

Objectives: Abdominal aortic aneurysm (AAA) in patients <30 years old is relatively rare. We retrospectively analyzed patients <30 years who received an AAA replacement. Materials: Among 3,003 patients who received an AAA replacement during the last 40 years, 10 patients <30 years old were retrospectively reviewed. All patients suffered from a connective tissue disease: eight from Marfan syndrome and two from Loeys-Dietz syndrome. Five patients had a history of cardiovascular surgery. Aortic pathologies were a dissection type in eight patients and a non-dissection type in two. All patients received a graft replacement of infrarenal AAA, with a bifurcated graft in six patients and a straight graft in four. Results: Except for cases that were urgent and emergent, rapid aneurysm expansion was noted in all cases. Mean AAA diameter at surgery was 46.7±9.2 mm. No hospital mortality was recorded. Eight patients required 10 additional cardiovascular surgeries: two root replacements, two total arch replacements, two descending aortic replacements, and four thoracoabdominal replacements. Conclusion: AAA replacement in patients <30 years is safe. In younger patients with a connective tissue disease, AAA should be included in the routine medical check-up, and earlier surgical indication should be considered for its rapid expansion.

Is debranching thoracic endovascular aortic repair acceptable as the first choice for arch aneurysm in the elderly?

OBJECTIVES: This study aimed to assess differences in midterm outcomes between total arch replacement (TAR) and debranching thoracic endovascular aortic repair (d-TEVAR) and to evaluate the validity of d-TEVAR as the preferred treatment choice for aortic arch aneurysm in the elderly. METHODS: We reviewed the case histories of 86 patients who had undergone TAR (64 men; mean age 78 ± 2.9 years) and 121 patients who had undergone d-TEVAR (90 men; mean age 82 ± 4.5 years) between 2007 and 2017; of these patients, 50 from each group were matched based on propensity scores to adjust for differences in patient characteristics. RESULTS: Rates of freedom from all-cause mortality at 2 and 4 years were similar between the 2 groups (88% and 77% in the TAR group vs 82% and 64% in the d-TEVAR group, P = 0.11), but rates of freedom from reintervention at 2 and 4 years were significantly higher in the TAR group (100% and 96%) than in the d-TEVAR group (97% and 88%) (P = 0.004). Propensity score matching yielded similar survival rates of 88% and 85% for TAR vs 86% and 71% for d-TEVAR (P = 0.53) and comparable freedom from reintervention rates (100% and 97% in TAR, 98% and 90% in d-TEVAR, P = 0.16) at 2 and 4 years. Cox regression analysis identified previous cerebral infarction [hazard ratio (HR) 3.9; P = 0.005 in TAR/HR 3.1; P = 0.002 in d-TEVAR] as an independent positive predictor of overall mortality in both groups. CONCLUSIONS: Midterm outcomes after TAR and d-TEVAR were satisfactory and propensity score matching-based evaluation revealed no significant differences in outcomes, implying that d-TEVAR is an acceptable first-choice procedure for aortic arch aneurysm in patients older than 75 years.