Total arch replacement for nondissecting aortic arch aneurysms: Risk stratification and long-term outcomes.

OBJECTIVES: This study evaluated 25-year outcomes and established risk stratification in patients undergoing total arch replacement with a 4-branched graft for nondissecting aortic arch aneurysm. METHODS: From October 1999 to December 2024, 554 patients were retrospectively analyzed. The primary end point was long-term overall survival. Secondary end points included 30-day mortality, hospital mortality, freedom from aorta-related death, and freedom from aortic events. Subgroup analyses stratified patients by age, renal function, their combination, and the number of risk factors for late mortality, and survival was compared across groups. RESULTS: Thirty-day and hospital mortality were 1.0% and 3.6%, respectively. At 10 years, overall survival, freedom from aorta-related death, and freedom from aortic events were 51.8 ± 2.8%, 89.5 ± 1.9%, and 70.5 ± 2.8%, respectively. Patients aged ≥85 years had significantly worse survival than younger groups. Those with estimated glomerular filtration rate (eGFR) ≥45 mL/min/1.73 m2 showed significantly better survival than those with eGFR <45. Multivariable analysis identified age ≥85 years, eGFR <45, chronic obstructive pulmonary disease, history of cerebrovascular disease, and peripheral artery disease as independent preoperative risk factors for late mortality. Long-term survival decreased significantly as the number of risk factors increased (P < .0001). CONCLUSIONS: Total arch replacement provides durable long-term outcomes with excellent freedom from aorta-related death. Optimal treatment should be individualized using a patient-centered approach determined on the basis of preoperative risk factors.