# Anatomy-driven strategies and mid-term outcomes of branched endovascular repair of the aortic arch: a single-center cohort study

## TL;DR

This study compares different endovascular repair techniques for aortic arch diseases and finds that age, not the number of branches repaired, most affects mid-term survival.

## Contribution

The study provides mid-term outcome comparisons of single- and double-branch TEVAR techniques and identifies age as a key mortality predictor.

## Key findings

- Single- and double-branch TEVAR showed no significant difference in mid-term mortality.
- Older age was an independent predictor of mortality, but branch count was not.
- All single-branch techniques had comparable mid-term survival.

## Abstract

Thoracic endovascular aortic repair (TEVAR) with branch reconstruction is an alternative to open surgery for aortic arch pathologies. However, mid-term data comparing different strategies are limited. This study aimed to evaluate the mid-term outcomes of single- and double-branch TEVAR and analyze the performance of different single-branch reconstruction techniques.

We retrospectively analyzed 198 consecutive patients who underwent TEVAR for aortic arch lesions with either single-branch (n = 169) or double-branch (n = 29) reconstruction at a single center between February 2015 and December 2023. The primary endpoint was the mid-term all-cause mortality. The secondary endpoints included technical success, perioperative safety, aorta-related complications, and reintervention rates. Kaplan-Meier survival analysis, multivariable Cox regression, and Restricted Mean Survival Time (RMST) analysis were performed. The influence of age was explored using Restricted Cubic Splines (RCS), modeling age continuously.

The overall technical success rate was 96.0%. The mean follow-up duration was 40.5 months. There was no significant difference in mid-term all-cause mortality between the single- and double-branch groups (Log-rank P = 0.710). Multivariable Cox regression identified older age as an independent predictor of mortality (HR 1.047 per year, 95% CI 1.012–1.084, P = 0.009) but not the number of branches reconstructed (P = 0.611). Among the single-branch techniques, RMST analysis confirmed no significant difference in mid-term survival (all pairwise P > 0.050). An inverse association between age and aorta-related complications was suggested (OR 0.957, 95% CI 0.923–0.993, P = 0.020), which most plausibly reflects selection bias and warrants confirmation in larger, multicenter studies.

In this single-center cohort study, single- and double-branch TEVAR yielded no statistically significant difference in mid-term survival. Age, and not the number of reconstructed branches, was the primary predictor of mortality. All single-branch techniques showed comparable mid-term survival, supporting an individualized, anatomy-driven approach. The observed inverse association between age and aorta-related complications highlights the critical role of patient selection in these complex procedures and warrants confirmation in larger, multicenter studies with standardized anatomical assessment and imaging follow-up.