• Brittany G Abt, Markian Bojko, Ramsey S Elsayed, Sukgu Han, Alan Wang, Isabelle Vu, Danielle Wishart, and Fernando Fleischman.
• Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif. Electronic address: Brittany.abt@med.usc.edu.
• J. Thorac. Cardiovasc. Surg. 2024 Jun 1; 167 (6): 20052012.e12005-2012.e1.

ObjectiveSparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement.MethodsWe retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality.ResultsA total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007).ConclusionsWe provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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