Sparce evidence suggests superiority of total arch replacement with branch-first technique (BF-TAR) and antegrade cerebral perfusion (ACP) over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement (T-TAR) versus BF-TAR.
We retrospectively reviewed 144 patients undergoing TAR from 1/2017-12/2021. Patients were dichotomized based on technique, either traditional TAR (T-TAR) or BF-TAR. Primary endpoints were 30-day mortality and adverse events. BF-TAR and T-TAR cohorts were compared using student t-tests and Chi-squared tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality.
68 patients (47.2%) underwent T-TAR and 76 (52.8%) underwent BF-TAR. The BF-TAR cohort had higher rates of chronic kidney disease (CKD), hypertension, atrial fibrillation, and previous myocardial infarction (p=0.04, 0.002, 0.035, 0.031 respectively). Majority of TARs (78, 55%) were performed for aneurysmal disease. Median ACP times were significantly shorter in the BF-TAR cohort (p=0.001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between TAR cohorts. BF-TAR group had significantly lower 30-day mortality compared to T-TAR group (4% vs 19%, p=0.004). After adjustment for CKD, non-elective status, ACP time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a BF-TAR was associated with a 93% reduced odds of 30-day mortality (OR 0.07, 95% CI 0.009-0.48, p=0.007).
We provide evidence that BF-TAR significantly reduces 30-day mortality compared to T-TAR.

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