Aortic arch surgery in octogenarians: is it justified?

European Journal of Cardio-Thoracic Surgery 46 (2014) 672 677 doi:10.1093/ejcts/ezu056 Advance Access publication 28 February 2014 ORIGINAL ARTICLE a Aortic arch surgery in octogenarians: is it justified? Hiroshi Kurazumi a, Akihito Mikamo a, *, Tomoaki Kudo a, Ryo Suzuki a, Masaya Takahashi a, Bungo Shirasawa a, Nobuya Zempo b and Kimikazu Hamano a Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan b Division of Vascular Surgery, Yamaguchi Prefecture Grand Medical Center, Hofu, Yamaguchi, Japan * Corresponding author. Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan. Tel: +81-836-22-2261; fax: +81-36-22-2423; e-mail: mikamo@yamaguchi-u.ac.jp (A. Mikamo). Received 12 September 2013; received in revised form 31 December 2013; accepted 20 January 2014 Abstract OBJECTIVES: Elderly patients are sometimes denied aortic arch surgery because of the perception of poor outcomes and an unacceptable quality of life (QOL). In this study, we evaluated the early clinical outcomes, long-term survival and QOL following surgical treatment for aortic arch disease in octogenarian patients. METHODS: A total of 47 consecutive patients over the age of 80 years were referred to our institutions. Of these patients, 20 underwent surgical intervention (surgical group) and 27 were treated medically (medical group). Kaplan Meier survival analysis was performed between the two groups, and the results were compared with age-matched population data. The risk factors for mortality were determined using a Cox regression analysis. A QOL assessment was performed using the 36-item Short Form Health Survey. RESULTS: The patient characteristics at baseline were not significantly different between the two groups. In the surgical cases, conventional total aortic arch replacement was performed in 15 patients, debranched thoracic endovascular aortic repair (TEVAR) in 2 and chimney TEVAR in 3. Emergency procedures were performed in 3 patients. No hospital deaths occurred in the surgical groups. Reoperation for bleeding was required in 2 patients, and prolonged mechanical ventilation was required in 4 patients. The 5-year survival was 61.5% in the surgical group and 14.2% in the medical group (P = 0.02). Freedom from aorta-related death at 5 years was 92.3% in the surgical group and 32.3% in the medical group (P = 0.01). There were no differences in the 5-year survival between patients undergoing surgical intervention and the sex- and age-matched population (P = 0.80), whereas the 5-year survival was significantly lower in patients who received medical therapy relative to the sex- and age-matched population (P < 0.001). Medical therapy was the sole risk factor for mortality (hazard ratio: 3.16, P = 0.04). Among the survivors at mid-term, the quality-of-life measures were similar between those in the surgical group and those in the medical group. CONCLUSIONS: Surgical intervention for aortic arch disease in octogenarians can yield satisfactory early clinical outcomes and acceptable mid-term survival with adequate daily activity. This study indicates that among octogenarians, age alone should not disqualify a patient from receiving an aortic arch intervention. Keywords: Octogenarians Aortic arch disease Total arch replacement INTRODUCTION The progress and development of medical therapy have contributed to increasing lifespan all over the world, which has significantly increased the number of people over the age of 80 years [1]. With this aging of the population and the greater use of diagnostic modalities, such as computed tomography (CT), magnetic resonance imaging and echocardiography, the diagnosis of asymptomatic aortic aneurysm is becoming increasingly common. Elderly patients often present with additional comorbid conditions, and past reports have indicated that cardiac surgery in elderly patients is associated with significant operative mortality Presented at the Postgraduate Course of the 27th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Vienna, Austria, 6 October 2013. and morbidity, as well as prolonged in-hospital treatment [2 4]. Cardiovascular surgeons often hesitate to perform aortic arch surgery on elderly patients, assuming poor clinical outcomes, because thoracic aortic surgery is thought to be a more invasive procedure relative to other types of cardiac surgery. Consequently, elderly patients might be denied aortic arch surgery despite the risk of sudden death due to the rupture of aneurysm. During the last decade, progress in the perioperative management, advances in the operative technique and the development of less invasive procedures (e.g. thoracic endovascular aortic repair (TEVAR)) have encouraged surgeons to more frequently perform aortic arch surgery on elderly patients. The purpose of this study is to justify surgical intervention for octogenarians suffering from aortic arch disease. The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

H. Kurazumi et al. / European Journal of Cardio-Thoracic Surgery 673 PATIENTS AND METHODS All procedures were approved by the Institutional Review Board of Yamaguchi University Hospital, and the study was conducted in accordance with the Declaration of Helsinki. Patients Consecutive 49 octogenarians who were referred to our institution for the treatment of aortic arch disease from August 2003 to August 2012 were enrolled in this study. The inclusion criteria for aortic arch lesion were defined as aneurysm diameter 60 mm, saccular aneurysm or impending rupture/rupture of aneurysm. Only the patients who required surgical reconstruction of their arch vessels were enrolled in this study, and patients who did not need surgical reconstruction of their arch vessels were excluded from this study, i.e. those who suffered from a distal arch aneurysm. Octogenarians who appear clinically frail are excluded from this study. All patients were discussed at a joint meeting of cardiologists and cardiovascular surgeons regarding the indications for intervention for their aortic arch disease. The surgeon met with all patients, both in the medical group and in the surgical group, and the patients provided adequate informed consent for the choice of surgical intervention or medical therapy, and the decisionmaking for the treatment was done under the instruction of patients and their families. Two patients were denied the operation by surgeons, because one had severe dementia and the other suffered from lung cancer on terminal stage, and they were excluded from this study. A total of 20 patients chose surgical intervention as the treatment for their aortic arch disease (the surgical group) and 27 patients underwent medical therapy (the medical group). Details of trial enrolment are shown in Fig. 1. All 27 patients in the medical group independently chose medical therapy despite receiving a recommendation from the surgeons for surgical therapy. In the surgical group, patients who were deemed not suitable for an open operation with full cardiopulmonary bypass and circulatory arrest had a debranching TEVAR or a chimney TEVAR. In the medical group, patients were administered antihypertensive agents, i.e. beta-blockers, angiotensinconverting enzyme inhibitors, angiotensin receptor blockers or calcium blockers, according to the guidelines for the management of aortic aneurysm and aortic dissection patients [5]. Operative procedures Of the 20 patients in the surgical group, 15 received open conventional aortic repair with cardiopulmonary bypass (CPB). Open surgery was performed through a median sternotomy under general anaesthesia. An arterial cannula was directly inserted to the bilateral axillary artery, and bicaval venous drainage with ventricular venting was routinely performed. Cold-blood cardioplegia was administered antegrade via the aortic root with an ascending aortic clamp or coronary perfusion. After inducing hypothermic circulatory arrest (rectal temperature <25 C), antegrade selective cerebral perfusion (ASCP) was initiated. Open distal anastomosis was first performed during hypothermic lower body circulatory arrest (LBCA). The circumferential pledgeted mattress sutures were performed in addition to a running suture for deep distal aortic anastomosis and graft graft anastomosis to reinforce the distal anastomosis and to avoid surgical bleeding from it. A quadrifurcated Dacron arch graft was used to repair the aortic aneurysm. Circulation of the lower body was resumed from a branch of the arch graft. The three arch vessels were reconstructed individually, and the proximal aortic anastomosis was then performed. Five of the 20 patients received TEVAR using a debranching or chimney technique to reconstruct the arch vessels without CPB. Two patients received debranching TEVAR; 1 patient underwent a right subclavian artery to the left carotid artery bypass before TEVAR, and the other patient underwent an ascending aorta to the bilateral subclavian artery and right carotid artery bypass before TEVAR. The other 3 patients received chimney TEVAR; chimney graft was applied to the brachiocephalic artery, left carotid artery or left subclavian artery to restore upper body circulation. In all TEVAR procedures, a GORE TAG thoracic endoprosthesis device (W. L. Gore and Associates, Flagstaff, AZ, USA) was used to avoid thoracic aortic aneurysms. Assessment of early clinical outcomes Operative mortality was defined as any death occurring within 30 days of the operation or any death during hospital stay after the operation. The postoperative course was followed up in terms of ICU stay, postoperative hospital stay, neurological events, renal status, respiratory status, bleeding and deep sternal infection. Prolonged ventilation was identified as intubation time 24 h. Assessment of late clinical outcomes To assess the late clinical outcomes, we investigated the overall survival, freedom from an aorta-related death and freedom from an aortic event. The follow-up rate was 100%. Aortic events were identified as aortic rupture/dissection, sudden death and reoperation/reintervention for aortic disease. The follow-up data were collected by reviewing the hospital charts and telephone questionnaires. The mean follow-up period was 23.2 ± 22.6 months (median: 46.8 months). AORTIC SURGERY Figure 1: Trial enrolment. A total of 49 patients were enrolled between August 2003 and August 2013. Assessment of health-related quality of life The mid-term survivor patients of the present study completed the 36-item Short Form Health Survey (SF-36) to assess their health-related quality of life (HRQOL). This instrument is a generic health profile with eight scales measuring the following domains of

674 H. Kurazumi et al. / European Journal of Cardio-Thoracic Surgery health: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. These scales can be aggregated into the physical component summary (PCS) and mental component summary (MCS). The PCS is an overall assessment of physical health that includes functioning and evaluation of one s ability to perform physical tasks. The MCS is an overall measurement of mental health, consisting of an assessment of psychological distress and well-being, social and role functioning and overall vitality. Scoring of the SF-36 is standardized and norm-based, with a mean of 50 (10 standard deviation (SD)) for the PCS and MCS within the Japanese general population. A higher score suggests a better HRQOL. The HRQOL questionnaire was sent in August 2012. At that time, 28 patients had survived and 19 patients were already dead. The questionnaire was sent to all 28 surviving patients, and we received 16 answers (response rate 57.1%). The HRQOL was evaluated 31.7 ± 26.1 months after choosing a treatment. Statistical analysis Results of continuous data are expressed as the mean ± SD. For the continuous data, the differences were evaluated using the Student s t-test. For the categorical data, the differences were evaluated using the χ 2 and Fisher exact tests. Time-to-event analyses were performed using Kaplan Meier estimates and then compared between groups using the log-rank test. Independent predictors of overall survival were examined using Cox regression analysis. The multivariable models included covariates with a P-value of <0.10 in the univariate analyses. All statistical analyses, except analysis between the estimated survival curve and the predicted survival curve, were performed using the StatView software (version 5.0). Predicted survival was calculated from sex- and agematched Japanese populations based on the Japanese abridged life tables published by the Ministry of Health, Labour and Welfare in Japan (http://www.mhlw.go.jp/toukei/list/list54-57.html). Statistical analysis between the estimated survival curve and the predicted survival curve was performed using Greenwood analysis manually. RESULTS Patient population and operative data Patient clinical profiles are given in Table 1. In the surgical group, 3 patients received emergent operations due to ruptured or impending ruptured aneurysm, whereas the medical group did not include any emergent cases. Although the differences were not statistically significant, the surgical group included more urgent/emergent cases, and patients in the medical group were 2 years older than those in the surgical group. Operative procedures and intraoperative parameters are given in Table 2. In the surgical group, 15 of the 20 patients received conventional open aortic graft replacements using CPB. The other 5 patients received TEVAR-related procedures. Almost all patients in the medical group presented with asymptomatic aortic arch aneurysm, which was diagnosed by chance upon CT scan. Early operative outcomes Perioperative complications and in-hospital status in the surgical group are given in Table 3. No hospital deaths occurred in the surgical groups. The duration of ICU stay was 3.4 ± 3.2 days (median: 7, 25th percentile: 4, 75th percentile: 10), and that of the postoperative hospital stay was 20.3 ± 18.1 days (median: 46, 25th percentile: 24, 75th percentile: 68). One patient in the surgical group was transferred to another hospital for rehabilitation because the activity of daily life was severely affected due to perioperative muscle weakness. Stroke, myocardial infarction, newly required haemodialysis and deep sternum infection were not observed. Reoperation for bleeding was required for 2 patients. One was bleeding from the vasa vasorum of residual excluded aneurysmal wall, and the other was bleeding from the free wall of the left ventricular (LV) due to an injury by the venting tube, which was inserted in the vein to LV via the left upper pulmonary artery. Of the 20 patients, 4 required prolonged ventilation for >24 h, and 1 patient required a tracheotomy due to respiratory failure. One patient was transferred to another hospital for rehabilitation because of severely affected activities of daily life due to perioperative muscle weakness. The rate of return to preoperative social activities was 95% (19/20). Late clinical outcomes Overall survival was significantly higher in the surgical group. Five-year survival was 61.5% in the surgical group and 13.6% in the medical group (P = 0.02), which is shown in Fig. 2A. We observed 4 late deaths in the surgical group and 14 in the medical group. In the surgical group, 1 patient died from a rupture of a thoracoabdominal aortic aneurysm 11 months after the total aortic replacement. However, in the medical group, 10 patients died from ruptures of aortic aneurysms. In the surgical group, 1 patient died from pneumonia, 1 from cancer and 1 from pancreatitis. In the medical group, 2 patients died from pneumonia, 1 from heart failure and 1 from aging. In addition, the freedom from aorta-related death and aortic event at 5 years was significantly higher in the surgical group. As Table 1: Patient characteristics Patient characteristics and clinical profiles Surgical group (n = 20) Medical group (n = 27) P-value Age (years) 82.6 ± 2.5 84.5 ± 3.9 0.064 Female (%) 5 (25) 8 (30) 0.755 Aneurysm diameter (mm) 67.4 ± 17.4 62.4 ± 8.3 0.217 Saccular aneurysm (%) 4 (20) 4 (15) 0.707 Hypertension (%) 16 (80) 15 (56 0.121 Diabetes mellitus (%) 1 (5) 2 (7) >0.999 Dyslipidaemia (%) 4 (20) 5 (19) >0.999 Smoking history (%) 7 (35) 9 (33) >0.999 Coronary artery disease (%) 2 (10 5 (19) 0.905 Peripheral vascular disease (%) 3 (15) 5 (19) >0.999 CVD (%) 2 (10) 3 (11) >0.999 Renal dysfunction (%) 0 (0) 3 (11) 0.250 HD (%) 0 (0) 1 (4) >0.999 COPD (%) 2 (10) 3 (11) >0.999 Marfan syndrome (%) 0 (0) 0 (0) >0.999 Urgent/emergent (%) 3 (15) 0 (0 0.070 JapanSCORE (%) 11.9 ± 14.2 7.9 ± 5.7 0.184 Logistic EuroSCORE (%) 21.2 ± 11.8 20.0 ± 9.2 0.711 A P-value less than 0.05 was considered statistically significant. CVD: cerebrovascular disease; HD: haemodialysis; COPD: chronic obstructive pulmonary disease; EuroSCORE: European system for cardiac operative risk evaluation.

H. Kurazumi et al. / European Journal of Cardio-Thoracic Surgery 675 Table 2: Operative procedures performed in the surgical group and the intraoperative data Open conventional aortic repair (n = 15) TEVAR-related procedure (n = 5) Total arch replacement 14 Debranching TEVAR 2 Hemiarch replacement 1 Chimney TEVAR 3 Operation time (min) 610 ± 126 Operation time (min) 330 ± 148 Blood loss (g) 982 ± 663 Blood loss (g) 527 ± 451 CPB (min) 311 ± 69 Aorta clamp time (min) 228 ± 69 ASCP (min) 151 ± 54 LBCA (min) 111 ± 40 Lowest rectal temperature ( C) 22.0 ± 1.9 Concomitant AVR 3 Concomitant CABG 4 Proximal landing Zone 0 Zone 1 Zone 2 2 2 1 CPB: cardiopulmonary bypass; ASCP: antegrade selective cerebral perfusion; LBCA: lower body circulatory arrest; AVR: aortic valve replacement; CABG: coronary artery bypass grafting. Table 3: Postoperative early clinical outcomes Outcomes Surgical group (n = 20) Hospital mortality (%) 0 (0) Intensive care unit stay (days) 3.4 ± 3.2 Postoperative hospital stay (days) 20.3 ± 18.1 Stroke (%) 0 (0) Myocardial infarction (%) 0 (0) New requirement of haemodialysis (%) 0 (0) Prolonged ventilation (>24 h) (%) 4 (20) Tracheotomy (%) 1 (5) Bleeding requiring reoperation (%) 2 (10) Deep sternal infection (%) 0 (0) shown in Fig. 2B and C, freedom from aorta-related death and aortic events were 92.3 and 86.3% in the surgical group and 32.3 and 32.3% in the medical group, respectively. Five-year survival of the patients undergoing surgical intervention was similar to that of the sex- and age-matched Japanese population (P = 0.807). However, the 5-year survival was significantly lower in patients who received medical therapy relative to the sex- and agematched Japanese population (P < 0.001), as shown in Fig. 2D. Risk factor assessment for mortality We also analysed the risk factors for mortality using Cox s proportional hazard models, which is given in Table 4. The univariate analysis revealed two risk factors: medical therapy and renal dysfunction. In the multivariate analysis, medical therapy was the sole risk factor for mortality (hazard ratio: 3.169, 95% confidence interval (CI) 1.041 9.647, P = 0.042). Health-related quality of life assessments We assessed the HRQOL of the survivors of this study using the SF-36 questionnaire. HRQOL was evaluated at 31.7 ± 26.1 months after making the choice of which treatment to receive. None of the HRQOL scores were significantly different between the two groups. The PCS was 50.4 ± 13.8 in the surgical group and 41.9 ± 12.8 in the medical group (P = 0.311). The MCS was 52.0 ± 8.9 in the surgical group and 50.4 ± 14.2 in the medical group (P = 0.798). Both the physical and mental summarized scores were similar between the groups (Table 5). DISCUSSION The number of cardio and thoracic aortic surgical procedures in patients 80 years of age or older is increasing, as lifespan expands across the world. In past decades, investigators reported the clinical outcomes of cardiac surgery for elderly patients, with hospital mortality rates that ranged from 3.2 to 18.9%, which are higher than those for younger patients [2, 3, 6 8]. Prior studies have identified the elderly as an at-risk population during major cardiac operations. However, favourable surgical outcomes were recently reported even in nonagenarians [9, 10]. Abel et al. [11] reported clinical outcomes in octogenarians after cardiac surgery, concluding that age is not an independent risk factor for hospital mortality. Tang et al. reported the excellent surgical outcomes for acute type A aortic dissection in octogenarians (operative mortality rate: 0%), concluding that surgery should be offered for acute type A aortic dissection even in the elderly population [12]. In this study, we failed to observe any hospital mortality or fatal sequelae, and the majority of the patients returned home after thoracic aortic surgery. Although advanced age may be an independent risk factor for operative mortality, we think that the operation should still be performed if the patients will receive obvious benefits from the surgical treatments. The other concern regarding surgical treatment for elderly patients is the postoperative HRQOL. The HRQOL assessment after cardiac surgery in elderly patients has been addressed in a few studies, which have invariably reported favourable results with negative effects in only a small subset of studies [10]. Grady et al. [13] reported the transition of the HRQOL after isolated cardiac operations. They found that the physical and mental components of the SF-36 improved from baseline within 3 6 months postoperatively and remained stable for 3 years. Caceres et al. [10] reported that elderly patients undergoing cardiac surgery AORTIC SURGERY

676 H. Kurazumi et al. / European Journal of Cardio-Thoracic Surgery Figure 2: Estimated time to event curve predicted using the Kaplan Meier method in octogenarian patients undergoing surgical and medical therapy. Survival curves of the surgical group are represented by a red solid line, and those of the medical group are represented by a blue solid line. Predicted survival curves of the surgical group and medical group, which were calculated relative to a sex- and age-matched Japanese general population, are represented by a red dashed line and a blue dashed line, respectively. ES: estimated survival; PS: predicted survival. Table 4: Risk factor analysis for mortality Univariate Multivariate Hazard ratio (95% CI) P-value Hazard ratio (95% CI) P-value Age 1.132 (0.444 2.887) 0.795 Female gender 1.360 (0.516 3.588) 0.534 Aneurysm diameter 1.601 (0.557 4.601) 0.763 Saccular aneurysm 1.883 (0.618 5.738) 0.265 Hypertension 0.658 (0.256 1.688) 0.383 Diabetes mellitus 2.632 (0.328 21.126) 0.362 Smoking history 0.934 (0.354 2.464) 0.889 CAD 1.632 (0.473 5.634) 0.438 CVD 0.990 (0.990 3.421) 0.987 Renal dysfunction 21.494 (1.344 343.796) 0.030 14.648 (0.906 236.778) 0.058 COPD 1.070 (0.245 4.666) 0.928 Urgent/emergent 0.863 (0.194 3.848) 0.847 Medical therapy 3.360 (1.113 10.147) 0.031 3.169 (1.041 9.647) 0.042 CI: confidence interval; CAD: coronary artery disease; CVD: cerebrovascular disease; COPD: chronic obstructive pulmonary disease. are highly symptomatic and have severely limited preoperative HRQOL; consequently, by easing their cardiac symptoms, surgical treatment is thought to improve their HRQOL despite the higher operative risk. However, most patients with thoracic aortic aneurysm do not present any symptoms, suggesting that invasive therapy, such as total arch replacement, incurs the risk of severely affecting the postoperative activity of daily life compared with the preoperative state. We assessed the HRQOL using the SF-36 questionnaire at 31.7 ± 26.1 months after the choice was made regarding treatment. Although we were only able to evaluate the HRQOL in the survivors of this study, and the pretreated assessment of the HRQOL was lacking, the HRQOL scores were not significantly different between the surgical group and the medical group. As 1 patient in the surgical group was transferred to another hospital for rehabilitation due to severely affected activities of daily life resulting from perioperative muscle weakness, the rate of return to preoperative social activities was 95% (19/20) in this study. These results appear to indicate an acceptable outcome in terms of the postoperative HRQOL. In this study, 15 of 20 patients in the surgical group received open conventional aortic arch repair with CPB. Generally, total arch replacement is thought to be one of the most invasive thoracic aortic surgeries. Previous reports revealed that the early mortality following aortic arch surgery is 10.1 12.7% [14, 15]. However, the early outcome for thoracic aortic surgery has been greatly

H. Kurazumi et al. / European Journal of Cardio-Thoracic Surgery 677 Table 5: HRQOL scores among the survivors who completed the SF-36 questionnaire Quality-of-life score components Surgical group (n = 10) Medical group (n =6) P-value Physical functioning 42.3 ± 14.1 26.8 ± 6.7 0.061 Role-physical 44.6 ± 16.8 35.9 ± 16.8 0.397 Bodily pain 53.7 ± 9.6 51.9 ± 10.9 0.754 Social functioning 49.9 ± 11.3 46.7 ± 12.8 0.655 General health 50.8 ± 12.0 46.1 ± 5.6 0.482 perceptions Vitality 46.7 ± 15.8 42.4 ± 13.9 0.642 Role-emotional 50.9 ± 13.1 45.7 ± 9.6 0.487 Mental health 54.6 ± 6.2 48.0 ± 9.6 0.146 PCS 50.4 ± 13.8 41.9 ± 12.8 0.311 MCS 52.0 ± 8.9 50.4 ± 14.2 0.798 HRQOL: health-related quality of life; SF-36: 36-item Short Form Health Survey; PCS: physical component summary; MCS: mental component summary. improved in recent years [16 18]. Additionally, less invasive procedures, such as debranching TEVAR or chimney TEVAR, can also be indicated for aortic arch aneurysm, although this technique remains under development [19]. The progress of open repair and the introduction of less invasive procedures encourage surgeons to perform surgical intervention for aortic arch disease in high-risk patients. Indeed, predicted survival in the surgical group, calculated according to the logistic European system for cardiac operative risk evaluation, was 21.2 ± 11.8%, suggesting that surgical treatment was worthwhile for the high-risk patients. Further progress of aortic surgery will lead to the widespread application of surgical intervention for high-risk patients in the near future. In our series, the CPB, ASCP and LBCA times were longer than those observed in previous reports, although our operative results were satisfactory. Corvera and Fehrenbacher [20] reported excellent results with no mortality after extensive arch and thoracic aortic surgery that required 5 h of CPB in their selected cohort. We believe that a prolonged CPB due to problems with aortic anastomosis and perfusion may be associated with high postoperative mortality and morbidity. Prolonged CPB in the absence of procedural or perfusion problems might be of little consequence in itself. The durations of CPB and ASCP in our surgery were mainly dependent on the LBCA time. In our practice, reasons for the long LBCA duration might include circumferential pledgeted mattress sutures in addition to a running suture for the deep distal aortic anastomosis and graft graft anastomosis (stepwise method). We believe that the most important goal for thoracic aortic surgery is to avoid surgical bleeding after repair. This study has several limitations. It is a retrospective study from only two hospitals, and the number of patients enrolled was small because our hospital is not a high-volume centre. The renal dysfunction was only observed in the medically treated group; therefore, the hazard ratio may not extrapolate to the surgically treated group. The hazard ratio might be inaccurate because of the insufficient number of patients. Patients in the early phase of this study were not given the option to receive the TEVAR-related procedure because TEVAR devices had not yet become commercially available in our country. In conclusion, surgical intervention for aortic arch disease can yield satisfactory clinical outcomes and mid-term survival with adequate daily activity in octogenarians. This study indicates that age alone should not be a disqualifying factor for aortic arch intervention in octogenarian patients. Conflict of interest: none declared. REFERENCES [1] Salomon JA, Wang H, Freeman MK, Vos T, Flaxman AD, Lopez AD et al. 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