Aortic arch surgery: the need for a step forward in risk assessment

Although many improvements have been made in recent decades, aortic surgery remains a challenging field that demands extensive experience and advanced technical skills to address complex scenarios [1]. Indeed, while on one hand, existing evidence indicates that larger aneurysms and older age are associated with an increased risk of adverse aortic events [2, 3] on the other hand surgery itself carries significant risks of major complications that could drastically compromise patients' quality of life. In this context, the ultimate goal of surgery is dual; to repair the diseased aorta and to reduce the risk of complications and mortality compared to the risks associated with the natural history of an untreated aneurysm. The study proposed by Rajesh et al. [4], spanning 2 international centres and encompassing 456 patients who underwent elective total aortic arch replacement between 2006 and 2020, aimed to elucidate the discrepancy between 30-day and 1-year mortality rates post-surgery. The primary focus was on discerning 1-year mortality rates, while a secondary analysis sought to identify variables linked to heightened mortality risks. Key findings unveiled a stark contrast between short-term and mid-term mortality rates, with a notable decline in survival probability observed at the 1-year mark. Postoperative complications, including stroke, renal failure, respiratory failure and reoperation for bleeding, emerged as pivotal factors contributing to increased mortality risks, particularly within the initial 4-month post-discharge period.