The Outcomes of Distal Aortic Reinterventions After Zone 2 Arch Replacement

Background: Zone 2 aortic arch replacement (Z2R) is an effective strategy for treating aortic pathology. However, the frequency and consequences of distal reinterventions (DRs) remain unknown. We evaluated the outcomes associated with planned distal reinterventions (PDRs) and unplanned distal reinterventions (UDRs) after Z2R. Methods: Patients requiring PDRs or UDRs after Z2R between 2007 and 2024 were reviewed. CTA/MRA scans were analyzed for aortic remodeling. The primary outcome was a composite of postoperative mortality, dialysis, paralysis and stroke (thoracoabdominal aortic aneurysm life-altering event; TALE) after DR. Secondary outcomes included cumulative reintervention burden, progression of false lumen thrombosis, and survival. Results: Among 111 Z2R patients followed for a median of 3.5 (1.5, 6.6) years, 55 (49.5%) required a total of 82 DRs: 25 with ≥1 UDR and 30 with only PDRs. PDRs were more often endovascular (93% vs. 72%, p = 0.02). TALE rates were similar between PDRs and UDRs (PDR: 9.3% vs. UDR: 12.8%, p = 0.88). Patients with UDRs had a greater cumulative reintervention burden (MCF 3, 95% CI 2–5 vs. MCF 1, 95% CI 1–1; p = 0.005). Neither PDRs nor UDRs were associated with differences in risk-adjusted mortality compared with no DR. Among dissection patients, PDR (63%) and UDR (100%) were associated with greater progression of false lumen thrombosis in the distal descending aorta compared to no DR (47%) (p = 0.04). Conclusions: Distal reinterventions after Zone 2 arch replacement are common and represent an important component of longitudinal aortic management. Patients undergoing exclusively planned distal reinterventions demonstrated a lower observed cumulative procedural burden than patients who experienced unplanned interventions. However, differences in baseline pathology, treatment pathways, and selection bias limit causal interpretation. Larger studies are needed to determine whether deliberate staging improves long-term outcomes.