Extended-arch repair for acute type-A aortic dissection: perioperative and mid-term results

Abstract

OBJECTIVES: Extended-arch techniques offer the potential to comprehensively treat acute type-A aortic dissection (ATAAD), but add surgical complexity compared to the standard hemiarch technique. This study describes both perioperative and mid-term outcomes following the introduction of an extended-arch technique for ATAAD. METHODS: Ours is a retrospective single-centre observational study of 95 consecutive patients with ATAAD from 2011 to 2016. The decision to perform extended-arch or hemiarch repair was individualized based on clinical and radiological features. Extended-arch repair was defined as replacement of the ascending aorta and arch with reimplantation of head vessels with or without distal endovascular extension. Clinical follow-up was 100% complete. Cross-sectional double-oblique measurements were performed for aortic remodelling analysis. RESULTS: Extended-arch (n = 28) and hemiarch (n = 67) repair resulted in a in-hospital mortality of 10% (n = 3) and 10%, (n = 7), and permanent neurological deficit rate of 7% and 12%, respectively. At a mean imaging follow-up duration of 2.7 ± 1.5 years, false lumen thrombosis was achieved in 57% and 9% of patients undergoing extended-arch and hemiarch repair, respectively. Rate of growth in the proximal descending aorta was 0.7 ± 2.3 mm/year in the extended-arch group vs 2.7 ± 3.9 mm/year in the hemiarch group. At a mean clinical follow-up time of 3.0 ± 1.6 years, open surgical aortic reoperation was 0% in the extended-arch group and 22% in the hemiarch group. CONCLUSIONS: Extended-arch repair of ATAAD can be introduced in the acute setting without increase in perioperative mortality or morbidity. At mid-term follow-up, extended-arch for ATAAD improves aortic remodelling and reduces the need for open surgical reoperation.

Neuroanatomy and severity of stroke in patients with type A aortic dissection

“…20 Collectively, findings from our series demonstrate that(1) metrics like NIHSS and mRS, can serve as meaningful surrogates of clinical outcomes after dissection repair that should be reported and that (2) neurologists provide tangible expertise in the diagnosis and management of stroke.…”

“…Both repair strategies have been previously described and reflect current practice pattern variations in ATAAD. 19,20 Neuroprotective strategy was left to the operating surgeon and generally involved either DHCA to 18°C or selective antegrade cerebral perfusion (SACP), defined as less than two inflow lines to the brain at 20-25°C. De-airing techniques commonly consisted of postural changes, inflation of the lung, air removal via an LV or root vent, and/or direct aspiration of air.…”

Is limited aortic resection more justified in elderly patients with type A acute aortic dissection?-insights from single center experience

“…Residual patent false lumen is a well-known risk factor for progressive aortic dilatation and poor long-term outcomes following type A AAD surgery [ 16 , 23 , 24 ]. Fichadiya A and his colleagues [ 25 ] analyzed that false lumen thrombosis was achieved in 57 and 9% of patients undergoing extended-arch (total arch) and hemi-arch repair, respectively. Rate of growth in the proximal descending aorta was 0.7 ± 2.3 mm/year in the extended-arch group versus 2.7 ± 3.9 mm/year in the hemi-arch group.…”

Type A aortic dissection: involvement of carotid artery and impact on cerebral malperfusion

“…In a meta-analysis involving 9 studies and 1827 patients, Yan and colleagues 28 demonstrated that despite significantly lower early mortality with the hemiarch approach (pooled risk ratio 0.71, 95% confidence interval: 0.54-0.94, p ¼ 0.02), it related to significantly higher incidences of aortic reoperation and dilatation of the false lumen (pooled risk ratio 3.14, 95% confidence interval: 1.74 -5.67, p < 0.001), indicating that such an approach carries a 214% increase in risk of aortic events compared to total arch replacement. A 2019 study by Fichadiya and colleagues 29 further supported this by reporting that 22% (13/60) of their hemiarch patients, but none of the extended arch patients (0/28), required open aortic reoperation; in 85% (11/13), it was due to dilatation of the distal arch or proximal descending thoracic aorta. These findings altogether reflect the risk of the hemiarch approach in retaining an incompletely thrombosed or patent false lumen, causing susceptibility to continuous dilatation of the residual aorta upon pressurization, the risk of aortic aneurysms, and the subsequent need for aortic reinterventions.…”

“…No differences in outcomes whether aggressive approach pursued or not 1 had no arch procedure More extensive procedure better for younger and hemodynamically stable patients. Fichadiya 29 Study period: 2011-2016 Significantly lower early mortality risk in hemiarch group (pooled risk ratio 0.69, p ¼ 0.005). 95 consecutive ATAAD patients: Significantly higher incidence of postoperative aortic events, including aortic reoperation and significant false lumen dilatation (risk ratio 3.14, p < 0.001).…”