Impact of ascending aortic, hemiarch and arch repair on early and long-term outcomes in patients with Stanford A acute aortic dissection

Abstract

Background: Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD. Methods: From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed. Results: There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke (p = 0.034), need for reopening due to bleeding (p = 0.031) and in-hospital mortality (p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival (p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke (p = 0.023), reopening for bleeding (p = 0.010) and in-hospital mortality (p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke (p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified. Conclusions: With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.

Acute type A aortic dissection in‐hours versus out‐of‐hours: A systematic review and meta‐analysis

“…Total arch replacement, long cardiopulmonary bypass time, and aortic cross-clamp are associated with poorer postoperative outcomes. [28][29][30] Nonetheless, we found no significant differences in these variables that could potentially confound the outcomes in this study. Furthermore, we recognize the importance of effective relational coordination between members of the surgical team in executing a highly technical operation, and that poorer 30-day mortality rates in the OHH cohort could be attributed to the inconsistent rota during OOH shifts.…”

“…In contrast, we examined intraoperative variables that might influence the outcomes, including types of aortic replacement surgery, cardiopulmonary bypass time, and aortic cross‐clamp time. Total arch replacement, long cardiopulmonary bypass time, and aortic cross‐clamp are associated with poorer postoperative outcomes 28‐30 . Nonetheless, we found no significant differences in these variables that could potentially confound the outcomes in this study.…”

Early Results of a Novel Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With Distal Anastomosis Line Beyond Aortic Arch Zone Zero

“…Hemiarch repair is associated with a shorter CPB time and operation time. However, the need for a second operation can be possible (9,(19)(20)(21). While total arch replacement with the frozen elephant trunk allows for the distal extension of the stent and allows sealing of potential distal intima tears.…”

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall’s Operation for Acute Type A Aortic Dissection

“…Studies by Colli et al and Russo et al concluded that perioperative risk factors play an important role on patient outcomes [ 10 , 11 ] . Merkle et al concluded that the incidence of perioperative complications increased significantly with extent of surgical approach [ 12 ] . Many surgeons have adopted the strategy of limiting the complexity of surgery with the primary goal being improvement of early operative outcome rather than long-term postoperative consequences [ 7 , 13 ] .…”

“…Cerebral malperfusion remains the most important cause of cerebral injury intraoperatively [ 19 ] . Studies by Kim et al and Merkle et al have shown that total arch replacement can cause more CVA [ 12 , 20 ] .…”