Is total arch replacement associated with an increased risk after acute type A dissection?

Abstract

Background: The surgical strategy for acute type A aortic dissection (AADA) usually consists of reconstruction of the tear-lesion in the affected part of the ascending aorta. The optimal strategy either to replace the ascending aorta (AAR) or to replace the ascending aorta and the total aortic arch (TAAR) is still under debate. Our study compares the 30-day mortality between AAR and TAAR in AADA surgery. Methods: In this retrospective observational study, we analysed a total patient cohort of 339 patients who underwent surgery for AADA from January 2001 until December 2016. A propensity score-matched analysis between the AAR-and the TAAR-group with 43 patients for each subgroup was subsequently carried out.A multivariable analysis was performed to identify risk-factors for the 30-d-mortality. The 30-day mortality was defined as the primary end-point and long-term survival was the secondary endpoint.Results: In 292 (86.1%) patients AAR and in 47 (13.9%) patients TAAR was performed for emergent AADA. Patients were older (P=0.049) in the AAR group. The median log Euro-SCORE was 25.5 % (12.7; 41.7) for AAR and 19.7% (11.7; 32.2) for the TAAR patient cohort (P=0.12). Operative time, cardiopulmonary bypass-(CPB), cross-clamp-and ischemic time were significantly longer in the TAAR group (P<0.001). The overall 30-day mortality-rate was 17.7% (n=60) but was not significantly different between the two groups (P=0.27). Forty-nine (16.8%) patients died in the AAR and 11 patients (23.4%) in the TAAR group. After propensity-score matching, no difference in mortality was seen between the subgroups as well (P=0.44). Multivariable analysis identified the Euro-SCORE, long operation-time, postoperative dialysis and arrhythmia and administration of red blood cell concentrates as risk factors for 30-day mortality, but not for TAAR versus AAR. Conclusions: The therapeutic goal in AADA surgery should be the complete restoration of the aorta to avoid further long-term complications and re-operations. Though 30-day mortality and postoperative comorbidity for AAR are comparable to those in TAAR after treatment of AADA in our analysis, decisionmaking for the surgical strategy should weigh the operative risk of TAAR against the long-term outcome.

Branch-first approach in aortic dissection: Initial results

“…Although being devoid of a statistical significance, total arch replacement was associated with high mortality in a German retrospective analysis. [5] Arch replacement had 23.8% mortality and ascending aorta replacement with a 16.8% and the propensity matching showed a lack of significance. Salem et al [5] reported 20.9% need for new-onset dialysis and 30.2% stroke rate postoperatively.…”

“…[5] Arch replacement had 23.8% mortality and ascending aorta replacement with a 16.8% and the propensity matching showed a lack of significance. Salem et al [5] reported 20.9% need for new-onset dialysis and 30.2% stroke rate postoperatively. These rates are significantly higher than the rates of postoperative morbidity in our study.…”

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“…(666)(667)(668) El reemplazo híbrido del arco con prótesis combinadas (trompa de elefante congelada) puede considerarse en casos de mala perfusión visceral y en casos de aneurisma o rotura torácica descendente (como pueden ser las disecciones retrógradas y la rotura intimal primaria en subclavia anómala). (669,670) El reemplazo extenso del arco en forma profiláctica puede considerarse en pacientes jóvenes, Marfan u otra aortopatía genética, ya que la tasa de complicaciones o reintervenciones relacionadas con la aorta en el seguimiento son elevadas y esto facilitaría un tratamiento posterior. (671-673)…”

Preoperative Imaging Signs of Cerebral Malperfusion in Acute Type A Aortic Dissection: Influence on Outcomes and Prognostic Implications—A 20-Year Experience

“…The surgical technique and the protocol followed in our university hospital has been previously described [12]. Experienced senior surgeons performed all cases under general anesthesia with standard hemodynamic monitoring.…”