Extent of Aortic Arch Repair in Acute Aortic Type A Dissection: How Far Should We Go?

Objectives: Total aortic arch replacement (TAR) with an elephant trunk represents the standard procedure for surgical treatment of acute type A aortic dissection (ATAAD) involving the distal aortic arch. Aim of the present study was to compare TAR to the hemiarch replacement (HAR) in terms of mortality, permanent neurological dysfunctions (PND) and aortic redo-surgery in a long-term follow-up.

Methods: A total of 114 patients with ATAAD treated between 12/2010 and 03/2020 in our unit presented a distal aortic arch dissection. The arch was inspected using hypothermic circulatory arrest (HCA) and selective cerebral perfusion (SCP). In 39 patients a TAR using an isle (59%) or singular anastomosis technique (41%) of the supra-aortic vessels was performed. In 13 of these patients (33%) the descending aorta was intraoperatively treated using an ET. In 66 ATAAD patients (75%) a HAR was performed, ranging from a simple replacement of the small inner curvature to the proximal two-thirds of the aortic arch.

Result: The groups were equal in terms of age, EuroSCORE, gender and comorbidities. A distal arch intimal tear was more often present in the TAR group (28 vs. 7%; p = 0.03). CPB (305 ± 99 vs. 240 ± 75 minutes; p = 0.001), cardiac arrest (187 ± 83 vs. 143 ± 59 minutes; p = 0.003) and SCP times (8 6 ± 35 vs. 44 ± 24 minutes; p = 0.001) were longer for TAR. Early mortality (30.8 vs. 17.3%; p = 0.151) and PND (25.6 vs. 13.3%; p = 0.074) were higher in the TAR group. The follow-up mortality was higher for TAR (1 year: 36 vs. 24%; 2 years: 41 vs. 25%, 5 years: 41 vs. 28%). A second aortic procedure was needed in three HA -patients (4%): one requested a redo-ascending procedure, one a conventional redo for TAR and another was treated electively with TEVAR. All redo and second-step procedures following HAR were successful. One TAR-patient (3%) received an emergent TEVAR because of a distal ET-anastomosis problem. He died two weeks later due to an infected aorto-tracheal fistula.

Conclusion: If the tissue structure permits, HAR should be primary considered in ATAAD, even if the distal arch is affected by dissection. A subsequent transposition of the supraaortic vessels followed by TEVAR is possible and safe.

Publication History

Article published online:
19 February 2021