Hemiarch replacement with concomitant antegrade stent grafting of the descending thoracic aorta versus total arch replacement for treatment of acute DeBakey I aortic dissection with arch tear

Abstract

For acute DeBakey I aortic dissection with arch tear, conventional distal reconstruction entails total arch replacement (TAR). Some surgeons at our institution have utilized an alternative reconstructive strategy-primary arch tear repair and transverse hemiarch reconstruction (THR) with concomitant antegrade thoracic endovascular aortic repair (TEVAR). We assessed early and mid-term outcomes comparing these two surgical strategies for arch tear management. A retrospective review of a prospectively maintained institutional aortic dissection database was carried out to compare early and mid-term outcomes for patients undergoing intervention for DeBakey I aortic dissection with arch tear. Hemiarch reconstruction with concomitant antegrade TEVAR was compared against conventional TAR. Arch tear at the origin of great vessels or greater curve was primarily repaired with interrupted sutures in TEVAR patients. From 2006 to 2013, 61 of 284 DeBakey I aortic dissection patients undergoing intervention for arch tear were retrospectively reviewed. Thirty-one patients had TAR (TAR group) and 30 patients had hemiarch + TEVAR (TEVAR group). Demographics and clinical presentation were similar. TEVAR group had more patients presenting in cardiogenic shock [3% (n = 1) vs 13% (n = 4), P = 0.2] and tamponade [10% (n = 3) vs 23% (n = 7), P = 0.2]. Intraoperatively, TEVAR group had lower cardiopulmonary bypass (239 ± 34 vs 313 ± 80 min, p0.001) and circulatory arrest (60 ± 15 vs 78 ± 45 min, P = 0.04) times. TAR group had higher in-hospital/30-day mortality [26% (n = 8) vs 13% (n = 4), P = 0.3], but stroke rates were similar [6% (n = 2) vs 7% (n = 2), P = 1]. One-year (80 ± 7.3 vs 71 ± 8.3%), 3-year (73 ± 8.3 vs 67 ± 8.6%) and 5-year (73 ± 8.3 vs 67 ± 8.6%) actuarial survival were improved in TEVAR group, although not significantly (log-rank, P = 0.56). TEVAR promoted increased false lumen thrombosis (43 vs 85%, P = 0.002). In treating DeBakey I aortic dissection with arch tear, hemiarch replacement with primary tear repair and concomitant TEVAR is a safe alternative to conventional TAR, with improved distal aortic remodelling.