Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection - analysis of the German Registry for Acute Aortic Dissection type A (GERAADA).

Abstract

Acute aortic dissection type A (AADA) remains a life threatening medical condition requiring emergent surgical therapy. Despite improvements in diagnostics, medical therapy and surgical technique, patient mortality and morbidity remains high (1). Standard treatment in the setting of AADA is the replacement of the ascending aorta with resection of the entry site, often in combination with an open distal anastomosis or hemiarch replacement, during a period of circulatory arrest with implementation of adjunct neuroprotective strategies such as cerebral perfusion and hypothermia (2). However, this treatment leaves the downstream aorta untouched and a residual dissection membrane remains in up to 70% of patients treated for AADA (3-7). The risk of progressive dilation with possible need for aortic re-intervention over the long-term remains (8-11). Due to this risk, a more aggressive approach with complete arch replacement and possible stenting of the proximal descending aorta via an antegrade approach has been adopted by a number of clinical institutions worldwide, to better obliterate the false lumen and thus reduce the incidence of late aortic complications (12-14). Other groups, however, have demonstrated an increased risk of mortality and morbidity when extensive surgery involving the aortic arch and the downstream aorta is implemented, thus recommending a more conservative approach to the treatment of AADA patients (15,16). The German Registry for Acute Aortic Dissection type A (GERAADA) is a web-based registry, initiated by the Working Group for Aortic Surgery and Interventional Vascular Surgery of the German Society for Thoracic and Cardiovascular Surgery. It is presently the largest registry worldwide documenting patients undergoing surgery for AADA (17-19). Analysis of GERAADA gave us the opportunity to compare the surgical outcomes of patients with DeBakey type I dissection treated by total arch replacement and those of hemiarch replacement with respect to early mortality, and onset of new neurological and malperfusion deficit.