Short- and long-term results of total arch replacement for acute type I aortic dissection in comparison to hemiarch replacement: a 10-year follow-up analysis

Abstract

Abstract Background Optimal management of the arch in cases of acute type-A aortic dissection (ATAAD) involving the aortic arch (DeBakey type I) is still controversial. Extended total arch replacement (TAR) to address re-entries increases the complexity of surgery and may be associated with worse short-term outcome. We aimed in this study to compare short- and long-term outcomes of TAR compared to hemiarch replacement. Methods We retrospectively analyzed data of patients operated for ATAAD in our center. The study was approved by the ethics committee. We used Student’s t-test or Mann-Whitney U test to compare continuous variables. We performed univariate Chi-square and multivariate logistic regression analysis. Log-rank test was used to compare long-term mortality between the two groups. In addition, hazard ratio (HR) with 95% confidence interval (CI) was reported. Results Between July 2007 and November 2021, 396 patients underwent surgery for ATAAD in our center. Among them, 326 (82%) presented with DeBakey type I dissection and were included in further analyses. TAR was performed in 103 (32%) patients, while hemiarch in 221 (68%) patients. Patients who received TAR were significantly younger (59.2±12.3 vs 64.0±13.5 years), had more frequently peripheral arterial disease (24% vs 15%, p=0.065), and presented more frequently preoperatively with neurological deficits (32% vs 18%, p=0.046). Patients in the TAR group received more aortic repair/replacement (29% vs 17%, p=0.018). New permanent postoperative neurological deficits (stroke or paraplegia) occurred in 10% of the TAR group and in 15% of the hemiarch group (p=0.463). Mortality at 30 days was higher in the TAR group but the difference was not statistically significant (27% vs 20%, p=0.198). In the multivariate analyses TAR was not an independent predictor for 30-day mortality (OR: 1.71, 0.91-3.19, p=0.092) or post operative neurological complications (OR: 0.66, 0.28-1.55, p=0.337). The estimated 10-year survival for patients with TAR was 56% compared to 63% for the hemiarch group (Logrank=0.450). In the multivariate Cox regression analysis, TAR was not an independent predictor for long-term survival (adjusted HR: 1.24, 0.79-1.94, p=0.348). Conclusions Total arch replacement was not an independent predictor for postoperative neurological complications, short-, or long-term mortality. Putting a potential surgeon bias aside, our results suggest that the fear of TAR may be overestimated.