Total Arch Versus Hemiarch Repair in Acute Type A Aortic Dissection: Systemic Review and Meta-Analysis of Comparative Studies.

Abstract

BackgroundWe aimed to compare the short and long-term outcomes of total arch replacement (TAR) versus hemiarch replacement (HAR) in the management of acute type A aortic dissection (ATAAD). MethodsWe searched the literature for studies directly comparing TAR to HAR in ATAAD. Hazard ratios were extracted from digitized Kaplan-Meier curves. ResultsA total of 6,526 patients were identified, of which 2,060 (32%) had received a TAR. Thirty-seven percent of patients were female and the mean age of the cohort was 59.8±11.8 years. TAR patients had a higher prevalence of preoperative malperfusion (34% vs. 26%). TAR group had higher odds of 30-days mortality (4404 patients; OR 1.79, 95% CI 1.29 to 2.49), renal failure requiring dialysis (3475 patients; OR 1.34, 95% CI 1.02 to 1.76), and a trend towards higher rates of stroke (3292 patients; OR 1.49, 95% CI 0.93 to 2.39). No significant differences were observed in terms of permanent spinal cord injury, visceral ischemia, or reoperation for bleeding. TAR group had a non-statistically significant increase in long-term mortality (4408 patients; HR 1.25, 95% CI 0.99 to 1.57), but trend towards improved freedom from long-term aortic reoperation (1359 patients; HR 0.53; 95% CI 0.18 to 1.59). In a subgroup analysis, the hazard ratio of long-term mortality favored TAR only in the subgroup of studies where the difference in malperfusion was greater than 10% between groups. ConclusionsTAR could be associated with improved freedom from long-term aortic reoperation but with potentially increased perioperative risks. We recommend a tailored surgical approach.