Total aortic arch replacement versus proximal aortic repair for acute type a aortic dissection: A single-center 30-year experience

Objective: Optimal surgical management of the aortic arch for acute type A aortic dissection remains contentious. We assessed clinical outcomes after total arch replacement and proximal aortic repair (ascending aortic ± hemiarch replacement) for acute type A aortic dissection. Methods: All patients surgically treated for acute type A aortic dissection at our institution between 1992 and 2021 were included. Study end points included all-cause mortality, distal aortic reintervention, stroke, and malperfusion syndrome. Results: A total of 357 patients underwent surgery for acute type A aortic dissection; 76 (21.3%) received total arch replacement, and 281 (78.7%) received proximal aortic repair. The frequency of total arch replacement increased over time (P < .01). In-hospital mortality was higher for total arch replacement between 1992 and 2009 (39.2% vs 20.3%, P = .03), but became more comparable to proximal aortic repair from 2010 onward (16.7% vs 13.0%, P = .53). For total arch replacement and proximal aortic repair, 10-year cumulative survival was 64.3% (95% CI, 52.3-76.2) and 54.3% (95% CI, 47.6-61.0), respectively. After initial 30-day postoperative survival, long-term mortality risk appeared lower for total arch replacement (hazard ratio, 0.49, 95% CI, 0.23-1.07), although not statistically significant. No significant differences in distal aortic reinterventions were observed (hazard ratio, 1.38; 95% CI, 0.67-2.82). The incidence of in-hospital stroke (17.1% vs 17.1%, P = 1.00) and malperfusion syndrome (28.9% vs 28.2%, P = .90) was comparable between both groups. Conclusions: In-hospital mortality after acute type A aortic dissection decreased over time despite the implementation of an aggressive approach to the dissected aortic arch. Long-term survival appears favorable after total arch replacement, but remains contingent on early postoperative survival. The surgical approach should be based on the patient's clinical presentation, while considering total arch replacement in patients at risk of aortic arch reinterventions.