Is Total Arch Replacement Associated with an Increased Risk for 30-day Mortality after Surgery for Acute Type A Dissection

Objective: Surgical strategy for acute type A aortic dissection (AAAD) usually consists of reconstruction of the tear lesion in the part of the affected ascending aorta. But the region with regard to postsurgical complications is the remaining diseased tissue of the aortic arch and the descending part of the thoracic aorta. Therefore, the optimal strategy whether to replace the ascending aorta (AAR) or to replace the total aortic arch (TAAR) to avoid long-term complications and further redo-surgery is still under debate. In our study, the influence of TAAR on postoperative outcome in this special cohort was evaluated.

Method: We retrospectively analyzed 341 consecutive patients who underwent surgery for AAAD from 2001 until 2016. In 48 (14.1%) patients, TAAR and in 293 (85.1%) patients, only AAR was performed for emergent AAAD. Median log EuroSCORE was 25.2 (12.1; 41.7)% for AAR and 20.1 (11.7; 36.7)% for TAAR population (p = 0.19). Aortic root replacement was performed in 65 (19%) patients and Frozen Elephant trunk Implantation in 7 (2.1%) patients. Patients were retrospective analyzed with the primary end-point of 30-day mortality.

Results: Patients were significantly older (p = 0.04) in the AAR group. Median Operative time (266 (219;317) versus 380 (279;429)min), median cardiopulmonary-bypass time (CBP)(156(129;195)versus 249(181;304)min), median cross-clamp time(81(65;108) versus131(96;204)min) and median ischemic-time (31(25;41) versus81(49;115)min) and median stay on ICU (5(2;10) versus10(2;14)days) were significantly longer in the TAAR group (p < 0.001). CT-Scan controlled postoperative neurologic damage (p = 0.59) and incidence of dialysis (p = 1.0) did not differ between AAR and TAAR. The overall 30-day mortality-rate was 18.6% (n = 59), but did not reach significance between the two groups. 47 (17.4%) patients died in the AAR and 12 patients (25%) in the TAAR group (p = 0.23). Logistic regression analysis identified operative- and CBP time as independent risk factors for 30-day mortality.

Conclusion: The therapeutic goal in AAD surgery should be the complete restoration of the aorta to avoid long-term complications and re-operation. Though 30-day mortality and postoperative co-morbidity for TAAR is comparable to AAR in the treatment of AAD in our analysis, operative procedure is more complex. Therefore TAAR remains an individual patient-derived decision to face operative risk factors associated with worse outcome, especially in the older population.