A Conservative Approach to Acute Type A Aortic Dissection: To Arch or Not To Arch?

Background: The primary objective of surgery for type A aortic dissection is to ensure immediate patient survival. Conservative operative treatment includes complete intimal tear resection and replacement of the ascending aorta, often combined with a hemiarch replacement. Current trends are directed toward more extensive arch procedures considering the fate of the distal aorta with potentially diseased tissue left in situ. The aim of this study is to demonstrate early outcomes and aortic arch reoperations during follow up after conservative aortic repair.

Method: In a single-center analysis, 250 patients were treated for acute type A aortic dissection between 2010 and 2020. Baseline characteristics, operative details and follow up reports, including regular computed tomography and aortic reinterventions, are presented. Follow-up events and survival are analyzed up to 12 years. The main focus was aortic redo and arch surgery, additional outcomes included early mortality and complications as well as survival during follow-up.

Results: The mean age of all patients was 63 ± 13 with 31% females (N = 78). Six percent of all patients had a confirmed bicuspid aortic valve (N = 16). The majority of cases were DeBakey type I dissections (71%, N = 179) with the entry located in the ascending aorta (70%, N = 174). The axillary artery was predominantly used for arterial bypass (71%, N = 178), utilizing unilateral antegrade cerebral perfusion in most cases (95%, N = 237). An aortic hemiarch replacement was performed in 67% of cases (N = 167). Only 9% of cases (N = 22) were treated by complete arch replacement. Early mortality (30 days or in-house) was 15.2% (N = 38). Five- and 10-year survival was 88.9 ± 3% and 80.8 ± 8%, respectively. Freedom from arch-related reoperations at 5 years was 81.4 ± 5%.

Conclusion: The results demonstrate that the primary objective of patient survival can be achieved with good results when applying a relatively conservative operative strategy. Within 5 years, up to 19% of patients required redo surgery involving complete arch replacement (after initial ascending or hemiarch surgery). Although long-term survival is satisfactory, a more aggressive approach to the arch may be advised. Further analyses are warranted to adequately assess the incidence of redo surgery after aggressive arch operations in comparison to the herein presented conservative approach.

Publication History

Article published online:
28 January 2023