Adult: Aorta
Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2023.04.012Get rights and content

Abstract

Objective

We compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention.

Methods

Nine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed.

Results

Mean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10).

Conclusions

Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.

Section snippets

Methods

Institutional review board (IRB) ethics approval was obtained as well as multicenter data sharing agreements for pooled analysis (IRB No. 119869; October 7, 2022). Individual patient consent was waived by IRB due to the retrospective nature of the study. Demographic, intraoperative, and perioperative outcome data were retrospectively entered into the Canadian Thoracic Aortic Collaborative database between 2002 and 2021, a database from which we have previously reported.18,19 Patients undergoing

Patient Characteristics

Mean age of the overall cohort was 66 ± 18 years, 30% (278 out of 929) were women, and age and sex were similar between groups. There was a signal toward increased connective tissue disorders (confirmed or suspected) (EA: n = 23 [9.9%] and HA: n = 42 [6%]; P = .125) among EA patients although this was not significant. Patients undergoing EA exhibited more hypertension (EA: n = 174 [74%] and HA: n = 466 [67%]; P = .037) and coronary artery disease (EA: n = 20 [8.5%] and HA: n = 93 [13%]; P

Discussion

Surgical experience and outcomes following ATAD repair have improved considerably in the past 2 decades.1,20, 21, 22, 23 EA procedures have gained traction in both the nonemergency and emergency settings with wide variability in techniques.10,11,13,24, 25, 26 Hesitancy to perform EA procedures in ATAD stems from concerns over technical complexity and increased perioperative risk, particularly with respect to stroke and spinal cord ischemia. In this study, one-quarter of patients had EA

Conclusions

We compare aggressive versus conservative approaches to aortic arch intervention among a large national cohort of patients with ATAD constituting more than 2 decades of experience. Extended arch interventions may be performed in ATAD with similar perioperative mortality and neurologic risk. Extended techniques should be approached with caution in the context of ATAD given the increased risk of perioperative complications. Nevertheless, extended repairs may improve resolution of malperfusion,

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    Dr Elbatarny is funded at the University of Toronto by the Vanier Graduate Research Award from the Canadian Institute of Health Research. Dr Ouzounian is partially funded at the University of Toronto through the Munk Chair in Advanced Therapeutics and the Antonio & Helga DeGasperis Chair in Clinical Trials and Outcomes Research. Dr Chu is supported at Western University through the Ray and Margaret Elliott Chair in Surgical Innovation. Dr Peterson is supported at the University of Toronto by the Walter and Maria Schroeder Foundation.

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