Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

J Thorac Cardiovasc Surg. 2021 Mar;161(3):873-884.e2. doi: 10.1016/j.jtcvs.2020.10.160. Epub 2020 Dec 10.

Abstract

Objective: The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.

Methods: From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).

Results: The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).

Conclusions: Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Keywords: acute aortic dissection; aortic arch management; arch branch vessel dissection.

Publication types

  • Research Support, N.I.H., Extramural
  • Webcast

MeSH terms

  • Acute Disease
  • Aged
  • Aorta, Thoracic / diagnostic imaging
  • Aorta, Thoracic / physiopathology
  • Aorta, Thoracic / surgery*
  • Aortic Aneurysm, Thoracic / diagnostic imaging
  • Aortic Aneurysm, Thoracic / mortality
  • Aortic Aneurysm, Thoracic / physiopathology
  • Aortic Aneurysm, Thoracic / surgery*
  • Aortic Dissection / diagnostic imaging
  • Aortic Dissection / mortality
  • Aortic Dissection / physiopathology
  • Aortic Dissection / surgery*
  • Blood Vessel Prosthesis Implantation* / adverse effects
  • Blood Vessel Prosthesis Implantation* / mortality
  • Cerebrovascular Circulation
  • Databases, Factual
  • Female
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications / mortality
  • Postoperative Complications / surgery
  • Reoperation
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome