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

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.

FIGURE 1.

A, The cumulative incidence of reoperation for distal aortic pathology in all patients, including the distal arch, descending thoracic, and thoracoabdominal aorta, after ATAAD repair in patients with and without ABVD without cerebral or upper-extremity MPS undergoing hemiarch replacement. Death was treated as a competing factor. The 8-year cumulative incidence of reoperation was significantly higher in the ABVD group (8-year: 19.2% vs 4.1%, P = .04). B, The cumulative incidence of reoperation for distal aortic pathology in patients with DeBakey I dissection only after ATAAD repair with hemiarch replacement. Death was treated as a competing factor. The 8-year cumulative incidence of reoperation was higher in the ABVD group (8 years: 19.2% vs 5.1%, P = .11). C, Cox proportional hazard regression determined ABVD (HR, 2.89; 95% CI, 1.01-8.27; P = .048) was an independent risk factor for reoperation for distal aortic pathology, including distal arch, descending thoracic, and thoracoabdominal aortas, after ATAAD repair with hemiarch replacement, whereas age, gender, and connective tissue disease were not risk factors. ABVD, Arch branch vessel dissection.

FIGURE 1.

A, The cumulative incidence of reoperation for distal aortic pathology in all patients, including the distal arch, descending thoracic, and thoracoabdominal aorta, after ATAAD repair in patients with and without ABVD without cerebral or upper-extremity MPS undergoing hemiarch replacement. Death was treated as a competing factor. The 8-year cumulative incidence of reoperation was significantly higher in the ABVD group (8-year: 19.2% vs 4.1%, P = .04). B, The cumulative incidence of reoperation for distal aortic pathology in patients with DeBakey I dissection only after ATAAD repair with hemiarch replacement. Death was treated as a competing factor. The 8-year cumulative incidence of reoperation was higher in the ABVD group (8 years: 19.2% vs 5.1%, P = .11). C, Cox proportional hazard regression determined ABVD (HR, 2.89; 95% CI, 1.01-8.27; P = .048) was an independent risk factor for reoperation for distal aortic pathology, including distal arch, descending thoracic, and thoracoabdominal aortas, after ATAAD repair with hemiarch replacement, whereas age, gender, and connective tissue disease were not risk factors. ABVD, Arch branch vessel dissection.

FIGURE 2.

Kaplan–Meier survival analysis of patients with and without ABVD without cerebral or upper-extremity MPS undergoing hemiarch replacement in ATAAD repair. The 8-year survival was similar between ABVD (76%, 95% CI, 63-85) and no ABVD (74%, 95% CI, 59-84, P = .30) groups.

FIGURE 3.

Hemiarch replacement is adequate in ATAAD repair in patients with ABVD without associated MPS but with an increased risk of reoperation on the aortic arch and distal aorta.

VIDEO 1.

Discussion of hemiarch repair in ATAAD repair in patients with ABVD without associated malperfusion. Video available at: https://www.jtcvs.org/article/S0022-5223(20)33297-9/fulltext.