Septuagenarians with acute type A aortic dissection undergoing extended aortic arch repair: a retrospective cohort study

Abstract

Background: Extended arch repair in elderly patients with acute type A aortic dissection (ATAAD) remains challenging for cardiac surgeons. Data on extended arch repair for ATAAD in septuagenarians are scarce.

Materials and methods: Consecutive adult patients with ATAAD undergoing extended arch repair from January 2015 to December 2021 were identified. According to age at presentation, 714 eligible patients were entered into either an elderly group (septuagenarians, n =65) or a control group (patients aged less than 70, n =649). Using propensity score matching, 60 pairs of patients were successfully established at a 1:1 ratio. In-hospital outcomes (operative death and major postoperative morbidity) and midterm outcomes (survival and aortic reintervention) were compared before and after matching.

Results: Operative death occurred in 64 patients (9.0%), including seven septuagenarians (10.8%) and 57 (8.8%) from the control group, without significant differences between groups before and after matching ( P =0.593 and 0.774, respectively). Major postoperative morbidity was observed in 298 patients (41.7%), including 29 (44.6%) in the elderly group and 269 (41.4%) in the control group ( P =0.622). Age-based grouping was not significantly associated with operative mortality or major postoperative morbidity in the crude, multivariable, and propensity score analyses. The 5-year cumulative survival and cumulative aortic reintervention rates in the elderly group were 83.5 and 4.6%, respectively, which were not statistically different from those in the control group before and after matching.

Conclusions: Extended arch repair may be safely and effectively performed in septuagenarians with ATAAD, with in-hospital and midterm outcomes comparable to those obtained in patients aged less than 70 years.

Figure 1

Total arch replacement with frozen elephant trunk procedure. (A) A catheter sheath containing a stent graft is inserted into the true lumen of the descending aorta in a bound, compressed state. (B) The stent graft is fixed in the true lumen of the descending thoracic aorta by the self-expanding stent. (C) The distal sutured end-to-end anastomosis is performed in zone 2, followed by reconstruction of the left carotid artery. (D) Proximal repair is performed, followed by reconstruction of the left subclavian artery, and finally, the innominate artery.

Figure 2

Flow chart for the selection of study population. ATAAD, acute type A aortic dissection.

Figure 3

Analysis of annual cases, the proportion of septuagenarians, and operative mortality. During the study period, the proportion of septuagenarians increased significantly over time (Cochran-Armitage test, P=0.002, Z=–2.568), and operative mortality in this study population decreased significantly over the years (Cochran-Armitage test, P=0.010, Z=3.110).

Figure 4

Associations between grouping and in-hospital outcomes. ^*The odds ratio from the univariate logistic regression model (the analysis included all 714 patients). ^**The odds ratio from the multivariable logistic regression model, with additional adjustment for the baseline variables with P < 0.10 in univariable analysis, including female sex, diabetes mellitus, coronary artery disease, chronic lung disease, previous cardiac surgery, previous stroke, limb malperfusion, and aortic sinus diameter (the analysis included all 714 patients). ^***The odds ratio from the multivariable logistic regression model with the same predefined covariates with matching according to propensity score (the analysis included 120 matched patients, including 60 septuagenarians and 60 with ages under 70). ^****The odds ratio from the multivariable logistic regression model with the same predefined covariates with stabilized inverse probability of treatment weighting according to propensity score (the analysis included all 714 patients). ^*****The odds ratio from the multivariable logistic regression model with additional adjustment for the propensity score (the analysis included all 714 patients).

Figure 5

Cumulative survival. (A) Kaplan–Meier analysis for cumulative survival in this study population. (B) Kaplan–Meier analysis for cumulative survival in the matched cohort.

Figure 6

Cumulative aortic reintervention rate. (A) Kaplan–Meier analysis of cumulative aortic reintervention rate in this study population. (B) Kaplan–Meier analysis of cumulative aortic reintervention rate in the matched cohort.