Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study

Abstract

Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.

Keywords: aortic arch repair; ascending aorta replacement; cerebrovascular perfusion; total arch replacement procedure; type A acute aortic dissection.

Figure 1

Title—Yearly volume of type A aortic dissection repairs. Yearly volume of type A aortic dissection repairs. The curves are color-coded according to the aortic segment replaced.

Figure 2

Survival according to the aortic segments replaced. Kaplan–Meier curves to assess survival after type A aortic dissection repair. The curves are color-coded according to the aortic segment replaced, and the relative shaded areas represent the 95% confidence interval. The censored patients are represented by the short vertical lines along the survival curves. The dotted black lines represent the estimated median survival, which could only be calculated if the survival had dropped by <50% for the relative subgroup at the end of the study period.

Figure 3

Survival according to the urgency status. Kaplan–Meier curves to assess survival after type A aortic dissection repair. The curves are color-coded according to the urgency status at presentation, and the relative shaded areas represent the 95% confidence interval. The censored patients are represented by the short vertical lines along the survival curves. The dotted black lines represent the estimated median survival, which could only be calculated if the survival had dropped <50% for the relative subgroup at the end.

Figure 4

Operative mortality during the study period. The line graph shows the operative mortality resulting from the sum of the percentages of cases over the years (2005–2021).