Survival following acute type A aortic dissection: a multicenter study

Abstract

Background: While surgery is almost always indicated for acute type A aortic dissections (ATAADs), the extent of surgery is often debated, with some surgeons preferring a conservative option and others preferring a more radical option This study aims to assess the outcome after surgery for ATAAD and the prognostic impact of surgical strategy (with vs. without aortic arch replacement).

Methods: Data was gathered between 1 January 2005 and 31 December 2021 and retrospectively analyzed with multivariable logistic and Cox regression to ascertain risk factors and survival respectively.

Results: A total of 601 patients underwent type A aortic dissection repair across the recruiting centers with an operative mortality of 24.3% (146 patients) which was considerably linked with the clinical condition at presentation. In-hospital mortality was 23.1% for ascending and root replacement alone vs. 28.7% for arch involvement. Overall survival was 73.3% after the first year, 68.2% at 5 years, and 53.5% at 10 years. The median follow-up period was 2.5 years [interquartile range (IQR), 6.6 years]. Aortic arch replacements were more often carried out in younger patients and those without adverse clinical conditions, although outcomes for patients who underwent either surgical option were comparable throughout apart from a higher rate of cerebrovascular complications in the arch group (7.6% vs. 21.9%) (P=0.01).

Conclusions: Surgery for ATAAD still confers a relatively high mortality. In our study, there was a higher stroke rate associated with patients who underwent arch replacements at the time of dissection despite them being younger. The choice of repair with or without arch replacement should be individualized to the patient and the severity of clinical status presentation.

Keywords: Acute type A aortic dissection (ATAAD); aortic root and arch repair; ascending aorta replacement (AAR); total arch replacement procedure (TARP); valve-sparing aorta replacement.

Figure 1

The yearly volume of type A acute aortic dissection repairs. The curves are color-coded according to the aortic segment replaced. The y-axis shows the year, x-axis shows the number of cases.

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 can only be calculated if the survival has dropped <50% for the relative subgroup at the end of the study period.

Figure 3

Survival according to 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 can only be calculated if the survival has dropped <50% for the relative subgroup at the end.

Figure 4

Ascending aorta replacement with hemiarch techniques or root replacement, and more extensive repair lead to consistently more less operative mortality in urgent and emergency 1 patients.