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A tailored strategy for repair of acute type A aortic dissection

Published:January 11, 2021DOI:https://doi.org/10.1016/j.jtcvs.2020.12.113

      Abstract

      Objective

      Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.

      Methods

      We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis.

      Results

      From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01).

      Conclusions

      A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AI (aortic insufficiency), ATAAD (acute type A aortic dissection), CI (confidence interval), CTD (connective tissue disease), CVG (composite valve graft), FET (frozen elephant trunk), IQR (interquartile range), MAE (major adverse events), MAPE (major adverse pulmonary events), OM (operative mortality), PND (permanent neurologic deficit), RCP (retrograde cerebral perfusion), SCI (spinal cord injury), TAR (total arch replacement), VSRR (valve-sparing root reimplantation)
      Figure thumbnail fx2
      Tailored approach to acute type A dissection repair leads to excellent long-term outcomes.
      A tailored conservative strategy for ATAAD using hemiarch and root-sparing techniques leads to favorable early outcomes with excellent long-term survival and freedom from late reoperation.
      Operative mortality for acute type A aortic dissection remains approximately 18% in large data sets. A tailored approach on the basis of conservative root-sparing and hemiarch techniques in higher-risk patients, and more extensive root replacement and total arch repair in lower-risk patients leads to consistently low operative mortality without compromising long-term durability.
      See Commentaries on pages 1708, 1709, and 1710.
      Acute type A aortic dissection (ATAAD) remains a highly lethal entity in the current era. Despite greater awareness and widespread accurate imaging leading to more rapid diagnosis and improved perioperative care, the operative mortality (OM) associated with repair of ATAAD is still disappointingly high. In centers reporting to large databases like the International Registry of Acute Aortic Dissection and the German Registry for Acute Aortic Dissection Type A, an OM of 18% to 20% is the norm with major neurologic injury, postoperative bleeding, and renal failure still complicating successful recovery in operative survivors.
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      In high-volume aortic centers of excellence, however, the OM for repair of complex ATAAD is approximately half that reported in the International Registry of Acute Aortic Dissection, German Registry for Acute Aortic Dissection Type A, and the Nordic Consortium for Acute Type A Aortic Dissection.
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      They also permit a more selective application of novel surgical techniques that might reduce the need for proximal and distal reoperations.
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      Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection.
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      Outcomes of valve-sparing root replacement in acute Type A aortic dissection.
      Nonetheless, although improved aortic remodeling is a worthy goal, the increase in neurologic complications associated with total arch replacement (TAR), concomitant antegrade stent grafting, and frozen elephant trunk (FET) must be considered when the immediate outcomes for such procedures are compared with those associated with a less complex ATAAD repair and a second downstream procedure.
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      • Martens A.
      Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.
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      David reimplantation with simultaneous total arch replacement and stented elephant trunk for acute type A aortic dissection.
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      • et al.
      Chronic type I and type III aortic dissections: a propensity analysis of outcomes after open distal repair.
      As a high-volume aortic center experienced in elective and urgent repair of both the proximal and distal aorta, we have concentrated our efforts in ATAAD repair on improving early results and reducing OM by using a conservative approach of root preservation and hemiarch reconstruction in most of our patients. Higher-risk patients with advanced age or more comorbidities had more conservative repairs to limit the surgical insult to these complicated patients. Total arch reconstruction and root replacement were reserved for specific subsets of patients that we believed would benefit from a more complex index operation without incurring additional immediate risk. We present our experience with this algorithm for repair of ATAAD and analysis of early morbidity and mortality as well as late survival and freedom from reoperation.

      Methods

      This study was approved by the institutional review board (1607017424), and need for individual patient consent was waived. We retrospectively reviewed our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from 1997 to 2019. This database is constantly updated and maintained by clinical information analysts. Data collection is validated regularly with internal and external control. Preoperative and postoperative variables are entered prospectively during in-hospital stay and follow-up data are entered on subsequent encounters. Follow-up data for survival and reintervention were updated by review of the electronic medical record, contacting referring physicians, or direct contact with patients and family. The primary end point was OM defined as 30-day and in-hospital mortality. Secondary end points were perioperative myocardial infarction (fourth universal definition), transient neurologic deficit (transient ischemic attack, confusion, delirium, agitation), permanent neurologic deficit (PND; stroke), spinal cord injury (SCI; paraplegia, paraparesis), respiratory failure, need for new dialysis, reexploration for bleeding, freedom from late reoperation, late survival, composite of major adverse events (MAE; OM, myocardial infarction, cerebrovascular accidents, need for dialysis, or need for tracheostomy), and composite of major adverse pulmonary events (MAPE; intubation >48 hours, pneumonia, reintubation, tracheostomy). Reintervention was defined as reoperation for the aortic valve, proximal aorta, or distal aorta.

      Operative Strategy

      All procedures were performed through a median sternotomy by a member of the aortic surgery group, consisting of the senior author and surgeons formally trained in the same operative techniques and decision-making process by the senior author. Central aortic true lumen cannulation using epi-aortic ultrasonography guidance and Seldinger technique was the preferred method of cannulation since 2014.
      • Shimura S.
      • Odagiri S.
      • Furuya H.
      • Okada K.
      • Ozawa K.
      • Nagase H.
      • et al.
      Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.
      Before this, and if central cannulation was not possible, femoral cannulation was used. Patients were placed on cardiopulmonary bypass and systemic cooling was initiated. The heart was arrested with antegrade cold potassium cardioplegia solution when ventricular fibrillation occurred or earlier if extensive root work was anticipated.
      The ascending aorta was resected down to the sinotubular junction. False lumen thrombus in the root was removed and the intima was reapproximated to the adventitia. Root anatomy and aortic valve leaflet quality were assessed. Patients having a root-sparing procedure had commissural resuspension using 4-0 pledgeted sutures above each commissure, even if the intimal separation extended down into the sinuses resulting in collapse of commissures. Biologic glue and felt neo-media were not used during reconstruction. Proximal anastomosis was performed using 4-0 or 5-0 polypropylene suture and this suture line was also used to affix the intima to the adventitia. Instead of felt neo-media, overlapping horizontal mattressed felt-pledgeted sutures were placed circumferentially around the anastomosis creating a continuous external ring of felt reinforcement. Patients with known connective tissue disease (CTD), dilated sinuses >4.5 cm in diameter on computed tomography scan or when intimal tears extended into the sinuses had aortic root replacement with a composite valve graft (CVG) or a valve-sparing root reimplantation (VSRR) procedure.
      • Gaudino M.
      • Lau C.
      • Munjal M.
      • Avgerinos D.
      • Girardi L.N.
      Contemporary outcomes of surgery for aortic root aneurysms: a propensity-matched comparison of valve-sparing and composite valve graft replacement.
      Those with normal sized roots but poor quality valve leaflets had separate aortic valve replacement.
      All arch repairs were performed using deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP) and target systemic temperature of 18°C, as previously described.
      • Lau C.
      • Gaudino M.
      • Iannacone E.M.
      • Gambardella I.
      • Munjal M.
      • Ohmes L.B.
      • et al.
      Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.
      Near-infrared spectroscopy was used to confirm symmetric cerebral cooling and warming (Somanetics, Troy, Mich). Before arresting the circulation the head was packed in ice and 500 mg of methohexital administered. RCP was delivered through the superior vena cava cannula at 150 to 300 mL/min at 14°C, keeping central venous pressure at 25 to 30 mm Hg. Arch reconstruction was performed with 1-branch and 4-branch Hemashield grafts (Maquet, Oakland, NJ) as indicated. A hemiarch technique was used in most of the patients, resecting all aortic tissue out to the left common carotid artery. TAR with island reimplantation of the great vessels was used if there was a large arch aneurysm or an extensive intimal tear in the arch. Arch debranching was performed in patients with CTD or significantly displaced great vessels. Antegrade cardiopulmonary bypass was resumed through the side-branch graft. RCP was maintained until full flow was reestablished to minimize the potential for air or debris embolization. When suture lines were confirmed to be hemostatic, systemic warming ensued, keeping a gradient of 10°C between the blood and core temperature. Remaining anastomoses were completed and reinforced as previously described. Cardiopulmonary bypass was discontinued at a core temperature of 35°C.

      Statistical Analysis

      Data were stored using Microsoft Access software (Microsoft Corp, Redmond, Wash) and analyzed using IBM SPSS Statistics version 24 (IBM Corp, Armonk, NY), R version 3.4.2 (R Foundation for Statistical Computing) and tableone, survminer, and cmprsk R packages. Data were compared using the χ2 test for categorical variables with frequency <5, Fisher exact test for categorical variables with frequency ≥5, and the Mann-Whitney test for continuous variables after checking for normality. Logistic and Cox multivariable regression analysis for in-hospital adverse events and long-term survival were computed to assess for significant predictors of such events. Goodness of fit was measured using Akaike information criterion for logistic regression and Akaike and Bayesian information criterion for Cox regression. Proportional hazards assumption was confirmed using Schoenfeld residuals (Figure E1). Multicollinearity was tested using variance inflation factor, including variables with variance inflation factor <2. There were <6% missing preoperative data and these were excluded from analysis. Long-term survival was assessed using the Kaplan–Meier method and compared using log rank test. All patients had at least 1 follow-up visit. Censoring of patients occurred at the time of their last follow-up. Competing risk of reoperation, with death as a competing risk, was calculated using the Fine and Gray method.
      • Fine J.P.
      • Gray R.J.
      A proportional hazards model for the subdistribution of a competing risk.

      Results

      A total of 343 patients underwent ATAAD repair from 1997 to 2019. All patients had at least 1 follow-up visit and median follow-up time was 67.5 months. The conservative group, consisting of 240 patients repaired with root-sparing and hemiarch techniques, was compared with the extensive group, consisting of 103 patients (58 root replacement/hemiarch, 36 total arch/root-sparing, and 9 combined root replacement and total arch). Separate analyses were performed to compare the root-sparing with the root replacement cohort and the hemiarch with the total arch cohort.
      The conservative group was more likely to be older (67 [interquartile range (IQR), 56-76] vs 60 [IQR, 47-69.5] years; P < .01) with more comorbidities such as hypertension (97.1% vs 88.3%; P = .01), previous myocardial infarction (21% vs 7.8%; P = .01), and renal dysfunction (35.8% vs 23.3%; P = .03). The extensive group was more likely to be male (55.8% vs 71.8%; P = .01) and have CTD (2.1% vs 12.6%; P < .01). The incidence of mild aortic insufficiency (AI) was similar between groups but the conservative group was more likely to have moderate AI (49.8% vs 26.7%; P < .01) and the extensive group had more severe AI (21.4% vs 53.5%; P < .01). Rates of malperfusion and rupture were similar (Table 1).
      Table 1Demographic and preoperative characteristics of patients with acute type A aortic dissection repaired with a conservative versus extensive approach
      Preoperative variableOverall (N = 343)Conservative (n = 240)Extensive (n = 103)P value
      Median age (IQR)65.00 (54.00-75.00)67.00 (56.00-76.00)60.00 (47.00-69.50)<.01
      Male sex208 (60.6)134 (55.8)74 (71.8).01
      Smoking207 (60.5)151 (63.2)56 (54.4).16
      HTN324 (94.5)233 (97.1)91 (88.3)<.01
      Previous MI58 (17.1)50 (21.0)8 (7.8)<.01
      COPD65 (19.0)51 (21.2)14 (13.6).13
      Diabetes47 (14.5)39 (17.0)8 (8.4).07
      Previous CVA60 (17.5)40 (16.7)20 (19.4).65
      Preoperative renal dysfunction110 (32.1)86 (35.8)24 (23.3).03
      Median ejection fraction (IQR)50.00 (45.00-50.00)50.00 (40.00-50.00)50.00 (45.00-50.00).28
      Connective tissue disease18 (5.2)5 (2.1)13 (12.6)<.01
      Shock61 (17.8)45 (18.8)16 (15.5).58
      Malperfusion97 (29.6)75 (32.3)22 (22.9).12
       Cerebral22 (6.7)18 (7.8)4 (4.2).33
       Coronary16 (4.9)14 (6.0)2 (2.1).16
       Extremity27 (8.2)19 (8.2)8 (8.3)1.00
       Intestinal6 (1.8)5 (2.2)1 (1.0).67
       Renal19 (5.8)13 (5.6)6 (6.2)1.00
       Spinal6 (1.8)5 (2.2)1 (1.0).67
       Multiple territories1 (0.3)1 (0.4)0 (0.0)1.00
      Rupture56 (16.5)37 (15.5)19 (18.6).59
      Degree of preoperative AI<.01
       Mild86 (26.1)66 (28.8)20 (19.8).11
       Moderate141 (42.7)114 (49.8)27 (26.7)<.01
       Severe103 (31.2)49 (21.4)54 (53.5)<.01
      Data are presented as n (%) except where otherwise noted. IQR, Interquartile range; HTN, hypertension; MI, myocardial infarction; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; AI, aortic insufficiency.
      In the arch analysis, 298 patients had hemiarch and 45 patients had TAR. The total arch group consisted of 17 zone 2 island reimplantation, 10 zone 3 island reimplantation, 10 zone 3 classic elephant trunk, and 8 zone 2 debranching. Hemiarch patients were more likely to have previous myocardial infarction (19.6% vs 0%; P = <.01). Total arch patients had more CTD (4.0% vs 13.3%; P = .02). In the root management analysis, 267 patients had root-sparing and 67 patients underwent root replacement. The root-sparing group had more hypertension (86.6% vs 96.4%; P = <.01), renal dysfunction (20.9% vs 34.8%; P = .04), and diabetes (3.1% vs 17.3%; P = .01). The root replacement group was younger (mean age 67 vs 55 years; P < .01) with more men (55.8% vs 80.6%; P < .01) and CTD (3.6% vs 11.9%; P = .02). The root replacement group had less mild or moderate AI and more severe AI (20.0% vs 76.9%; P < .01; Table E1).
      The conservative group had shorter cardiopulmonary bypass (135 [IQR, 124-153.5] vs 164 [IQR, 143-179.5] minutes; P < .01), cross-clamp (80 [IQR, 70.8-94] vs 115 [IQR, 94-139.5] minutes; P < .01), and circulatory arrest times (23 [IQR, 20-27.8] vs 24 [IQR, 20-41] minutes; P = .05; Table 2). The total arch group had longer cardiopulmonary bypass, cross-clamp, and circulatory arrest times. The root replacement group had longer cardiopulmonary bypass and cross-clamp time but shorter circulatory arrest times. Nine of the root replacements (13.4%) were David VSRR (Table E2).
      Table 2Intraoperative details of patients with acute type A aortic dissection repaired with a conservative versus extensive approach
      Intraoperative variableOverall (N = 343)Conservative (n = 240)Extensive (n = 103)P value
      CPB time, minutes143.00 (127.00-167.00)135.00 (124.00-153.50)164.00 (143.00-179.50)<.01
      Cardiac ischemia time, minutes88.00 (73.00-110.50)80.00 (70.75-94.00)115.00 (94.00-139.50)<.01
      RCP time, minutes23.00 (20.00-29.00)23.00 (20.00-27.00)23.00 (20.00-40.00).04
      CA time, minutes24.00 (20.00-29.00)23.00 (20.00-27.75)24.00 (20.00-41.00).05
      Site of cannulation.83
       Central true lumen130 (38.0)91 (38.1)39 (37.9)1
       Axillary2 (0.6)1 (0.4)1 (1.0).51
       Femoral210 (61.4)147 (61.5)63 (61.2)1
      Concomitant procedures
       CABG3 (0.9)3 (1.3)0 (0.0).61
       MVR2 (0.6)1 (0.4)1 (1.0)1
      Total arch replacement45 (13.1)0 (0.0)45 (43.7)<.01
      Aortic root replacement67 (19.5)0 (0.0)67 (65.0)<.01
      Data are presented as median (interquartile range) or n (%), except where otherwise noted. CPB, Cardiopulmonary bypass; RCP, retrograde cerebral perfusion; CA, circulatory arrest; CABG, coronary artery bypass grafting; MVR, mitral valve replacement.
      The incidence of myocardial infarction, stroke, tracheostomy, renal failure, and re-exploration for hemorrhage were not statistically different (Table 3). The incidence of PND was 3.8% versus 1% (P = .29) in the conservative and extensive groups, respectively. However, composites of MAE (15.1% vs 5.9%; P = .03) and MAPE (16.2% vs 7.8%; P = .05) were higher in the conservative group. Overall OM was 5.6% with no significant difference between the conservative and extensive cohorts (7.1% vs 2%; P = .1). In the root and arch analyses, there were no significant differences in postoperative outcomes between groups (Table E3). Overall survival in the conservative versus the extensive groups at 5 years was 76.9% versus 81.4% and at 10 years was 63.2% versus 66.2% (P = .55), respectively (Figure 1). The incidence of reoperation was significantly higher in the extensive group at 5 years (3.8% vs 12.8%) and 10 years (5.6% vs 21%; P = <.01; Figure 2). Most of the reoperations (92.6%) involved the distal aorta. Only 2 patients required proximal reoperation. One additional patient had reoperation for coronary bypass and 1 met criteria for a proximal valve reoperation but declined reoperative surgery.
      Table 3Postoperative outcomes of patients with acute type A aortic dissection repaired with a conservative versus extensive approach
      Postoperative outcomeOverall (N = 343)Conservative (n = 240)Extensive (n = 103)P value
      MAE42 (12.3)36 (15.1)6 (5.9).03
      MI5 (1.5)4 (1.7)1 (1.0)1
      Neurologic deficit17 (5.0)15 (6.2)2 (1.9).16
       Permanent neurologic deficit10 (2.9)9 (3.8)1 (1.0).29
       Temporary neurologic deficit7 (2.0)6 (2.5)1 (1.0).62
      MAPE47 (13.7)39 (16.2)8 (7.8).05
      Tracheostomy16 (4.7)14 (5.8)2 (1.9).2
      GI complication14 (4.1)11 (4.6)3 (2.9).68
      Renal dysfunction
       ATN14 (4.1)12 (5.0)2 (1.9).31
       New dialysis12 (3.5)10 (4.2)2 (1.9).48
      Re-exploration for bleeding26 (7.6)18 (7.5)8 (7.8)1
      Operative mortality19 (5.6)17 (7.1)2 (2.0).1
      Data are presented as n (%) except where otherwise noted. MAE, Major adverse events (includes operative mortality, myocardial infarction, cerebrovascular accidents, need for dialysis, or need for tracheostomy); MI, myocardial infarction; MAPE, major adverse pulmonary events (includes intubation >48 hours, pneumonia, reintubation, and tracheostomy); GI, gastrointestinal; ATN, acute tubular necrosis.
      Figure thumbnail gr1
      Figure 1Kaplan-Meier survival estimate of patients with acute type A aortic dissection repaired with a conservative versus extensive approach. Long-term survival was similar whether a conservative aortic root-sparing hemiarch procedure or a more extensive root replacement/total arch replacement was performed. Overall survival in the conservative versus the extensive groups at 5 years was 76.9% vs 81.4% and at 10 years was 63.2% vs 66.2% (P = .55).
      Figure thumbnail gr2
      Figure 2Competing risk analysis for reoperation (with death as a competing risk) in patients with acute type A aortic dissection repaired with a conservative versus extensive approach. The incidence of reoperation was significantly higher in the extensive group at 5 years (3.8% vs 12.8%) and 10 years (5.6% vs 21%; P = <.01).
      In multivariable regression analysis, ejection fraction (odds ratio, 0.95 [95% confidence interval (CI), 0.91-0.98]; P = .01), and diabetes (odds ratio, 2.65 [95% CI, 1.08-6.26]; P = .03) were independent predictors of MAE. Extensive versus conservative approach did not predict MAE but was a predictor of late reoperation (hazard ratio, 3.05 [95% CI, 1.29-7.2]; P = .01). CTD was a predictor of reoperation in univariable but not multivariable analysis (Tables 4 and 5).
      Table 4Univariable and multivariable predictors of major adverse events
      Major adverse events include operative mortality, myocardial infarction, cerebrovascular accidents, need for dialysis, or need for tracheostomy.
      in patients who underwent repair of acute type A aortic dissection
      VariableUVAMVA
      OR (95% CI)P valueOR (95% CI)P value
      Age1.04 (1.02-1.07)<.011.03 (1.00-1.06).08
      Sex1.06 (0.55-2.10).87– (–)
      Ejection fraction0.92 (0.89-0.95).000.95 (0.91-0.98).01
      Hypertension0.69 (0.21-3.06).57– (–)
      Chronic pulmonary disease3.14 (1.55-6.24)<.010.89 (0.34-2.17).8
      Diabetes3.39 (1.53-7.25)<.012.65 (1.08-6.26).03
      Previous myocardial infarction5.61 (2.78-11.28).001.67 (0.66-4.01).27
      Preoperative renal impairment4.16 (2.15-8.29).001.76 (0.76-4.01).18
      Extensive vs conservative approach0.35 (0.13-0.81).020.59 (0.19-1.57).32
      Total arch vs hemiarch
      Collinear with approach.
      0.3 (0.05-1.02).1– (–)
      Root replacement
      Collinear with approach.
      0.4 (0.12-1.05).09– (–)
      Variables with P value < .2 in univariable analysis were included in multivariable model. UVA, Univariable analysis; MVA, multivariable analysis; OR, odds ratio; CI, confidence interval.
      Major adverse events include operative mortality, myocardial infarction, cerebrovascular accidents, need for dialysis, or need for tracheostomy.
      Collinear with approach.
      Table 5Univariable and multivariable predictors of late reoperation in patients who underwent repair of acute type A aortic dissection
      VariableUVAMVA
      HR (CI)P valueHR (CI)P value
      Age0.98 (0.96-1.01).171.00 (0.97-1.03).96
      Sex0.89 (0.41-1.95).78– (–)
      Ejection fraction1.01 (0.96-1.07).64– (–)
      Hypertension0.38 (0.113-1.26).110.77 (0.20-2.96).7
      Chronic pulmonary disease0.67 (0.2-2.23).51– (–)
      Connective tissue disease3.00 (1.03-8.78).051.55 (0.44-5.41).5
      Diabetes0.36 (0.05-2.70).32– (–)
      Previous myocardial infarction0.45 (0.107-1.91).28– (–)
      Preoperative renal impairment0.82 (0.327-2.03).66– (–)
      Extensive vs conservative approach3.45 (1.56-7.60)<.013.05 (1.29-7.20).01
      Total arch vs hemiarch
      Collinear with approach.
      4.64 (2.02-10.70)<.01– (–)
      Root replacement
      Collinear with approach.
      1.47 (0.637-3.39).37– (–)
      Variables with P value < .2 in univariable analysis were included in multivariable model. UVA, Univariable analysis; MVA, multivariable analysis; HR, hazard ratio; CI, confidence interval.
      Collinear with approach.

      Discussion

      The ideal repair strategy for ATAAD would result in the lowest OM for the index procedure along with minimal risk of late reoperation. However, the additional surgical complexity required to achieve this result might be accompanied by increased operative times and risk secondary to prolonged periods of end organ and cardiac ischemia. Pooled multicenter data corroborates this concept. The Society of Thoracic Surgeons data from 2014 to 2016 showed an OM of 26.9% with TAR compared with an OM of 16.3% for hemiarch repair.
      • Helder M.R.K.
      • Schaff H.V.
      • Day C.N.
      • Pochettino A.
      • Bagameri G.
      • Greason K.L.
      • et al.
      Regional and temporal trends in the outcomes of repairs for acute type A aortic dissections.
      A meta-analysis in which proximal was compared with extensive arch repair showed the former to have reduced risk of early mortality (relative risk, 0.69) but higher risk of distal reoperations (relative risk, 3.14).
      • Yan Y.
      • Xu L.
      • Zhang H.
      • Xu Z.Y.
      • Ding X.Y.
      • Wang S.W.
      • et al.
      Proximal aortic repair versus extensive aortic repair in the treatment of acute type A aortic dissection: a meta-analysis.
      Single-center studies, however, report conflicting results. Rylski and colleagues reported a rise in OM as the extent of arch repair increased (ascending only, 9.8%; hemiarch, 21.6%; and TAR, 28.6%).
      • Rylski B.
      • Beyersdorf F.
      • Kari F.A.
      • Schlosser J.
      • Blanke P.
      • Siepe M.
      Acute type A aortic dissection extending beyond ascending aorta: limited or extensive distal repair.
      Kim and colleagues could not corroborate these findings when they compared their experience with TAR and hemiarch repair (13.4% vs 9.7%).
      • Kim J.B.
      • Chung C.H.
      • Moon D.H.
      • Ha G.J.
      • Lee T.Y.
      • Jung S.H.
      • et al.
      Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection.
      However, they did identify a significantly higher incidence of PND in the TAR group (22.7% vs 6.3%). Further evidence of the disparities in outcome metrics for repair of ATAAD abound throughout the literature. Di Eusanio and colleagues compared conservative repair with TAR and reported the incidence of OM (24.1% vs 22.6%) and PND (9.1% vs 7.5%) to be quite similar whereas Zhang and colleagues compared conservative hemiarch repair with FET and also reported no difference in mortality (5.4% vs 5.7%) or PND (1.4% vs 2.3%).
      • Di Eusanio M.
      • Berretta P.
      • Cefarelli M.
      • Jacopo A.
      • Murana G.
      • Castrovinci S.
      • et al.
      Total arch replacement versus more conservative management in type A acute aortic dissection.
      ,
      • Zhang H.
      • Lang X.
      • Lu F.
      • Song Z.
      • Wang J.
      • Han L.
      • et al.
      Acute type A dissection without intimal tear in arch: proximal or extensive repair?.
      Nonetheless, whether one supports a more conservative surgical approach or aggressive techniques such as TAR, antegrade stent graft deployment or FET, few centers report mortality rates consistently below 10%.
      To minimize OM without compromising late survival or reoperation rates, we use a tailored “conservative” approach to ATAAD. We prefer to reserve more extensive operations in the root and arch for lower-risk patients who we believe are at increased risk for future reoperation. Our conservative group consisted of older patients with more comorbidities, such as hypertension, coronary disease, and renal dysfunction. This group received hemiarch replacement and root-sparing aortic valve resuspension. The extensive group consisted of patients who are at greater risk for downstream reoperations because of young age and a higher incidence of CTDs. Their stable status upon presentation with ATAAD and more limited comorbidities convinced us that they could better tolerate the longer cross-clamp and bypass times needed to complete more extensive repairs. TAR was performed on those with large arch aneurysm, tears involving the distal arch, or CTD. Aortic root replacement was performed in patients with large root aneurysms, intimal tears extending into a sinus, or CTD. Those with more moderately sized root or arch aneurysms underwent conservative repair, particularly if they were of advanced age, had extensive comorbidities, or hemodynamic instability.
      We believe this tailored approach to ATAAD repair has been successful, yielding an overall OM of 5.6% that was not different between the conservative or extensive strategies (7.1% vs 2%; P = .1). Similar results were also shown with respect to individual complications. The incidence of permanent and temporary neurologic injury was low in both groups supporting our preferred cerebral protection strategy of deep hypothermic circulatory arrest and RCP.
      • Lau C.
      • Gaudino M.
      • Iannacone E.M.
      • Gambardella I.
      • Munjal M.
      • Ohmes L.B.
      • et al.
      Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.
      Although there was a relatively high incidence of preoperative malperfusion in both groups (32.3% vs 22.9%; P = .12), permanent sequelae were uncommon, in part because of our preferred strategy of primary aortic repair and rapid restoration of effective true lumen blood flow, preferentially through central true lumen aortic cannulation. Composite outcomes of MAE (15.1% vs 5.9%; P = .03) and MAPE (16.2% vs 7.8%; P = .05) were both higher in the conservative group and likely a reflection more of preoperative comorbidity rather than surgical technique. Although an extensive versus conservative approach was a predictor of MAE in univariable analyses, this was not confirmed in multivariable analysis. Despite the extensive group having the anticipated longer operative times, careful preoperative patient selection can mitigate that additional risk and lead to a gratifyingly high rate of early and late survival. The 5-year (76.9% vs 81.4%) and 10-year (63.2% vs 66.2%) survival were similar in both groups (P = .55). The risk of reoperation was higher in the extensive group at 5 and 10 years but is likely due to a higher incidence of CTD and a younger patient cohort rather than surgical technique. Although CTD itself was not a predictor of late reintervention in multivariable analysis, the extensive approach did predict a need for reintervention and most reinterventions were on the distal aorta. This seeming contradiction is likely because an extensive approach with root replacement in those with CTD mitigated risk of any proximal reintervention. However, the extensive group accounts for patients with CTD in addition to those with other features that increase risk of future reintervention. The Michigan group has reported results similar to ours when using a conservative approach to aortic root and arch pathology.
      • Yang B.
      • Malik A.
      • Waidley V.
      • Kleeman K.C.
      • Wu X.
      • Norton E.L.
      • et al.
      Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection.
      A wide range of management strategies exists for the aortic arch in the setting of ATAAD, ranging from ascending replacement only to hemiarch replacement, TAR, antegrade stent graft, or TAR with FET. As shown by our data, hemiarch replacement is a durable technique with a 5.6% cumulative risk of reoperation at 10 years when performed in selected patients without preexisting arch aneurysm or CTD. Rylski and colleagues reported similar success with a 1.3% arch reintervention and 5% descending reintervention rates.
      • Rylski B.
      • Milewski R.K.
      • Bavaria J.E.
      • Vallabhajosyula P.
      • Moser W.
      • Szeto W.Y.
      • et al.
      Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection.
      In our arch analysis, we found that in patients with CTD or arch aneurysms, TAR can be performed safely (OM, 0%; PND, 2.2%), especially in younger patients with few comorbidities. Although large database studies
      • Helder M.R.K.
      • Schaff H.V.
      • Day C.N.
      • Pochettino A.
      • Bagameri G.
      • Greason K.L.
      • et al.
      Regional and temporal trends in the outcomes of repairs for acute type A aortic dissections.
      and single-center reports have shown increased mortality
      • Rylski B.
      • Beyersdorf F.
      • Kari F.A.
      • Schlosser J.
      • Blanke P.
      • Siepe M.
      Acute type A aortic dissection extending beyond ascending aorta: limited or extensive distal repair.
      and PND
      • Kim J.B.
      • Chung C.H.
      • Moon D.H.
      • Ha G.J.
      • Lee T.Y.
      • Jung S.H.
      • et al.
      Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection.
      when extensive arch repair is performed, we believe proper patient selection, cerebral protection, and meticulous attention to surgical hemostasis can reduce major morbidity and mortality to levels associated with less complex repairs.
      Efforts to induce downstream aortic remodeling and reduce distal reinterventions included hemiarch replacement with antegrade stent graft placement. Vallabhajosyula and colleagues reported similar OM, PND (5% vs 8%; P = .51), and SCI (0 vs 1%; P = 1) rates with improved false lumen thrombosis of the stented segment (82% vs 39%; P < .01) when stent graft was performed at the time of the index ATAAD repair.
      • Vallabhajosyula P.
      • Szeto W.Y.
      • Pulsipher A.
      • Desai N.
      • Menon R.
      • Moeller P.
      • et al.
      Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate.
      Freedom from open reintervention was nonsignificantly better in the stented group (98% vs 90%; P = .1) but endovascular late reintervention was significantly higher (18% vs 3%; P = .01).
      • Vallabhajosyula P.
      • Szeto W.Y.
      • Pulsipher A.
      • Desai N.
      • Menon R.
      • Moeller P.
      • et al.
      Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate.
      Preventza and colleagues reported similar OM (12.7% vs 17.4%; P = .41) and PND (6.3% vs 5.3%; P = .75) without a significantly higher SCI rate (7.9% vs 1.8%; P = .99). Need for reintervention was also not significantly different but in a matched comparison, 5-year survival was better in the stented group (49.9% vs 41.6%; P = .015).
      • Preventza O.
      • Olive J.K.
      • Liao J.L.
      • Orozco-Sevilla V.
      • Simpson K.
      • Rodriguez M.R.
      • et al.
      Acute type I aortic dissection with or without antegrade stent delivery: mid-term outcomes.
      Roselli and colleagues reported an OM of 4.2%, PND risk of 4.2%, and SCI risk of 4.2% in a selected group of patients who received an antegrade stent graft.
      • Roselli E.E.
      • Idrees J.J.
      • Bakaeen F.G.
      • Tong M.Z.
      • Soltesz E.G.
      • Mick S.
      • et al.
      Evolution of simplified frozen elephant trunk repair for acute debakey type I dissection: midterm outcomes.
      Although thrombosis of the false lumen in the stented segment was 92%, 5-year freedom from reintervention was only 72% and survival 80%.
      • Roselli E.E.
      • Idrees J.J.
      • Bakaeen F.G.
      • Tong M.Z.
      • Soltesz E.G.
      • Mick S.
      • et al.
      Evolution of simplified frozen elephant trunk repair for acute debakey type I dissection: midterm outcomes.
      Although the appearance of aortic remodeling is desirable, we have not adopted this more aggressive arch approach because of a lack of evidence showing reintervention rates that would be lower than what we are currently achieving.
      TAR with FET is another arch repair strategy worthy of consideration. Sun and colleagues have been strong advocates for this extensive repair strategy and reported their results with this technique in 148 ATAAD with either arch tear, arch aneurysm, or Marfan syndrome.
      • Sun L.
      • Qi R.
      • Zhu J.
      • Liu Y.
      • Zheng J.
      Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type a dissection involving repair of the aortic arch?.
      They reported outstanding results with no difference in in-hospital mortality (4.7% vs 6.1%; P = .74), stroke (2.7% vs 1.5%; P = 1), or SCI (1.4% vs 0; P = 1) compared with hemiarch replacement. False lumen thrombosis was improved and there were fewer reinterventions in the FET group (1 vs 4 patients; P = .03). However, despite better aortic remodeling there was no difference in late mortality.
      • Sun L.
      • Qi R.
      • Zhu J.
      • Liu Y.
      • Zheng J.
      Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type a dissection involving repair of the aortic arch?.
      Shrestha and colleagues also routinely used FET for ATAAD. Their in-hospital mortality of 13% is similar to the OM reported with many other approaches. However, a stroke rate of 15% and 5% incidence of SCI are concerning, particularly when considering that 12% of operative survivors still required downstream aortic reinterventions.
      • Shrestha M.
      • Haverich A.
      • Martens A.
      Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.
      SCI is a particularly devastating complication associated with the FET technique. In a large meta-analysis of FET in patients with ATAAD, the pooled rate of SCI was 4.7% but was significantly higher when stent length exceeded 15 cm or coverage of the aorta extended to T8 or lower.
      • Preventza O.
      • Liao J.L.
      • Olive J.K.
      • Simpson K.
      • Critsinelis A.C.
      • Price M.D.
      • et al.
      Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients.
      An arch surgery database analysis including 507 patients also concluded that FET had a higher risk of SCI than conventional TAR (1.5% vs 3.9%; P = .03).
      • Poon S.S.
      • Tian D.H.
      • Yan T.
      • Harrington D.
      • Nawaytou O.
      • Kuduvalli M.
      • et al.
      Frozen elephant trunk does not increase incidence of paraplegia in patients with acute type A aortic dissection.
      In our experience with a tailored, conservative ATAAD operation, postoperative SCI was not seen. Furthermore, in experienced hands, SCI after elective, open thoracoabdominal aortic aneurysm repair for chronic type A dissection is an infrequent complication.
      • Gambardella I.
      • Gaudino M.
      • Lau C.
      • Munjal M.
      • Elsayed M.
      • Girardi L.N.
      Surgical outcomes of chronic descending dissections: type I versus III debakey.
      For the limited percentage of patients who require late distal reintervention, it is debatable whether the routine use of FET should be recommended. However, it might be beneficial for a select group of patients that we expect to be at high risk for distal reintervention.
      Root replacement is a more complex procedure requiring significantly longer bypass and cross-clamp times than root-sparing. Coronary button reimplantation might be quite hazardous because of fragile, dissected tissue. Postoperative bleeding and ischemia can be potentially lethal. However, patient selection and greater experience with elective root surgery can mitigate the increased risks incurred in the setting of ATAAD.
      • Gaudino M.
      • Lau C.
      • Munjal M.
      • Avgerinos D.
      • Girardi L.N.
      Contemporary outcomes of surgery for aortic root aneurysms: a propensity-matched comparison of valve-sparing and composite valve graft replacement.
      Although those who underwent root replacement via CVG or VSRR tended to have more CTDs and more severe AI, we did not find an increase in OM compared with those who had root-sparing procedures (6.2% vs 3%; P = .48). Other experienced centers reported similar results.
      • Yang B.
      • Norton E.L.
      • Hobbs R.
      • Farhat L.
      • Wu X.
      • Hornsby W.E.
      • et al.
      Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: twenty-year experience.
      ,
      • Chiu P.
      • Trojan J.
      • Tsou S.
      • Goldstone A.B.
      • Woo Y.J.
      • Fischbein M.P.
      Limited root repair in acute type A aortic dissection is safe but results in increased risk of reoperation.
      It is worth noting again, however, that conservative root-sparing surgery is suitable for most ATAAD patients even when significant AI is present. In our series, 69.4% of patients in the root-preserving group had moderate or greater AI. Valvular dysfunction was primarily due to collapse of 1 or more aortic valve commissures rather than true native valve pathology. In the extensive group, much of the severe AI was related to root dilatation as well. Meticulous resuspension of the commissures with a particular focus on restoring the proper diameter of the sinotubular junction universally resolved the AI in the conservative group. With 100% follow-up of this group who underwent conservative root management, we are confident that this technique is not only safe but durable. At 10 years, the cumulative incidence of proximal reoperation was only 3.7% and not different from those who required full root replacement. Others with long periods of follow-up report results similar to ours.
      • Wang Z.
      • Greason K.L.
      • Pochettino A.
      • Schaff H.V.
      • Suri R.M.
      • Stulak J.M.
      • et al.
      Long-term outcomes of survival and freedom from reoperation on the aortic root or valve after surgery for acute ascending aorta dissection.
      ,
      • Nishida H.
      • Tabata M.
      • Fukui T.
      • Takanashi S.
      Surgical strategy and outcome for aortic root in patients undergoing repair of acute type A aortic dissection.
      The relative merits of CVG versus VSRR can be debated as definitive therapy for root pathology in the setting of ATAAD. We are very selective in our application of VSRR and only advocate for its use when excellent leaflet morphology is present in young, stable patients. Others are more committed to VSRR and have shown excellent short- and midterm results.
      • Sievers H.H.
      • Richardt D.
      • Diwoky M.
      • Auer C.
      • Bucsky B.
      • Nasseri B.
      • et al.
      Survival and reoperation after valve-sparing root replacement and root repair in acute type A dissection.
      Longer follow-up will be necessary before we could support more widespread use of this very complex, time-consuming, and sometimes unpredictable procedure across a larger population of patients who present with ATAAD.
      This study is limited by its retrospective nature. Additionally, there is an inherent selection bias between the 2 groups that confounds the comparative statistics. However, our goal was not to state that one is better than the other or that one method should be used for all patients. The goal was to show that using tailored selection, high- and low-risk patients can be repaired with excellent operative outcomes without compromising long-term durability. Last, the use of P value threshold-based modeling for the multivariable model has limitations.

      Conclusions

      A conservative approach to ATAAD using hemiarch and root-sparing techniques simplifies the operation and produces consistent results with low OM (Figure 3). A tailored approach reserving complex arch and root repair for younger, stable patients at risk for future reintervention (eg, CTD or arch aneurysm) and a more conservative strategy in older, less stable patients with more comorbidity yields excellent operative outcomes. Careful patient selection limits the surgical insult in higher-risk patients while allowing for extensive repairs in lower-risk patients, who are at risk for needing late reinterventions. Additionally, long-term survival and risk of reintervention are not compromised with this approach. In this study, the extensive approach is a marker for a higher-risk population with CTD or preexisting large aneurysm, which predict the need for late reoperation. Although extensive operations such as root replacement, TAR, and FET might be beneficial for this populations, their routine use might not be necessary for most patients.
      Figure thumbnail gr3
      Figure 3A tailored strategy for repair of type A aortic dissection leads to favorable operative and long-term outcomes. A total of 343 patients underwent repair with a 5.6% operative mortality. The long-term survival was similar between the conservative (root-sparing/hemiarch) group and the extensive (total arch and/or root replacement) group. Need for reintervention was not increased using a conservative approach.

      Conflict of Interest Statement

      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

      Appendix E1

      Figure thumbnail fx3
      Figure E1Diagnostic plot for Cox multivariable analysis showing Schoenfeld residuals (global and individual Schoenfeld tests were insignificant) for patients who underwent type A aortic dissection repair. These plots confirm the proportional hazards assumption. CTD, Connective tissue disease.
      Table E1Demographic and preoperative characteristics of patients who underwent repair of acute type A aortic dissection separated according to root and arch management techniques
      Preoperative variableArch managementRoot management
      Hemiarch (n = 298)Total arch (n = 45)P valueRoot-sparing (n = 276)Root replacement (n = 67)P value
      Median age, y65 (54-75)65 (54-75).6267 (57-76)55 (43-66)<.001
      Male sex181 (60.7)27 (60.0)1.00154 (55.8)54 (80.6)<.001
      Smoking183 (61.4)24 (53.3).45171 (61.9)36 (53.7).052
      HTN282 (94.6)42 (93.3).99266 (96.4)58 (86.6).004
      Previous MI58 (19.6)0 (0).00350 (18.3)8 (11.9).30
      COPD57 (19.1)8 (17.8).9958 (21.0)7 (10.4).071
      Diabetes41 (14.4)6 (15.4)1.0045 (17.3)2 (3.1).007
      Previous CVA50 (16.8)10 (22.2).4950 (18.1)10 (14.9).66
      Preoperative renal dysfunction98 (32.9)12 (26.7).5196 (34.8)14 (20.9).041
      Median ejection fraction50 (40-50)50 (45-50).4450 (45-50)50 (44-50).67
      Connective tissue disease12 (4.0)6 (13.3).02410 (3.6)8 (11.9).015
      Shock54 (18.1)7 (15.6).8350 (18.1)11 (16.4).88
      Malperfusion92 (31.9)5 (12.5).01978 (29.7)19 (29.2)1
       Cerebral21 (7.3)1 (2.5).49519 (7.2)3 (4.6).587
       Coronary16 (5.6)0 (0.0).23514 (5.3)2 (3.1).747
       Extremity25 (8.7)2 (5.0).55320 (7.6)7 (10.8).449
       Intestinal6 (2.1)0 (0.0)15 (1.9)1 (1.5)1
       Renal18 (6.2)1 (2.5).55513 (4.9)6 (9.2).304
       Spinal5 (1.7)1 (2.5).5456 (2.3)0 (0.0).603
       Coronary, renal, spinal, intestinal1 (0.3)0 (0.0)11 (0.4)0 (0.0)1
      Rupture40 (13.4)9 (20.0).9840 (14.5)9 (13.4).34
      Degree of preoperative AI
       Mild69 (24.1)17 (38.6).0481 (30.6)5 (7.7)<.001
       Moderate124 (43.4)17 (38.6).63131 (49.4)10 (15.4)<.001
       Severe93 (32.5)10 (22.7).2253 (20.0)50 (76.9)<.001
      Data are presented as median (interquartile range) or n (%) except where otherwise noted. HTN, Hypertension; MI, myocardial infarction; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; AI, aortic insufficiency.
      Table E2Intraoperative details of patients who underwent repair of acute type A aortic dissection separated according to root and arch management techniques
      Intraoperative variableArch managementRoot management
      Hemiarch (n = 298)Total arch (n = 45)P valueRoot-sparing (n = 276)Root replacement (n = 67)P value
      CPB time, minutes138 (125-160)170 (154-182)<.001138 (126-159)165 (142-183)<.001
      Cardiac ischemia time, minutes85 (72-108)100 (88-121).00182 (71-97)130 (112-149)<.001
      RCP time, minutes22.00 (20-26)41 (35-47)<.00124 (20-30)20 (18-23)<.001
      CA time, minutes22.50 (20-27)43 (35-50)<.00124 (21-30)21 (18-24)<.001
      Site of cannulation.52
       Central true lumen111 (37.4)19 (42.2).63106 (38.5)24 (35.8).80
       Axillary1 (0.3)1 (2.2).451 (0.4)1 (1.5).35
       Femoral185 (62.3)25 (55.6).50168 (61.1)42 (62.7).89
      Concomitant procedures
       CABG3 (1.0)0 (0.0)1.003 (1.1)0 (0.0)1.00
       MVR2 (0.7)0 (0.0)1.001 (0.4)1 (1.5).35
      Data are presented as median (interquartile range) or n (%) except where otherwise noted. CPB, Cardiopulmonary bypass; RCP, retrograde cerebral perfusion; CA, circulatory arrest; CABG, coronary artery bypass grafting; MVR, mitral valve replacement.
      Table E3Postoperative outcomes of patients who underwent repair of acute type A aortic dissection separated according to root and arch management techniques
      Postoperative outcomeArch managementRoot management
      Hemiarch (n = 298)Total arch (n = 45)P valueRoot-sparing (n = 276)Root replacement (n = 67)P value
      MAE40 (13.5)2 (4.4).13938 (13.8)4 (6.1).130
      MI5 (1.7)0 (0.0).844 (1.4)1 (1.5)1.00
      Neurologic deficit15 (5.0)2 (4.4)117 (6.2)0 (0.0).077
       Permanent neurologic deficit9 (3.0)1 (2.2)110 (3.6)0 (0.0).239
       Temporary neurologic deficit6 (2.0)1 (2.2)17 (2.5)0 (0.0).403
      MAPE43 (14.4)4 (8.9).43842 (15.2)5 (7.5).145
       Tracheostomy15 (5.0)1 (2.2).6515 (5.4)1 (1.5).29
      GI complication13 (4.4)1 (2.2).7912 (4.3)2 (3.0).87
      Renal dysfunction
       ATN12 (4.0)0 (0.0).3810 (3.6)2 (3.0)1.00
       New dialysis13 (4.4)1 (2.2)1.0013 (4.7)1 (1.5).32
      Re-exploration for bleeding24 (8.1)2 (4.4).5820 (7.2)6 (9.0).83
      Operative mortality19 (6.4)0 (0.0).1617 (6.2)2 (3.0).48
      Data are presented as n (%) except where otherwise noted. MAE, Major adverse events (include operative mortality, myocardial infarction, cerebrovascular accidents, need for dialysis or need for tracheostomy); MI, myocardial infarction; MAPE, major adverse pulmonary events (includes intubation >48 hours, pneumonia, reintubation and tracheostomy); GI, gastrointestinal; ATN, acute tubular necrosis.

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      Linked Article

      • Commentary: The surgeon and the tailor. A continuous partnership
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          The proper treatment of acute type A aortic dissection remains a surgical challenge that presents significant operative mortality. In this peculiar emergency clinical condition, both surgical dexterity and surgical strategy play an important role in the final result. Different clinical presentations associated with variable anatomical tissue destruction explain the significant difference in mortality and overall results that are present in the majority of the reports in the literature.
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      • Commentary: The human factor in repair of acute dissection
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          “A perfection of means, and confusion of aims, seems to be our main problem.” —Albert Einstein
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      • Commentary: A tailored strategy for repair of acute type A aortic dissection: Balancing risk versus benefit
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          Current surgical aortic repair strategies for the treatment of acute type A aortic dissection vary in extent and technical complexity. Consequently, clinical outcomes, including operative mortality, complication rates, and reintervention rates, differ depending on the chosen repair strategy, extent of repair, and the underlying aortic pathology. The expert consensus document of the European Association for Cardio-Thoracic Surgery and the European Society for Vascular Surgery recommends performing extended procedures in the arch to prevent disease progression and to anticipate future endovascular modular distal extension, especially for patients with concomitant pathologies in the descending aorta.
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