Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

We compared perioperative outcomes of Acute Type A Aortic Dissection (ATAD) patients undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention. 929 patients underwent ATAD repair (2002 - 2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included: elephant trunk, antegrade TEVAR, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, CT malperfusion resolution, and a composite. Multivariable logistic regression was also performed. Mean age was 66±18 years, 30% (278/929) were women, and HA was performed more frequently (75%, n=695) than EA (25%, n=234). EAD techniques included: dissection stent (39/234, 17%), TEVAR (18/234, 7.7%), and elephant trunk (87/234, 37%). In-hospital mortality [EA: n=49, 21%; HA: n=129, 19%, p=0.42], and neurological deficit [EA: n= 43, 18%; HA: n=121, 17%, p=0.74] were similar. EA was not independently associated with death [EA vs HA OR: 1.09 (0.77-1.54), p=0.63] or neurologic deficit [EA vs HA OR: 0.85 (0.47 - 1.55), p=0.59]. Composite adverse events differed significantly [EA vs HA OR: 1.47 (1.16 - 1.87) p=0.001]. Malperfusion resolved more frequently after EAD [EAD: n=32 (80%), EAND: n=18 (56%), HA: n=71 (50%), p=0.004], though multivariable analysis was not significant [EAD vs HA OR: 2.17 (0.83 - 5.66), p=0.10]. Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.