Simple vs Complex Aortic Arch Repair in Acute Type A Aortic Dissection

BACKGROUND: The purpose of this study was to evaluate the clinical outcomes of patients undergoing a simpler (hemiarch) vs complex (zone 2 arch) aortic repair for acute type A aortic dissection (TAAD). STUDY DESIGN: Adults (18 years or older) who underwent hemiarch or zone 2 arch repair for acute, hyperacute, or acute on chronic TAAD at a single institution between January 2018 and April 2024 were reviewed. Disabling stroke was defined as a modified Rankin scale of 4 or greater. Statistical analysis included univariate comparisons, Kaplan–Meier analysis, and multivariable modeling. RESULTS: Two hundred eighty-three patients with acute TAAD underwent hemiarch (44.5%, n = 126) and/or zone 2 arch (55.5%, n = 157) repair. Hemiarch patients were older (63.3 ± 14.1 vs 56.3 ± 12.2 years, p < 0.001), but had lower rates of preoperative cerebrovascular disease (11.1% [n = 14] vs 21.7% [n = 34], p = 0.03), chronic kidney disease (16.7% [n = 21] vs 33.1% [n = 52], p = 0.003), and previous sternotomy (13.5% [n = 17] vs 35.0% [n = 55], p < 0.001). Cardiopulmonary bypass and cross-clamp times were shorter in hemiarch patients (214 ± 78.5 vs 261 ± 62.3 minutes, p < 0.001; 135 ± 54.4 vs 182 ± 60.0 minutes, p < 0.001, respectively). Postoperatively, there was no difference in the rate of disabling stroke (4.5% [n = 13], p = 0.12), tracheostomy (14.8% [n = 43], p = 0.15), pneumonia (17.2% [n = 50], p = 0.24), or renal failure requiring permanent dialysis (6.2% [n = 18], p = 0.47). In multivariable analysis, older age (hazard ratio 1.05, 95% CI 1.02 to 1.08) was a risk factor for longitudinal mortality, while complex aortic arch repair did not confer an increased risk (hazard ratio 0.68, 95% CI 0.35 to 1.31). CONCLUSIONS: Complex aortic arch reconstruction provides a framework for downstream endovascular procedures for the remaining aorta and can be performed in acute TAAD without increased risk of morbidity or mortality compared with a simpler repair.