Midterm Outcomes Of One-Stage Hybrid Aortic Arch Repair For Stanford Type A Aortic Dissection

Objective With aging of the population and of society,the incidence of aortic dissection has increased in recent years and more patients are facing with multiple comorbidities.The management of dissecting aortic arch aneurysms remains a clinical challenge despite significant advances have occurred in the surgical and anesthetic techniques during the past two decades.Combining open surgical methods for achieving arch vessels reconstruction and the creation of a proximal landing zone followed by thoracic endovascular aortic repair(TEVAR),the hybrid aortic arch repair(HAAR)has emerged as an effective treatment in aortic arch aneurysms.However,outcomes regarding dissecting aortic aneurysm is limited.This study sought to identify the midterm outcomes of one-stage HAAR in patients with Stanford type A aortic dissection(STAAD).Methods Between January 2010 and December 2015,75 consecutive patients with STAAD involving the aortic arch who underwent one-stage type II HAAR at our institution were identified.During this period,496 consecutive patients with STAAD involving the aortic arch received traditional total aortic arch replacement(TAR)combined with elephant trunk implantation.Inclusion criteria of HAAR and TAR included:(1)acute or chronic Stanford type A aortic dissection(DeBakey type ? aortic dissection affecting the arch);(2)Adult patients(age>18).Patients with isolated penetrating aortic ulcer,isolated intramural aortic hematoma,and isolated true or false thoracic aortic aneurysm were excluded in our review.The preoperative,perioperative and postoperative data of patients in the HAAR group and TAR group were compared.A propensity score-matching analysis was applied to adjust for baseline risk factors.The in-hospital and follow-up data were investigated.Results 571 patients were included for analysis(428 men;mean age,48.9 ± 11.1 years)and there were 75 patients received one-stage type II HAAR(HAAR group)while 496 patients received total aortic arch replacement combined with stented elephant trunk implantation(TAR group).For all patients,the mean CPB time was 196±60 minutes and mean aortic cross-clamping time was 98±32 minutes.The concomitant procedures were as follow:composite aortic root replacement in 152(26.6%)patients and coronary artery bypass graft in 70(12.3%)patients.The mean follow-up time was 41.1 ± 22.1 months.In-hospital mortality was 4.7%and the 5-year survival rate was 89.5%for all patients.In HAAR group,stent graft deployment rate was 100%after arch vessel debranching and there was no postoperative endoleak.Midterm outcomes between the propensity-matched groups were compared(59 HAAR vs.TAR pairs).There were no significant differences in the baseline characteristics between the two groups after matching.HAAR group showed shorter cardiopulmonary bypass time(133±38 min vs.206±57 min,p<0.001),aortic cross-clamping time(55±21 min vs.105±28 min,p<0.001),postoperative ventilation time(29±31 h vs.42±55 h,p = 0.002)and intensive care unit stays(79±62 h vs.101±111 h,p = 0.01)than the TAR group.There were no significant differences in in-hospital mortality,rate of stroke and rate of paraplegia between the two groups,however,better 5-year survival rate was found in HAAR group(94.9%vs.75.8%,p = 0.005).Multivariate Cox proportional hazards regression analysis for the entire patients showed that cardiopulmonary bypass time(p = 0.001),acute aortic dissection(p = 0.029)and patients' age>60 years(p = 0.001)were the independent risk factors of postoperative all-cause death.Conclusions With a decreased time for cardiopulmonary bypass and the avoidance of deep hypothermic circulatory arrest,in the present study,HAAR shows good midterm outcomes for patients with Stanford type A aortic dissection after propensity score matching-analysis.Future randomized controlled trials are needed and long-term follow-up is necessary.HAAR may represent a technical advancement in the field of aortic arch surgery.