Long‐term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta‐analysis of Kaplan–Meier‐derived individual patient data

Abstract

Objectives: To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD).Methods: We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.Results: Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk

Total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Aggressive versus conservative

“…Several cohort studies have compared PAR and TAR for ATAAD, with the majority of results aligning with those of Sa et al 2 suggesting TAR's superiority over PAR (with or without hemiarch). In the 14‐year study of 213 ATAAD patients by Vendramin et al, 3 Group 1 consisted of 138 patients who underwent PAR while Group 2 included 75 TAR patients.…”

“…The authors concluded that TAR seems to be the more favorable approach for treating ATAAD due to improved long-term survival and lower risk of need of reoperation. 2 Several cohort studies have compared PAR and TAR for ATAAD, with the majority of results aligning with those of Sa et al 2 suggesting TAR's superiority over PAR (with or without hemiarch). In the 14-year study of 213 ATAAD patients by Vendramin et al, 3 Group 1 consisted of 138 patients who underwent PAR while Group 2 included 75 TAR patients.…”

“…It is worth noting that this study can be considered the first of its kind using reconstructed time‐to‐event data and Kaplan–Meier‐derived IPD to directly compare PAR and TAR. The authors concluded that TAR seems to be the more favorable approach for treating ATAAD due to improved long‐term survival and lower risk of need of reoperation 2 …”

“…Although surgical intervention is well‐established as being the gold standard approach for treating ATAAD, a variety of surgical techniques exist which has sparked controversy within the literature. The main two strategies for ATAAD surgical repair are proximal aortic replacement (PAR), either limited to the ascending aorta or extending to include the lesser curvature of the aortic arch (i.e., hemiarch), and total arch replacement (TAR) using the elephant trunk technique (conventional or frozen) 2 . Nevertheless, the question of which of these two strategies if the more optimal is still debatable, which was addressed in a recent meta‐analysis by Sa et al 2 …”

Editorial: Novel insights into aortic arch repair

“…In this context, Tirone-David expresses concerns that aortic arch replacement is not appropriate for the “general cardiac surgeon” ( 6 ). On the other hand, it has to be taken into account that Sa et als' meta-analysis demonstrated that an aggressive approach seems to confer better long-term survival and lower risk for reoperation in the follow-up of patients treated for ATAAD ( 7 ). Following these considerations, many new surgical techniques, perfusion strategies, and graft devices have been introduced in the last few years: from ABO perfusion strategy to normothermic frozen elephant trunk surgery without circulatory arrest, and from new FET graft devices to different types of HAR.…”