Clamp On vs Off Impact of Distal Anastomotic Technique During Ascending Aortic Replacement in Acute Type A Aortic Dissection: IRAD Insights.

OBJECTIVES

Most ascending aortic replacements for acute type A aortic dissection (ATAAD) are performed utilizing hypothermic circulatory arrest with an "open" distal anastomosis ("hemiarch"), whereas some are completed without ever removing the aortic cross-clamp. We sought to determine the impact of distal anastomotic technique in ascending aortic replacement for ATAAD repair.

METHODS

All patients in the IRAD Interventional Cohort database who underwent ATAAD repair between 2010 and 2020 were identified (n = 2559). Data for distal anastomotic technique were available in 2031 patients who underwent ascending aortic replacement, divided into 2 groups, based on whether they underwent hypothermic circulatory arrest (Clamp Off, n = 1900 [93.5%]) or not (Clamp On, n = 131, [6.5%]). We then propensity-matched 101 pairs of patients and analysed operative data and short- and mid-term outcomes.

RESULTS

In-hospital mortality for the unmatched population was 13.1% (266 deaths), not statistically different between the matched groups (Clamp Off, 11.0% vs Clamp On, 5.1% P = .22). There were no statistically significant differences observed in 3-year post-discharge survival curves between matched cohorts (Clamp Off, 89.5% vs Clamp On, 90.4%; stratified log-rank P-value = .46). Major perioperative complications (renal failure requiring dialysis, reoperation for bleeding, respiratory insufficiency) were not significantly different between the groups, notably including stroke (Clamp Off, 10.2% vs Clamp On, 5.8%, P = .32).

CONCLUSIONS

In this propensity-matched cohort, postoperative mortality, major morbidity, and mid-term survival were comparable between open distal anastomosis and clamp-on strategies in selected patients undergoing ascending aortic replacement for ATAAD.