Extended arch replacement is associated with improved long-term outcomes in acute type A aortic dissection with ascending entry tear.

OBJECTIVE

It remains controversial whether extended arch repair for acute type A aortic dissection reduces dissection-related distal aortic events and improves long-term outcomes in patients with ascending aortic entry tears. Accordingly, we evaluated long-term surgical outcomes in acute type A aortic dissection, focusing on the extent of arch repair.

METHODS

This international retrospective study included 914 patients with acute type A aortic dissection (mean age 66 ± 13 years) with ascending entry tears who underwent surgery at 2 specialized centers between 1997 and 2024. Patients were stratified into hemiarch replacement (n = 495) or extended arch replacement (partial or total arch; n = 419) groups. The primary end point was all-cause mortality; the secondary end point was dissection-related distal aortic events. Propensity score matching was performed using 18 baseline and operative variables. Mean follow-up was 5.9 ± 5.7 years (5390 patient-years).

RESULTS

In-hospital mortality decreased significantly over time (1997-2006: 19%; 2007-2016: 11%; 2017-2025: 9.0%; P = .007), driven mainly by improvements in the extended arch replacement group (24%, 8.7%, and 7.4%, respectively; P = .016). In a well-matched cohort of 182 patient pairs, extended arch replacement was associated with lower 10-year all-cause mortality (27% vs 39%; P = .011) and a lower cumulative incidence of distal aortic reintervention (11% vs 19%; P = .036). On multivariable analysis, extended arch replacement independently protected against a composite end point of death or distal aortic events (adjusted hazard ratio, 0.60; 95% CI, 0.47-0.78; P < .001).

CONCLUSIONS

In patients with acute type A aortic dissection with ascending aortic entry tears, extended arch replacement was associated with a progressive reduction in in-hospital mortality and superior long-term outcomes compared with hemiarch replacement, supporting its use in selected patients.