title: Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic Dissection.
abstract: BACKGROUND
  Surgical management of aortic arch in type A acute dissection (TAAD) is controversial. This study compared short-term and long-term outcomes of total arch replacement (TAR) interventions versus more conservative arch management (CAM).
  
  
  METHODS
  Between 1997 and 2012, 240 patients underwent TAAD surgery in our institution; 53 (22.1%) received TAR and 187 (77.9%) received CAM. Compared with CAM patients, those undergoing TAR were younger (59.1 vs 64.4 years, p = 0.004) and were less likely to present with cardiogenic shock (3.8 vs 14.4, p = 0.02). Distal site of intimal tear (arch or descending aorta) was predictive of TAR management (odds ratio [OR], 9.1; p < 0.001).
  
  
  RESULTS
  Hospital mortality was similar in the groups (24.1% vs 22.6%; p = 0.45), and no other significant differences were observed in terms of major postoperative complications. Age (OR, 1.047; p = 0.007) and cardiopulmonary bypass time (OR, 1.005 per minute; p = 0.05) emerged as independent predictors of hospital death. The TAR management did not affect hospital mortality (propensity score [PS] adjusted OR: 1.51, p = 0.36). On Kaplan-Meier analysis, 7-year survival (TAR, 52.1% ± 0.9% vs CAM, 57.2% ± 4.2%, log-rank p = 0.9) and freedom from aortic re-intervention (TAR, 71.6% ± 1.3% vs CAM, 85.4% ± 3.9%, log-rank p = 0.3) were similar. The PS-adjusted Cox regression showed no relationship between type of arch management and follow-up survival (hazard ratio [HR], 1.001; p = 0.8) or need for re-intervention (HR, 1.507; p = 0.4).
  
  
  CONCLUSIONS
  In our experience TAR and CAM were associated with similar hospital mortality and morbidity rates. Nevertheless, the more extensive arch interventions were not protective for long-term survival and freedom from aortic re-intervention. Thus, in TAAD patients TAR remains indicated by site of intimal tear and patient-specific factors.
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Electronic address: marco.dieusanio2@unibo.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Di Eusanio
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Berretta
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Mariano
authors.initials: M
authors.lastname: Cefarelli
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Alfonsi
authors.initials: A
authors.lastname: Jacopo
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Murana
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Castrovinci
authors.affiliation: Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
mesh_terms: D000208:Acute Disease; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000145:classification* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods