title: Hemiarch replacement with concomitant antegrade stent grafting of the descending thoracic aorta versus total arch replacement for treatment of acute DeBakey I aortic dissection with arch tear†.
abstract: OBJECTIVE
  For acute DeBakey I aortic dissection with arch tear, conventional distal reconstruction entails total arch replacement (TAR). Some surgeons at our institution have utilized an alternative reconstructive strategy-primary arch tear repair and transverse hemiarch reconstruction (THR) with concomitant antegrade thoracic endovascular aortic repair (TEVAR). We assessed early and mid-term outcomes comparing these two surgical strategies for arch tear management.
  
  
  METHODS
  A retrospective review of a prospectively maintained institutional aortic dissection database was carried out to compare early and mid-term outcomes for patients undergoing intervention for DeBakey I aortic dissection with arch tear. Hemiarch reconstruction with concomitant antegrade TEVAR was compared against conventional TAR. Arch tear at the origin of great vessels or greater curve was primarily repaired with interrupted sutures in TEVAR patients.
  
  
  RESULTS
  From 2006 to 2013, 61 of 284 DeBakey I aortic dissection patients undergoing intervention for arch tear were retrospectively reviewed. Thirty-one patients had TAR (TAR group) and 30 patients had hemiarch + TEVAR (TEVAR group). Demographics and clinical presentation were similar. TEVAR group had more patients presenting in cardiogenic shock [3% (n = 1) vs 13% (n = 4), P = 0.2] and tamponade [10% (n = 3) vs 23% (n = 7), P = 0.2]. Intraoperatively, TEVAR group had lower cardiopulmonary bypass (239 ± 34 vs 313 ± 80 min, p0.001) and circulatory arrest (60 ± 15 vs 78 ± 45 min, P = 0.04) times. TAR group had higher in-hospital/30-day mortality [26% (n = 8) vs 13% (n = 4), P = 0.3], but stroke rates were similar [6% (n = 2) vs 7% (n = 2), P = 1]. One-year (80 ± 7.3 vs 71 ± 8.3%), 3-year (73 ± 8.3 vs 67 ± 8.6%) and 5-year (73 ± 8.3 vs 67 ± 8.6%) actuarial survival were improved in TEVAR group, although not significantly (log-rank, P = 0.56). TEVAR promoted increased false lumen thrombosis (43 vs 85%, P = 0.002).
  
  
  CONCLUSIONS
  In treating DeBakey I aortic dissection with arch tear, hemiarch replacement with primary tear repair and concomitant TEVAR is a safe alternative to conventional TAR, with improved distal aortic remodelling.
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA prashanth.vallabhajosyula@uphs.upenn.edu.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Jean Paul
authors.initials: JP
authors.lastname: Gottret
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: J Daniel
authors.initials: JD
authors.lastname: Robb
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Nimesh D
authors.initials: ND
authors.lastname: Desai
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects / Q000706:statistics & numerical data*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D015607:Stents
keywords: Arch tear; DeBakey I aortic dissection; TEVAR; Total arch replacement