title: Classification and outcomes of extended arch repair for acute Type A aortic dissection: a systematic review and meta-analysis.
abstract: Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation.
  
  
  
  Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated.
  
  
  
  Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05).
  
  
  
  Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.
authors.affiliation: Toronto Western Hospital EW 1-433, Toronto, Ontario, Canada.
authors.forename: Holly N
authors.initials: HN
authors.lastname: Smith
authors.affiliation: Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
authors.forename: Munir
authors.initials: M
authors.lastname: Boodhwani
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Maral
authors.initials: M
authors.lastname: Ouzounian
authors.affiliation: Department of Anesthesiology, Hospital of the Sacred Heart of Montreal and the University of Montreal, Montreal, Quebec, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Saczkowski
authors.affiliation: Department of Anaesthesia, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Gregory
authors.affiliation: Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Herget
authors.affiliation: Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
authors.forename: Jehangir J
authors.initials: JJ
authors.lastname: Appoo
mesh_terms: D000208:Acute Disease; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D014943:Global Health; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D011183:Postoperative Complications / Q000145:classification* / Q000453:epidemiology; D015607:Stents
keywords: Aorta; Aortic dissection; Aortic repair; Extended arch