Relationship between the extent of aortic replacement and stent graft for acute DeBakey type I aortic dissection and outcomes: Results from a medical center in Taiwan

Background Total arch replacement (TAR) and/or stent graft implantation has been proposed as the primary surgical treatment for acute DeBakey type I aortic dissection. However, the suggestion was based on excellent outcomes of high-volume or aortic centers. How about the real results in most places around the world? The purpose of this study was intended to compared in-hospital mortality, major complications, and aortic remodeling between TAR and/or stent graft implantation in a medical center of northern Taiwan. Methods Between January 2008 and August 2017, 156 patients with acute type I aortic dissection underwent surgery at our institution, including proximal aortic replacement only (Group I, n = 72), concomitant TAR (Group II, n = 23), concomitant TAR extended with stent grafting (Group III, n = 45), and proximal aortic replacement with descending aortic stent grafting (Group IV, n = 16). Results No significant differences were found in underlying disease and preoperative presentations, including operative risk among four groups. Overall in-hospital mortality was 22.4% (13 patients in Group I, 9 in Group II, 12 in Group III, and 1 in Group IV). New-onset stroke occurred in 15 patients postoperatively (3 patients [5.2%] in Group I, 3 [21.4%] in Group II, and 9 [26.5%] in Group III after excluding 36 patients with documented preoperative cerebrovascular accident or cerebral malperfusion). Root reconstruction and TAR were significantly associated with in-hospital mortality. TAR was significantly associated with surgery-related stroke. Compared to those in Group I, true lumen expansion and false lumen shrinkage during 1-year aortic remodeling were significantly higher in Groups III and IV. Both TAR and descending aorta stent grafting were significantly associated with decreased risk of patent false lumen. Conclusions Proximal aortic replacement remains the preferred surgical strategy for acute type I aortic dissection, with lower mortality and neurological complications. Proximal descending aorta stent grafting may benefit aortic remodeling, even without TAR.