What is the optimal surgical strategy for Stanford Type A acute aortic dissection in patients with a patent false lumen at the descending aorta?

OBJECTIVES: Aggressive total arch replacement (TAR) to obtain thrombosis of the distal false lumen (FL) in patients with Stanford Type A acute aortic dissection, particularly with a patent FL at the descending aorta, is discussed. The aim of this study was to examine the efficacy of our strategy. METHODS: In the last 20 years, we retrospectively reviewed the records of 518 patients with Type A acute aortic dissection who underwent an emergent surgery. Among them, 290 patients with a preoperative patent FL at the descending aorta were enrolled in this study. Patients were divided in 2 groups: the non-TAR group (n = 124; 68 +/- 14 years) and the TAR group (n = 166; 61 +/- 13 years). RESULTS: In-hospital mortality was 11% (32/290) without significant difference between the 2 groups (the non-TAR group 13% vs the TAR group 10%, P = 0.45). The rates of FL thrombosis of the entire descending aorta were detected at 32% in the non-TAR group and 41% in the TAR group (P = 0.16). Freedom from distal aortic dilatation >= 50mm was significantly higher in the TAR group (P = 0.03) than in the non-TAR group. Independent predictors of distal aortic dilatation >50mm were patients in the non-TAR group (P = 0.01; hazard ratio 3.1, 95% confidence interval 1.28-8.05) and unachieved primary entry tear resection (P = 0.002; hazard ratio 6.2, 95% confidence interval 1.38-8.66). CONCLUSIONS: Our surgical strategy with an aggressive entry resection with higher rate of TAR was acceptable. In patients with a patent FL at the descending aorta, TAR should be considered to prevent the future growth of the distal aorta.