Limited versus extended arch replacement during acute type A aortic dissection repair for nonsyndromic patients with dissected arch vessels.

Background: It remains controversial whether extended arch (EA) replacement should be indicated for arch vessel dissection (AVD) during acute type A aortic dissection (ATAAD) repair. We aimed to evaluate the impact of hemiarch versus EA replacement on clinical outcomes in nonsyndromic patients with AVD undergoing ATAAD repair. Methods: We enrolled nonsyndromic patients with AVD but without cerebral or upper limb malperfusion who underwent ATAAD repair at our institution between 1999 and 2022. Clinical outcomes were analyzed after adjustment with inverse probability of treatment weighting (IPTW). The association of adverse events with death was assessed using time-dependent Cox regression models. Results: Among the 181 patients in the study cohort, 117 underwent hemiarch replacement (64.6%) and 64 underwent EA replacement (35.4%). Operative mortality occurred in 9 patients (7.7%) in the hemiarch group and 7 patients (10.9%) in the EA group (P = .464). In the IPTW-adjusted cohort, the risk of stroke (subdistribution hazard ratio [HR], 2.32; 95% confidence interval [CI], 1.04-5.20; P = .041) was significantly higher in the EA group compared to the hemiarch group, whereas the risks of death (P = .088) and reintervention (P = .634) were comparable in the 2 groups over a median follow-up of 7.6 years (interquartile range, 2.2-13.9 years). In the time-dependent Cox models, stroke (HR, 2.05; 95% CI, 1.09-3.84) and reintervention (HR, 2.65; 95% CI, 1.47-4.79) yielded an increased risk of death. Conclusions: In nonsyndromic patients with AVD undergoing ATAAD repair, EA replacement was associated with an increased risk of stroke, whereas hemiarch replacement did not lead to increased aorta reinterventions, suggesting that hemiarch replacement is an acceptable option for repairing ATAAD in these patients.