Distal anastomotic new-entry tear after type A aortic dissection repair: Incidence patterns and long-term outcomes by extent of aortic replacement.

Objective: The study objective was to investigate the incidence patterns, anatomic distribution, and long-term outcomes of distal anastomotic new-entry tear in acute type A aortic dissection according to the extent of aortic replacement. Methods: This retrospective study analyzed 409 patients with acute type A aortic dissection who underwent surgical repair between 2003 and 2023. Patients were categorized by the extent of aortic replacement: hemiarch replacement (n = 173), partial arch replacement (n = 126), and total arch replacement (n = 110). Distal anastomotic new-entry tear was identified using postoperative contrast-enhanced computed tomography. Long-term outcomes were distal anastomotic new-entry tear status (distal anastomotic new-entry tear vs nondistal anastomotic new-entry tear) and the extent of aortic replacement (hemiarch replacement, partial arch replacement, and total arch replacement). Results: Distal anastomotic new-entry tears occurred in 27.4% of the patients, predominantly in the greater curve of aortic arch across all replacement types. Supra-aortic branch dissection was an independent risk factor for distal anastomotic new-entry tear occurrence (odds ratio, 2.80, P < .001). Patients with distal anastomotic new-entry tear were younger and predominantly male. Long-term survival was similar between the distal anastomotic new-entry tear and nondistal anastomotic new-entry tear groups; distal anastomotic new-entry tear significantly increased the cumulative incidence of distal aortic reoperation, particularly in patients with hemiarch replacement and partial arch replacement, but not in those with total arch replacement. Multivariate analysis identified distal anastomotic new-entry tear (hazard ratio, 3.95, P < .001) and Marfan syndrome (hazard ratio, 7.46, P = .005) as independent predictors of distal reoperation. Conclusions: Distal anastomotic new-entry tear commonly develops at the greater curve of the aortic arch after acute type A aortic dissection repair and substantially increases the risk of distal reoperation after hemiarch replacement and partial arch replacement but not total arch replacement, suggesting that total arch replacement may protect against distal anastomotic new-entry tear-related reoperations, particularly in patients with supra-aortic branch dissection. Careful surgical planning and long-term surveillance are crucial for optimizing outcomes.