Total Arch vs Hemiarch Repair in Acute Type A Aortic Dissection: Systematic Review and Meta-Analysis of Comparative Studies.

Background: We aimed to compare the short- and long-term outcomes of total arch replacement (TAR) vs hemiarch replacement (HAR) in the management of acute type A aortic dissection.

Methods: We searched the literature for studies directly comparing TAR to HAR in acute type A aortic dissection. Hazard ratios (HRs) were extracted from digitized Kaplan-Meier curves.

Results: A total of 6526 patients were identified, of which 2060 (32%) had received a TAR. A total of 37% of patients were female, and the mean age (standard deviation) of the cohort was 59.8 ± 11.8 years. TAR patients had a higher prevalence of preoperative malperfusion (34% vs 26%). The TAR group had higher odds of 30-day mortality (4404 patients; odds ratio [OR] 1.79, 95% confidence interval [CI] 1.29-2.49), renal failure requiring dialysis (3475 patients; OR 1.34, 95% CI 1.02-1.76), and a trend toward higher rates of stroke (3292 patients; OR 1.49, 95% CI 0.93-2.39). No significant differences were observed in prevalence of permanent spinal cord injury, visceral ischemia, or reoperation for bleeding. The TAR group had a non-statistically significant increase in long-term mortality (4408 patients; HR 1.25, 95% CI 0.99-1.57), but showed a trend toward improved freedom from long-term aortic reoperation (1359 patients; HR 0.53; 95% CI 0.18-1.59). In a subgroup analysis, the hazard ratio of long-term mortality favoured TAR in only the subgroup of studies in which the difference in malperfusion was > 10% between groups.

Conclusions: TAR could be associated with improved freedom from long-term aortic reoperation but with potentially increased perioperative risks. We recommend a tailored surgical approach.