Is extended arch replacement justified for acute type A aortic dissection?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether patients with acute type A aortic dissection have a better outcome after total arch replacement. Altogether, 138 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country they are from, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All studies are retrospective. Five representative studies reported that total arch replacement could be performed safely without increasing operative mortality and morbidity compared with hemiarch replacement, but with an overall longer time of cardiopulmonary bypass and circulatory arrest. The other three reports documented an apparently higher early mortality rate in the total arch group than in the hemiarch group. In terms of long-term results, freedom from reoperation on the distal aorta is similar for patients treated with total arch replacement and with hemiarch replacement at 5 and 10 years in four papers. As for the false lumen, three reports documented that the rate of complete thrombosis of the false lumen in the proximal descending aorta was significantly higher in the total arch group than in the hemiarch group (P < 0.05). Only one study reported similar rates of complete thrombosis formation of the distal aorta in the two groups at different follow-up points (P > 0.05). The remaining four reports did not provide information about the false lumen. Evidence for long-term outcomes, albeit limited, has proved that better results of thrombosis of the false lumen can be achieved with a more extensive total arch repair. Although the literature shows no advantage of the total arch over a more limited approach, the more extensive approach may be required to achieve this goal when the entry tear extends to, or is localized in, this segment of the aorta. This suggests that a more extensive surgical strategy can be justified when it is based on circumstances, on the individual patient's clinical condition, and on the anatomical and pathological features of the dissection.