IYSC03 - Staged Aortic Repair using Preemptive Total Arch Replacement with Elephant Trunk Implantation for Communicating DeBakey IIIb Chronic Dissecting Aortic Aneurysm

Objectives: Although surgical strategies for communicating DeBakey IIIb chronic dissecting aortic aneurysm (CD3bDA) with proximal extent of false lumen (FL) around the left subclavian artery include open proximal anastomosis technique (OPAT) using deep hypothermic circulatory arrest through left thoracotomy, there are concerns about fatal perioperative complications. To reduce surgical invasiveness, staged aortic repair with preemptive total arch replacement plus elephant trunk implantation (TARET) has been adopted for CD3bDA.

Methods: From 2002 to 2021, 51 patients underwent open surgical repair for CD3bDA whose proximal extent of FL ranged from Zone 1 to 3 according to the SVS/STS aortic dissection classification; 18 patients received preemptive TARET (the TARET group), whereas 33 patients received thoracoabdominal aortic aneurysm repair (TAAA) or descending thoracic aneurysm repair (DTA) using OPAT (the OPAT group). Staged aortic repair included additional surgeries of the distal dissecting aorta. Early and late postoperative outcomes were compared between the two groups.

Results: Between TARET and OPAT groups, there were no significant differences in age (62.1±3.0 vs. 56.0±2.2 years), gender (male 83.3% vs. 84.9%), and connective tissue disease (11.1% vs. 18.2%), except the proximal extent of FL in the TARET group was significantly more proximal than in the OPAT group (Zone 2.3±0.1 vs. 2.9±0.1, p=0.002).
Early outcomes were associated with the incidence of stroke (0% vs. 6.1%), spinal cord injury (5.6% vs. 3.0%) and in-hospital mortality (0% vs. 6.1%), although no significant differences were observed in all these factors between the groups.
During a follow-up of 82.3 months, the additional distal surgeries for residual dissecting vessels in the TARET group was significantly higher than in the OPAT group (2.4±0.2 vs. 1.4±0.1, p< 0.0001). The 10-year overall survival for TARET and OPAT were 75.4% and 70.0%, and aorta-related death-free survival rates were 93.3% and 91.6%, but the aorta-related reintervention-free survival rate in the TARET group was significantly lower than in the OPAT group (78.8% vs. 100%: p=0.032) (Fig 1).

Conclusions: Staged aortic repair using TARET for CD3bDA may improve the incidence of early adverse events, but did not reduce the incidence of aorta-related reintervention during the follow-up period. Considering the optimal primary surgical repair based on long-term outcomes, patient-specific TAAA or DTA repair using OPAT may be adopted rather than defaulting to preemptive TARET.