Frozen elephant trunk for acute type A aortic dissection: long-term outcomes over two decades

Background and Aims: The management of acute type A aortic dissection (ATAAD) has evolved considerably over the decades and a more aggressive approach with extended arch repair has been increasingly adopted in the past 20 years. This study aims to evaluate the early and long-term outcomes of frozen elephant trunk and total arch replacement (FET + TAR) technique in patients with ATAAD. Methods: From April 2003 to December 2014, 850 patients with ATAAD (mean age 46.5 ± 10.7 years; 169 women [19.9%]; 136 with malperfusion syndrome [16.0%]) underwent FET + TAR at our center. Aortic root or valve procedures were performed in 456 patients (53.6%). The early and long-term outcomes of FET + TAR were analysed and compared to hemiarch repair in 72 propensity-matched pairs. Results: Operative mortality was 8.4% (71/850). Spinal cord injury occurred in 2.5% (21/850), stroke in 3.5% (30/850), re-exploration for bleeding in 5.6% (48/850) and acute kidney injury in 8.7% (74/850). Follow-up was complete in 99.2% (773/779) at mean duration of 12.5 ± 4.0 years (range .2–22.0). There were 153 late deaths and 90 reoperations at median 7.5 and 5.2 years (interquartile range 4.4–9.6 and 1.2–9.7), respectively. Cerebrovascular accident (hazard ratio [HR] 2.34; P = .031) and visceral ischaemia (HR 4.12; P = .005) were risk factors of late death. At 20 years, survival and freedom from reoperation were 70.0% and 85.4% (95% confidence interval [CI], 65.8%–74.0% and 80.1%–89.4%), respectively. In competing risks analysis, the incidences were 25%, 13% and 62% for death, reoperation and reoperation-free survival at 15 years, respectively. Compared to hemiarch repair, FET showed similar operative mortality (6.9% vs 4.2%, P = .719) and lower incidences of late adverse events (LAE), including death, reoperation and distal aortic dilation (16.4% vs 33.8%, P = .048), with significantly higher freedom from LAE at 20 years (78% vs 45.6%; 95% CI, 58.8%–89.0% vs 27.7%–61.8% P = .042). Conclusions: In this series spanning two decades, the FET + TAR technique achieved satisfactory long-term survival and freedom from reintervention in patients with ATAAD, showing lower risk of late death, reoperation and distal aortic dilation compared to hemiarch repair. These results argue favourably for the use of FET technique in ATAAD repair.