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Outcomes of Hemiarch Versus Zone 2 Arch Replacement for DeBakey Type I Aortic Dissection
John J Kelly1, Lauren A Gillinov1, Yu Zhao1
1Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, United States.
Insights
Zone 2 arch replacement for DeBakey type I acute aortic dissection offers similar survival to hemiarch repair. While distal reinterventions are more frequent after zone 2, they are typically less invasive, suggesting a safe alternative for selected patients.
Area of Science:
- Cardiovascular Surgery
- Aortic Surgery
- Thoracic Surgery
Background:
- DeBakey type I acute aortic dissection is a life-threatening condition requiring prompt surgical intervention.
- Current surgical strategies include hemiarch and zone 2 arch replacement, each with distinct implications for aortic repair.
- Comparing outcomes is crucial for optimizing treatment pathways.
Purpose of the Study:
- To compare perioperative and long-term outcomes of hemiarch versus zone 2 arch replacement in patients with DeBakey type I acute aortic dissection.
- To evaluate differences in mortality, survival rates, and the need for subsequent interventions.
Main Methods:
- A retrospective analysis of 743 patients undergoing surgical repair for DeBakey type I acute aortic dissection between 2002 and 2023.
- Propensity-score matching created comparable cohorts of hemiarch (n=437) and zone 2 arch replacement (n=137) patients.
- Key outcomes assessed included 30-day mortality, ten-year survival, and distal reintervention rates.
Main Results:
- Thirty-day mortality was comparable between hemiarch (11.9%) and zone 2 arch replacement (8.0%), with no increased risk for zone 2 on multivariable analysis.
- Ten-year survival rates were similar: 56.2% for hemiarch and 59.8% for zone 2.
- Distal reinterventions were more common after zone 2 (46.7%) than hemiarch (15.8%), but predominantly involved less invasive thoracic endovascular aortic repair (TEVAR) in the zone 2 group.
Conclusions:
- Zone 2 arch replacement demonstrates comparable early and late survival to hemiarch replacement for DeBakey type I acute aortic dissection.
- The higher rate of distal reinterventions after zone 2 replacement primarily consists of lower-risk TEVAR procedures.
- Zone 2 arch replacement may offer a more complete aortic repair option without increasing perioperative risk in carefully selected patients.
Objectives:
The objective of this study was to compare perioperative and long-term outcomes of hemiarch versus zone 2 arch replacement for DeBakey type I acute aortic dissection.
Methods:
From 2002 to 2023, 743 patients underwent surgical repair for DeBakey type I acute aortic dissection with either hemiarch (N = 605, 81.4%) or zone 2 arch replacement (N = 138, 18.6%). 4:1 propensity-score matching yielded a cohort of 437 hemiarch patients (76.1%) and 137 zone 2 patients (23.9%). Key outcomes included 30-day mortality, 10-year survival, and distal reintervention.
Results:
In the matched cohort, 30-day mortality was 11.9% for hemiarch and 8.0% for zone 2 arch replacement (P = .198). On multivariable analysis, zone 2 arch replacement was not associated with increased risk of 30-day mortality. Ten-year survival was similar between groups, at 56.2% (50.6%-62.6%) in the hemiarch group and 59.8% (46.4%-77.1%) in the zone 2 group. Distal reintervention was more common after zone 2 arch replacement (46.7% vs 15.8%), though the majority of reinterventions in the zone 2 group were thoracic endovascular aortic repair procedures (95.3%). In contrast, over half (53.6%) of distal reinterventions after hemiarch repair were open procedures.
Conclusions:
Zone 2 arch replacement resulted in comparable early and late survival to hemiarch replacement. Although distal reinterventions were more common after zone 2 arch replacement, these were predominantly low-risk thoracic endovascular aortic repair procedures. In appropriately selected patients, zone 2 arch replacement may enable more complete aortic repair without added perioperative risk.
