Prognostic analysis of acute type A aortic dissection after different surgical interventions: a cohort study

Abstract

Background: Acute type A aortic dissection (ATAAD) requires emergency surgery, but the choice of primary surgery remains controversial. It is believed that simple ascending aorta replacement may lead to higher postoperative survival rate, while the Sun procedure [frozen elephant trunk (FET) + total arch replacement (TAR)] performed in the first stage may obtain better long-term results. The study aimed to compare the outcome of ATAAD patients who underwent the Sun procedure with those without TAR + FET. Methods: Data of 452 patients with ATAAD admitted to Beijing Anzhen Hospital for surgical treatment from August 1, 2020, to August 16, 2022, were collected and analyzed. Patients with the Sun procedure (n=344) were compared to those without the Sun procedure (n=108). The two groups of patients were matched using propensity score matching (PSM), and the risk factors of poor prognosis were analyzed. Results: The average postoperative follow-up period was 976±414 days, and the loss of follow-up rate was 0. The postoperative 30-day mortality rates were 12.56% and 5.38% in the Sun procedure group and the non-Sun procedure group after PSM matching, respectively (P=0.06). Multivariate logistic regression analysis showed that postoperative cardiogenic shock, postoperative cerebral malperfusion syndrome (MPS), postoperative spinal MPS, and need for continuous renal replacement therapy (CRRT) were independent risk factors for postoperative 30-day death. The 3-year survival rates were 85.02% and 91.40% in the Sun procedure group and the non-Sun procedure group after PSM matching, respectively (P=0.12). According to multivariate cox regression analysis, the independent risk factors associated with postoperative midterm death were consistent with those associated with 30-day postoperative death that pointed out by logistic regression. The incidence of spinal MPS after the Sun procedure was higher than that in the non-Sun procedure group (P=0.003). At 3-year follow-up, the probability of no distal aortic events (DAEs) was 97.17% and 91.59%, in the Sun procedure group and non-Sun procedure group, respectively, representing a significant difference (P=0.02). Multivariate Cox regression showed that Marfan syndrome and non-Sun procedure were risk factors for DAEs. Fine-Gray analysis also produced results similar to multifactor cox regression analysis, that Marfan syndrome and non-Sun procedure were risk factors for DAEs. Conclusions: There was no significant difference in postoperative mortality between the Sun procedure group and the non-Sun procedure group. The incidence of spinal MPS in the Sun procedure group was higher than that in the non-Sun procedure group, while the incidence of DAEs in the Sun procedure group was lower than that in non-Sun procedure group.