Twenty-Five Years of Open Type A Aortic Dissection Repair: Influence of Surgical Evolution and Patient Selection on Outcomes

BACKGROUND: This study evaluated operative mortality and morbidity in acute type A aortic dissection (ATAAD) over 25 years, focusing on the impact of evolving surgical techniques and patient selection. METHODS: A retrospective analysis was conducted of 498 patients undergoing ATAAD repair between 1998 and 2022 at a tertiary aortic center. Patients were stratified into surgical eras 1 (1998-2010, n = 190) and 2 (2011-2022, n = 308). The primary outcome was operative mortality, and secondary outcomes included major adverse events, stratified by organ system. RESULTS: Patients in era 2 were older (era 1, 58 [SD, 13.7] years vs era 2, 60.4 [SD, 13.4] years; P = .06), had higher rates of preoperative malperfusion (era 1, 45.8% vs era 2, 55.8%; P = .034), and higher German Registry for Acute Aortic Dissection Type A risk scores (era 1, 18.8% [SD, 10.8%] vs era 2, 22.1% [SD, 14.4%]; P = .004). Surgical strategies evolved, with increased use of total arch procedures (era 1, 5.3% vs era 2, 12%; P = .012), axillary artery cannulation (era 1, 44.2% vs era 2, 80.2%; P < .001), and antegrade cerebral perfusion (era 1, 44.2% vs era 2, 95.8%; P < .001). Operative mortality remained unchanged (era 1, 15.3% vs era 2, 14.0%; P = .7). Multivariable analysis identified axillary cannulation (odds ratio [OR], 0.4; P = .002) associated with improved survival, whereas cardiopulmonary bypass time (OR, 1.009; P < .001) and higher German Registry for Acute Aortic Dissection Type A scores (OR, 1.05; P < .001) were associated with decreased survival. CONCLUSIONS: ATAAD surgery has become more complex, with increased use of arch repairs and advanced neuroprotection strategies. Despite an older, higher-risk cohort, surgical outcomes remain stable. Axillary artery cannulation was associated with improved survival.