Modified "In Situ" Arch Replacement With An Integrative Frozen Elephant Trunk Device For Acute Type A Aortic Dissection

Background: Total arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified "in situ" arch replacement with an integrative FET device for aTAAD. Methods: From January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/- or supra-arch vessels and dilated aortic arch (>= 45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining "island" arch with the prosthetic vessel and the proximal part of the FET. Results: MiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend. Conclusions: MiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.