Staged hybrid approach for acute type A aortic dissection: zone 2 arch replacement and completion thoracic endovascular aortic repair upon indication.

Objective: This study evaluates a staged selective hybrid approach for acute type A aortic dissection. The approach involves a zone 2 aortic arch replacement with debranching of the brachiocephalic trunk and left common carotid artery to create a landing zone for thoracic endovascular aortic repair. This repair is performed either pre-emptively in the subacute phase to promote remodelling or electively in the chronic phase to manage aneurysm formation.

Methods: Between January 2022 and December 2023, data from patients undergoing this approach were prospectively collected and retrospectively analyzed. The study included all patients treated with zone 2 arch replacement and debranching for acute type A aortic dissection. Preoperative characteristics, surgical outcomes and follow-up interventions, including thoracic endovascular aortic repair, were assessed.

Results: Of the 91 patients treated for acute type A aortic dissection, 25 underwent zone 2 arch replacement. No perioperative stroke or mortality occurred in this group (mean age 62.7 years, 52% male). Eleven patients (44%) underwent thoracic endovascular aortic repair during follow-up (median interval 152 days, range 38-574). Seven repairs were performed within 6 months of the initial operation. All procedures were technically successful without complications. Early imaging showed stable or reduced aortic diameters in all thoracic endovascular aortic repair patients. In the 14 patients managed conservatively, no relevant aortic growth was observed.

Conclusions: Zone 2 aortic arch replacement with debranching in acute type A aortic dissection can be performed safely. Selective pre-emptive thoracic endovascular aortic repair promoted favourable remodelling, potentially reducing the need for complex, open surgical reinterventions.