Root and arch replacements in acute type A aortic dissection suggest lower risk of open distal reintervention

<h2>Abstract</h2><h3>Objective</h3> This study aimed to evaluate how different approaches for root and arch management during the first surgery for acute type A aortic dissection impact long-term freedom from reintervention, particularly distal reintervention. <h3>Methods</h3> This is a retrospective cohort study analyzing 164 patients who underwent acute type A aortic dissection surgery from January 2009 to April 2024. Patients were stratified into root replacement (n = 75) and non-root replacement (n = 89) groups. The root replacement group was further stratified by arch intervention type. Kaplan-Meier analysis and Cox regression models were performed to assess the impact of root and arch interventions on freedom from reinterventions. <h3>Results</h3> Root replacement significantly reduced the risk of any reintervention (hazard ratio, 0.496, <i>P</i> = .032) and open distal reintervention (hazard ratio, 0.307, <i>P</i> = .037) in univariate analyses, but not in multivariate analysis. Total arch replacement significantly reduced the risk of open distal reintervention (hazard ratio, 0.056, <i>P</i> = .011) in multivariate analysis. Patients undergoing combined root and total arch replacement demonstrated 100% 5-year freedom from open distal reintervention, compared with 82% for combined root and hemiarch replacement and 76% for non-root replacement, although only a trend was observed (p_logrank = .060). <h3>Conclusions</h3> Root and total arch replacements in acute type A aortic dissection demonstrated reduced risk of reinterventions, particularly open reintervention distal to the arch. More aggressive approaches have the potential to reduce the burden and cost of subsequent operations and improve long-term outcomes. However, although root and total arch replacements offer excellent long-term benefits, they are more complex with potentially higher perioperative risks. The decision to pursue more aggressive interventions should be based on a comprehensive patient assessment.