The fate of the downstream aorta after open aortic repair for acute DeBakey type I aortic dissection: total arch replacement with elephant trunk technique versus non-total arch replacement†

Impact of Residual Entry Tears in the Descending Aorta After Type A Dissection

BACKGROUND

Aggressive resection/exclusion of the primary entry in the descending aorta remains controversial in older patients with acute type A aortic dissection (ATAAD). We investigated the effect of residual primary entry in the descending aorta in younger and older groups.

METHODS

Patients with ATAAD who underwent emergency operation (n = 1103) were divided into younger (<70 years; n = 681) and older (≥70 years; n = 422) cohorts. Each cohort was further divided into groups with or without residual primary entry in the descending aorta. After propensity score matching, 179 and 71 matched pairs were obtained in the younger and older cohorts, respectively. Surgical outcomes were compared between the residual and nonresidual groups in each age cohort.

RESULTS

In the younger cohort, the cumulative incidence rate of distal aortic events was significantly higher in the residual than in the nonresidual group at 10 years (35% [95% CI, 27%-44%] vs 22% [95% CI, 15%-31%], P = .001). However, in the older group, residual or nonresidual primary entry did not affect the rates at 10 years (11% [95% CI, 5%-20%] vs 9% [95% CI, 4%-17%], P = .75). Multivariate analysis identified age <70 years (hazard ratio, 2.188; 95% CI, 1.493-3.205; P < .001) and residual primary entry at the descending aorta (hazard ratio, 2.142; 95% CI, 1.559-2.943; P < .001) as significant predictors for distal aortic events.

CONCLUSIONS

Aggressive resection/exclusion of the primary entry in the descending aorta should be considered for patients aged <70 years to avoid distal aortic events; however, it might not always be appropriate for the older patients ≥70 years.

Distal aortic progression following acute type A aortic dissection repair among patients with bicuspid and tricuspid aortic valves

OBJECTIVE

The study objective was to analyze long-term growth and outcomes of the distal aorta after open acute type A aortic dissection repair in patients with bicuspid aortic valves or tricuspid aortic valves without connective tissue disease.

METHODS

From 1996 to 2021, 60 patients with bicuspid aortic valves and 655 patients with tricuspid aortic valves without connective tissue disease underwent open repair for acute type A aortic dissection. Data were collected from the local Society of Thoracic Surgeons database, medical record review, surveys, and the National Death Index and Michigan Death Index (December 12, 2021).

RESULTS

Compared with the tricuspid aortic valve group, the bicuspid aortic valve group was significantly younger, had more severe aortic insufficiency (33% vs 22%, P = .05), and had less hypertension (67% vs 78%, P = .05). Intraoperatively, patients with bicuspid aortic valves received more aortic root replacements (70% vs 26%, P < .001), less zone 2 aortic arch replacement (8.3% vs 20%, P = .03), and longer median cardiopulmonary bypass (233 vs 214 minutes, P = .05) and aortic crossclamp (184 vs 141 minutes, P < .001) times. The average annual aortic arch growth rate (0.23 mm/year vs 0.39 mm/year, P = .52) and descending aorta growth rate (0.61 mm/year vs 0.79 mm/year, P = .39) were similar between the bicuspid aortic valve and tricuspid aortic valve groups. The bicuspid aortic valve group had lower annual abdominal aorta growth (0.51 mm/year vs 0.68 mm/year, P = .03). The cumulative incidence of reoperation for the distal aorta (9.7% vs 16.0%, P = .77) was similar between the bicuspid aortic valve and tricuspid aortic valve groups. The 10-year survival was higher in the bicuspid aortic valve group (75.4% vs 66.0%, P = .03).

CONCLUSIONS

Patients with bicuspid aortic valves could be treated similarly as patients with tricuspid aortic valves without connective tissue disease in the setting of open acute type A aortic dissection repair.

Safety and effectiveness of the sutureless integrated stented graft prosthesis in an animal model

Background

Prolonged circulatory arrest time is an independent risk factor for postoperative adverse events of type A aortic dissection (TAAD) surgery. Further reduction of the circulatory arrest time is essential to improve surgical outcomes. This study aimed to evaluate the safety and effectiveness of the novel Sutureless Integrated Stented (SIS) graft prosthesis in an animal experiment.

Materials and methods

Straight type of the SIS graft prosthesis was implanted into the descending aorta of 10 adult male sheep, and the use of the device was scored on a scale of 1-10. Aortic digital subtraction angiography (DSA) was performed at 4, 14, and 26 weeks to investigate the prostheses. After 26 weeks, the animals were sacrificed for histological analysis.

Results

The immediate success rate of the surgery was 100 %, and the overall mean score of the use of the device was 9.65 ± 0.99. Three animals died from non-device-related causes during follow-up. Aortic DSA showed filling defects in 5 animals. Histological analysis revealed that all prostheses were intact. Except for 2 early deaths, the other 8 prostheses were endothelialized with mild inflammation, foreign body reactions, and intimal fibrosis. The mean cross-sectional area of the sutureless region was reduced by 26.4 % (range, 1.3-39.1 %).

Conclusions

The safety and effectiveness of the novel SIS graft prosthesis were acceptable, and the delivery system exhibited a promising performance. Using the SIS graft prosthesis in TAAD surgery was expected to simplify the procedures and shorten the circulatory arrest time. Further large-scale clinical trials are required to verify these findings.

Effects of Residual Arch Tears on Late Outcomes After Hemiarch Replacement for DeBakey I Dissection

BACKGROUND

This study evaluated the effect of residual arch tears on late reinterventions and arch dilatation after hemiarch replacement for patients with acute DeBakey type I aortic dissection.

METHODS

Between January 1995 and October 2018, 160 consecutive patients who underwent hemiarch replacement for DeBakey type I dissection were retrospectively enrolled. They were divided into patients with (n = 73) and without (n = 87) residual arch tears. The arch tears group was subdivided into the proximal/middle arch (n = 26) and distal arch (n = 47) groups to evaluate arch growth rates according to the locations of residual arch tears. The endpoints were arch growth rate and late arch and composite events.

RESULTS

The arch diameter increased significantly over time in patients with residual arch tears (1.620 mm/y, P < .001). The increase occurred more rapidly when residual tears occurred at the distal arch than at the proximal/middle arch level (2.101 vs 1.001 mm/y). In the adjusted linear mixed model, residual arch tears or luminal communications at the distal arch level were significant factors associated with increases in the arch diameter over time. The 10-year freedom from late arch and composite event rate was significantly lower for patients with residual arch tears than for those without (82.4% vs 95.5%, P = .001; and 68.0% vs 89.3%, P = .002, respectively).

CONCLUSIONS

Residual arch tears are significant factors associated with late arch dilatation and reinterventions, especially for patients with distal arch tears. Extensive arch replacement during the initial surgery to avoid residual arch tears may improve long-term outcomes.

The Effect of Ascending Aortic Repair on Left Ventricular Remodeling

Left ventricular (LV) hypertrophy is common in patients with thoracic aortic diseases and is associated with increased long-term mortality. Thoracic aortic aneurysms are reported to increase LV afterload because of kinetic energy loss within the aneurysm sac, which may improve after surgical repair. However, LV afterload may also increase because of the stiffness of prosthetics used for aortic repair. We sought to investigate the long-term effect of surgical aortic repair with prostheses on postsurgical LV mass. We reviewed patients who underwent ascending aortic replacement with a prosthesis at our institution from January 2008 to December 2018. We calculated the LV mass index based on pre- and postoperative echocardiogram measurements. The primary outcome was the change in LV mass index 6 months after aortic repair. Patients aged <18 years and those who had concomitant cardiac operations, severe aortic valve disease, or who had no echocardiographic data were excluded. Of 1,008 patients who underwent ascending aortic replacement, 134 (51 with acute aortic dissections) were included. The median baseline and follow-up LV mass index were 107 (90 to 135) g/m² and 101 (83 to 123) g/m², respectively. Overall, there was a significant reduction of LV mass index over time (p = 0.03). LV mass index decreased in 77 patients (59%). Presentation due to acute aortic dissection (p = 0.03) and baseline LV mass index (p <0.001) were significant predictors of LV mass reduction. In conclusion, LV mass index may significantly decrease over time after the aortic repair, but the course is highly variable. The largest decrease occurred in patients who presented because of aortic dissections rather than for elective repair of aneurysms.

Effects of a frozen elephant trunk on postoperative renal dysfunction in acute type A aortic dissection extending into the renal artery

BACKGROUND

We investigated the effects of frozen elephant trunk (FET) implantation on clinical outcomes in patients with acute type A aortic dissection (ATAAD) extending into the renal artery (RA).

METHODS

Between May 2016 and April 2021, 136 patients underwent surgery for ATAAD at our hospital. Patients who died within 7 days postoperatively and those without preoperative contrast-enhanced computed tomography (CT) data were excluded from the study. The remaining 125 patients were included in this study. A preoperative CT-documented RA abnormality was found in 53 patients. Clinical outcomes, including renal dysfunction and CT findings, were compared between 29 patients with and 24 patients without the FET prosthesis.

RESULTS

Among the 53 patients with RA abnormalities, origin of the RA from the false lumen was the most common type of abnormality. The percentage of men and rate of arch repair were higher, and the operation, cardiopulmonary bypass, and lower body hypothermic circulatory arrest times were longer in the FET than in the non-FET group. Early mortality rates were similar between groups. The incidence of postoperative acute kidney injury (AKI) was lower in the FET group (35% vs. 67%, p = 0.028). Multivariable analysis showed that FET implantation was associated with a low incidence of AKI (odds ratio: 0.28, 95% confidence interval: 0.08-0.96; p = 0.043). Among the 125 patients with or without RA abnormalities, no predictor of AKI was identified.

CONCLUSION

FET implantation protected against postoperative AKI in patients with ATAAD extension into the RA.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis

OBJECTIVES

Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD).

METHODS

A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed.

RESULTS

A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm.

CONCLUSIONS

In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.

Influence of residual primary entry following the tear-oriented strategy for acute type A aortic dissection

OBJECTIVES

Although a tear-oriented strategy has contributed to improving short-term surgical outcomes of acute type A aortic dissection (ATAAD), long-term clinical influences of residual entry tear in the downstream aorta have not been fully investigated. The goal of this study was to assess the long-term surgical outcomes of ATAAD with or without a residual entry tear in the downstream aorta.

METHODS

Medical records of 1107 patients with ATAAD who underwent emergency surgery between 1990 and 2018 were retrospectively reviewed. A tear-oriented paradigm was adopted for the baseline strategy. The 837 patients in whom the entry tears were resected comprised the resected group, and the 270 patients with a residual entry tear comprised the residual group. Of these patients, 252 in each group were analysed using propensity score matching, and long-term outcomes were compared with or without residual entry.

RESULTS

Hospital deaths were lower in the resected group (3.2% vs 8.3%; P = 0.020). The survival rate was not significantly different between the groups: It was 83.8% and 68.5% in the resected group and 80.2% and 66.5% in the residual group at 5 and 10 years, respectively (P = 0.600). However, residual entry in the downstream aorta affected the distal aortic event-free survival rate (90.4% and 80.6% in the resected group and 82.3% and 67.4% in the residual group at 5 and 10 years, respectively; P = 0.003). Furthermore, multivariable risk analysis of 1107 patients confirmed that a residual entry in the downstream aorta was a risk factor for distal aortic events.

CONCLUSIONS

The tear-oriented strategy remains the gold standard for high-risk patients; however, the extensive operation might be considered for stable patients to reduce long-term aortic events.

Postoperative Maximal Aortic Diameter is a Significant Predictor of Dilation of the Residual Dissected Aorta after Aortic Replacement for Acute Debakey Type I Aortic Dissection

BACKGROUND

This study investigated the impact of aortic diameter on late aortic dilation of the residual dissected aorta after tear-oriented aortic replacement for acute DeBakey type I aortic dissection.

METHODS

Of 133 patients who underwent aortic replacement for acute DeBakey type I/II aortic dissection between 2008 and 2019, 45 patients with a residual dissected aorta after surgery for acute DeBakey type I aortic dissection and who underwent computed tomography at predischarge and after 1 year were retrospectively assessed. The aortic diameter and false lumen area were measured at 3 levels: the maximal aortic site, seventh thoracic vertebra, and celiac axis. Multivariable Cox regression analysis was employed to identify the predictors of late aortic dilation, defined as an aortic growth rate of ≥5 mm/year or a maximal aortic diameter of ≥55 mm.

RESULTS

During a median follow-up of 75 [range: 13-152] months, 6 patients (5 men; mean age: 57 ± 14 years) experienced aortic dilation. All 6 patients had the maximal aortic diameter between the distal aortic arch and seventh thoracic vertebra level at the last computed tomography. Multivariable Cox regression analysis showed that the predischarge maximal aortic diameter was an independent determinant of late aortic dilation (hazard ratio: 2.28/mm, 95% confidence interval: 1.10-5.86).

CONCLUSIONS

Predischarge maximal aortic diameter is a significant predictor of late aortic dilation in patients with a residual dissected aorta after tear-oriented surgical repair of acute DeBakey type I aortic dissection.

Clinical outcomes of a fenestrated frozen elephant trunk technique for acute type A aortic dissection

OBJECTIVES

We investigated the outcomes of a fenestrated frozen elephant trunk (FET) technique performed without reconstruction of one or more supra-aortic vessels for aortic repair in patients with acute type A aortic dissection.

METHODS

We investigated 22 patients who underwent the fenestrated FET technique for acute type A aortic dissection at our hospital between December 2017 and April 2020. The most common symptom was chest pain and/or back pain. Nine patients presented with malperfusion and 1 with cardiac arrest, preoperatively. A FET was deployed under hypothermic circulatory arrest and manually fenestrated under direct vision. Single fenestration was made in the FET in 15 patients, 2 fenestrations in 5 patients and a total fenestrated technique in 2 patients. Concomitant procedures were performed in 5 patients.

RESULTS

The cardiopulmonary bypass, aortic cross-clamp and hypothermic circulatory arrest times were 181 ± 49, 106 ± 43 and 37 ± 7 min, respectively. In-hospital mortality, stroke, or recurrent nerve injury did not occur in any patient. One patient developed paraparesis, which completely recovered at discharge. During the follow-up period (mean 18 ± 7 months), 1 patient died of heart failure. Fenestration site occlusion did not occur. Follow-up computed tomography (mean 12 ± 6 months postoperatively) revealed that the maximal aortic diameter remained unchanged at the levels of the distal end of the FET, the 10th thoracic vertebra and the coeliac artery; however, the aortic diameter was significantly reduced at the level of the pulmonary artery bifurcation.

CONCLUSIONS

The fenestrated FET technique is a simple, safe and effective procedure for selected patients with acute type A aortic dissection.

The frozen elephant trunk technique in acute DeBakey type I aortic dissection

Although advances in the field of cardiovascular surgery have improved outcomes for patients with acute DeBakey type I aortic dissection, postoperative in-hospital mortality and morbidity remain substantial. The frozen elephant trunk technique has become a treatment option for this disease and was developed primarily to extend repair into the proximal descending thoracic aorta during aortic arch repair (because the descending thoracic aorta is largely inaccessible via median sternotomy), thus avoiding, delaying, or facilitating subsequent repair of residual native aorta. In this review, we discuss the evidence for and future development of frozen elephant trunk reconstruction for acute DeBakey type I aortic dissection.

Contemporary Surgical Strategies for Acute Type A Aortic Dissection

Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Critical appraisal of multidimensional CT measurements following acute open repair of type A aortic dissection

INTRODUCTION

To identify patients with aneurysmal degeneration of the native aorta following type A aortic dissection (TAAD), reproducible serial measurements of aortic dimensions are critical. We used a systematic workflow for measuring aortic geometry following TAAD, using computed tomography angiography data, and test its reproducibility.

METHODS

The workflow for aortic measurements included centerline generation, luminal diameter, and area measurement at six anatomically defined locations along the aorta and luminal volumetric measurements in the descending aorta. Two independent observers measured the aortic geometry in 20 surgically repaired TAAD patients, preoperatively and at 3 months follow-up. To test reproducibility, intraobserver and interobserver agreement scores were analyzed using a concordance correlation coefficient (CCC).

RESULTS

The interobserver agreement scores of the diameter, area, and volumetric measurements in the descending aorta were acceptable. The agreement scores of the area measurements were highest, with CCCs ranging from 0.909 to 0.984. Luminal diameter measurements scored lower than luminal area measurements and were least reproducible at the mid aortic arch (CCC < 0.886). Overall, intraobserver agreement scores were better than interobserver agreement scores (SD of mean difference was 1.89 vs 1.94 for intraobserver vs interobserver diameter measurements, and 0.61 vs 0.66 for area measurements).

CONCLUSION

Although overall reproducibility was acceptable in descending aortic measurements, our results show that it remains challenging to reliably measure luminal diameters, compared with areas. To aid identification of early adverse remodeling following acute TAAD, novel two- and three-dimensional measurement techniques are needed that capture locoregional changes in the false lumen and true lumen morphology more accurately.

The Impact of a Reentry Tear After Open Repair of Nonsyndromic Acute Type I Aortic Dissection

BACKGROUND

The role of a reentry tear in the descending thoracic aorta (DTA) after repair of acute aortic dissection is not well known. We therefore investigated the impact of reentry tear location on late aorta reintervention and the aortic expansion rate after open repair of acute type I aortic dissection.

METHODS

We analyzed 309 nonsyndromic acute type I aortic dissection patients who were treated with a repair to the proximal aorta between 1994 and 2017. The locations of reentry tears, identified with predischarge computed tomography, were the proximal DTA in 119 patients (38.5%), distal DTA in 78 (25.2%), and abdominal aorta in 129 (41.7%). Patients who had a proximal DTA reentry tear were defined as the PDR group (119 [38.5%]), and the others were defined as the non-PDR group (190 [61.5%]).

RESULTS

The 15-year freedom from aorta reintervention was significantly lower in the PDR group (51.5% ± 0.7% vs 90.4% ± 4.4%, P < .001). The aortic expansion rates of the proximal DTA (7.6 ± 16.1 mm/y vs 0.1 ± 2.5 mm/y, P < .001) and distal DTA (6.8 ± 15.5 mm/y vs 0.3 ± 3.1 mm/y, P < .001) were significantly higher in the PDR group. The 15-year freedom from significant aortic expansion was significantly lower in the PDR group (34.6% ± 6.9% vs 83.6% ± 7.9%, P < .001). Multivariate analysis showed that a proximal DTA reentry tear was an independent risk factor for aorta reintervention (hazard ratio, 4.955; 95% confidence interval, 1.691-14.523; P = .004) and significant aortic expansion (HR, 4.214; 95% CI, 1.691-10.498; P = .002).

CONCLUSIONS

A proximally located DTA reentry tear was associated with an increased risk of late aorta reintervention and distal aortic dilatation.

Gender-related differences in patients with acute aortic dissection type A

OBJECTIVE

Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A.

METHODS

Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery.

RESULTS

Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21).

CONCLUSIONS

Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders.