Hemiarch repair versus total-arch repair with frozen elephant trunk for acute type A aortic dissection: A propensity score–matched study

Objective The optimal extent of arch repair remains controversial in acute type A aortic dissection (ATAAD). While hemi-arch replacement (HAR) may offer more favorable perioperative outcomes, total-arch replacement with frozen elephant trunk (TAR with FET) may offer superior long-term outcomes. This study aims to compare these strategies in a contemporary single-center cohort. Methods Patients undergoing arch repair for ATAAD between January 2020 and January 2025 were included. Propensity score matching was used for further analyses. Primary outcomes included operative mortality and aortic reinterventions. Secondary outcomes included reexploration for bleeding, renal failure, respiratory failure, neurological complications, and aortic positive remodeling, defined as true lumen expansion greater than 50%. Results Among 786 patients (171 hemi-arch, 615 total-arch), 272 patients were included in the matched cohort, comprising 136 matched pairs of HAR and TAR with FET, with a median follow-up of 3 years. Perioperative outcomes were comparable: operative mortality (5.1% HAR vs. 7.4% TAR with FET; Odds ratio: 1.50; p = 0.442), renal failure (12.5% vs. 8.8%; OR: 0.71; p=0.353), respiratory failure (22.8% vs. 25.7%; OR: 1.17; p=0.579), and neurological complications (13.2% vs. 16.2%; OR: 1.29; p = 0.481). Meanwhile, 3-year survival ( p = 0.420) and aortic reintervention rates ( p = 0.135) were also comparable. Computed tomography angiography demonstrated superior aortic remodeling after TAR with FET replacement, with a greater true lumen ratio and a higher rate of true lumen expansion (28.7% vs. 42.9%; OR: 0.54; p = 0.019). In a subgroup analysis of patients with acute malperfusion, perioperative mortality and major complications remained high overall. However, no significant differences were observed between HAR and TAR with FET in this subgroup. Conclusions HAR and TAR with FET were associated with similar perioperative outcomes and 3-year survival rate. Although aortic remodeling is superior in TAR with FET group, 3-year aortic reintervention rates were comparable. Our findings suggest that TAR may be considered more proactively in high-volume aortic centers, however, the longer term clinical benefits remain undefined. Further study is warranted.