1. Less invasive surgical treatment for acute type A aortic dissection involving the arch Qian Chang, Yan Li, Xiaogang Sun, Xiangyang Qian, Cuntao Yu, Yizhen Wei, Chuan Tian National Center for Cardiovascular Disease & Fuwai Hospital, Beijing, China

2. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Background Acute type A aortic dissection (ATAAD) involving the arch has high mortality and morbidity –Operative mortality ~20% Less complex procedures have traditionally been used –“Get in and get out” strategy – Distal aorta: aneurysmal dilatation or fatal rupture – 5-year need for reoperation 15-25% More extensive procedures are prompted –Total arch replacement + stented elephant trunk (TAR+SET) –Arch debranching + Arch TEVAR (Hybrid total arch TEVAR)

3. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Objective In patients presenting with ATAAD involving the arch, compare –Total arch repair + SET –Hybrid total arch TEVAR assess the fate of the distal aorta following extensive aortic repair procedures.

4. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Methods Large prospective database at our institution queried from 2009 to 2013 ​ ​ 186 patients with ATAAD involving the arch underwent extensive aortic repair procedures - TAR+SET, n=136 - Hybrid arch repair, n=50 ATAAD involving the arch was defined as (1)with the primary tear in the transverse arch or the descending aorta (2)with aneurysm formation in the aortic arch or the distal aorta (>40 mm) (3)with the involvement of in the brachiocephalic artery.

5. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Right axillary artery cannulation with selective cerebral perfusion; DHCA Implantation of Stented elephant trunk TAR with a 4-branched graft aortic and epi-arch artery reconstruction Surgical Technique 1: TAR+SET Stented elephant trunk

6. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital CPB with mild hypothermia Ascending aorta replacement using a 4-branched graft Arch debranching and epi-arch artery bypass Surgical Technique 2: Hybrid arch repair, Surgical Part

7. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Through retrograde or antegrade access A self-expanding stent graft deployed distal to the origin of the side branches of the ascending aortic graft Surgical Technique 2: Hybrid arch repair, TEVAR Part

8. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Results – Patient Demographics Variables *p<0.05 Hybrid Group (N=50) TAR +SET Group (N=136) Median Age (y)*62 (55-75)47 (29-72) Gender-male39 (78.0%)111 (81.6%) Median Logistic EuroSCORE*13.68 (10.20-53.06) 10.20 (9.04-51.39) Median EuroSCORE II (%)*8.71 (5.03-50.92) 5.03 (4.52-44.92) Etiology Hypertension44 (88.0%)111 (81.6%) Arthrosclerosis6 (12.0%)2 (1.5%) Genetically triggered023 (16.9%) Smoking29 (58%)89 (65.4%) Coronary artery disease*9 (18%)8 (5.9%) Congestive heart failure*6 (12%)9 (6.6%) Renal dysfunction*11 (22%)14 (10.3%) Chronic lung disease*10 (20%)13 (9.6%) Diabetes mellitus*8 (16%)7 (5.1%) Previous cerebrovascular disease*15 (30%)12 (8.8%)

9. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Results –Operative data Variables * p<0.05 Hybrid Group (N=50) TAR+SET Group (N=136) Repeat sternotomy1 (2.0%)3 (2.2%) Concomitant procedures Aortic valve repair14 (28.0%)32 (23.5%) Bentall procedure2 (4.0%)40 (29.4%) Wheat procedure03 (2.2%) Coronary Artery Bypass Grafting4 (8.0%)15 (11.0%) Femoral-femoral bypass2 (4.0%)21 (15.4%) Median operative time （ min ） Cardiopulmonary bypass time*130.7±22.6160.5±35.7 Myocardial ischemia time*48.5±12.8101.3±26.4 Selective cerebral perfusion timeNA24.6±8.4 Blood transfusion (red blood cells ） * 6u 9u

10. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Results –Short-term outcomes Short-term Outcomes Hybrid Group (N=50) TAR + SET Group (N=136) 30-d Mortality2 (4.0%)6 (4.4%) In-hospital mortality3 (6.0%)8 (5.9%) Stroke2 (4.0%)7 (5.1%) Paraparesis0 (0.0%)8 (5.9%) Permanemt paraplegia0 (0.0%)6 (4.4%) Injury to recurrent nerves0 (0.0%)5 (3.7%) New renal insuffiiciency9 (28.0%)33 (24.3%) Temporary hemodialysis5 (10.0%)21 (15.4%) Permanemt hemodialysis0 (0.0%)2 (1.5%) Reopearting for bleeding1 (2.0%)3 (2.6%) Need for tracheostomy3 (6.0%)10 (7.4%) Pulmonary infection10 (20.0%)28 (21.3%) Gastrointestinal bleeding / ischemia1 (2.0%)12 (8.8%) Poor wound healing / dehiscence0 (0.0%)3 (2.2%) Lower extremity amputation0 (0.0%)2 (1.5%) Graft Infection0 (0.0%)1 (0.7%) Median ICU Stay (d)4 (1-31)5 (1-40)

11. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Long-term results – Overall survival Kaplan-Meier curves for overall survival - TAR+SET - Hybrid arch repair Log-rank P=0.7

12. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Long-term results – Event-free survival Kaplan-Meier curves for MAEs-free survival MAEs = sudden death, stroke, aortic rupture, aortic reintervention - TAR+SET - Hybrid arch repair Log-rank P=0.3

13. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital - Cross-sectional CT scans during follow-up indicated thrombosis formation and expansion of the true lumen in the descending aorta. Upper row, Preoperative CT scan; Lower row, Postoperative CT scan.

14. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital Conclusions Hybrid arch repair demonstrated the superiority of the combination of the surgical and interventional approaches while avoiding the weaknesses associated with DHCA. This procedure has the potential to be an alternative for conventional total arch replacement for high-risk patients.

15. All Rights Reserved, Duke Medicine 2008 National Center for Cardiovascular Disease Fuwai Hospital