Acute type A aortic dissection (ATAAD) represents one of the most critical emergencies in cardiovascular surgery. Urgent surgical intervention remains the only effective strategy to ensure survival. However, the optimal extent of surgical repair in cases involving the aortic arch remains debated. While some surgeons advocate for limited procedures confined to the ascending aorta or hemiarch, others favor a more extensive strategy, such as total arch replacement (TAR) with frozen elephant trunk (FET), aiming to decrease late complications and reduce the need for subsequent reinterventions.

TAR combined with FET has been proposed as a comprehensive solution that addresses the proximal tear while stabilizing the descending thoracic aorta. Nevertheless, this approach entails greater technical complexity, longer operative times, and potentially increased perioperative risk. Moreover, robust long-term outcome data have historically been scarce. The present study assesses long-term survival, reintervention rates, and functional status in a large single-center cohort undergoing TAR with FET for ATAAD.

Between 2010 and 2022, 1672 patients with ATAAD underwent TAR with FET at Fuwai Hospital. Clinical data were collected prospectively, and long-term follow-up was systematically performed. The median follow-up duration was 4.5 years, with a maximum exceeding 13 years. Primary endpoints included operative mortality, long-term mortality, and reoperation. Risk factors were analyzed using logistic regression for operative mortality and Cox proportional hazards models for long-term mortality and reintervention. Functional status was assessed using a structured activities-of-daily-living scale.

Operative mortality was 6.3%. Overall survival reached 87.9% at 5 years and 81.4% at 10 years. The cumulative incidence of reoperation at 10 years was 13.3%. Among survivors, nearly 90% maintained complete independence and were capable of performing general physical work. The cohort was predominantly male (79.9%), with a median age of 48 years.

Female sex, advanced age, coronary artery disease, preoperative malperfusion, and prolonged CPB time were independently associated with increased mortality. Marfan syndrome, prior TEVAR, and specific root procedures were linked to a higher risk of reintervention.

The authors conclude that TAR with FET provides acceptable operative mortality and favorable long-term outcomes, including sustained functional independence, and should be considered in experienced centers.

COMMENTARY:

ATAAD remains one of the most demanding conditions in cardiovascular surgery. The work by Zhang et al. enters an especially relevant debate: how extensive should the initial repair be? Historically, limited strategies aimed at resolving the acute life-threatening component while minimizing CPB and HCA times have predominated. Although pragmatic, such approaches often leave residual distal dissection, progressive aneurysmal degeneration, and a considerable rate of late reintervention. In contrast, the concept of performing an extensive, definitive repair during the index operation represents a paradigm shift. The goal is not only to rescue the patient from the acute phase but also to optimize long-term prognosis. The strength of this study lies precisely in its capacity to provide long-term data supporting this philosophy.

First, the sample size and duration of follow-up are remarkable, particularly in the ATAAD field, where large single-center cohorts with over a decade of follow-up are uncommon. This volume allows for a robust analysis of outcomes and associated risk factors. Importantly, the authors go beyond survival and include functional status, offering clinically meaningful information. The finding that nearly 90% of survivors remain capable of general physical activity 10 years after surgery is highly relevant: the benefit of surgery is not limited to survival, but extends to quality of life.

A key message is that an aggressive surgical strategy does not necessarily translate into worse early outcomes when performed in high-volume, experienced centers. The observed operative mortality compares favorably with many series of more limited repairs. This underscores the importance of institutional experience and procedural standardization, which may be more decisive than the extent of repair itself.

The association between female sex and both early and late mortality aligns with several international registries, although the underlying mechanisms remain incompletely understood. The authors suggest plausible biological explanations, but this finding emphasizes the need for heightened vigilance in this subgroup. Likewise, preoperative malperfusion significantly increased early mortality but did not adversely affect long-term outcomes, suggesting that comprehensive anatomical repair may mitigate the long-term impact of initial ischemic injury.

Regarding reintervention, the strong association with prior TEVAR and Marfan syndrome reinforces the concept of aortic dissection as a chronic and progressive disease. In these patients, the index procedure should be viewed as the first stage of lifelong management. In this context, FET may provide a strategic advantage by facilitating subsequent distal aortic interventions.

Nevertheless, caution is warranted when generalizing these results. The study originates from a national referral center with an annual volume exceeding 100 arch replacements, a figure that is rarely matched in most institutions. Outcomes may reflect not only the surgical strategy but also the learning curve and team organization.

Furthermore, the absence of a control group undergoing a more conservative approach precludes direct comparison within the same population. The relatively young age of the cohort may also contribute to favorable long-term results. These limitations do not detract from the study’s value but highlight that no single strategy is universally applicable.

Overall, this study supports a growing body of evidence suggesting that extensive arch repair with FET, when performed in expert centers, may represent a long-term investment rather than an excessive risk. Rather than definitively answering how much to repair, this work invites a more nuanced question: in which patients, in which centers, and under which circumstances should we pursue a more aggressive initial strategy?

REFERENCE:

Zhang K, Qiu J, Wu J, Zhou C, Ji Y, Xie E, et al. Long-term outcomes in total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2025;170:994-1005. doi:10.1016/j.jtcvs.2024.11.025