Zone 1 total arch replacement with frozen elephant trunk for type A dissection: early-to-mid-term outcomes

Background Total arch replacement with frozen elephant trunk is widely used to treat acute Stanford type A aortic dissection. Zone 1 proximalization, which requires concomitant extra-anatomical left subclavian artery bypass, may provide a practical balance between safety and technical complexity. Although the early outcomes of this procedure have previously been reported, comprehensive mid-term data, particularly regarding left subclavian artery bypass durability, remain limited. This study aimed to evaluate the early and mid-term outcomes of zone 1 proximalization in total arch replacement with frozen elephant trunk for acute Stanford type A aortic dissection. Methods This retrospective observational study included 80 patients with acute type A aortic dissection who underwent zone 1 total arch replacement with frozen elephant trunk, which requires concomitant extra-anatomical left subclavian artery bypass, between 2014 and 2025 at two institutions. Primary outcomes were postoperative mortality and freedom from aorta- and left subclavian artery bypass-related events. Secondary outcomes included perioperative complications and reinterventions. Event-free survival was assessed using Kaplan–Meier analysis. Results Thirty-day and in-hospital mortality rates were 8.8% and 10.0%, respectively. Stroke occurred in 12.5% of patients and spinal cord injury in 5.0%. Freedom from aorta-related events was 88.4%, 84.0%, and 81.5% at one, three, and five years, respectively; corresponding rates for left subclavian artery bypass-related events were 95.6%, 91.5%, and 86.4%, respectively. Of the 21 aorta-related events, 62% involved the downstream aorta and were managed with endovascular repair. The eight left subclavian artery bypass-related events were mostly asymptomatic occlusions caused by technical issues. Distal stent graft-induced new entry, a major late complication, was associated with a larger zone 4 diameter. Conclusions This descriptive study provided early and mid-term outcome data for zone 1 total arch replacement with frozen elephant trunk in patients with acute type A aortic dissection. The long-term durability of the left subclavian artery bypass remains a concern. Considering the anatomical features of the patient and ensuring vigilant follow-up may reduce downstream events, making this procedure a viable option for selected patients.