Distal Anastomosis New Entry After Hemiarch or Partial Arch Repair for Acute Type A Dissection: Incidence and Risk of Distal Reoperation

Objective: Distal anastomosis new entry (DANE) is an intimal tear at the distal suture line arising during repair of acute type A aortic dissection (ATAAD) that may sustain false lumen perfusion and drive adverse remodeling. We assessed its incidence, predictors, and long-term consequences after hemiarch or partial arch repair. Methods: We retrospectively analyzed 139 consecutive patients with DeBakey I ATAAD treated from 2005 to 2021 who underwent contrast-enhanced computed tomography within 3 months postoperatively. DANE was defined as any interluminal communication within 2 cm of the distal anastomosis. The primary endpoint was distal aortic reoperation. The cumulative incidence was estimated with Fine–Gray competing risk methods and predictors of DANE with Firth’s penalized logistic regression. Results: DANE was identified in 21 patients (15.1%). The 10-year cumulative incidence of distal reoperation was 32.4% (95% confidence interval [CI]: 12% to 56%) with DANE versus 4.0% (95% CI: 1% to 10%) without (Gray’s test, P < 0.001). In multivariable Fine–Gray analysis, DANE (subdistribution hazard ratio [SHR] = 6.26, 95% CI: 1.95 to 20.1, P = 0.002) and preoperative descending aortic reentry (SHR = 4.17, 95% CI: 1.12 to 15.5, P = 0.033) independently predicted distal reoperation; each 1 mm increase in DANE diameter raised the subdistribution hazard by 7% (SHR = 1.07, 95% CI: 1.03 to 1.12, P < 0.001). An arch entry tear predicted DANE formation in univariable logistic regression (odds ratio = 3.57, 95% CI: 1.18 to 10.9, P = 0.025). A Firth’s penalized 3-predictor model (arch entry tear, experienced aortic surgeon, descending reentry) yielded a 0.704 optimism-corrected area under the curve. Conclusions: DANE substantially increased the long-term risk of distal aortic reoperation after ATAAD repair, with risk graded by tear diameter.