Hemostatic Properties of Aortic Root Preservation versus Root Replacement for Acute Type A Aortic Dissection: A Pooled Analysis

Objective: We reviewed the available literature on patients undergoing aortic repair for acute type A aortic dissection (ATAAD) with either aortic root preservation (RP) or root replacement (RR).

Methods: Original research studies that evaluated short- and mid-term hemostatic properties of RP versus RR groups were identified, from 2000 to 2024. Intraoperative transfusions of red blood cells (RBCs), reoperation for bleeding, strategy of hemostatic sealing of the anastomosis in root repair following the reapproximation of the dissected layers of the aortic wall (with/without biological glue), and operative mortality were the primary endpoints. Postoperative morbidity and overall and reoperation-free survival at one and five years were the secondary endpoints. A sensitivity analysis was performed using the leave-one-out method.

Results: Ten studies were included in the qualitative and quantitative synthesis, incorporating data from 6850 patients (RP: 4389 patients; RR: 2461 patients). Root preservation demonstrated a lower median transfusion of RBCs (WMD: -1.00; 95% CI: -1.41, -0.59; p < 0.01) and incidence of reoperation for bleeding compared to root replacement (OR: 0.67; 95% CI: 0.58, 0.77; p < 0.01). The majority of studies did not use biological glue in root repair to avoid the risk of an anastomotic pseudoaneurysm. No difference was found regarding postoperative morbidity, along with mid-term overall and reoperation-free survival.

Conclusions: Root preservation without the use of biological glue during aortic repair is associated with enhanced hemostatic traits compared to the root replacement approach. A future well-designed Randomized Controlled Trial should further validate our outcomes.