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Ann Thorac Surg 1998;66:402-411
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Operation for acute and chronic aortic dissection: recent outcome with regard to neurologic deficit and early death

^a Department of Surgery, The Methodist Hospital and Baylor College of Medicine, Houston, Texas, USA

Address reprint requests to Dr Safi, 6550 Fannin, Suite 1603, Houston, TX 77030

Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. We reviewed our experience in the repair of acute and chronic aortic dissection with regard to early neurologic deficit and death.

Methods. Between February 1991 and June 1996, we performed 206 operations on 195 patients for aortic dissection. Ascending or arch repair, or a combination (type A dissection) was performed on 92 of 206 patients (45%); 44 of 92 (48%) were acute dissection and 48 of 92 (52%) were chronic. Descending or thoracoabdominal repair (type B dissection) was performed on 114 of 206 patients (55%); 22 of 114 (19%) were acute and 92 of 114 (81%) were chronic.

Results. Among type A cases, strokes occurred in 6 of 92 patients (7%) overall; 4 of 44 (9%) were acute cases and 2 of 48 (4%) were chronic (p < 0.34). Early deaths for type A were 11 of 92 (12%) overall; 9 of 44 (20%) acute and 2 of 48 (4%) chronic (p < 0.02). In type B cases, neurologic complications were 15 of 114 (13%) overall; 7 of 22 (32%) were acute cases and 8 of 92 (9%) were chronic (p < 0.004). Early deaths for type B were 12 of 114 (11%) overall; 3 of 22 (14%) acute and 9 of 92 (10%) chronic (p < 0.6). Preoperative hypotension was significant in acute type A patients, with strokes in 2 of 7 (29%) hypotensives compared with 2 of 37 (5%) normotensives (p < 0.05) and early death in 4 of 7 (57%) hypotensives versus 5 of 37 (14%) normotensives (p < 0.009).

Conclusions. Morbidity and mortality for repair of chronic dissection types A and B were acceptable. Preoperative hypotension in acute type A dissection was a major predisposing factor toward stroke (29% versus 5%, p < 0.05). Acute type B dissection had acceptable mortality (14%) but a high rate of neurologic complications (32%).

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
In the frequent catastrophic cascade of events immediately after an aortic dissection, patient survival relies on rapid diagnosis and early therapeutic intervention [1-3]. The patient is at the greatest risk in the acute phase, within 14 days of the initial dissection, when complications brought on by hemorrhage or rupture are most likely. The decision to manage surgically or medically depends on the time elapsed since onset, the dissection location, and urgency of presentation. Most often the treatment of type A, which originates in the ascending aorta, is surgical. Type B, in the descending thoracic aorta, is more often treated medically in the acute stage and surgically in the chronic stage. In this study we examined the results of our operative treatment of aortic dissection during the past 5 years, with particular attention to the differences in morbidity and mortality between acute and chronic aortic dissection patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patient population
Between February 1991 and June 1996, 206 operations were performed on 195 patients by one surgeon (H.J.S.). Patient characteristics are as follows for the 92 type A patients: acute dissection, 44 (48%); stroke, 6 (7%); 30-day mortality, 11 (12%); hypotensive crisis (systolic blood pressure <60 mm Hg or moribund presentation, ie, cardiopulmonary arrest, pulseless, or in shock), 7 (8%); cerebrovascular disease (stroke, transient ischemic attack, or atheroocclusive disease of the carotid arteries), 12 (13%); heart disease (aortic valve disease, atheroocclusive disease of the coronary arteries, or cardiomyopathy), 20 (22%); previous aortic operation, 32 (35%); hypertension, 56 (61%); current smoker, 22 (24%); and for the 114 type B patients: acute dissection, 22 (19%); neurologic deficit (paraplegia or paraparesis), 15 (13%); 30-day mortality, 12 (11%); renal insufficiency, 13 (11%); heart disease, 28 (25%); previous proximal aortic operation, 28 (25%); hypertension, 91 (80%); and current smoker, 41 (28%). The selected risk factors for stroke in type A dissection and for spinal cord neurologic deficit in type B are shown in Table 1. Men comprised more than two-thirds of all patients. Patients were divided roughly in half between operation for repair of the ascending aorta (type A dissection) and repair of the descending thoracic or thoracoabdominal aorta (type B dissection). A greater number of type A repairs, however, took place in the acute phase (44 of 92 or 48%) compared with type B repairs (22 of 114 or 19%) (p < 0.001). Age did not differ significantly between these two groups. Six of 92 (7%) of the type A repairs were in patients with Marfan’s syndrome, as were 7 of 114 (6%) of type B repairs. Twenty-five of 92 type A patients (27%) underwent the first stage of aortic repair with the elephant trunk technique; 1 had an acute dissection, the remainder had chronic dissections. Twelve of 24 patients had completed the second half of this two-stage repair at the time of this study. The specific operations performed for the 92 type A patients were as follows: aortic valve and ascending aorta, 9 (10%); aortic valve, ascending aorta and arch, 16 (17%); ascending aorta, 20 (22%); ascending aorta and proximal arch, 9 (10%); ascending aorta and transverse arch, 11 (12%); transverse arch, 2 (2%); elephant trunk, stage 1, 25 (27%); and for the 114 type B patients: elephant trunk, stage 2, 12 (11%); descending thoracic aorta, type A, 1 (0.8%); descending thoracic aorta, types A, B, 9 (8%); descending thoracic aorta, types A, B, C, 16 (14%); thoracoabdominal aortic aneurysm, type I, 29 (25%); thoracoabdominal aortic aneurysm, type II, 42 (37%); thoracoabdominal aortic aneurysm, type III, 4 (4%); and abdominal aorta, 1 (0.8%). Among acute type A patients, 7 were hypotensive, with preoperative cardiopulmonary arrest in 4 patients and blood pressure below 60 mm Hg in 3. In September 1992, we abandoned the simple cross-clamp technique in favor of the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage, which was consequently used in 73 of 114 type B patients (64%). Similarly, retrograde cerebral perfusion, in addition to hypothermic circulatory arrest, was added to the surgical protocol for ascending and arch patients in February 1994 for 77 of 92 type A patients (84%).

Patient selection and operative methods
Our protocol for treating acute aortic dissection depends on the patient presentation. If a patient had a moribund presentation to the emergency department he or she was sent directly to the operating room for anesthesia induction and transesophageal echocardiography to identify the site and extent of the intimal disruption. A patient who presented with acute symptoms, but was not moribund, was admitted to the surgical intensive care unit where he or she was evaluated with transesophageal echocardiography and prepared for operation as soon as possible.

Acute type A dissection
After transfer to the operating room, median sternotomy was performed and the patient was placed on cardiopulmonary bypass and the systemic temperature cooled for profound hypothermia. Cannulation was femoral–femoral for cardiopulmonary bypass, and to the superior vena cava for retrograde cerebral perfusion. Myocardial protection was provided throughout the procedure by cardioplegic perfusion through the coronary sinus, keeping the myocardial temperature less than 15°C. Venting through the left superior pulmonary vein or artery prevented ventricular distention and allowed optimal decompression of the left ventricle. When the electroencephalogram was isoelectric and the nasopharyngeal temperature reached approximately 12°C, the pump was stopped, and retrograde cerebral perfusion was begun through the superior vena cava. The rate of pump flow did not exceed 500 mL/min and the pressure did not exceed 25 mm Hg. The ascending aorta was inspected for the site and extent of the tear, the involvement of the transverse arch, and assessment of intimal disruption requiring repair. The ascending aorta was opened longitudinally and then transected just proximal to the innominate artery. Provided the transverse arch was free of reentry, we sutured the intima and adventitia together with fine 4-0 and 5-0 polypropylene suture (Fig 1A ). A gelatin woven Dacron graft was sutured to the reinforced proximal aortic arch in end-to-end fashion, and reinforced from both inside and outside with 4-0 pledgeted sutures (Figs 1B, 1C). When the distal anastomosis was completed, retrograde cerebral perfusion was stopped and cardiopulmonary bypass restarted through the femoral artery to evacuate all air and debris from the brachiocephalic vessels. The graft was clamped proximal to the origin of the innominate artery. Flow to the cerebral and systemic circulation was restored and the head of the table was elevated. On rare occasions when the brachiocephalic arterial flow was not adequate, as manifested by low radial artery pressure and due to a dissecting flap, we cannulated the ascending aortic graft and delivered flow to the head in antegrade fashion. The patient was rewarmed with restoration of antegrade flow.

View larger version (180K): [in this window] [in a new window]   Fig 1. (A) The intima and adventitia are sutured together. (B, C) Reinforcement of graft and aortic arch with pledgeted sutures. (D, E) Pledgeted reinforcement of supracoronary intima and adventitia.

View larger version (130K): [in this window] [in a new window]   Fig 2. Composite valve graft with modified Cabrol reattachment of left coronary artery.

Chronic type A dissection
Chronic type A dissection was treated in the same manner as ascending/arch aortic aneurysm [4]. Graft replacement is the treatment of choice, and the main indications for operation for chronic type A dissection were aortic size or presence of symptoms. The operation was performed with or without aortic valve and root replacement as required (Figs 3A, 3B). The elephant trunk technique was used in 24 of 48 (50%) chronic dissection patients in which the dissection extended into the descending thoracic aorta.

View larger version (113K): [in this window] [in a new window]   Fig 3. Chronic type A dissection; completed valve and graft replacement using the elephant trunk technique.

Operative technique for acute dissection of the descending thoracic or thoracoabdominal aorta was not unlike the techniques previously described for aneurysms occurring in this portion of the aorta [6]. The proximal descending thoracic aorta distal to the left subclavian was transected completely and lifted off the esophagus. Both proximal and distal intima and adventitia of the transected aorta were reinforced in the same manner as that for the ascending aorta with a 4-0 polypropylene suture. A gelatin woven Dacron graft was sewn directly to the reinforced acutely dissected proximal thoracic aorta with the posterior row reinforced using interrupted polypropylene sutures. The descending thoracic graft was cut to length and sutured to the reinforced distal aorta, rechanneling blood into the true lumen of the distal aorta. The adjuncts of cerebrospinal fluid drainage and distal aortic perfusion were used in all patients after 1992 [6].

When most of the descending and abdominal aorta required replacement (type II thoracoabdominal aortic aneurysm), we opened the entire thoracoabdominal aorta, excised the septum between the false and true lumen, and reattached the visceral vessels and renal arteries to the graft either directly or using a woven Dacron graft. We ligated all the intercostal and lumbar arteries because the friable tissue was likely to lead to catastrophic bleeding and a fatal outcome.

Chronic type B dissection
Chronic type B aortic dissection was treated in the same manner as descending thoracic or thoracoabdominal aortic aneurysm [6]. In patients with chronic dissection, we preferred to reimplant intercostal arteries T-9 through T-12 [7] using either a sidearm graft or a side hole to which we reattached the arteries directly (Figs 4A, 4B).

View larger version (79K): [in this window] [in a new window]   Fig 4. Chronic type B dissection; completed graft replacement with intercostal artery reattachment.

	Results

Top Abstract Introduction Material and methods Results Comment References

	Comment

Top Abstract Introduction Material and methods Results Comment References

Transesophageal echocardiography is extremely useful for localizing intimal tears in the aorta. This imaging modality also simplifies management of acute aortic dissection because we are able to establish a diagnosis of type A or B dissection in acutely ill patients and immediately choose the proper mode of treatment. We believe that the pledgeted interrupted suture line, as compared with the felt sandwich technique, provides superior stabilization of the defective aortic wall and decreases problems of stenosis after the repair.

Acute type B aortic dissection of the distal aorta presents an entirely different set of problems than type A of the proximal aorta. Acute type B dissection can be stabilized medically before being treated surgically with a reasonable perioperative risk and selective treatment has met with a degree of success at some institutions [16]. Antihypertensive treatment, however, does not forego the necessity to closely monitor these patients. Hospital mortality of primary medical treatment remains relatively high and a substantial percentage of patients requires operation during initial hospitalization [17]. The main causes of death in both medical and surgical groups are rupture and abdominal malperfusion. We advocate conservative medical therapy and watchful waiting for treatment of acute type B aortic dissection as described in the methods section.

Improvements in surgical techniques over the past 10 years have helped to reduce morbidity and mortality in patients undergoing graft replacement for aortic aneurysms. Such improvements include refinements in circulatory support adjuncts such as retrograde cerebral perfusion also used for type A aortic dissection [4]. Although we did not see statistically significant multivariate effects of retrograde cerebral perfusion in this population, several confounding factors made it difficult to evaluate. In acute type A dissection, half of the strokes we observed occurred in patients with severe hypotension and much of the damage was done before the operation began, therefore the stroke rate could not be expected to respond to the generally beneficial effect of retrograde cerebral perfusion. Future studies on the role of retrograde cerebral perfusion in the acute type A aortic dissection population with larger sample sizes are warranted.

Distal aortic perfusion and cerebrospinal fluid drainage should also be valuable aids in the prevention of spinal cord morbidity in type B aortic dissection. In this population, as with type A dissection, the relationship between acuity of the presentation and extent of the aortic injury made the effects of adjuncts difficult to summarize statistically. Patients with acute dissection are at much higher risk for developing neurologic complications and those with acute dissection of type II extent are at highest risk, but we did not have sufficient data to evaluate the usefulness of the adjuncts. As in type A dissection, further experience is required to evaluate the role of adjuncts in acute type B aortic dissection.

In conclusion, our experience indicates that acute type A aortic dissection should be treated aggressively with operation. Surgical treatment of chronic type A aortic dissection presenting as aneurysm has improved greatly in the past 10 years and can be treated in the same manner as typical ascending and arch aortic aneurysm with similar outcome. For acute type B aortic dissection, conservative medical therapy remains the definitive therapy. Surgical repair becomes the only option when medical therapy fails, but carries a high risk of neurologic deficit, particularly in dissections that involve the total descending aorta. Although mortality for type B dissection is commensurate to that for thoracoabdominal aortic aneurysm, neurologic morbidity is by comparison disproportionately high, possibly because of inability to reattach friable intercostal arteries. Morbidity and mortality rates for chronic aortic dissection patients continue to improve, with outcomes very similar to those for aneurysm patients and attributable to the same technical advances. We emphasize the critical need for follow-up for the dissection patient by regular computed tomographic scans or transesophageal echocardiography. Whether treatment has been medical or surgical, sudden appearance of a previously undetected aneurysm or extension of the dissection is always a threat.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hazim J. Safi Michael J. Reardon George V. Letsou John C. Baldwin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Safi, H. J. Articles by Baldwin, J. C. Search for Related Content PubMed PubMed Citation Articles by Safi, H. J. Articles by Baldwin, J. C.