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Ann Thorac Surg 1999;67:1975-1978
© 1999 The Society of Thoracic Surgeons

Subtypes of acute aortic dissection

^a Department of Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York, USA

Address reprint requests to Dr Lansman, Department Cardiothoracic Surgery, Mount Sinai Medical Center, Box 1028, New York, NY 10029

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. This series consists of a 12-year experience with a policy of identifying and replacing the aortic segment containing the primary intimal tear for repair of acute aortic dissection.

Methods. Patients with type A dissection underwent urgent surgery. Patients with type B dissection were referred for surgery based on selective criteria, including aortic dilatation greater than 5 cm. A classification system for acute dissection is described that specifies the site of intimal tear while retaining the clinical relevance of the Stanford system.

Results. Of 168 acute dissections, 139 were type A and 29 were type B. The site of intimal tear was as follows: ascending aorta, 83 cases; arch, 32 cases; descending aorta, 29 cases; multiple tears, 11 cases (10 included arch tears); no tear (intramural hematoma), 6 cases; not noted, 7 cases. Only 60% of acute type A dissections arose from solitary intimal tears in the ascending aorta, whereas 30% had arch tears. Hospital mortality for type A dissection was 13.7% (18.8% for arch tears, NS) and 0% for type B. False lumen patency was 57.1% for type A dissection and 18.8% for type B dissection (p = 0.002), yet survival was similar for these groups. Ten-year survival for type A dissection with arch tear (0.51 ± 0.12) was lower than 10-year survival for type A dissection with ascending tear (0.74 ± 0.05; p = 0.77), and significantly lower than for type A dissection with descending tear (0.88 ± 0.12; p = 0.029).

Conclusions. Systematic resection of the primary tear yielded similar hospital mortality, 5-year survival, and aorta-related event-free survival rates for subtypes of acute type A dissection. Excellent results were obtained with a selective approach to type B dissection.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
This series consists of a 12-year experience with a policy of identifying and replacing the aortic segment containing the primary intimal tear for repair of acute aortic dissection. For all type A and appropriate type B dissections, an open anastomosis [1, 2] was performed under deep hypothermic circulatory arrest [3], permitting careful exploration of the ascending arch and proximal descending aorta.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Definitions
Dissections were categorized on the basis of false lumen propagation in the ascending aorta (Stanford classification [4]) as well as the site of intimal tear, yielding the subcategories noted in Table 1. Hospital mortality rates are reported, and aorta-related event-free survival was defined to include hospital deaths, late deaths and aorta-related re-operation or rupture.

Follow-up
Postoperative clinical evaluations and CT scans were conducted annually. Follow-up was 96% complete, ranging from 0 to 12.3 years (average 3.8).

Statistics
Student’s t test and ² tests were used to compare groups. Survival curves were calculated by the Kaplan-Meier method and compared using the log rank method. Five and 10 year survival, as calculated by the Kaplan-Meier method, was compared between groups using z-scores.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Categories of acute dissection
Between September 1985 and December 1997, 361 patients underwent surgery for aortic dissection. Of 168 cases with acute dissection, 139 were Stanford type A and 29 were type B. The site of intimal tear was as follows: ascending aorta, 83 cases; arch, 32 cases; descending aorta, 29 cases; multiple tears, 11 cases (10 included arch tears); no tear (intramural hematoma), 6 cases; and not noted, 7 cases. Subcategorizing these cases (Table 1), only 60% of acute type A dissections were type A-ascending (Fig 1 ). Arch tears, either solitary or as one of multiple tears, were found in 30% of acute type A dissections. Clinical characteristics of the types and subtypes of acute dissection are presented in Table 2.

View larger version (27K): [in this window] [in a new window]   Fig 1. Incidence of subtypes of acute type A and type B aortic dissection

Stroke with permanent dysfunction occurred in 8.6% of cases: in 9.6% of ascending tears, in 6.5% of arch tears, and in no cases with descending tears (NS). Stroke occurred in 43% of type A-ascending cases found to have clot or atheromatous material in the arch at exploration, but this association was not statistically significant. Previous neurologic history, preoperative hemodynamic compromise and new preoperative neurologic symptoms were also not significantly predictive of stroke in this series. There was 1 case of paraplegia (3.5%) following repair of a type B dissection.

Surgical procedures
Aortic root treatment
Indications for radical aortic root replacement included an abnormal aortic valve, dilatation of the aortic root or sinotubular ridge, Marfan’s syndrome, and coronary dissection. Radical root replacement was undertaken in 25 cases: 22% of type A-ascending cases, 12.9% of type A-arch cases, and 12.5% of type A-descending cases. Hospital mortality was 16.0% for radical root replacement and 10.8% for root repair (37 cases; NS). During root replacement, the coronary ostia were generally reimplanted as buttons [7] (10 cases; no mortality), but a modified Cabrol technique [8] was used if the coronary ostia were significantly dissected (13 cases, 30.8% mortality, NS) and 2 patients underwent the classic Bentall procedure (no mortality).

Extent of resection
Patients with type A-ascending dissection generally underwent ascending aorta replacement (42 cases), or ascending aorta plus hemiarch replacement (39 cases), although 2 patients underwent full arch replacement (mortality respectively: 14.3%, 12.8%, 50%; NS). Twenty-four patients with type A-arch dissection underwent ascending aorta plus hemiarch replacement, 6 underwent full arch replacement and 1 patient underwent wrapping of the arch (mortality respectively: 16.7%, 33.3%, 0%; NS). There were 8 cases of type A-descending dissection: 1 patient underwent replacement of the ascending aorta, 3 patients underwent ascending aorta plus hemiarch replacement, and 4 patients underwent full arch replacement (no mortality).

One patient with type B-arch dissection underwent full arch replacement, 9 patients underwent distal hemiarch replacement, 19 underwent descending aorta replacement and 2 had thoracoabdominal replacements (no mortality).

Acute dissection following previous surgery
Fifteen patients undergoing surgery for acute dissection had had previous cardiothoracic surgery. Twelve had type A dissection (mortality 16.6%) and 3 type B (no mortality). The most common previous procedure was coronary bypass surgery for patients with type A-ascending dissection and a Bentall procedure for patients with type A-arch dissection.

Follow-up
Survival
Survival following type A and type B dissection was not significantly different at 5 years (0.74 ± 0.04 vs 0.83 ± 0.08) or at 10 years (0.68 ± 0.05 vs 0.74 ± 0.11). Ten-year survival for type A-arch dissection (0.51 ± 0.12) was lower than 10-year survival for type A-ascending dissection (0.74 ± 0.05; p = 0.77), and significantly lower than 10-year survival for type A-descending dissection (0.88 ± 0.12; p = 0.03; Fig 2 ). Aorta-related event-free survival was not significantly different between type A and type B dissection, nor between subtypes of acute type A dissection.

View larger version (38K): [in this window] [in a new window]   Fig 2. Kaplan-Meier survival curves for subtypes of acute type A aortic dissection. ARCH = type A-arch, ASC = type A-ascending, DESC = type A-descending.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The two fundamental anatomic variables defining acute aortic dissection are the origin and propagation of the false lumen, and the two widely accepted schemes for classifying acute dissection are based on one or both variables.

The DeBakey classification [9], which involves both variables, specifies site of intimal tear and associated false lumen propagation. However, the system is limited by making the variables dependent, linking a given tear with a given direction and extent of propagation. Some resulting categories have marginal clinical significance, such as type II dissection, while many possible anatomic variations are omitted. Although straightforward, the Stanford classification [4], based only on the presence (type A) or absence (type B) of false lumen propagation in the ascending aorta, is limited by its simplicity. Frequent clinically relevant variations in the site of intimal tear cannot be noted. Often it is assumed that the intimal tear is above the commissura in type A dissection and in proximity to the subclavian artery in type B dissection, but other patterns are common. In this study, for example, 39% of type A dissections were not associated with an isolated tear in the ascending aorta. Both the DeBakey and Stanford classification schemes preclude categorizing dissections arising from intimal tears in the aortic arch. The DeBakey classification does not include a category with a tear in the arch, and the Stanford system is independent of intimal tears.

Ideally, a classification for acute dissection should describe origin and propagation independently. We continue to use the Stanford classification to categorize propagation, because it is clinically functional: type A dissection requires urgent surgery, and type B may not. The site of the intimal tear is added to the appropriate Stanford category, generating the classification scheme outlined in Table 1. Classifying acute dissections in this fashion is attractive for a number of reasons. This system retains the clinical relevance of the Stanford system, is fully capable of describing all anatomic combinations of origin and propagation, and does not require a new alphanumeric nomenclature. Also, subcategorizing acute dissections conveys clinically relevant information. For example, as compared to patients with type A-ascending dissection, patients with type A-arch dissection are more likely to present with both anterior and posterior chest pain but not severe hypertension [5]; they tend to be older, are less likely to be male or to present with aortic regurgitation, are more likely to present with rupture (Table 2), and may have diminished survival. Lastly, comparing literature reports would be less confusing if acute dissections were subcategorized as described, since this system groups patients with similar anatomic lesions.

In general, our policies for treating acute dissection are aggressive for type A [5, 8] and selective for type B [6]. For type A dissection, radical root replacement, when indicated, did not incur a significantly higher mortality than root repair, and may be associated with better event-free survival [8]. For subtypes of type A dissection, systematic resection of the primary tear yielded similar hospital mortality, 5-year survival, and aorta-related event-free survival rates. Ten-year survival for type A-arch dissection was lower than other type A subtypes, perhaps reflecting the older age of these patients. A selective approach to Type B dissection [6], including surgical therapy for patients presenting with aortic dilatation, resulted in no hospital mortality, 3.4% paraplegia, an 18% incidence of false lumen patency, and excellent long-term survival.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Ott D.A., Frazier O.H., Cooley D.A. Resection of the aortic arch using deep hypothermia and temporary circulatory arrest. Circulation 1978;58(Pt 1):I-227-I-231.
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3. Griepp R.B., Stinson E.B., Hollingsworth J.F., Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
4. Daily P.O., Trueblood H.W., Stinson E.B., Wuerflein R.D., Shumway N.E. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-247.[Medline]
5. Lansman S.L., Raissi S., Ergin M.A., Griepp R.B. Urgent operation for acute transverse aortic arch dissection. J Thorac Cardiovasc Surg 1989;97:334-341.[Abstract]
6. Schor J.S., Yerlioglu M.E., Galla J.D., Lansman S.L., Ergin M.A., Griepp R.B. Selective management of acute type B aortic dissection: long-term follow-up. Ann Thorac Surg 1996;61:1339-1341.[Abstract/Free Full Text]
7. Midulla P.S., Ergin A., Galla J., et al. Three faces of the Bentall procedure. J Card Surg 1994;9:466-481.[Medline]
8. Ergin M.A., McCullough J., Galla J.D., Lansman S.L., Griepp R.B. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840-845.[Abstract]
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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): Steven L. Lansman Jock N. McCullough Khanh H. Nguyen David Spielvogel James J. Klein Jan D. Galla Randall B. Griepp Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lansman, S. L. Articles by Griepp, R. B. Search for Related Content PubMed PubMed Citation Articles by Lansman, S. L. Articles by Griepp, R. B.