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Ann Thorac Surg 2002;74:S1844-S1847
© 2002 The Society of Thoracic Surgeons
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
* Address reprint requests to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu, Japan, 431-3192
e-mail: tkazui{at}hama-med.ac.jp
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: To evaluate the impact of an aggressive surgical approach on early and late outcome in type A aortic dissection.
METHODS: From 1983 to 2001, 240 patients underwent operation for acute (n = 138) and chronic (n = 102) type A aortic dissection. The extent of distal aortic resection included the ascending aorta in 39 (16%) patients, hemiarch (HAR) in 47 (20%), and total arch (TAR) in 154 (64%), including 19 patients who also had their descending aorta replaced (DAR).
RESULTS: The in-hospital mortality did not differ between TAR with or without DAR and other more conservative techniques (12.3% versus 16.3%). Actuarial survival at 10 years including in-hospital mortality was 72.4% ± 3.3% and freedom from reoperation was 77.2% ± 3.6% for all patients: neither was influenced by the extent of distal aortic resection or acuity of aortic dissection. Multivariate analysis revealed younger age and failure to resect the intimal tear to be independent determinants for late reoperation. However, in contrast to 22 patients who had more conservative operations, none of the patients with TAR required reoperation on the aortic arch through a sternotomy incision.
CONCLUSIONS: An aggressive surgical approach did not adversely influence early and late survival following type A aortic dissection; it reduced the necessity of late reoperation and facilitated distal aortic reoperation.
Limited ascending aortic replacement (AAR) with resection of the intimal tear, if any, has been the standard surgical procedure for type A aortic dissection. With recent improvements in surgical techniques and cerebral protection methods, more extended aortic replacement—such as total arch replacement (TAR) [1–3]—has been advocated to improve late surgical outcome although this aggressive approach has tended to increase operative mortality in previous reports [4–6]. The purpose of the present study was to evaluate the impact of an aggressive surgical approach on early and late outcome in type A aortic dissection.
Patients and methods
Patients
Two hundred and forty patients underwent surgical repair of type A aortic dissection performed by the senior author (TK) from January 1983 to December 2001. Their age ranged from 17 to 91 years, with a mean of 58 ± 14. One hundred and forty-six (61%) of the patients were male and 94 (39%) female.
One hundred and thirty-eight patients (58%) were operated on during the acute stage (within 2 weeks of the onset of aortic dissection) and the remaining 102 patients (42%) during the chronic stage. The patients with acute type A aortic dissection had a higher incidence of dissection-related complications such as shock, cardiac tamponade, myocardial ischemia, cerebral ischemia, renal/mesenteric ischemia, and leg ischemia than did the patients with chronic aortic dissection. Thirty-four patients (14%) had Marfan’s syndrome and 45 (19%) had undergone previous cardiovascular operation.
To make the diagnosis of aortic dissection and to select the surgical technique, aortography or digital subtraction angiography was performed in about 40% of the acute cases and in 100% of the chronic cases. Computed tomography or echocardiography including the transesophageal Doppler technique was used in most recent cases of acute and chronic dissection.
Operative technique
Extracorporeal circulation was established by cannulating the femoral artery or the right axillary artery if indicated, with venous drainage through a single two-stage cannula placed in the right atrium. Operative techniques used in this series according to the acuity of dissection are listed in Table 1.
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Distally, patch angioplasty was performed in the initial 4 patients with chronic dissection. AAR was performed 35 patients (15%). In the earlier period, the dissected aortic wall was reapproximated with reinforcement by a Teflon felt strip. Since 1994 the proximal and distal aortic repairs have been performed using gelatin-resorcinol-formaldehyde (GRF) glue (Cardial; Technopole, Sainte-Etienne, France). Hemiarch replacement (HAR) with an open distal anastomosis under profound hypothermic circulatory arrest with or without retrograde cerebral perfusion was performed in 47 recent patients (20%).
TAR was performed in 154 patients (64%), including 19 patients with chronic dissection who also had descending aortic replacement (DAR). The indications for and technical details of TAR using en-bloc repair or a separated graft technique with the aid of antegrade selective cerebral perfusion (SCP) have been described previously [2, 11].
For the distal anastomosis of TAR in chronic cases, a fenestration was made in the intimal flap at the site of the distal graft anastomosis to restore blood flow into both true and false lumens when the distal organs were perfused from the false lumen. An elephant trunk in conjunction with TAR was performed in 35 patients (15%) and was liberally used for chronic cases in which future distal aortic repair was expected.
Resection of the primary intimal tear was performed in 84% of patients with acute dissection and in 97% of patients with chronic dissection in this series.
Concomitant procedures included coronary artery bypass grafting (CABG) in 13 patients, mitral valve replacement or repair in 5, and patch aortoplasty for supravalvular aortic stenosis in 1(1%).
Statistical methods
The continuous data in this study are expressed as the mean ± standard deviation (SD). Categorical variables were compared by means of Fisher’s exact test, and continuous variables with Student’s t test. From 39 preoperative and perioperative variables, independent risk factors for in-hospital mortality and those for late dissection-related reoperation were examined by multivariable analysis using a forward stepwise logistic regression model. Survival and freedom from reoperation were estimated by the Kaplan-Meier method, and expressed as mean ± standard error of mean (SEM). Differences in survival and freedom from reoperation were determined by log-rank analysis.
Results
The overall in-hospital mortality was 13.8% (33 of 240 patients). In-hospital mortality was influenced by the acuity of aortic dissection (acute, 18.1%; chronic, 7.8%, p < 0.05), and the period of operation (1983 to 1996, 18.8%; 1997 to 2001, 1.4%, p < 0.001). However, extent of distal aortic replacement did not affect the in-hospital mortality (AAR or patch aortoplasty, 12.8%; HAR, 19.1%; TAR, 13.3%; TAR with DAR, 5.3%).
Multivariable analysis indicated that shock, renal/mesenteric ischemia, nonuse of four-branched arch graft, and DeBakey type I aortic dissection were independent predictors of in-hospital mortality.
Figure 1 shows the actuarial survival curves according to the extent of distal aortic replacement. Overall actuarial survival at 10 years, including in-hospital mortality, was 72.4% ± 3.3%. Long-term survival was influenced neither by the acuity of dissection (acute, 69.6% ± 4.5%; chronic, 75.9% ± 4.8%) nor by the extent of distal aortic replacement (AAR or patch aortoplasty, 68.3% ± 8.1%; HAR, 67.4% ± 7.8%; TAR, 74.5% ± 4.4%; TAR with DAR, 83.5% ± 8.7%).
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Comment
This is a retrospective analysis of surgical outcome of both acute and chronic type A aortic dissection in which 64% of patients underwent TAR with or without DAR. The strategies and surgical techniques used for type A aortic dissection have significantly varied over time. Therefore it is rather difficult to compare the early and late clinical outcomes involving different surgical techniques simply because of the different patient backgrounds associated with each technique. The effect of an aggressive approach like TAR on the long-term results of acute and chronic type A aortic dissection has not been reported previously.
In previous reports, risk factors for in-hospital mortality, particularly in acute type A aortic dissection, were increasing age, preoperative dissection-related complications such as shock, organ malperfusion, concomitant aortic arch repair, and period of operation [4, 5, 8–11]. An aggressive surgical approach—like TAR in acute cases and even TAR with DAR in chronic cases—did not emerge as a risk factor in our series. That is probably because of patient selection as well as a learning curve in terms of surgical technique. AAR was performed in the early period; HAR recently has been used mostly for aged patients or for those with serious preoperative complications whereas TAR was performed in only selected cases.
The 74% 10-year survival in our series is slightly better than the 30% to 60% survival rates reported in previous reports adopting a more conservative approach [5, 8, 9, 12, 13]. The distal aortic reoperation rate 10 years after initial surgery was 77.2% ± 3.6% in this study, which is comparable with the 60% to 80% figures found in previous reports [5, 12, 13, 14]. Controversy still exists whether extended TAR can reduce the risk of reoperation in the late postoperative period and eventually improve long-term results. Long-term survival of extended TAR in our series tended to improve although the differences between it and other approaches were not always statistically significant. Freedom from reoperation with extended TAR was not different from that with conservative approaches. This finding could possibly be explained by our recent meticulous follow-up, our aggressive approach toward reoperation, and the liberal use of the elephant trunk technique in chronic dissection cases to facilitate reoperation for possible aneurysm formation in the distal thoracoabdominal aorta through a left thoracotomy. However, extended TAR did reduce the risk of reoperation on the aortic arch through a median sternotomy when compared with AAR and HAR in our series. This is a major advantage of TAR because a previous proximal aortic operation is a well-known risk factor for reoperation-related mortality and morbidity [15]. Extended TAR with DAR can be performed in selected cases of chronic dissection with an acceptable risk. ([7])
References
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  A. Geirsson, J. E. Bavaria, D. Swarr, M. G. Keane, Y. J. Woo, W. Y. Szeto, and A. Pochettino Fate of the Residual Distal and Proximal Aorta After Acute Type A Dissection Repair Using a Contemporary Surgical Reconstruction Algorithm Ann. Thorac. Surg., December 1, 2007; 84(6): 1955 - 1964. [Abstract] [Full Text] [PDF]
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 T. B. Reece, C. G. Tribble, R. L. Smith, R. R. Singh, B. M. Stiles, B. B. Peeler, J. A. Kern, and I. L. Kron Central cannulation is safe in acute aortic dissection repair J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 428 - 434. [Abstract] [Full Text] [PDF]
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J. Bachet, F. Larrazet, B. Goudot, G. Dreyfus, T. Folliguet, F. Laborde, and D. Guilmet When Should the Aortic Arch Be Replaced in Marfan Patients? Ann. Thorac. Surg., February 1, 2007; 83(2): S774 - S779. [Abstract] [Full Text] [PDF]
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 O. Chavanon, V. Costache, V. Bach, A. Ketata, M. Durand, R. Hacini, F. Thony, and D. Blin Preoperative predictive factors for mortality in acute type A aortic dissection: an institutional report on 217 consecutives cases Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 43 - 46. [Abstract] [Full Text] [PDF]
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S. Saccani, F. Nicolini, B. Borrello, A. Agostinelli, P. Larini, C. Marcato, and T. Gherli New technologies for the treatment of type A aortic dissection: A case report J. Thorac. Cardiovasc. Surg., June 1, 2004; 127(6): 1821 - 1823. [Full Text] [PDF]
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