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Ann Thorac Surg 2003;75:525-529
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Is extended aortic replacement in acute type A dissection justifiable?

^a Herz- und Gefaess-Klinik, Bad Neustadt, Germany

Accepted for publication August 29, 2002.

* Address reprint requests to Dr Urbanski, Herz- und Gefaess-Klinik, Salzburger Leite 1, 97616 Bad Neustadt, Germany
e-mail: urbanski{at}kardiochirurg.de

	Abstract

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 
BACKGROUND: The aim of this study was to evaluate the effectiveness of our surgical strategy for acute aortic dissection based on the extent of the dissection and the site of the entry, with special emphasis on resection of all dissected aortic segments if technically possible.

METHODS: Between January 1995 and March 2001, 43 consecutive patients underwent operations for acute aortic dissection. In all patients the distal repair was performed under circulatory arrest without the use of an aortic cross-clamp. Fifteen patients underwent aortic arch replacement with additional reconstruction of supra-aortic vessels in 3 patients. Complete replacement of all dissected tissue could be achieved in 21 patients (group 1). Because of the distal extent of the dissection beyond the aortic arch, replacement of all the dissected tissue was not possible in 22 patients (group 2).

RESULTS: Early mortality was 4.7% (2 patients), and the incidence of perioperative cerebrovascular events was 7.0% (3 patients). All of these events occurred in group 2 (p < 0.025). During the follow-up period of 6 years or less, 5 patients died, all from causes not related to the aorta or the aortic valve. A persisting patent false lumen was observed in 14 of the 36 surviving patients (39%).

CONCLUSIONS: Extended replacement of the dissected ascending aorta and aortic arch can be done with good early and midterm results, even though it requires a complex surgical technique. Therefore we advocate complete replacement of the dissected parts of the aorta in all patients in whom this is technically possible.

	Introduction

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Strategies for the extension of distal repair in acute type A aortic dissection vary greatly, ranging from the conservative approach, which is to replace only the ascending aorta and avoid an arch replacement because of its potentially higher surgical risk, to the aggressive approach advocating replacement of the dissected arch regardless of the site of the entry [1–7].

In this article we report early and midterm results after surgical repair of acute aortic dissection, with particular emphasis on complete resection of the dissected aortic wall, which was possible in almost half of the patients.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 
Between January 1995 and March 2001, 43 consecutive patients were operated on in our hospital by one author (PPU) for repair of acute aortic dissection. The study population included 28 men and 15 women with a mean age of 59 years (range, 36 to 78 years).

Aortic dissection and valvular function were evaluated for all patients by transesophageal echocardiography. In addition, computed tomography was performed in 31 patients. Angiography was only done with hemodynamically stable patients who had suspected coronary heart disease (18 patients). Complete resection of the dissected aorta was judged as possible on the basis of imaging procedures and was confirmed intraoperatively in 21 patients (group 1). In this group the dissection extended from the ascending aorta into the proximal aortic arch or involved the entire aortic arch. The entire thoracic aorta was dissected in the remaining 22 patients (group 2); in some patients this included the supra-aortic branches or the iliac arteries, or both. Preoperative patient data are presented in Table 1.

Complete resection of the dissected aortic segments was technically possible in 21 patients (group 1). In 12 patients, the ascending aorta was transected obliquely from the base of the innominate artery to the inner curvature of the arch, and the distal aortic segment was anastomosed to a collagen-coated Dacron graft (InterGard, InterVascular, La Ciotat, France), a procedure known as the hemi-arch repair. In another 9 patients the dissected aortic arch was resected completely and the tube graft was anastomosed to the proximal descending aorta, thus also permitting an anastomosis with nondissected aortic tissue. As the supra-aortic branches were not included in the dissection, it was possible in all patients to excise their ostia as a longitudinal patch of the aortic wall and reimplant this segment into the tube graft using one anastomotic suture line. The graft was then cross-clamped proximal to the innominate artery, and cardiopulmonary bypass was resumed in all patients of group 1 by retrograde femoral artery perfusion.

Because of the extension of the dissection into the distal aorta, complete resection of the dissected segments was not possible in 22 patients (group 2). In 12 of these patients a primary intimal tear in the ascending aorta was observed, whereas in 4 patients multiple tears in the ascending aorta and the aortic arch were present. In 6 patients, no tear was found in the ascending aorta or in the aortic arch. In 16 patients the ascending aorta was transected obliquely from the base of the innominate artery to the inner curvature of the arch. The dissected layers of the aorta were reapproximated with gelatin resorcin formaldehyde glue (Colle Chirurgicale Cardial; Cardial-Bard, St. Etienne, France) or more recently with a synthetic glue (Glubran 2; GEM Srl, Viareggio, Italy), and the distal aortic stump was anastomosed to a Dacron graft. The suture line was reinforced by attaching a Teflon strip to the outside of the aortic wall. In 4 patients with intimal tears located in the aortic arch, a larger portion of the arch had to be replaced. In 2 of these patients the aortic arch was completely replaced and the supra-aortic branches were separately reimplanted into the graft because of intimal tears between their origins. In the other 2 patients a partial arch replacement including the innominate artery was performed. The dissected innominate artery was resected proximally and reimplanted into the tube graft using a graft interposition. In 2 of 6 patients with retrograde dissection originating from tears in the distal aorta, the aortic replacement was also extended beyond the ascending aorta. One patient underwent complete aortic arch replacement because of aneurysmatic dilatation. In the other patient the aortic arch and proximal descending aorta were replaced using an elephant trunk technique to close a tear located about 5 cm below the left subclavian artery. In all patients with extended aortic replacement, the dissected layers of the distal aortic wall were also approximated with glue before anastomosis.

As it was difficult to determine during the operation whether or not there were additional intimal tears in the descending aorta, antegrade perfusion was started by cannulation of the tube graft in all group 2 patients. For this reason a tube graft with a side branch (InterGard-Hemabridge; InterVascular, La Ciotat, France) was used.

The remaining procedure was identical for all patients in groups 1 and 2. Depending upon the proximal extent of the dissection, either a supracoronary graft or an infracoronary valved composite graft was used to replace the ascending aorta. A valve-sparing procedure was performed only in combination with resection of the dissected wall of Valsalva’s sinus. Finally the proximal and distal grafts were connected by a continuous suture. Operative data are shown in Table 2, whereas Table 3 shows the extent of the aortic replacement according to subtypes of dissection.

Statistical analysis
Values in the tables and text are expressed as mean ± standard deviation unless otherwise indicated. All statistical analyses were performed using SPSS software (SPSS Inc, Chicago, IL). The continuous clinical data of the two groups were compared by using the t test or Mann–Whitney’s U test, and the categorical variables were tested by the ² test. Fischer’s exact test was used for variables with very small incidence. Survival rates were calculated using the Kaplan-Meier method. A p value less than 0.05 was considered statistically significant.

Follow-up
For follow-up, patients and their physicians were contacted. All survivors underwent transthoracic echocardiography, and some patients also underwent transoesophageal echocardiography. In addition, the survivors in group 2 underwent thoracoabdominal computed tomography. Written documents as well as echocardiographic and radiologic images were requested from physicians or hospitals and reviewed.

	Results

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 
Early mortality and morbidity
There were 2 perioperative deaths (4.7%), both in group 2. One patient with postoperative pulmonary and renal failure died on the postoperative day 8 because of a pericardial tamponade. At autopsy no bleeding source could be found. Another patient died on postoperative day 15 after a perioperative myocardial infarction. His underlying coronary artery disease was not preoperatively diagnosed because of hemodynamic instability, and the diagnosis was only established at autopsy. In both patients, dissection was present involving the supra-aortic and iliac arteries.

Three perioperative cerebrovascular events were observed in group 2 and none in group 1. Paresis of the left recurrent nerve occurred in 2 patients after complete aortic arch replacement. Two patients in group 1 who had undergone previous cardiac operations required re-thoracotomy because of bleeding not related to the anastomoses. Early morbidity data are presented in Table 4.

There were 5 late deaths within the follow-up period. Three of the deaths (group 1) were caused by myocardial infarction, pneumonia, and malignancy. Two of the deaths (group 2) were caused by pneumonia and cardiac arrest; a valve or aortic-related cause was ruled out at autopsy.

Actuarial survival rates (including operative deaths) for all patients were 87.6% ± 5.2% at 1 year and 84.6% ± 5.8% at 3 years (Fig 1).

View larger version (8K): [in this window] [in a new window]   Fig 1. Actuarial survival for all 43 patients after operation for acute type A aortic dissection.

There were no reoperations within the follow-up period.

One thromboembolic event (a minor stroke in a patient with chronic atrial fibrillation and without an artificial valve in group 1) was reported. No hemorrhagic complications were reported.

	Comment

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 
There is no standard procedure for surgical treatment of acute aortic dissection involving the ascending aorta because of the fact that the results of surgical therapy for different subtypes of acute aortic type A dissection are not easily comparable. It remains especially controversial whether aortic replacement beyond the ascending aorta should be performed when the dissection extends into and past the aortic arch. However there are certain principles of operative techniques, regardless of the individual pathology, which we believe should include the use of deep hypothermic circulatory arrest for distal aortic repair. We agree with others [9–11] that circulatory arrest without aortic cross-clamping before starting the distal repair is of the utmost importance for the surgical strategy in acute type A aortic dissection; in addition this makes cannulations of vessels other than the femoral artery unnecessary with the exception of patients with malperfusion of the lower body or severe arteriosclerosis of the femoral arteries.

In our strategy, the site of the entry and the extent of the dissection are the basis for the extension of the aortic replacement to be performed. The aim of this strategy is to resect the aortic segment with the primary intimal tear plus all of the dissected aortic wall if technically possible.

In 21% of our patients we found a dissection extending up to the aortic isthmus but involving the proximal aortic segments. This frequent subtype of aortic dissection can and, in our opinion, should be treated by complete replacement of the dissected aortic wall.

Our data suggest that patients in whom complete resection of the dissected aorta is possible, an extension of the aortic replacement into the aortic arch does not increase the surgical risk, because this risk depends not only on the complexity of the procedure, but also on the extent of the aortic dissection. The duration of circulatory arrest for total aortic arch replacement with anastomoses made to nondissected vessel walls is not longer than the time needed for ascending aortic replacement with one complicated anastomosis to a dissected aortic wall. As another advantage, Massimo and colleagues [12] observed a low incidence of bleeding using a similar strategy. With complete replacement of the dissected aorta postoperative sequelae (such as a patent false lumen and redissection) influencing late survival [13, 14] can be avoided. In our study population, 39% of the surviving patients had a persisting patent false lumen whereas others reported a 70% to 100% incidence after replacement of the ascending aorta alone [14, 15].

Even if a complete resection of the dissected aortic wall cannot be attained, under certain circumstances aortic arch replacement seems to have a beneficial effect. We agree with other authors [1–3, 5, 12, 14, 16, 17] that complete or partial arch replacement is indicated when the primary intimal tear is located in the arch or when the arch is aneurysmatically dilated.

When the intimal tear is located in the proximal descending aorta, arch replacement by elephant-trunk technique with standard or stented graft combined with proximal aortic repair can lead to the obliteration of the remaining false lumen [18, 19]. Alternatively, the transfemoral implantation of a stented graft into the proximal descending aorta to close the intimal tear combined with proximal aortic repair can be performed [20, 21].

In summary, we see a general indication for distal extension of the ascending aortic replacement or for total aortic arch replacement in acute type A dissections when thereby a complete resection of all dissected aortic segments can be achieved and the intimal tear is excluded. This procedure is technically possible when the dissection extends into the proximal section of the descending aorta and can be performed with good early and midterm results, even though it requires a complex surgical technique.

	Addendum

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Since March 2001, 9 additional consecutive patients underwent the operation as previously described because of acute type A aortic dissection. Complete aortic replacement of the dissected area was achieved in 7 patients including 4 patients in whom extended aortic operations with complete aortic arch replacements were performed. All patients are alive and well.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 
We would like to thank Silvia Martin for preparing the article and Monica Meyer for reviewing the article.

	References

Top Abstract Introduction Patients and methods Results Comment Addendum Acknowledgments References

 

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