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Ann Thorac Surg 2003;76:1951-1956
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion

Toshihiko Ueda, MDa*, Hideyuki Shimizu, MDa, Kenichi Hashizume, MDa, Kiyoshi Koizumi, MDa, Mitsuharu Mori, MDa, Hankei Shin, MDa, Ryohei Yozu, MDa

a Section of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan

Accepted for publication June 6, 2003.

* Address reprint requests to Dr Ueda, Section of Cardiovascular Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, 160-8582 Tokyo, Japan.
e-mail: uedatosh{at}kmh.gr.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: The early outcome after aortic arch surgery has improved. However, some operative survivors have died as a result of postoperative problems soon after discharge. This study determines the factors affecting mortality within 1 year of total arch replacement.

METHODS: Between July 1993 and November 2001, 103 patients (mean age 65 ± 11 years, 26 women, 35 dissections) underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion. Eighteen operations including 14 acute dissections were performed on an emergency basis. Concomitant procedures were root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and open endovascular stent-graft in 9. The average time (minutes) for bypass, aortic cross-clamp, selective cerebral perfusion, and distal arrest were respectively 273 ± 79, 163 ± 54, 145 ± 36, and 69 ± 22.

RESULTS: Mechanical heart support was necessary in 3 patients. Stroke occurred in 9 patients, transient neurologic dysfunction in 7, and paraplegia/paraparesis in 4. The only independent determinant for postoperative stroke was a history of stroke (odds ratio 16.3, 95% confidence interval: 2.8 to 93.8). Thirty-one patients required ventilator support for more than 5 days. Hemodialysis was needed in 5 patients. Sternal infection or mediastinitis occurred in 6 patients. The in-hospital mortality was 12% (12 of 103). The actuarial survival rate at 1 year was 83%, and was 67% at 5 years. For the 1-year mortality independent determinants were emergency surgery (odds ratio 5.3, 95% confidence interval: 1.6 to 17.9) and age 75 years or older (odds ratio 4.0, 95% confidence interval: 1.1 to 13.9).

CONCLUSIONS: Total arch replacement using a branched arch graft with selective antegrade cerebral perfusion has a favorable 1-year mortality rate except for patients undergoing emergency surgery and for elderly patients.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Mortality and morbidity associated with transverse aortic arch surgery is not rare whatever method of brain protection is adopted [1]. Hospital mortality rates including those from emergency operations reported in recent large studies are nearly 10% [2–6]. Most of these studies do not distinguish total arch resection from partial or hemiarch resection although total arch resection requires more complicated techniques and a longer duration of brain protection.

Kazui and colleagues [7] have reported outcomes after total arch replacement using a branched arch graft with selective cerebral perfusion. They found that hospital mortality ran at 13% but the survival rate at 1 year after surgery was 83%. In the study by Estrera and colleagues [4] the survival curve in patients undergoing ascending or aortic arch operation or both with hypothermic circulatory arrest and retrograde cerebral perfusion also showed a steep fall over the year after the operation. Some patients who survived the operation died soon after discharge. Recent studies on the natural history of aortic aneurysms also look at the estimated yearly rupture rate [8, 9]. The present study aims to determine the risk factors associated with mortality within 1 year postoperatively in patients undergoing total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patients
Between July 1993 and November 2001 selective cerebral perfusion was used in 176 of 177 patients undergoing aortic arch repair. Of these 176 patients, 124 underwent total arch replacement. This study enrolled the 103 patients who underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion (Table 1). Patients undergoing en-bloc reattachment of the arch vessels (n = 3) and patients requiring a left thoracotomy (n = 18) were excluded from this study.


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  		Table 1. Demographics of Patients Undergoing Total Arch Replacement Through a Median Sternotomy Using a Branched Arch Graft and Selective Antegrade Cerebral Perfusion

 
The mean age plus or minus standard deviation of these 103 patients was 65 ± 11 years (range, 28 to 80). Twenty-six patients were female and 77 were male. In 35 patients the etiology of the aneurysm was aortic dissection including 14 patients operated on during the acute stage. Seven patients showed classic Marfan syndrome. Twenty-seven patients had a history of prior aortic surgery: 15 had undergone either proximal aortic repair or aortic valve replacement and the remaining 12 had undergone distal aortic repair. An emergency operation was necessary in 18 patients and 3 patients had catastrophic circulatory status before the operation.

A history of stroke was noted in 8 patients and 2 other patients had experienced a transient ischemic attack. One patient had spinocerebellar degenerative disease. Coronary artery disease was noted preoperatively in 17 patients. Five patients had a history of chronic obstructive pulmonary disease. Renal dysfunction (glomerular filtration rate < 40 mg · mL-1 · min-1 or serum creatinine level > 2.0 mg/dL) was noted in 14 patients but no patient needed preoperative hemodialysis.

Operative procedures
Details of the surgical techniques and selective cerebral perfusion are described elsewhere [6, 10]. Median sternotomy was performed in all patients. The left sternocleidomastoid muscle was incised to access the arch vessels. The cardiopulmonary bypass circuit included a centrifugal pump and a membrane oxygenator together with a heat exchanger. The arterial line was bifurcated for the femoral artery and for antegrade perfusion through the ascending aorta or through a branch of the graft. A second arterial line equipped with an air filter was used for selective perfusion of the arch vessels using a roller pump. The end of the line was trifurcated and was then connected to the perfusion catheters, which had a balloon and a pressure monitor line in their tips (15F for the braciocephalic artery, 12F for the left common carotid and the left subclavian artery).

One arterial line was always placed in the femoral artery. When malperfusion was anticipated in patients with aortic dissection or when the distal aorta was found to contain mural thrombi, the main perfusion route was instituted through a cannula in the ascending aorta or the right subclavian artery (n = 66). A two-stage venous cannula was used in most patients. After institution of total cardiopulmonary bypass the patient was cooled. The left vent catheter was then inserted through the right superior pulmonary vein. Myocardial protection was based on antegrade perfusion of either crystalloid or blood cardioplegic solution. Distal anastomosis of the coronary artery bypass and the aortic root procedures were performed during the period of cooling when cross-clamps on the ascending aorta could be applied.

Circulation was arrested at a rectal temperature of below 23°C and the aortic arch was opened and the three arch vessels severed in a single cut. A perfusion catheter was inserted into each arch vessel and was gently secured using a tourniquet after the balloon had been inflated. The perfusion flow rate was maintained initially at 10 mL · min-1 · kg-1 and then adjusted to ensure the perfusion pressure measured at the tip of the catheter in the left common carotid artery remained between 40 and 60 mm Hg.

Woven Dacron vascular grafts sealed with collagen (Hemashield; Meadox Medical, Oakland, NJ) were used. Before 1997 a branched arch graft was constructed in the operating room; since then the graft has been commercially available. Distal aortic anastomosis was first performed. Upon completion of the anastomosis any debris or air in the descending aorta was evacuated by retrograde perfusion through the femoral cannula and antegrade perfusion was established through a branch graft. In the earlier cases anastomosis and unclamping of the left subclavian artery, the proximal aorta, the left common carotid artery, and the braciocephalic artery were performed in that order. Rewarming was started during anastomosis of the braciocephalic artery. From April 1999 in order to prevent mismatches between brain metabolism and temperature reattachment of the arch vessels was performed before the proximal aortic anastomosis and rewarming began only after cessation of selective cerebral perfusion. The flow rate of each arch vessel during selective cerebral perfusion has also been monitored since 1999 with a transit type ultrasonic flow meter.

Concomitant procedures are shown in Table 2: aortic root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and left upper lung resection in 1 patient. In patients with acute dissection, gelatin-resorcinol-formaldehyde glue was used as an adjunct to secure anastomosis. In 3 patients whose left vertebral artery originated separately from the aortic arch, the saphenous vein graft was interposed in an end-to-side manner between the artery and the branch graft reattachment to the left subclavian artery. Distal aortic anastomosis was performed by the elephant trunk technique in 24 patients. Between October 1999 and June 2000 the endovascular open stent-graft technique was used in 9 patients to eliminate distal aortic diseases, after the report by Kato and colleagues [11]. However we gave up this technique as likely to cause spinal damage [12].


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  		Table 2. Concomitant Surgical Procedures

 
Follow-up
Patients were followed up to either death or the end date of the study (November 30, 2002). During the study period we lost track of 2 patients. The median follow-up period was 36 months with a maximum of 114 months.

Data analysis
All statistical analyses were performed using the SPSS statistical software program (SPSS, Chicago, IL). The Kaplan-Meier method was used to calculate the cumulative survival rate. Continuous data were expressed as mean ± 1 standard deviation. Univariate analysis was performed using Fisher's two-tailed exact test. All variables showing a p value less than 0.1 on the exact test were included in the multivariate analysis. Independent risk factors for postoperative neurologic stroke and any death within a year of surgery were examined using a stepwise multiple logistic regression analysis. All p values less than 0.05 were taken as significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Operative data
The mean cardiopulmonary bypass time was 273 ± 79 minutes; the mean aortic cross-clamp time was 163 ± 54 minutes; the selective cerebral perfusion time was 145 ± 36 minutes; and the distal circulatory arrest time was 69 ± 22 minutes (Table 3). The mean volume of intraoperative blood transfusion including the red blood cell and the fresh frozen plasma was 30 ± 24 U and the platelet transfusion was 24 ± 18 U.


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  		Table 3. Operative Data

 
Postoperative morbidity
Nine patients had a postoperative stroke, which showed on a computed tomography scan (Table 4). In 4 of these 9 patients the neurologic deficit had almost completely disappeared before hospital discharge. Transient neurologic dysfunction (including delirium and delayed awakening) with no new cerebral lesion was observed in 7 patients. The mean selective cerebral perfusion time in patients with postoperative stroke was 144 ± 33 minutes, similar to the mean for all patients. Paraplegia or paraparesis occurred in 4 patients whose distal circulatory arrest time varied from 77 to 89 minutes. One paraplegic patient had preoperative spinocerebellar degenerative disease. The distal false lumen of the second patient with chronic dissection was completely obliterated immediately after surgery. The third patient with acute dissection died soon after the operation because of very low output and hypotension; upon autopsy his lower thoracic spinal cord was found to be necrotic. In the fourth patient a distal open endovascular stent-graft was used.


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  		Table 4. Postoperative Complications Associated With Total Arch Replacement

 
Four patients had perioperative myocardial infarction and mechanical heart support was needed by 3 of these, of whom 1 died. Fifty-three patients needed respiratory support for more than 3 days postoperatively and 31 patients needed it for more than 5 days. Hemodialysis was required in 5 patients, all of whom died in hospital. Preoperative renal dysfunction was noted in only 1 of these patients. Sternal infection or mediastinitis or both occurred in 6 patients, of whom 2 died in hospital.

Mortality after surgery
The 30-day mortality was 7 of 103 (Table 5). The causes of these 7 deaths were low cardiac output in 3 patients, respiratory failure in 2, mediastinitis in 1, and laryngospasm in 1. Five other patients died in hospital, 1 each from respiratory failure, aspiration, mediastinitis, multiple organ failure, and accident. Of the 91 operative survivors, 6 died within 1 year of surgery. Three of these 6 patients were severely exhausted at the time of discharge (cachexic) although they had not suffered any postoperative neurologic complication. They could not eat well at home. Two of these 3 patients died of pneumonia and the third died probably as a result of renal failure. One patient died 2 months after discharge of distal aortic rupture. His planned second operation had been postponed in view of his poor recovery from total arch replacement. The causes of the remaining two 1-year deaths were subarachnoid hemorrhage and peritonitis after resection of an ovarian tumor. Thirteen additional deaths occurred more than 1 year after discharge: 1 patient died as a consequence of reoperation due to endocarditis, 2 patients died of aortic rupture, and 1 patient suffered sudden death. The causes of death in the remaining 9 patients were pneumonia in 3, renal failure in 2, cervical osteomyelitis in 1, and unknown in 3. The Kaplan-Meier actuarial survival rate was 83% at 1 year and 67% at 5 years (Fig 1).


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  		Table 5. Mortality After Total Arch Replacement in 103 Patients

 


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  		Fig 1. Actuarial survival curve estimated by the Kaplan-Meier method in patients undergoing total arch replacement (n = 103) through a median sternotomy using selective cerebral perfusion and a branched arch graft.

 
The Appendix shows the variables included in the univariate analysis. From multivariate stepwise logistic regression analysis the only independent determinant of postoperative stroke was a history of stroke (Table 6). The independent determinants of 1-year mortality were emergency surgery and age 75 years or more.


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  		Table 6. Independent Determinants of Postoperative Stroke and 1-Year Mortality in Patients Undergoing Total Arch Replacement

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Of 103 patients undergoing total arch replacement only 47 (46%) had no significant postoperative complication. In particular 30% of our patients required ventilator support for more than 5 days. In the study by Kazui and colleagues [7] of 220 patients undergoing total arch replacement using a branched arch graft and selective cerebral perfusion, 72 patients (33%) required ventilator support for more than 5 days. In contrast the study by Di Eusanio and colleagues [5] using selective cerebral perfusion found that only 13% of 413 patients required ventilator support for more than 5 days. More than half of their patients underwent partial arch resection. It is likely that total arch resection affects postoperative pulmonary function, as it demands longer pump and distal circulatory arrest times and more transfused blood.

The long distal arrest time in the present study is attributed to the difficulty of distal anastomosis. Because the suture line was often very deep in the left thorax we preferred meticulous mattress sutures to secure distal anastomosis. Although the incidence of postoperative spinal damage was not low (4%), each patient who suffered paraplegia/paraparesis had some cause (stated in the Results section) other than a long distal arrest time.

Neurologic problems were by far the most serious postoperative complications after aortic arch repair. Svensson and colleagues [13] recently reported the outcome of a multimodal protocol for brain protection. In their study in which either hypothermic circulatory arrest with retrograde cerebral perfusion or selective cerebral perfusion was used stroke occurred in only 2.0% of 403 patients undergoing ascending or arch aortic operations. They conclude that the benefit of antegrade or retrograde perfusion is unproven. Increasing evidence shows however that occurrence of cerebral complications associated with hypothermic circulatory arrest is time-dependent irrespective of the use of retrograde cerebral perfusion [2, 3, 14]. In contrast with selective cerebral perfusion the duration of brain protection was not a determinant of cerebral complication [5, 7, 10]. The independent determinants of permanent neurologic dysfunction associated with selective cerebral perfusion are old cerebral infarct, pump time [7], urgency status [5], and in the current study a history of stroke.

Most of our patients had distal aortic arch lesions caused by severe arteriosclerosis. Also the orifice of each arch vessel usually had a dirty atheroma. We believe that such lesions should be extirpated using the branch grafts. Both distal anastomosis deep in the left thorax and reattachment of the diseased arch vessel can take long times. We therefore preferred selective cerebral perfusion to hypothermic circulatory arrest for cerebral protection during total arch replacement using a branched graft. Nine patients in our study had a history of stroke and 4 of these had a further stroke postoperatively. Cerebrovascular occlusive disease was found to exist preoperatively in all 4 of these patients. A history of stroke is still a risk factor for postoperative stroke [10]. From mid 1999 we altered the timing of rewarming. To prevent mismatches between brain metabolism and temperature, rewarming was begun only after cessation of selective cerebral perfusion. The number of patients operated on by this new technique is still too small for statistical evaluation.

Axillary/subclavian artery perfusion has been recommended to prevent atheroma emboli [15]. The present study found no difference in the incidence of stroke between patients undergoing femoral artery perfusion and patients undergoing subclavian artery perfusion. We maintain that retrograde perfusion through the femoral artery is a safe and useful technique for appropriately chosen patients.

The in-hospital mortality rate of 12% in the present study was similar to the rate of 13% reported by Kazui and colleagues [7]. The survival curves after aortic arch surgery show a steep fall over the year after the operation, especially among patients undergoing total arch replacement [4, 7]. The 1-year survival rate was as low as 83% in both our study and that of Kazui and colleagues. Recent studies on the natural history of thoracic aortic aneurysms referred to the yearly death, dissection, or rupture rate [8, 9]. We therefore focus on the 1-year mortality.

One of the two independent determinants of 1-year mortality in the current study is emergency surgery, which is a known risk factor for hospital death in patients undergoing aortic arch surgery [3, 5, 7]. Kazui and colleagues [7] suggested that in-hospital mortality after total arch replacement is determined principally by the preoperative state of the patients. This explains their recent conclusion that total arch replacement should not be performed routinely in patients with acute type-A aortic dissection [16]. Unlike degenerative aortic aneurysm the extent of aortic resection in acute type-A aortic dissection often depends on the surgeon's experience [17, 18]. The present results support the conclusion of Kazui and colleagues [16].

Another determinant of 1-year mortality is age 75 years or older. Elderly patients often did not recover well after total arch replacement even if they had been healthy preoperatively. Furthermore some of them became systemically exhausted and died of pulmonary infection or other unknown causes after discharge. Total arch replacement using the present technique clearly imposes great surgical stress on patients, to which the elderly are less resilient. Similarly when hypothermic circulatory arrest with or without retrograde cerebral perfusion was used for brain protection, age was reported to be an independent risk factor of hospital mortality and of poor long-term survival [3, 4].

Elefteriades [19] concludes that a patient having an aorta that has reached 6 cm maximal diameter should expect rupture or dissection within 1 year and an annual death rate of 14%. Excluding our 36 patients having the risk factors for 1-year mortality (18 patients undergoing emergency surgery and 18 patients aged 75 or older), we find a 1-year mortality rate of 10% (7 of 69). We therefore believe that our current technique of total arch replacement is clinically acceptable for patients aged 74 years or less who undergo the operation as scheduled.


   Appendix
 
Preoperative and operative variables included in analysis
The p values (ps for postoperative stroke, pd for 1-year mortality) in univariate analysis using Fisher's two-tailed exact test are shown when they are below 0.1.

Age more than = 65 years, more than = 70 years, more than = 75 years (pd = 0.082); sex (pd = 0.069); Marfan syndrome; prior aortic surgery [proximal aorta, distal aorta]; history of stroke (ps = 0.005); coronary artery disease; renal dysfunction; chronic obstructive lung disease; emergency surgery (pd = 0.015); preoperative shock (pd = 0.078); aortic dissection [acute (pd = 0.067), chronic]; aortic root replacement; coronary artery bypass grafting; elephant trunk technique; open endovascular stent grafting; arterial perfusion through the femoral artery; pump time more than 240 minutes (ps = 0.067), more than 300 minutes; aortic cross-clamp time more than 150 minutes (ps = 0.078), more than 180 minutes (ps = 0.056), more than 210 minutes (ps = 0.056); distal circulatory arrest time more than 60 minutes, more than 90 minutes; blood transfusion more than = 20 units, more than = 30 units, more than = 40 units, more than = 50 units (pd = 0.095); platelet transfusion more than = 20 units (pd = 0.066), more than = 30 units, more than = 40 units.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Okita Y., Minatoya K., Tagusari O., Ando M., Nagatsuka K., Kitamura S. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001;72:72-79.[Abstract/Free Full Text]
  2. Okita Y., Takamoto S., Ando M., Morota T., Matsukawa R., Kawashima Y. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg 1998;115:129-138.[Abstract/Free Full Text]
  3. Ueda Y., Okita Y., Aomi S., Koyanagi H., Takamoto S. Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors. Ann Thorac Surg 1999;67:1879-1882.[Abstract/Free Full Text]
  4. Estrera A., Miller C., III, Huynh T., Porat E., Safi H. Replacement of the ascending and transverse aortic arch: determinants of long-term survival. Ann Thorac Surg 2002;74:1058-1065.[Abstract/Free Full Text]
  5. Di Eusanio M., Schepens M.A.A.M., Morshuis W.J., Di Bartolomeo R., Pierangeli A., Dossche K.M. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg 2002;124:1080-1086.[Abstract/Free Full Text]
  6. Ueda T., Shimizu H., Kawada S. Operative procedures and surgical outcomes of patients undergoing repair of the ascending aorta and/or transverse aortic arch. In: Kawada S., Ueda T., Shimizu H., eds. Cardio-aortic and aortic surgery. Tokyo: Springer-Verlag, 2001:105-110.
  7. Kazui T., Washiyama N., Muhammad B., et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3-9.[Abstract/Free Full Text]
  8. Juvonen T., Ergin M.A., Gala J.D., et al. Prospective study of the natural history of thoracic aortic aneurysms. Ann Thorac Surg 1997;63:1533-1545.[Abstract/Free Full Text]
  9. Davies R.R., Goldstein L.J., Coady M.A., et al. Yearly rupture rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 2002;73:17-28.[Abstract/Free Full Text]
  10. Ueda T., Shimizu H., Ito T., et al. Cerebral complications associated with selective perfusion of the arch vessels. Ann Thorac Surg 2000;70:1472-1477.[Abstract/Free Full Text]
  11. Kato M., Ohnishi K., Kaneko M., Ueda T., Kishi D., Mizushima T. A new grafting-implanting method for thoracic aortic aneurysm or dissection with a stent-graft. Circulation 1996;94(Suppl 2):188-193.
  12. Miyairi T., Kotsuka Y., Ezure M., et al. Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia. Ann Thorac Surg 2002;74:83-89.[Abstract/Free Full Text]
  13. Svensson L.G., Nadolny E.M., Kimmel W.A. Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations. Ann Thorac Surg 2002;74:2040-2046.[Abstract/Free Full Text]
  14. Hagl C., Ergin M.A., Gala J.D., et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 2001;121:1107-1121.[Abstract/Free Full Text]
  15. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery: an alternative site of arterial canuulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-890.[Abstract]
  16. Kazui T., Washiyama N., Bashar A.H.M., et al. Surgical outcome of acute type A aortic dissection: analysis of risk factors. Ann Thorac Surg 2002;74:75-81.[Abstract/Free Full Text]
  17. Sabik J.F., Lytle B.W., Blackstone E.H., McCarthy P.M., Loop F.D., Cosgrove D.M. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 2000;119:946-962.[Abstract/Free Full Text]
  18. Hirotani T., Kameda T., Kumamoto T., Shirota S. Results of a total aortic arch replacement for an acute aortic arch dissection. J Thorac Cardiovasc Surg 2000;120:686-691.[Abstract/Free Full Text]
  19. Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74(Suppl):S1877–80



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