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Ann Thorac Surg 2003;76:1957-1961
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Routine extended graft replacement for an acute type a aortic dissection and the patency of the residual false channel

^a Department of Cardiovascular Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan

Accepted for publication June 19, 2003.

^* Address reprint requests to Dr Hirotani, Department of Cardiovascular Surgery, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan.
e-mail: hero.takashi{at}nifty.ne.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment Conclusions References

 
BACKGROUND: Recent surgical progress has had an impact on the mortality of acute type A aortic dissection. Routine aortic arch replacement, irrespective of the location of the intimal tears, may improve not only the outcome of the residual dissection but the operative mortality, because complete resection of intimal tears, including those invisible through the aortotomy in the ascending aorta is achieved.

METHODS: During the past 7 years, total aortic arch replacement was performed in 50 consecutive patients with acute type A aortic dissection. Cerebral protection was achieved by deep hypothermia associated with pharmacologic cerebroplegia. Computed tomography and aortic angiography were performed to examine 48 patients for the possible presence of residual false channels before discharge.

RESULTS: The duration of circulatory arrest ranged from 30 to 84 minutes. The hospital mortality was 10%, and a cerebral complication was observed in 1 patient. No evidence of a persisting false channel was detected in 27 patients (54%) who were totally thrombosed. During the follow-up period (range: 2 months to 7 years), 2 patients died of hepatoma or pneumonia, respectively, and 2 patients underwent reoperation for recurrence of a dissection at the sinus of Valsalva. The Kaplan-Meier method estimated a 7-year survival of 82%, and a 7-year freedom from reoperation of 93%.

CONCLUSIONS: These results suggest that our aggressive use of routine aortic arch grafting can be accomplished with an acceptable risk and that our strategy not only improved the late results but the mortality associated with repairs for acute type A aortic dissection.

	Introduction

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Controversy still exists regarding the extent of distal aortic resection for acute type A (Stanford classification) aortic dissection [1–3], because patients with this serious disease are still at substantial risk even when the ascending aorta alone is replaced, despite advances in surgical techniques and the quality of prosthetic grafts. We hypothesized that difficulty in improving the operative results was attributable to the surgical strategy of not operating on the aortic arch when no evidence of intimal tears was found in the aortic arch when observed through the aortotomy in the ascending aorta. We predicted that routine aortic arch replacement in all patients with acute type A aortic dissection extending to the aortic arch would improve not only the outcome of the residual dissection in the chronic phase but the operative mortality, because routine aortic arch grafting would completely resect all intimal tears, including those that were invisible through the aortotomy in the ascending aorta. Complete resection of intimal tears may contribute to reducing the pressure in the residual false lumen and to preventing both intra- and postoperative bleeding from the distal anastomotic site. Furthermore, even in patients in which the intimal tear is located in the ascending aorta, total arch replacement moves the distal anastomosis far from the site of origin of the dissection process (initial intimal tear), around which the aortic wall is extremely fragile.

Since September 1995, our surgical strategy has been routinely and simultaneously replacing the ascending and transverse aorta with a prosthesis in all patients whose aortic arch has been injured by the dissection, whether the intimal tear was located in the aortic arch or not.

Since our cardiovascular center was established in 1992, and only a few patients were treated by the previous conservative strategy, ie, ascending aortic repair alone or hemi-arch repair, the results of our aggressive approach could not be compared with the results of the former strategy.

The objective of this study was to evaluate the effectiveness of this surgical strategy by analyzing the operative results, midterm survivals, reoperation rates, and the patency of a residual false lumen based on the postoperative computed tomography (CT) and aortic angiography findings.

	Material and methods

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Between the time when our aggressive surgical strategy was adopted in September 1995 and December 2002, repair of acute type A aortic dissection was performed on a total of 53 consecutive patients at Tokyo Saiseikai Central Hospital. The diagnosis was made on the basis of the CT, aortic angiography, or echocardiography findings. Aortic dissections that occurred intraoperatively were excluded from the study. Among the 53 patients, 50 patients had an aortic dissection that extended to the descending aorta, and simultaneous replacement of the ascending and transverse aorta with the prosthesis was performed in all of them. The aortic dissection in the other 3 patients was limited to the ascending aorta (DeBakey type II aortic dissection), and ascending aortic replacement alone was performed. These 3 patients were excluded from patients of this study. In all 50 patients the repair was performed within 14 days of the onset of symptoms. The mean interval between the initial symptom of aortic dissection and surgery was 2.7 ± 4.8 days, and in 70% of the patients the repair was performed within 24 hours. Patient age was 61.5 ± 10.5 years (range: 34 to 79 years) old. The location of the initial intimal tear, based on the preoperative aortography and intraoperative findings, was in the ascending aorta in 19 patients (38%), the aortic arch in 16 patients (32%), from the ascending aorta to the aortic arch in 5 patients (10%), and in the proximal descending aorta in 8 patients (16%). The precise site was not identified in the remaining 2 patients (4.0%). Preoperative complications related to the aortic dissection included shock (defined as a systolic blood pressure of less than 80 mm Hg) in 15 patients (30%), cardiac tamponade in 22 patients (44%), aortic regurgitation that was observed on an echocardiogram to be more than moderate in degree in 20 patients (40%), transient cerebral ischemia in 10 patients (20%), leg ischemia in 11 patients (22%), renal ischemia that was defined as a serum creatinine level of more than 2.0 g/dL in 8 patients (16%), coronary ischemia in 8 patients (16%), paraparesis in 5 patients (10%), and mesenteric ischemia in 2 patients (4.0%). No patients exhibited Marfan's syndrome.

Surgical technique
Although some minor aspects of the surgical technique varied during the study period, our surgical strategy of performing simultaneous replacement of the ascending aorta and the aortic arch in all patients whose aortic dissection involved the aortic arch remained the same. A median sternotomy was performed in all patients. The femoral artery with the stronger pulsation and the right axillar artery were both cannulated as arterial accesses to prevent any malperfusion as a result of retrograde perfusion. In addition, an attempt was made to preserve normograde perfusion during cardiopulmonary bypass (CPB) in all patients by using a larger caliber cannula in the axillar artery than in the femoral artery, especially when the true lumen in the descending aorta was severely compressed by the expanded false lumen. A venous drainage cannula was inserted into the right atrium. The left side of the heart was vented through the right superior pulmonary vein. Figure 1 illustrates a schema for our surgical technique. Following the establishment of CPB, the ascending aorta was cross-clamped just proximal to the origin of the innominate artery. The aorta was then opened longitudinally, and cold crystalloid cardioplegic solution was directly infused into the coronary ostia. The supracoronary ascending aorta that had been injured by the dissection was totally resected, and the infracoronary ascending aorta, if dissection was present in it, was not resected but reconstructed with continuous mattress sutures and circular Teflon collars (DuPont Pharmaceuticals, Wilmington, DE) on both the inside and outside, and gelatin-resorcin-formol glue (Cardial, Saint-Etienne, France) was applied to the false channel as previously reported in detail [4]. An attempt was made to preserve the aortic valve in all patients except for those with preexisting dilatation of the aortic sinuses. While the proximal stump was reconstructed, the body temperature was lowered by systemic cooling. After the attending neurologists confirmed the total disappearance of any electroencephalographic activity, a combination of thiopental, nicardipine, and mannitol was used for brain protection as previously reported [5]. In the most recent 9 patients, the strong free-radical scavenger edaravon was included in the combination for the same purpose. The CPB was then discontinued. The aortic arch was opened, and the proximal descending aorta was transected circumferentially just distal to the ostium of the left subclavian artery or intimal tear in the proximal descending aorta, if exposed. In 7 of 8 patients whose intimal tear was located in the proximal descending aorta, a complete resection of the intimal tear could be achieved. The aortic arch was routinely totally resected together with the proximal segments of the brachiocephalic vessels. The distal aortic stump was reconstructed in the same manner as the proximal stump. A prosthetic graft with a total of four limbs, three limbs to reconstruct the brachiocephalic vessels and one limb to establish arterial access for CPB after aortic arch repair, was then anastomosed to the distal aortic stump, and the innominate and left common carotid arteries were reconstructed. Next, the arch graft was cross-clamped in the preinnominate area and CPB was resumed through the limb for arterial access for CPB. During rewarming, the arch graft was anastomosed to the proximal aortic stump, which had already been reconstructed, and then to the left subclavian artery. CPB was terminated when normothermia had been achieved (Fig 1).

View larger version (29K): [in this window] [in a new window]   Fig 1. Schema for our surgical technique of the aortic arch repair for acute type A aortic dissection. See the text for the details. (GRF = gelatin-resorcin-formol glue [Cardial, Saint-Etienne, France].)

Statistical analysis
Quantitative variables that approximated a normal distribution are reported as the mean ± standard deviation. Midterm survival and the freedom from reoperation were estimated by the Kaplan-Meier method.

	Results

Top Abstract Introduction Material and methods Results Comment Conclusions References

 
Cardiopulmonary bypass
Nasopharyngeal temperature decreased to 14.3°C ± 2.0°C (range: 11°C to 22°C) for the period of circulatory arrest, and rectal temperature decreased to 17.9°C ± 1.9°C (range: 14°C to 22°C). The -stat method of blood pH regulation was used during hypothermia. The duration of circulatory arrest was 49.4 ± 11.6 minutes (range: 30 to 84 minutes.).

Mortality
Five of 50 patients died (10%) during hospitalization. The causes of death were graft-versus-host disease due to transfusion, respiratory failure due to uncontrolled bronchial asthma, ventricular arrhythmia, rupture of the residual false lumen in the sinus of Valsalva, and mesenteric necrosis, respectively.

Morbidity
Two patients were reopened because of bleeding from the anastomotic site of the carotid artery and distal aortic stump, respectively. Respiratory failure requiring the aid of a respirator for more than 3 days was observed in 2 patients. Six patients experienced ischemic damage of various tissues postoperatively due to hypoperfusion during or after the operation: myonephropathic metabolic syndrome (MNMS) secondary to lower limb ischemia in 3 patients, mesenteric necrosis in 1 patient, paralytic ileus in 1 patient, splenic infarction in 1 patient, and renal infarction in 1 patient. All 3 patients who had MNMS postoperatively underwent a fenestration of the false channel after central grafting. And, 2 of these patients temporarily required hemodialysis after the operation, but completely recovered from the renal failure during their hospital stay. The other patient died of respiratory failure due to uncontrolled bronchial asthma. One patient, who had mesenteric necrosis, died of uncontrolled metabolic acidosis after exploratory laparotomy. Each patient who had a paralytic ileus, a splenic infarction, or a renal infarction recovered with a conservative therapy. All patients who had fenestration of the residual false lumen survived the operation and no ischemic episodes occurred postoperatively. No evidence was found indicating any expansion of the residual false lumen compared with its size before the operation during the period of the follow-up (mean follow-up period: 27 ± 9.5 months).

Neurologic complications
All patients except the 2 patients who died soon after the operation of ventricular arrhythmia and mesenteric necrosis, respectively, underwent CT of the head and careful neurologic examinations conducted by the attending neurologists after the operations. A new lesion was observed on the CT scan in only 1 patient. That patient had monoparesis of her right upper arm due to a small cerebral infarction. The duration of the circulatory arrest required for her aortic arch repair was 37 minutes. She recovered completely without any neural deficit 1-month after surgery.

Three of 5 patients who had had paraparesis at the time of admission recovered spontaneously before surgery, probably due to a spontaneous fenestration of a false channel (reentry). In 2 other patients, who did not receive a fenestration of the false channel, spinal damage was noted postoperatively, but both of them could walk unassisted at the time of discharge.

The interval between the completion of the operation and recovery of consciousness was 4.4 ± 3.4 hours (range: 0.5 to 13 hours). This long interval may be attributable to the use of large doses of thiopental.

Patency of residual false lumen
All survivors of the operation, except for 2 patients who had required hemodialysis postoperatively, were examined by aortography and body CT (n = 43), and radiologists evaluated these studies using the state of residual false channels located in the infracoronary ascending aorta and descending thoracic or abdominal aorta. In 27 patients (63%) no evidence of a persisting false channel was detected. In 12 patients (28%) a false channel in the thoracic aorta was totally thrombosed, but a false channel in the abdominal aorta was perfused through the intimal tear in the abdominal aorta or iliac arteries and persisted. In only 4 patients (9.3%) there was a residual false channel noted in the thoracic aorta. In one of these 4 patients, a minor leakage was demonstrated at the distal anastomotic site by postoperative aortography.

Midterm results
The survivors of the operation (n = 45) were followed postoperatively for an average of 3.6 years (range: 6 months to 7.5 years). All patients were followed monthly, and the state of the residual false channels was evaluated by CT every 6 months. Two patients underwent reoperation for recurrence of dissection in the proximal aortic stump. In one of them, the dissection recurred around the sinus of Valsalva 1.5 years after the initial operation, and acute aortic regurgitation also recurred. In the other patient, severe hemolysis and deformity of the sinus of Valsalva occurred 7-months after the initial operation. In both patients, the intima of the sinus of Valsalva had detached from the aortic wall, and reconstruction preserving the aortic valve was judged to be difficult. Replacement of the sinus of Valsalva with a Freestyle stentless porcine aortic root bioprosthesis with coronary artery reimplantation was performed in both patients, but one of them died of left ventricular dysfunction during the operation. In addition to these serious events, one patient experienced a transient cerebral ischemic attack, and another patient developed upper limb ischemia caused by occlusion of the limb graft to the left subclavian artery. Both patients were successfully managed by conservative treatment. Except for the 2 patients who were reoperated, none of the patients experienced any recurrences of the dissection, and all of the false channels that were revealed to be totally thrombosed on the predischarge aortography have continued to be occluded. Late death occurred in 2 patients, and it was due to hepatoma 3-years after the operation, and pneumonia 1-year after the operation, respectively. Figure 2 illustrates the actuarial survival curve estimated by the Kaplan-Meier method, and the 7-year survival was 82%. Figure 3 indicates the freedom from reoperation estimated by the same method, and the 7-year freedom from reoperation was 93%.

View larger version (13K): [in this window] [in a new window]   Fig 2. Survival of patients who had acute aortic arch dissection and underwent simultaneous replacement of the ascending and transverse aorta with a prosthesis. Numbers in parentheses indicate the number of patients at risk at each interval.

View larger version (12K): [in this window] [in a new window]   Fig 3. Freedom from reoperation in patients who had acute aortic arch dissection and underwent simultaneous replacement of the ascending and transverse aorta with a prosthesis. Numbers in parentheses indicate the number of patients at risk at each interval.

	Comment

Top Abstract Introduction Material and methods Results Comment Conclusions References

In order to ensure complete resection of intimal tears, we decided on a surgical strategy that consists of routinely simultaneous replacement of the ascending and transverse aorta with a prosthesis in all patients whose aortic arch has been injured by the dissection, whether the intimal tear is located in the aortic arch or not. The main benefits of this aggressive approach are prevention of perioperative rupture of a residual false channel and avoidance of reoperation through the initial median sternotomy. Routine aortic arch grafting has the added benefit of completely resecting any intimal tear located in the aortic arch, whereas, when ascending aortic grafting alone is performed, there may remain a small intimal tear that is invisible through an aortotomy in the ascending aorta may remain in the unresected aortic arch. We have sometimes found intimal tears in the resected aortic arch specimen that were judged not to be present in the aortic arch both before and during the operation. In this series, intimal tears were found in the resected aortic arch speciment in 21 patients (42%) and in the resected proximal descending aorta in 7 patients (14%), and in 10 of these 28 patients (36%) no intimal tears had been visible through the aortotomy in the ascending aorta under circulatory arrest by looking directly into the aortic arch.

The low patency rate of the distal false channel of our study is consistent with the rate of 26.5% reported by Takahara and colleagues [6], who performed total arch grafting in all patients with acute type A aortic dissection extending to the descending aorta, and it is clearly lower than in some previous reports (40.8% to 47.3%) [7, 8] in which aortic arch grafting was performed only in selected patients. The superior results regarding the patency of residual false channels in our study are thought to be attributable to the complete resection of intimal tears located in both the ascending and transverse aorta.

As a result, the high rate of obliteration of the residual false channel also contributed to our good late results in the form of a higher survival rate (82% at 7 years) and higher freedom from reoperation (93% at 7 years).

Simultaneous replacement of the ascending and transverse aorta results have been reported generally with a less satisfactory outcome, especially in patients with visceral ischemia, such as renal-mesenteric ischemia or myocardial ischemia [9]. However, complete hemostasis and restoration of flow to compromised branch vessels is critical to achieving survival, especially in such critically ill patients. To ensure this, we have aggressively replaced both the ascending aorta and transverse aorta routinely in all patients with acute type A aortic dissection extending to the aortic arch, irrespective of the location of the intimal tear. The hospital mortality of our strategy in 50 consecutive patients was 10%, which is comparable to the mortality in recent reports (14% to 32.5%) in which aortic arch grafting was performed only in selected patients [1, 7, 9, 10, 11], and it is almost identical to the mortality rate in recent reports (6.2% to 8.3%) in which aortic arch grafting was performed in all patients [6, 12, 13].

Owing to the extremely high rate of obliteration of the false channel in the descending thoracic aorta, intraluminal pressure of the residual false channel decreased, and as a result, distal anastomosis was performed without great difficulty or bleeding in most of our patients and sufficient flow in the compromised branch vessels was restored through the expanded true channel postoperatively. In addition, we excised the entire aortic wall from the supracoronary ascending aorta to the transverse aorta together with the proximal segments of the brachiocephalic vessels using a similar manner as Massimo and colleagues [14], who observed a low incidence of bleeding even in extremely aggressive surgical procedure of total excision of the dissected aortic wall and, as a result, all anastomoses were performed without great difficulty and uncontrollable bleeding.

	Conclusions

Top Abstract Introduction Material and methods Results Comment Conclusions References

 
This was a retrospective nonrandomized study, and there was no evidence indicating that all patients with acute type A aortic dissection extending to the aortic arch should undergo simultaneous replacement of the ascending and transverse aorta. However, aggressive surgical treatment that includes aortic arch grafting can be accomplished with acceptable risk and this treatment may be an alternative at experienced centers.

	References

Top Abstract Introduction Material and methods Results Comment Conclusions 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): Takashi Hirotani Tsukasa Nakamichi Shigeyuki Takeuchi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hirotani, T. Articles by Takeuchi, S. Search for Related Content PubMed PubMed Citation Articles by Hirotani, T. Articles by Takeuchi, S. Related Collections Great vessels