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Ann Thorac Surg 2006;82:1665-1669
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Validity of a Limited Ascending and Hemiarch Replacement for Acute Type A Aortic Dissection

Motomi Shiono, MD, PhD*, Mitsumasa Hata, MD, PhD, Akira Sezai, MD, PhD, Tetsuya Niino, MD, PhD, Shinya Yagi, MD, PhD, Nanao Negishi, MD, PhD

Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan

Accepted for publication May 25, 2006.

* Address correspondence to Dr Shiono, Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan (Email: mshiono{at}med.nihon-u.ac.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: The extent of arch repair at emergency surgery for acute type A dissection is controversial. This study was designed to evaluate the rationale of tear-oriented conservative ascending/hemiarch replacement, comparing it against total arch replacement.

METHODS: A total of 134 consecutive patients with acute type A dissection who underwent emergency surgery between 1995 and 2005 were reviewed.

RESULTS: The median age was 68 years (range, 19 to 90); the patients were 62 men and 72 women. The extent of aortic resection included the ascending aorta and hemiarch in 105 patients (group AH) and the total aortic arch in 29 patients (group TA). The hospital mortality rates in groups AH and TA were 6.7% and 6.9%, respectively. The actuarial survival rates were 77.4% (AH) and 80.8% (TA) after 5 years, and 63.5% (AH) and 80.8% (TA) after 10 years. The freedom rates from reoperation were 91.3% (AH) and 88.0% (TA) after 5 years, and 60.9% (AH) and 76.6% (TA) after 10 years. Multivariate analysis indicated that predictors of reoperation were Marfan syndrome and aortic valve regurgitation.

CONCLUSIONS: Limited ascending/hemiarch replacement did not increase the risk of reoperation and would not compromise late results.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Acute type A aortic dissection is a lethal aortic disease with an extremely poor prognosis unless timely surgical intervention is performed. In the majority of patients, a partial or hemiarch replacement is sufficient, as the intimal tear is generally located in the ascending aorta or the proximal aortic arch [1]. Although aggressive aortic arch repair is advocated in some selected patients [2–4], it remains questionable whether extended arch repair can reduce the risk of repeat surgery and improve long-term surgical results. The extent of aortic replacement and operating time have been reported as significant risk factors for hospital mortality in previous reports [1, 5, 6]. This study was undertaken to analyze a consecutive series of patients with acute type A aortic dissection, aiming to evaluate the rationale of tear-oriented conservative ascending/hemiarch replacement with resection of the intimal tear, with a comparison against total arch replacement.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients
A total of 134 consecutive patients who underwent emergency surgery for acute type A aortic dissection at our institution from July 1995 to July 2005 were reviewed retrospectively. Our Institutional Review Board has waived the need for patients' consent for this study, and approval was provided before publication of this manuscript and report of the information. All of the surgeries were performed within 72 hours of onset. The extent of aortic resection included the ascending aorta and hemiarch in 105 patients (78%; group AH) and the total aortic arch in 29 patients (22%; group TA). The clinical characteristics and perioperative variables of these patients, consisting of 61 men and 73 women, are presented in Tables 1 and 2. Go The mean age of the patients was 65.3 years (range, 19 to 90). Pain in the chest and back was the common presenting symptom. Computed tomography scans and echocardiography were the common definitive diagnostic modalities before emergency surgery. Upon confirmation of the diagnosis by these diagnostic modalities, the patient was transferred to the operating room as soon as possible.


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  		Table 1. Patient Characteristics
 

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  		Table 2. Surgery Data and Postoperative Data
 
Surgical Technique
Cardiopulmonary bypass was initiated through femorofemoral cannulation for the patients in preoperative shock. After a median sternotomy was performed, a two-staged venous cannula was inserted through the right atrium, in the cases with stable hemodynamic condition. In all of the patients, deep hypothermic circulatory arrest and antegrade selective cerebral perfusion were employed, for brain protection, and the heart was arrested with cold crystalloid cardioplegia (St. Thomas solution). Under deep hypothermia below 20°C, the ascending/arch aorta was opened longitudinally, and the aortic segment that included the intimal tear was resected. The extent of aortic replacement was decided based on the location of the intimal tear (tear-oriented surgery [7]). Ascending/hemiarch aortic replacement was performed in patients with the intimal tear localized in the ascending aorta or in the lesser curvature of the transverse aortic arch proximal to the left subclavian artery. When the intimal tear was extended close to the orifice of the arch vessels, total arch replacement was performed. Gelatin-resorcin-formalin (GRF) glue was applied to both the proximal and distal dissected ends of the false lumen, and then the glued stumps were reinforced with felt strips, and the resected aorta was replaced with a presealed branched woven Dacron graft (C. R. Bard, Haverhill, Pennsylvania). Antegrade arterial circulation was established through a side branch of the Dacron graft, after completion of an open distal anastomosis. When the intimal tear could not be found, only ascending aortic replacement was performed, to avoid serious complications. After rewarming was completed, cardiopulmonary bypass was discontinued, and the cannulas were removed.

Follow-Up
We examined the patients at our outpatient clinic or contacted the physicians treating them for follow-up. The retrospective postoperative follow-up rate was 100% for as long as 10 years (425.6 patient-years).

Statistical Analysis
Statistical analysis was performed with StatView software (SAS Institute, Cary, North Carolina). All pertinent perioperative risk factors were examined by {chi}2 test or Fisher's exact test, as appropriate; continuous variables were examined by Student's t test, and the results were expressed as percentage and the mean ± SD, respectively. Univariate analysis was followed by multiple logistic regression, to determine independent risk factors for reoperation. Actuarial survival and freedom rates from reoperation were calculated by the Kaplan-Meier method, and the log-rank test (Mantel-Cox test) was used for comparison between the two groups. A value of p less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
The two groups (ascending/hemiarch replacement and total arch replacement) examined were not significantly different from each other with respect to the majority of perioperative variables that were believed to have an impact on outcome, except for patient age. Total arch replacement was performed in younger patients more often compared with ascending/hemiarch replacement (p = 0.005). Resection of the intimal tear could be performed successfully in a total of 123 patients (92%). There were no significant differences in concomitant procedures, impossible entry-resection, patency rate of the distal false lumen after surgery, and closing interval of the false lumen for follow-up (Table 2).

Mortality
The overall hospital mortality rate was 6.7% (9 of 134). The hospital mortality rates in groups AH and TA were 6.7% and 6.9%, respectively; their causes of death were multiple organ failure (3 patients), low cardiac output syndrome (2 patients), pneumonia (1 patient), hepatic failure due to cirrhosis (1 patient), bleeding (1 patient), and pulmonary hypertensive crisis due to a patent ductus arteriosus (1 patient). There was no significant difference in the hospital mortality between the two groups (p = 0.69). The overall late mortality rate was 15.2% (19 of 125) after discharge from the hospital. The causes of late deaths were pneumonia, at 2, 3, and 8 months after surgery (4 patients); spontaneous death by senility, at 14 and 74 months after surgery (2 patients); stroke, at 3 and 4 months after surgery (2 patients); repeat surgery, at 43 and 52 months after surgery (2 patients); cancer, at 20 and 72 months after surgery (2 patients); mediastinitis, at 3 months after surgery (1 patient); pancytopenia, at 3 months after surgery (1 patient); arrhythmia, at 6 months after surgery (1 patient); ileus, at 3 months after surgery (1 patient); rupture of the thoracic aorta, at 13 months after surgery (1 patient); sepsis, at 24 months after surgery (1 patient); and rupture of an abdominal aortic aneurysm, at 76 months after surgery (1 patient; Table 3). The late mortality rates between the two groups were not significantly different (p = 0.89).


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  		Table 3. Late Mortality and Late Complications
 
The actuarial survival rates, including hospital mortality, of each group were 85.0% (AH) and 80.8% (TA) after 1 year, 77.4% (AH) and 80.8% (TA) after 5 years, and 63.5% (AH) and 80.8% (TA) after 10 years. Log-rank survival analysis indicated no significant difference in the survival rates between the two groups (p = 0.72). The actuarial survival curves for the two groups are shown in Figure 1.


Figure 1
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  		Fig 1. Actuarial survival curve for the two groups (ascending/hemiarch replacement [AH] and total arch replacement [TA]) after emergency surgery for acute dissection.

 
Reoperation
Repeat surgery was performed in 12 patients: because of enlargement of the distal aorta in 7 patients; aortic valve regurgitation in 3; redissection of the aortic root in 1; and mitral valve regurgitation in 1. Total arch replacement was performed in 4 patients: thoracoabdominal aortic replacement in 3 patients with Marfan syndrome; aortic valve replacement in 2 patients; root replacement in 1; abdominal aortic replacement in 1; and mitral valve replacement in 1. The freedom from reoperation rates were 97.7% (AH) and 95.7% (TA) after 1 year, 91.3% (AH) and 88.0% (TA) after 5 years, and 60.9% (AH) and 76.6% (TA) after 10 years. Log-rank survival analysis indicated no significant difference in the freedom rates between the two groups (p = 0.48). The actuarial reoperation-free curves for the two groups are shown in Figure 2.


Figure 2
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  		Fig 2. Reoperation-free curve for the two age groups (ascending/hemiarch replacement [AH] and total arch replacement [TA]) after emergency surgery for acute dissection.

 
Multivariate analysis of perioperative risk factors indicated that independent predictors of reoperation were Marfan syndrome (p = 0.01, odds ratio 2.44, and 95% confidence interval: 1.47 to 35.1) and severe aortic valve regurgitation (p = 0.03, odds ratio 2.14, and 95% confidence interval: 1.04 to 2.63). There was no difference in survival/reoperation according to whether the distal false lumen remained open.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
According to the International Registry of Acute Aortic Dissection database from multi-institutional experiences, mortality of patients with type A dissection managed surgically was 26% [8]. Most articles consistently report hospital mortality exceeding 15% in Western countries [8–11]. However, recent technical improvements in emergency surgery for acute aortic dissection have resulted in a marked decline in hospital mortality. Many factors, such as cardiac tamponade and dissection-related organ malperfusion, contribute to hospital mortality and morbidity. The extent of aortic replacement and period of surgery have also been reported as significant risk factors for hospital mortality in previous reports [1, 5, 6], and it remains questionable whether extended arch repair can reduce the risk of repeat surgery and improve the long-term surgical results.

In this study, the hospital and late mortality rates of the two groups were remarkably low, and ascending/hemiarch replacement was not associated with an increase of reoperation after emergency surgery in acute type A aortic dissection. Both limited ascending/hemiarch replacement and extended arch replacement demonstrated similar results superior to previous reports. Two variables, Marfan syndrome and severe aortic valve regurgitation, were found to be statistically significant risk factors for reoperation.

In addition to excision of the intimal tear resulting in decompression of the false lumen, another objective of emergency surgery for acute type A dissection is to restore competence of the aortic valve. Valve-related repeat surgery is not common, and therefore, most such patients need aortic valve preservation or repair in acute type A dissection [12, 13]. Glue-aided repair of the aortic valve and dissected aortic wall is simple, fast, and easily reproducible. Our policy supports a conservative tear-oriented approach presented by Westaby and associates [7]. However, some reports have described tissue toxicity from formaldehyde [14]. The use of biologic glues for reapproximating the layers of the dissected aortic root is associated with a certain amount of risk of aortic wall necrosis. Therefore, care should be taken to ensure proper use of these glues [15]. In our series, all of the patients underwent GRF glue-aided repair for both the aortic valve and the dissected aortic wall. Another important role of the glue is to strengthen the aortic wall and to avoid leakage or rupture from needle holes, by reinforcing the glued aortic wall with the placement of felt strips on the aortic stumps. This additional reinforcement with felt strips was considered to provide a relatively low repeat-surgery–free rate [16]. During the follow-up period, we have experienced 4 aortic valve-related reoperations: aortic valve regurgitation in 3 patients, and aortic root replacement in 1, due, respectively, to deteriorated regurgitation and redissection of the aortic root. Proper use of GRF glue will decrease the morbidity after the aortic repair. In patients with severe aortic valve regurgitation, because of a markedly dilated aortic root due to extended proximal dissection, aortic root replacement with valved-composite graft would be recommended.

In the majority of patients, a partial or hemiarch replacement is sufficient, as the intimal tear is generally located in the ascending aorta or the proximal aortic arch [1]. In our series, 78% of the patients (105 of 134) underwent ascending alone or ascending and hemiarch replacement. Transverse arch replacement was performed in 29 patients, and concomitant root replacement was performed in 9, for Marfan syndrome or dilated aortic root. The patency rate of the distal false lumen was 11.4% (group AH) and 24.1% (group TA; p = 0.08) in our series, compared with 47.3% reported previously [17]. In the treatment of acute type A dissections, operative strategy and anastomotic technique play important roles in reducing the incidence of patency and related complications of the distal false lumen. Both glue-aided repair and reinforcement with felt strips have greatly improved the suture-holding capacity of the dissected tissue, resulting in a relatively low incidence of reoperation and a patent false lumen, even in limited ascending/hemiarch replacement.

Despite the aggressive aortic arch repair advocated in some selected patients [2–4], it remains questionable whether limited ascending/hemiarch replacement can increase the risk of reoperation and compromise long-term surgical results. The extent of aortic replacement and period of surgery have been reported as significant risk factors for in-hospital mortality in previous reports [1, 5, 6]. Although our series of arch repair, which required longer cardiopulmonary bypass time and consequently a longer surgical period, revealed low mortality and high reoperation-free rates, long-term10-year results have demonstrated that limited ascending/hemiarch replacement showed compatible results with extended arch replacement. Dissection-related organ malperfusion, such as neurologic disorder and mesenteric/renal and myocardial ischemia, will have an effect on hospital mortality and morbidity [3, 8, 18–20]. For patients with serious dissection-related organ malperfusion, a conservative limited ascending/hemiarch replacement would be preferable. As the main goal of emergency surgery for acute dissection is saving the patient's life, conservative tear-oriented surgery may be appropriate.

Aortic repair and decompression of the false lumen should be performed before malperfusion causes irreversible damage to the malperfusion organs. Therefore, early recognition of the disease and earlier referral to surgical units would improve the outcome of emergency surgery for this lethal disease. Antegrade arterial perfusion provides a better solution for intraoperative malperfusion by femoral artery cannulation. In our study, antegrade aortic perfusion after completion of the open distal anastomosis was applied in all of the patients, and there were no serious or lethal complications due to dissection-related malperfusion.

In this study, the hospital mortality rate at reoperation was 8.3% (1 of 12), although additionally 1 patient died after arch replacement at a different hospital. Repeat surgery is a major risk factor for long-term mortality in all patients with acute aortic dissection, even when initial emergency surgery has been successfully performed. Although a partial or hemiarch replacement is sufficient in the majority of patients, extended total arch replacement is advocated for selected patients, such as young patients or those with Marfan syndrome or a markedly dilated aortic arch.

In conclusion, hospital mortality could be reduced dramatically in both ascending/hemiarch replacement and total arch replacement. Early recognition of the disease and earlier referral to surgical units would improve the outcome of emergency surgery for this lethal disease. A limited ascending/hemiarch replacement did not increase the risk of reoperation and would not compromise late surgical results.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors are grateful to Kaname Hirayanagi, PhD, for his statistical review for this study.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Ehrlich MP, Ergin MA, McCullough JN, et al. Results of immediate surgical treatment of all acute type A dissections Circulation 2000;102(Suppl 3):248-252.
  2. Moon MR, Sundt III TM, Pasque MK, et al. Does the extent of proximal or distal resection influence outcome for type A dissections? Ann Thorac Surg 2001;71:1244-1249.[Abstract/Free Full Text]
  3. Kazui T, Washiyama N, Bashar AH, 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]
  4. Pugliese P, Pessotto R, Santini F, Montalbano G, Luciani GB, Mazzucco A. Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach Eur J Cardiothorac Surg 1998;13:576-580.
  5. Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dissection of ascending aortaShould the arch be included?. J Thorac Cardiovasc Surg 1992;104:46-59.[Abstract]
  6. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections J Thorac Cardiovasc Surg 2000;119:946-962.[Abstract/Free Full Text]
  7. Westaby S, Saito S, Katsumata T. Acute type A dissection: conservative methods provide consistently low mortality Ann Thorac Surg 2002;73:707-713.[Abstract/Free Full Text]
  8. Mehta RH, Suzuki T, Hagan PG, et al. Predicting death in patients with acute type a aortic dissection Circulation 2002;105:200-206.[Abstract/Free Full Text]
  9. Ehrlich M, Fang WC, Grabenwoger M, Cartes-Zumelzu F, Wolner E, Havel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection Circulation 1998;98(Suppl 2):294-298.[Abstract/Free Full Text]
  10. Fann JI, Smith JA, Miller DC, et al. Surgical management of aortic dissection during a 30-year period Circulation 1995;92(Suppl 2):113-121.[Abstract/Free Full Text]
  11. Neri E, Toscano T, Massetti M, et al. Operation for acute type A aortic dissection in octogenarians: is it justified? J Thorac Cardiovasc Surg 2001;121:259-267.
  12. von Segesser LK, Lorenzetti E, Lachat M, et al. Aortic valve preservation in acute type A dissection: is it sound? J Thorac Cardiovasc Surg 1996;111:381-390.[Abstract/Free Full Text]
  13. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection Ann Thorac Surg 1997;64:1108-1112.[Abstract/Free Full Text]
  14. von Oppell UO, Karani Z, Brooks A, Brink J. Dissected aortic sinuses repaired with gelatin-resorcin-formaldehyde (GRF) glue are not stable on follow up J Heart Valve Dis 2002;11:249-257.[Medline]
  15. Kazui T, Washiyama N, Bashar AH, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root Ann Thorac Surg 2001;72:509-514.[Abstract/Free Full Text]
  16. Hata M, Shiono M, Sezai A, Iida M, Negishi N, Sezai Y. Type A acute aortic dissection: immediate and mid-term results of emergency aortic replacement with the aid of gelatin resorcin formalin glue Ann Thorac Surg 2004;78:853-857.[Abstract/Free Full Text]
  17. Ergin MA, Phillips RA, Galla JD, et al. Significance of distal false lumen after type A dissection repair Ann Thorac Surg 1994;57:820-824.[Abstract/Free Full Text]
  18. Kawahito K, Adachi H, Murata S, Yamaguchi A, Ino T. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management Ann Thorac Surg 2003;76:1471-1476.[Abstract/Free Full Text]
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