The aortic arch management for type A aortic dissection: aggressive but experienced (original) (raw)
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Extended versus limited arch replacement in acute Type A aortic dissection
European Journal of Cardio-Thoracic Surgery
OBJECTIVES: The recommended extent of surgical resection and reconstruction of the arch in acute DeBakey Type I aortic dissection is an ongoing controversy. However, several recent reports indicate a trend towards a more extensive arch operation in several institutions. We have analysed the recent data from the International Registry of Acute Aortic Dissection to assess the choice of procedure over time and to evaluate the surgical outcome in a 'real-world' database. Our aim was to compare short-and mid-term outcomes of limited repairs versus complete arch surgery. METHODS: Of the 1241 patients included in the 'Interventional Cohort' of the International Registry of Acute Aortic Dissection from March 1996 to March 2015, 907 underwent ascending aortic or hemiarch replacement (Group A) and 334 had extended arch replacement (Group B). An extended resection was a surgeon's 'judgement call'. Logistic regression analysis, propensity-adjusted multivariable comparisons and Kaplan-Meier curves were used for analyses. RESULTS: Overall in-hospital mortality was 14.2% with no difference between groups (Group A 13.1%, Group B 17.1%). Coma/altered consciousness (odds ratio 3.16, 95% confidence interval 1.60-6.25, P = 0.001), hypotension, tamponade or shock (2.03, 1.11-3.73, P = 0.022) and any pulse deficit (1.92, 1.04-3.54, P = 0.038) were predictors of in-hospital mortality in a propensity score-adjusted multivariable analysis. Overall 5-year survival was 69.4% in the ascending group and 73.1% in the total arch group (P = 0.83 by Kaplan-Meier analysis). For survivors of the index hospitalization, the 5-year freedom from death, aortic rupture and reintervention were 71.1% in Group A and 76.4% in Group B (P = 0.54 by Kaplan-Meier analysis). CONCLUSIONS: Selective, or 'surgeon's choice', extended arch replacement had no discernible acute downside compared with less extensive surgery. Whether extended arch replacement improves the prognosis beyond 5 years remains to be settled.
Aortic arch surgery after previous type A dissection repair: results up to 5 years†
Interactive cardiovascular and thoracic surgery, 2015
Open aortic arch surgery after type A dissection repair is challenging. We sought to review our surgical experience to analyse the causes and timing, establish the risk profile for this patient population, and better define outcomes. From 2000 to 2014, we identified 55 patients who required aortic arch surgery after a previous type A dissection repair. Medical records were available for review including computerized tomographic angiograms, cerebral protection strategies and follow-up. The mean interval from previous type A dissection repair to aortic arch surgery was 5.7 ± 5.4 years. At reoperation 36 patients (65%) had total arch replacement and 19 (35%) had hemiarch replacement. Indications for reoperations were: enlarging aneurysm in 27 (49%), impending rupture in 12 (22%), chronic dissection in 10 (18%) and aneurysms in 6 (11%). Arterial peripheral cannulation was used in 80% of patients. Selective antegrade cerebral perfusion was used in 35 patients (64%) and retrograde perfusi...
Aortic Arch Replacement for Dissection
Operative Techniques in Thoracic and Cardiovascular Surgery, 1999
The management of aortic dissection remains among the most challenging issues for the thoracic surgeon. Aside from dealing with the fear and trepidation that this condition instills in the average referring physician, aortic arch dissections are difficult problems that mandate expeditious diagnosis and initiation of early appropriate therapy. Although descending (Type B) d' issections can usually be treated with aggressive medical (nonoperative) therapy, Type A and aortic arch dissections usually require direct surgical intervention. This direct, usually emergent, surgical therapy is directed toward prevention of catastrophic pump failure, whether from tamponade into the pericardial sac, myocardial ischemia due to coronary ostia involvement, left ventricular overload from acute massive aortic regurgitation, or, in the case of arch dissection, neurological compromise resulting from occlusion of the cerebral vessels.
Technical advances in total aortic arch replacement
The Annals of Thoracic Surgery, 2004
Background. We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair.
The Annals of Thoracic Surgery, 2003
factor for mortality? Is extended arch replacement for acute Type A aortic dissection an additional risk http://ats.ctsnetjournals.org/cgi/content/full/76/4/1209 located on the World Wide Web at: The online version of this article, along with updated information and services, is Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Background. We report our experience with surgery for acute type A aortic dissection with involvement of the aortic arch. Methods. From January 1986 to December 2001, 277 patients underwent surgery for acute type A aortic dissection. In 70 patients (25.3%), surgery was extended into the aortic arch: hemiarch and total arch replacement in 53 (75.7%) and 17 (24.3%) patients, respectively. Deep hypothermic circulatory arrest was used in 19 patients, antegrade selective cerebral perfusion in 38, and combined deep hypothermic circulatory arrest with antegrade selective cerebral perfusion in 13. Results. Operative mortality was 18.6% (13/70) after extended replacement into the arch versus 21.7% (45/207) after surgery limited to the ascending aorta (p ؍ 0.62). Multivariate analysis did not reveal significant risk factors for operative mortality. Postoperatively, 5 patients (8.1%) had a new postoperative cerebral vascular accident (CVA).Multivariate analysis showed an earlier date of operation as the only independant determinant for a new postoperative CVA (p ؍ 0.0162, RR ؍ 0.80/year, 95% CI ؍
Technical advances in total aortic arch replacement. Discussion
The Annals of Thoracic Surgery, 2004
Background. We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair.
Hybrid repair of aortic arch dissections
Journal of Vascular Surgery, 2013
Objective: Hybrid interventions combining debranching of supra-aortic branch vessels with stent grafting of the aortic arch have become an attractive alternative to open repair for aortic arch pathologies. However, results in patients with dissections of the aortic arch remain unclear. We present our experience with hybrid aortic arch repair for acute and chronic type B aortic dissections (TBAD) involving the distal part of the arch and aortic dissections distal to previous repair of the ascending aorta. Methods: Between January 2004 and December 2011, hybrid arch repair with supra-aortic branch revascularization involving at least one carotid artery bypass and simultaneous or staged thoracic endovascular aortic repair was performed in 17 patients with a dissection involving the arch. Indications for hybrid repair were complicated acute TBAD in five patients (three impending ruptures, two malperfusion syndromes), chronic aneurysmal degeneration of a TBAD involving the aortic arch in eight, and chronic aneurysmal degeneration of a dissection distal to previous repair of the ascending aorta in four. Total arch debranching was performed in seven patients and cervical debranching in 10. Median follow-up was 13 months (range, 3-69 months). Results: Overall 30-day mortality and in-hospital mortality rates were 29% (5 of 17 patients). In-hospital death occurred in three of five patients (60%) with a complicated acute TBAD vs in two of 12 patients (17%) with chronic dissection (P [ .12) and in one of seven (14%) with total arch debranching vs four of 10 patients (40%) with cervical debranching (P [ .34). Two (12%) fatal strokes and four (24%) retrograde aortic dissections occurred. Retrograde aortic dissections tended to be more prevalent in patients with acute TBAD than in those with chronic dissection (3 of 5 vs 1 of 12; P [ .053). No spinal cord ischemia was recorded. Two other patients died, at 8 and 26 months, after the operation of causes not related to the aortic dissection. Persistent perfusion in the aortic false lumen of the graft exclusion segment was identified in six patients, due to type III endoleak (n [ 2) requiring additional endovascular intervention, type II endoleak (n [ 3), or retrograde perfusion from distal fenestrations (n [ 2). No proximal type I endoleak was identified. During follow-up, the dissected aorta distal to the stent graft remained stable in all surviving patients. Conclusions: In this series, mortality rates and incidence of retrograde aortic dissection were significant after hybrid repair of aortic arch dissections, especially in acute cases. These results are in contrast with previously published series including other aortic arch pathologies. They suggest that dissections of the aortic arch may represent a less favorable patient cohort.
Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch
AORTA, 2014
Objectives: It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age-and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. Methods: Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). Results: Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P ؍ 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P ؍ 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P ؍ 0.47), renal failure (4.3% versus 6.2%, P ؍ 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P ؍ 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P ؍ 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age-and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) ؍ 3.11; 95% confidence interval (CI) ؍ 1.44-6.73], New York Heart Association (NYHA) class > III (HR ؍ 2.25; 95% CI ؍ 1.38-3.67), circulatory arrest time > 100 minutes (HR ؍ 2.92; 95% CI ؍ 1.57-5.43), peripheral vascular disease (HR ؍ 2.44; 95% CI ؍ 1.25-4.74), and concomitant coronary artery bypass graft operation (HR ؍ 2.14; 95% CI ؍ 1.20-3.80). Conclusions: Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex-and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class > III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival.