Is close radiographic and clinical control after repair of acute type A aortic dissection really necessary for improved long-term survival?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether radiographic and clinical control after surgery for acute type A aortic dissection (AAD) is needed for improved long-term survival. Altogether, 118 relevant papers were identified using the reported search, of which seven represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that most patients after surgery for AAD remain at risk for dissection-related aortic complications. Late aortic growth is often slow and linear, but the occurrence of major aortic events is unpredictable and can initially present more than a decade postoperatively. Risk factors for rapid late aortic enlargement and reoperations include patent or partially thrombosed false lumen, large aortic size, Marfan syndrome and younger age. Whether performing a more extensive first procedure (e.g. aortic arch replacement±elephant trunk) can be translated into improved outcome and a lower incidence of aorta-related reoperations remains to be elucidated. Aortic reoperation rates range between 10% and >20% within the first 10 years. Optimal systolic blood pressure control (<120 mmHg), including β-blocker therapy, seems to decrease late aortic dilatation and the incidence of aortic reoperations. Close and careful lifelong surveillance of patients after AAD repair including radiographic and clinical controls to evaluate the status of the remaining aorta, and thus to facilitate adaptations of medical therapy and planning of timely reprocedures seems mandatory for improved long-term survival. A suggested timeframe for computed tomographic (CT) imaging after surgery for AAD is before discharge, at six and 12 months postdissection and, if stable, annually thereafter. Patients with large aneurysms (aortic diameter≥50 mm) should be maintained at radiographic intervals of six months or less. If the thoracic aneurysm is moderate in size and remains stable over time, magnetic resonance imaging instead of CT-scanning is reasonable to minimize the patient's radiation exposure.