Late Outcome after Surgery for Type-A Aortic Dissection.

Mikko Jormalainen,Tatu Juvonen,Maarit Venermo,Peter Raivio,Antti Vento,Hannu-Pekka Honkanen,Caius Mustonen,Fausto Biancari

doi:10.3390/jcm9092731

Abstract

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.

Highlights

Surgery for acute Stanford Type A aortic dissection (TAAD) is associated with substantial early mortality and morbidity [1,2]
At 10 years, the cumulative incidence of rupture of the distal aorta or distal aortic reoperation was higher when the diameter of the descending thoracic aorta was ≥35 mm, but the difference did not reach statistical significance
The present study showed that: (1) late survival of patients operated for TAAD was satisfactory and, when a policy of strict postoperative surveillance was applied, only a small number of them died of aortic-related events; (2) primary surgery was limited to the aortic segment involved by the intimal tear with a low risk of aortic reoperation; (3) reoperations on the dissected abdominal aorta accounted for half of the distal aortic procedures; (4) patients with a descending thoracic aorta diameter ≥35 mm at primary surgery had a significantly increased risk of distal aortic reoperations

Summary

Introduction

Surgery for acute Stanford Type A aortic dissection (TAAD) is associated with substantial early mortality and morbidity [1,2]. These extensive aortic interventions are supposed to protect the fragile remaining aorta from degeneration and to confer a reduction in volume and lead to thrombosis of the false lumen These procedures can be associated with adverse events [5] and do not completely prevent late events [6,7,8,9]: these aspects may not justify their associated increased risks and costs. In this scenario of uncertainty, evaluation of the long-term outcome after surgery for TAAD is of importance to estimate the risk of late aortic-related complications and to identify patients who may most benefit from a more extensive surgical and/or completion endovascular procedure.

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Conclusion