Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management

Abstract

Controversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting. From 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n=88) or thoracoabdominal (n=81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention. Thirty-day mortality was 8% (n=14). Serious complications included neurologic (n=12 [spinal cord n=4, 2.4%]), respiratory (n=32), and renal failure (n=1 descending thoracic artery only vs 17 thoracoabdominal, P<.001). Chronic obstructive pulmonary disease predicted early mortality (hazard ratio 8.0, P=.005). Survival at 1, 2, and 5 years was 76%, 69%, and 55%, respectively; 23 patients (14%) required reintervention. Event-free survival at 5 years was 51% and 47% after descending thoracic artery only or thoracoabdominal repair, respectively. Greater maximum aortic diameter (hazard ratio 1.9, P=.03) and greater diameter at the diaphragm (hazard ratio 3.7, P=.01) or renal segment (hazard ratio 4.3, P=.03) predicted poor outcome. Early outcomes are good and late outcomes are less than desirable after open repair of chronic distal aortic dissection, regardless of the extent of repair. High-risk and late-stage patients with larger and more extensive aneurysmal degeneration warrant further investigation, including the use of newer, less-invasive techniques. Select patients at risk for aneurysmal degeneration should undergo a more aggressive initial approach with aortic dissection repair.