Distal Reoperation Research Articles

Distal Reoperations after Repair of Acute Type A Aortic Dissection-Incidence, Causes and Outcomes.

In patients with acute type A aortic dissection (A-AAD) whether initial repair should include also aortic arch replacement is still debated. We aimed to assess if extensive aortic repair prevents from reoperations patients with A-AAD. Outcomes after distal reoperation following repair of A-AAD (n = 285; 1977 to 2018) were analysed in 22 of 226 who underwent ascending aorta/hemiarch replacement (Group ) and 7 of 59 who had ascending aorta/arch replacement (Group ). Distal reoperation was more common in Group (n = 22) than in Group (n = 0) (p 0.001) while thoracic endovascular stenting was more frequent in Group (7 vs 3, p 0.001). Indications for reoperation were pseudoaneurysm at distal anastomosis (n = 4, 18%) and progression of aortic dissection (n = 18, 82%) in Group . Indication for thoracic endovascular stenting was progressive aortic dissection in 3 patients of Group and in 6 of Group . Second reoperation was required in 2 patients from Group (2%) during a mean follow-up of 5 years. Median follow-up was 4 years in Group and 7 years in Group (p = 0.36). Hospital mortality was 14% in Group and 0% in Group (p = 0.3). Actuarial survival is 68 10%, and 62 11% for Group and 100% for Group at 5 and 10 years (p = 0.076). Distal reoperations after A-AAD repair have an acceptable mortality. An extensive initial repair has lower rate of reoperation and better mid-term survival and should be indicated especially for young patients in experienced centers.

Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection

To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.

Optimal timing and sequence of ventriculoperitoneal shunt and gastrostomy placement

ABSTRACT Background: The optimal timing of ventriculoperitoneal shunt (VPS) and gastrostomy placement, relative to the safety of simultaneous versus staged surgery, has not been clearly delineated in the literature. Objective: To study the optimal inter-procedural timing relative to distal VPS infection and pertinent reoperation. Methods: A fifteen-year, retrospective, single-center study was conducted on adults undergoing VPS and gastrostomy within 30-days. Patients were grouped according to inter-procedural interval: 0–24 hr (immediate), 24 hr-7 days (early), and 7–30 days (delayed). The primary endpoint of the study was VPS infection and distal shunt complications requiring reoperation. Potential predictors of the primary end point (baseline cohort characteristics, procedural factors) were examined with standard statistical methods. Results: A total of 188 patients met inclusion criteria. The average interval between procedures was 7 ± 6 days, with 43.1% undergoing VPS prior to gastrostomy. Primary endpoint was encountered in 5 patients (2.7%): 1 (5.9%) of 17 patients undergoing immediate placement, 3 (2.8%) of 107 with early placement, and 1 (1.6%) of 64 with delayed placement. Although not statistically significant, 3.7% of patients undergoing VPS first had the primary endpoint, compared to 1.9% of those with gastrostomy. There were no statistically significant associations between the primary outcome and peri-operative CSF counts, gastrostomy modality, hydrocephalus etiology, chronic steroid use, or extended antibiotic administration. Conclusion: Although the low overall event rate in this cohort precludes definitive determination regarding differential safety, the data generally support a practice of performing the procedures >24-hours apart, with placement of gastrostomy prior to VPS.

DARTS Trial

DARTS Trial

Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome?

Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS. The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed. Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death. This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.

Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years.

Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using the frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation. The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2±10.5 years and 426 were male (82.2%). The mean time from symptomatic onset to surgery was 4.8±3.7 days. Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass (CPB), cross-clamp and selective antegrade cerebral perfusion were 201±50, 112±34, and 26±10 minutes, respectively. Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), re-exploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0±4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, and anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P<0.001) and malperfusion syndrome (binary) (OR 2.291; 95% CI 1.283-6.650; P=0.011) were predictive of operative mortality, while multiple malperfusion predicted late death (hazard ratio, HR 6.815; 95% CI 2.447-18.984; P<0.001). Risk factors for late death and distal reoperation included MFS (HR, 1.824; 95% CI 1.078-3.087; P=0.025) and malperfusion (HR, 1.787; 95% CI 1.042-3.064; P=0.035). In this large series of patients with ATAAD, the FET + TAR technique has achieved favorable early and long-term survival and freedom from reoperation up to 15 years. Marfan syndrome and malperfusion syndrome were risk factors for early and late mortality and distal reoperation. This study adds long-term evidence supporting the use of the FET + TAR technique in patients with ATAAD involving the arch and descending aorta.

Limited repair with tear-oriented approach for type A aortic dissection.

Acute type A aortic dissection (ATAAD) remains an eminent, life-threatening disease. Although centers of excellence report mortality rate after ATAAD repair as low as 5% to 8%, data from the International Registry of Acute Aortic Dissection continue to demonstrate a high mortality rate of around 17% to 18%. Tear-oriented approach to determine the extent of repair has been widely accepted to treat ATAAD. In recent years, aggressive approach with total arch replacement - especially using hybrid procedure with the antegrade stent grafting in the proximal descending aorta - have been advocated to decrease the future downstream reoperations in younger patients or to treat malperfusion syndrome. In this article, we review outcomes comparing limited/tear-oriented approach vs. extended repair based on updated outcomes after ATAAD repair to evaluate for the indications and validity of each approach. We found that extended repair remains a high-risk operation in most hands and distal reoperation rate in contemporary series are as low as 10%. In addition, we did not find data to support concomitant antegrade stenting to improve outcomes in patients with distal malperfusion. In conclusion, we do not recommend beyond the tear-oriented approach, as any future benefit with extended repair seems outweighed by the incremental risk with the short-term risk in most hands.

1-Year Follow-Up Study of Preemptive TEVAR for Residually Dissected Aortas after Proximal Open Repair of Acute Type A Aortic Dissection in High-Risk Patients for Late Re-Intervention

Introduction - Disease progression often occurs in residually dissected aorta after proximal open repair of acute type A aortic dissection (ATAD), requiring distal reoperations, with high mortality and morbidity(1). Unlike type B dissection, the efficacy of preemptive thoracic endovascular aneurysm repair (TEVAR) on the residual disease remains to be seen. We hypothesized that patients who were likely to develop late aneurysmal dilatation of false lumen would benefit from this preemptive approach. Methods - Initially, to analyze risk factors for late aortic events, 108 patients who survived proximal repair for ATAD from 2001 to 2010 were reviewed. During mean follow-up of 40 months, 12 patients required 14 distal re-interventions. On statistic analysis, we identified age < 60 years (p<0.01), aortic diameter > 46mm (p<0.01), and patent false lumen (p<0.05) as factors that predisposed patients who underwent the proximal repair to require late re-interventions. In 2015, we began performing preemptive TEVARs. From April 2015 to January 2016, 11 patients (mean age, 56 years; 72% men) who met the criterion of the aforementioned 3 risk factors underwent preemptive TEVARs. Devices used consisted of a proximal covered stent graft and a distal bare metal stent (Zenith Dissection Endovascular system). Simultaneously, subclavian revascularization was performed in 4 patients and 2 debranching in 2 patients. The interval between proximal repair and TEVAR averaged 122 days (range, 50-297). All patients received 12-month surveillance, including computed tomography (CT). Results - Successful graft deployment and coverage of the primary entry tear was achieved in all patients with no early deaths or intraprocedural conversions. One patient required coil occlusion of the left subclavian artery 5 days post-procedure for retrograde perfusion of the false lumen. No other serious adverse events occurred within 12 months. Survival was 100% at 1 year. Surveillance CT data showed the false lumen was completely (n=8) or partially (n=3) thrombosed in the thoracic aorta at the 12-month visit. Of the 7 patients who underwent the preemptive TEVAR within 3 months, all had complete false lumen thrombosis at the thoracic level. Six of the 7 patients experienced complete shrinkage of false lumen of the thoracic aorta. From pre-treatment to the 12-month visit, the average true lumen area increased by 203 mm2 (p<0.01), and the average false lumen decreased by 276mm2 (p<0.05), at the level of the maximum aortic diameter. Conclusion - TEVAR for residually dissected aortas after proximal open repair of acute type A aortic dissection can be done with a high rate of thoracic aortic remodeling in high-risk patients for late re-intervention. Especially, results of TEVAR within 3 months after open repair are promising. The encouraging results will stimulate further research to define the utility of the preemptive TEVAR. References(1)Geirsson A, Bavaria JE, Swarr D, Keane MG, Woo YJ, Szeto WY, Pochettino A. Fate of the residual distal and proximal aorta after acute type A dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007:84;1955-64.

Can Frozen Elephant Trunk Cure Type I Dissection Confined to Thoracic Aorta in Marfan Syndrome?

This study sought to evaluate the long-term impact of frozen elephant trunk (FET) on the distal aorta of patients with Marfan syndrome (MFS) who had type I dissection confined to the thoracic aorta (above the diaphragmatic hiatus). Between 2003 and 2016, 42 patients with MFS (Ghent or revised Ghent criteria) (age 33.3 ± 8.9 years; 27 men; 64.3%) sustaining type I dissection above the diaphragmatic hiatus involving the aortic arch (22 acute; 52.4%) underwent total arch replacement and FET. Dissection extended distally to the mid-descending aorta in 32 (76%) and to above the diaphragmatic hiatus in 10 (24%) patients. Operative mortality was 4.8% (2 of 42). Follow-up was 100% at 6.3 ± 3.0 years. Maximal aortic sizes at the mid-descending aorta, diaphragmatic hiatus, renal arteries, and largest segment of abdominal aorta were 22.8, 21.1, 19.1, and 19.9 mm preoperatively and 23.1, 22.0, 19.8, and 22.4 mm on the latest computed tomographic angiography. Dilation and complete remodeling of the distal aorta occurred in 10.0% (4 of 40) and 90% (36 of 40) of patients, respectively. One late death occurred, and 3 distal reoperations were performed. Preoperative abdominal aortic maximal aortic size was predictive of distal dilatation (mm) (hazard ratio, 1.78; P= .021) and reoperation (≥25 mm vs <25 mm) (hazard ratio, 12.88; P= .037). At 10 years, freedom from dilation, reoperation, and death were 69.8%, 78.1%, and 90.0%, respectively. At 8 years, the rates of death, reoperation, and reoperation-free survival were 10%, 11%, and 79%, respectively. The FET technique has a positive remodeling impact on type I dissection confined to the thoracic aorta in patients with MFS. This study adds evidence supporting the safety and durability of this extended approach for type I aortic dissection in MFS.

Fate of distal aorta after frozen elephant trunk and total arch replacement for type A aortic dissection in Marfan syndrome

ObjectiveThe use of the frozen elephant trunk technique for type A aortic dissection in Marfan syndrome is limited by the lack of imaging evidence for long-term aortic remodeling. We seek to evaluate the changes of the distal aorta and late outcomes after frozen elephant trunk and total arch replacement for type A aortic dissection in patients with Marfan syndrome. MethodsBetween 2003 and 2015, we performed frozen elephant trunk + total arch replacement for 172 patients with Marfan syndrome suffering from type A aortic dissection (94 acute; 78 chronic). Mean age was 34.6 ± 9.3 years, and 121 were male (70.3%). Early mortality was 8.1% (14/172), and follow-up was complete in 98.7% (156/158) at a mean of 6.2 ± 3.3 years. Aortic dilatation was defined as a maximal diameter of greater than 50 mm or an average growth rate of greater than 5 mm/year at any segment detected by computed tomographic angiography. Temporal changes in the false and true lumens and maximal aortic size were analyzed with linear mixed modeling. ResultsAfter surgery, false lumen obliteration occurred in 86%, 39%, 26%, and 21% at the frozen elephant trunk, unstented descending aorta, diaphragm, and renal artery, respectively. The true lumen expanded significantly over time at all segments (P < .001), whereas the false lumen shrank at the frozen elephant trunk (P < .001) and was stable at distal levels (P > .05). Maximal aortic size was stable at the frozen elephant trunk and renal artery (P > .05), but grew at the descending aorta (P = .001) and diaphragm (P < .001). Respective maximal aortic sizes before discharge were 40.2 mm, 32.1 mm, 31.6 mm, and 26.9 mm, and growth rate was 0.4 mm/year, 2.8 mm/year, 3.6 mm/year, and 2.6 mm/year. By the latest follow-up, distal maximal aortic size was stable in 63.5% (99/156), and complete remodeling down to the mid-descending aorta occurred in 28.8% (45/156). There were 22 late deaths and 23 distal reoperations. Eight-year incidence of death was 15%, reoperation rate was 20%, and event-free survival was 65%. Preoperative distal maximal aortic size (mm) predicted dilatation (hazard ratio, 1.11; P < .001) and reoperation (hazard ratio, 1.07; P < .001). A patent false lumen in the descending aorta predicted dilatation (hazard ratio, 3.88; P < .001), reoperation (hazard ratio, 3.36; P = .014), and late death (hazard ratio, 3.31; P = .045). ConclusionsThe frozen elephant trunk technique can expand the true lumen across the aorta, decrease or stabilize the false lumen, and stabilize the distal aorta in patients with Marfan syndrome with type A aortic dissection, thereby inducing favorable remodeling in the distal aorta. This study adds long-term clinical and radiologic evidence supporting the use of the frozen elephant trunk technique for type A dissection in Marfan syndrome.

Techniques and outcomes of secondary open repair for chronic dissection after acute repair of type A aortic dissection.

Despite successful repair of acute type A aortic dissection (TAAD), the distal false lumen may remain patent resulting in progressive degeneration of the remaining distal aorta. This can lead to aneurysmal dilatation and risk of rupture. Open distal reoperation to replace the residually dissected thoraco-abdominal aorta may be accomplished with acceptable morbidity and mortality in experienced hands. This can be facilitated when the index operation for acute TAAD is tailored to exclude all primary tears and set the arch and descending aorta for a subsequent open, endovascular or hybrid procedure.

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry

ObjectivesTo describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. MethodsA retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. ResultsThe median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. ConclusionsType A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.

Long-term outcomes of total arch replacement with the non-frozen elephant trunk technique for Stanford Type A acute aortic dissection.

Arch repair using the frozen elephant trunk (FET) technique has been utilized to treat Type A acute aortic dissection. In contrast, the long-term outcomes of the non-FET technique focus on the thrombosed false lumen (FL), and distal aortic reoperation rates remain unclear. The goal of our study was to investigate the efficacy and long-term outcomes of the non-FET technique as the benchmark. We reviewed 518 patients with Type A acute aortic dissection in the last 20 years. Among them, 139 hospital survivors (61 ± 12 years) who had undergone total arch replacement with the non-FET technique were enrolled. A total of 86% (120/139) of patients had a patent FL at the descending aorta preoperatively. The median follow-up period was 41 (1-219) months. No spinal cord ischaemia and new entry tear formation were observed. Postoperative FL thrombosis of the entire descending aorta was obtained in 47% (66/139) and in 39% (47/120) of patients who had a patent FL preoperatively. Freedom from dissection-related distal reoperation rates at 1, 3, 5 and 10 years were 87%, 83%, 81% and 78%, respectively. The results of multivariate analysis indicated that the predictors of a dissection-related reoperation were connective tissue disease [hazard ratio (HR) 4.6, P = 0.006], re-entry at the superior mesenteric artery (HR 2.9, P = 0.04), unachieved primary entry resection (HR 5.3, P = 0.001) and preoperative maximum descending aortic diameter ≥38 mm (HR 11.6, P < 0.001). Total arch replacement with the non-FET technique was safe and reliable from the viewpoint of spinal cord ischaemia. Further comparative studies between the FET and the non-FET techniques are required.

Tubularized incised plate urethroplasty for distal and midpenile hypospadias reoperation: A single institute experience

Objective: Our study aimed to evaluate our experience in tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Patients and methods: This was a retrospective study in which we reviewed the medical records of 56 patients who underwent tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Tubularized incised plate urethroplasty was performed using a surgical technique like the primary tubularized incised plate repair based on the Snodgrass’s method. We recorded complications and functional outcomes of redo procedures. Results: We reviewed 56 patients who ranged in age from 2–16 years (mean 7.02±3.8 years). The overall complication rate was 33.9% ( n=19). Eight patients (14.3%) had fistula, six had meatal stenosis (10.7%), four had dehiscence (7.1%), and one had neourethral stenosis (1.8%). The complications occurred in 13 of mid-penile cases representing 50% of mid-penile cases but occurred in six cases of distal-penile cases (20%). The success rate of tubularized incised plate urethroplasty reoperation was 94.6% after repair of fistula and meatal stenosis by simple closure of fistula and meatoplasty. Conclusion: Tubularized incised plate urethroplasty is a safe and effective alternative procedure for hypospadias reoperations. The outcome is favorable if the urethral plate has no scars and with distal meatal location. The complication rate increases if the third redo is done and with midpenile meatal location.

Staged Tubularized Autograft Repair for Primary Proximal Hypospadias with 30-Degree or Greater Ventral Curvature

We report outcomes in consecutive patients with primary proximal hypospadias and ventral curvature 30 degrees or greater after degloving, all repaired with 2-stage tubularized autografts, a variation of the Nicolle-Bracka procedure. Consecutive boys with proximal hypospadias and ventral curvature 30 degrees or greater after degloving underwent transection of the urethral plate. In addition, those with persistent ventral curvature 30 degrees or greater underwent 3 ventral corporotomies without corporal grafting for straightening. Staged graft urethroplasty was performed using prepuce, or labial mucosa, when the family requested preputioplasty. The goal in all cases was a straight penis with a normally positioned neomeatus. A total of 43 boys completed both stages with postoperative followup. Mean ventral curvature was 70 degrees, which necessitated corporotomy in 65%. There was no recurrent ventral curvature. Preputial grafts were used in 88%. A skin graft or scrotal flap was needed for ventral shaft coverage at the second stage in 4 boys (9%). During followup of an average of 22 months urethroplasty complications were diagnosed in 10 (23%), mostly glans dehiscence and fistulas. Of these patients 9 underwent 12 reoperations. Success was achieved in 42 (98%) patients. Staged tubularized autograft resulted in a straight penis with a normally positioned neomeatus in boys with the most severe proximal hypospadias in 77%, increasing to 98% after 1 or 2 distal reoperations for complications. There was no recurrent ventral curvature after 3 corporotomies without corporal grafting. Urethroplasty graft take was reliable.

Descending endografts for type A dissections: con.

An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. Studies on the fate of residual dissection after acute type A aortic dissection repair in the past decade have driven surgeons to seek procedures to avoid distal reoperation. Aggressive surgical approach with total arch replacement in acute type A dissection has demonstrated lower incidence of distal reoperation and slower aortic growth rate compared to less aggressive ascending/hemiarch repair. Recently, successful results of thoracic endovascular aortic repair (TEVAR) in type B aortic dissection have encouraged surgeons to further attack acute type A aortic dissection with hybrid approach: antegrade endografting in the descending thoracic true lumen as an adjunct to hemiarch or total arch repair. However, is the hybrid approach with simultaneous descending endografting justified in all the acute type A aortic dissection cases? The outcomes of the hybrid approach reported by the several groups have demonstrated 80-100% of false lumen thrombus formation in the proximal descending aorta (stented segment); however, the complete obliteration of the false lumen is only 17-50%. The incidence of distal reoperation/reintervention after hybrid approach is as high as 14% and an adjunctive procedure is often performed. Moreover, there are concerns about additional risks associated with the hybrid procedures, such as spinal cord injury (SCI), stent graft induced new entry and stroke. The data on this new approach are still very limited. Hence, further study is warranted to prove its safety and durability.

Reoperation for enlargement of the distal aorta after initial surgery for acute type A aortic dissection

We investigated the long-term outcomes of repair for acute type A aortic dissection on the basis of false lumen status and assessed treatment modalities for the enlarged downstream aorta. Between January 1990 and March 2013, 534 patients underwent surgery for acute type A aortic dissection. In-hospital mortality was 9.3% (50/534), and follow-up was 98% (472/484). Of the 472 hospital survivors, 451 (96%) underwent contrast-enhanced computed tomography within 1 month of surgery. Risk-adjusted survival and distal aortic events were investigated in these 451 patients. Surgical outcomes of distal reoperations were assessed in 37 patients. Postoperative false lumen patency was 62% (280/451). Eighteen patients died of aortic rupture, 17 (94%) with a patent false lumen. A patent false lumen decreased survival (hazard ratio [HR], 1.70; P=.012) and increased distal aortic events (HR, 4.11; P=.001). Other predictors identified were age (HR, 1.07; P<.001) and male sex (HR, 1.89; P=.002) for late mortality, and Marfan syndrome (HR, 6.6; P<.001), distal aortic diameter greater than 45 mm (HR, 4.4; P<.001), and nonresection of the primary entry (HR, 2.3; P=.005) for distal aortic events. Distal reoperations comprised open repair of the arch (n=13), descending aorta (n=16), or thoracoabdominal aorta (n=7) or thoracic endovascular aortic repair (n=7), with no in-hospital death or paraplegia. Although thoracic endovascular aortic repair yielded false lumen thrombosis around the stent graft in 80% of patients (4/5), complete false lumen thrombosis was achieved in 20% (1/5). False lumen patency influences the late outcomes of acute type A aortic dissection repair. Outcomes of distal reoperation were acceptable; thus, careful follow-up and timely reoperation may improve the late outcomes.

Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate

Previously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair. DeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained. Preoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P<.001). In-hospital/30-day mortality (10% vs 14%; P=.51), stroke (5% vs 8%; P=.6), and paraplegia (0% vs 1%; P=1) were similar in the stented versus standard groups. Mean follow-up was 2.7 ± 2.3 and 2.2 ± 2.1 years. Actuarial survival in stented versus standard groups at 1 and 7 years was 86% versus 81% and 76% versus 60% (P=.5). Thoracic aorta false lumen obliteration was improved in the stented group (82% vs 39%; P<.001), along with improved freedom from open distal aortic reoperation rate (98% vs 90% at 6 years, P=.1). Endovascular distal aortic reintervention rate was higher in the stented group (18% vs 3%; P=.008), with zero mortality. Antegrade stent graft deployment during acute DeBakey type I dissection repair is safe method to promote distal aortic remodeling without increasing postoperative or midterm mortality. This technique provides increased freedom from open distal aortic reoperations compared with standard open repair.

Mortality and reoperations in survivors operated on for acute type A aortic dissection and implications for catheter-based or hybrid interventions

This study investigated late outcomes (mortality, reoperations) and their associated predictors after operations for acute type A aortic dissection. The role catheter-based and hybrid interventions is discussed. All hospital survivors operated on for acute type A aortic dissection from 1990 through 2009 were reviewed, with cross-sectional follow-up. Mortality (overall and aortic) and freedom from reoperations (proximal and distal) were estimated using actuarial methods. Preoperative, intraoperative, and postoperative variables (n = 44) associated with late outcomes were analyzed with univariable and multivariable (Cox) statistical methods. Of 360 operated-on patients, 291 hospital survivors (81%) were monitored for a median of 5.5 years (1864 patient-years). Total late mortality was 30% (n = 86), with estimated (standard error) survival of 82% (3%), 64% (4%), and 48% (6%) at 5, 10, and 15 years, respectively. Aortic events accounted for at least 27% (up to 42% including unknown causes) of late deaths. In Cox analysis, variables independently related (hazard ratios [95% confidence limits]) to late mortality were increased age (1.6 per 10 years [1.3, 2.0]), earlier operation (<2005; 2.3 [1.2, 4.6]), permanent neurologic damage (2.6 [1.6, 4.2]), and respiratory insufficiency (3.4 [1.8, 6.4]). Thirty-four patients underwent 46 reoperations, 21 on the proximal and 25 on the distal aorta, up to 19 years after the primary operation; respective in-hospital reoperative mortality was 14% and 12%. Estimated freedom (standard error) from aortic reoperation was 95% (2%), 87% (4%), and 61% (5%) at 5, 10, and 15 years, respectively. In multivariable Cox analysis (hazard ratios [95% confidence limits]), use of surgical adhesive at the primary operation (4.2 [1.6, 11]) and temporary neurologic damage (3.2l [1.2, 8.9]) were independently related to proximal reoperation, and DeBakey type I dissection (10.5 [1.4, 80]) was related to late distal reoperation. Catheter-based (endovascular, percutaneous) or hybrid procedures were not used in any patients but could have been used in up to 74% of reoperations, including in four of six of those that resulted in in-hospital death and putatively in 10 of 17 patients who sustained lethal aortic events without reoperation. Despite close follow-up, aortic-related death after a successful operation for acute type A aortic dissection is prevalent, and overall mortality remains substantial. Reoperations are not uncommon, may be indicated very late as well as repeatedly in the same patient, and are associated with a significant mortality. Increased use of applicable but seemingly under-used catheter-based or hybrid treatment approaches could benefit this growing patient population by offering repeat intervention to more patients and as substitute for reoperative open surgery in selected cases.

Should the dissected aortic arch be replaced in acute type A dissection? The Mayo Clinic perspective.

Should the dissected aortic arch be replaced in acute type A dissection? The Mayo Clinic perspective.