Distal aortic interventions after repair of ascending dissection: The argument for a more aggressive approach

Abstract

Objective: Survivors of ascending aortic dissection repair frequently require downstream aortic interventions. Because of a paucity of data, we assessed early and long-term outcomes, and risk factors, of these distal procedures.Methods: From January 1993 to January 2011, 305 patients underwent 429 distal aortic interventions after acute type A (95% DeBakey type I) dissection repair performed 3.8 years earlier (median); 11% of interventions used an endovascular approach. Maximum aortic size was 5.9 AE 1.3 cm. Median follow-up was 3.6 years.Results: Hospital mortality was 6.1%. Risk factors included graft infection, concomitant coronary artery bypass grafting, combined open arch and descending procedures, and lower distal anastomotic site. Within 10 years, the probability of patients undergoing a reintervention was 38%, with a cumulative incidence of 55 per 100 patients; however, 40 (9.3%) were stage-II elephant trunks. Patients with larger aortic diameters distal to the initial repair, and a stage-I elephant trunk, were more likely to undergo distal interventions. Survival was 65% at 10 years. Higher body mass index, a longer time between reinterventions, graft infection, combined open arch and descending procedures, and lower distal anastomosis sites were risk factors. The extent of aorta replaced was not associated with increased morbidity or mortality, unless it involved a combined open arch and descending aorta procedure.Conclusions: Distal interventions after ascending aortic dissection repair are feasible, but they are associated with early morbidity and subsequent reinterventions. Rigorous follow-up with early reintervention is important for improving short-and long-term outcomes. An extended hybrid endovascular repair for initial dissection warrants study.

Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy

“…In this study, we examined 129 reoperations (in 89 patients) performed at a single referral aortic center after index repair for acute type A dissection. The results suggest that reoperation after acute Length of stay, d 6 (5-10) 6 (5-9) 9 (7)(8)(9)(10)(11)(12)(13)(14) Discharge to location other than home…”

“…Elective reoperation (hybrid arch repair, total arch replacement, and distal repair) was associated with 0% in‐hospital mortality. Outcomes of distal aortic interventions were also examined by Roselli et al in 305 patients who underwent reoperation after index type A dissection repair. The authors reported hospital mortality of 6.1% and overall survival of 84% and 73% at 1 and 5 years, respectively.…”

Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease

“…Studies from high-volume centers on recent experience with total arch replacement have reported a mortality as low as 2%, and it has been consistently <10% even during reoperations. 9–13 These encourraging results favor consideration for a more aggressive approach at the time of initial intervention that can offer long-term benefits in patients with extensive aortic disease.…”

Extended Arch Procedures for Acute Type A Aortic Dissection: A Downstream Problem?

“…Current discussion regarding the management of acute type A aortic dissection (ATAAD) is focused on whether to perform a proximal repair, such as a hemiarch resection, or an extended repair, such as a total arch replacement, possibly including an elephant trunk or fixed elephant trunk, in hopes of improving long-term outcomes. Suggested indications for performing an extended repair include: young age, 1 connective tissue disorder, 1 enlarged arch, 1 and malperfusion, 2,3 with strategies ranging from extended repair for all ATAAD 4 to more selective approaches. Many recommend a "tear directed" strategy, advocating extended repair for intimal tears on the greater curve of the arch, 1,5 large tears in the proximal descending aorta, 6 or for all arch tears.…”