Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database

Abstract

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.

Acute type A aortic dissection – a review

“…A NORCAAD report from Pan et al recently showed freedom from reoperation rates of 98% at one year and 95% at five years [8]. Other studies have shown freedom from reoperation of 82-94% at five years [85,101,102]. However, Wang et al found that patients with connective tissue disease had a 45% risk of reoperation at a median follow-up time of 2.5 years and Pan et al found that patients with connective tissue disease had a five times higher risk of proximal reoperation [8,103].…”

“…Conservative approaches are being increasingly challenged, and more extensive primary aortic repairs suggested, addressing associated and potential future problems of aortic dilatation (in the root, arch, proximal descending aorta, or entire thoracoabdominal aorta) that may both affect longterm survival and necessitate reinterventions. Reoperations after primary ATAAD repair are not uncommon in longterm survivors, or up to 25-30% [83,84], and mortality is at a respectable 10-20% for elective reoperations on the proximal aorta (25-31% on the distal aorta),but as high as 67% in acute settings [8,[83][84][85].…”

Efficacy of Total Aortic Arch Replacement Combined with Frozen Elephant Trunk in Aortic Reoperation

“…Among the patients undergoing a secondary TAR+FET procedure, the mortality rate within 30 days after operation was 13.6%, and the long-term mortality rate was 23.7%, which is generally equivalent to the in-hospital mortality rates of 9–25% in other studies [21–23]. Thus, TAR+FET is feasible for use in treating macrovascular disease after cardiac surgery and does not increase the risk of mortality.…”

Early and late outcomes after open ascending aortic surgery: 47-year experience in a single centre

“…Previous studies have reported reoperation rate to be from 7.8 to 23.2% and that reoperation rates were not associated with preoperative aortic regurgitation severity, surgical technique nor any other factors for that matter [ 1 , 10 , 18 ]. Reoperations are technically challenging due to tight adhesions and the mortality still remains high especially for distal re-dos [ 19 ]. It can be speculated that actual indications for reintervention on the aorta are hitherto unclear and represent subjective institutional and surgeon-dependent thresholds for surgery, but further studies on subject are warranted.…”