Imaging Surveillance After Proximal Aortic Operations: Is it Necessary?

Abstract

Background Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance. Methods Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk. Results Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038). Conclusions Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.

Fate of the Aortic Arch Following Surgery on the Aortic Root and Ascending Aorta in Bicuspid Aortic Valve

“…We have shown that over a median follow-up of nearly 6 years the aortic arch dimensions following surgery on the proximal aorta in patients with BAV remained unchanged and that surgery for aortic arch dilatation after replacement of the root and ascending aorta is uncommon. This is consistent with recent findings from Iribarne and colleagues [17] who demonstrated a low reintervention rate in patients undergoing proximal aortic surgery, with a freedom from reintervention of 92.9% at up to 9 years. In particular, of the 308 patients with bicuspid aortopathy, only 3 (0.9%) required reintervention during follow-up, although they have not specified whether this was due to arch dilatation.…”

Invited Commentary

“…At least in this intermediate follow-up, there was no real justification for follow-up of the aortic arch. Similarly, two references from the Duke Aortic program [2] and the Mayo Clinic [3] showed similar results without demonstrating a surveillance benefit in these patients; patients with bicuspid aortic valves in particular were free of distal aortic intervention. However, all three of these studies clearly demonstrate the need for ongoing aortic root and valve imaging over time because reinterventions in the roots are not uncommon.…”

Hybrid two-stage repair of Stanford A dissection with visceral or peripheral malperfusion

“…This could ensure the surgeon inserts the stent into the true lumen by angiography. In addition, the hybrid surgery results in 80–100% of false lumen thrombus formation in proximal descending aorta (stented segment) [ 24 – 26 ].…”