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

Abstract

BackgroundThe optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy.Methods and ResultsAll aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes included organ‐specific morbidity and 1‐ and 5‐year outcomes as estimated using the Kaplan–Meier method. The majority of initial reoperations were proximal aortic (aortic valve, aortic root, or ascending) or aortic arch procedures (62.5%, n=55); most initial reoperations were performed in the elective setting (83.1%, n=74). Additional nonstaged second or more reoperations were required in 21 patients (23.6%) after the initial reoperation, during a median follow‐up of 2.5 years after the initial reoperation. Thirty‐day or in‐hospital mortality for all reoperations was 7.0% (elective: 6.3%; nonelective: 11.1%) with acceptable rates of organ‐specific morbidity, given the procedural complexity. One‐ and 5‐year overall survival after initial reoperation was 85.9% and 64.9%, respectively, with aorta‐specific survival of 88% at 5 years.ConclusionsReoperation after acute type A aortic dissection repair is associated with low rates of mortality and morbidity. These data support more limited index repair for acute type A dissection, especially for patients undergoing index repair in lower volume centers without expertise in extensive repair, because reoperations, if needed, can be performed safely in referral aortic centers.

Acute type A aortic dissection – a review

“…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]. This possibly indicates that a more aggressive primary approach may be feasible in patients with hereditary conditions.…”

招請講演

“…Data on this more aggressive approach, such as that from the German Registry for Acute Aortic Dissection type A (GERAADA), demonstrates higher early mortality and morbidity with index total arch as compared to hemi-arch replacement, and therefore the appropriateness of this more aggressive approach requires further study. Data from our institution on outcomes of aortic reoperation after prior acute type A dissection repair demonstrates that the majority (83%) of such cases are elective and can be performed with low rates of operative mortality (6%) and organspecific morbidity [5]. These data provide support for limited index repair for acute type A dissection, especially for patients undergoing repair in lower volume centers without expertise in extensive repair.…”

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

“…However, for patients that have undergone one re-intervention, the rate of re-re-interventions is as high as 40% at 5 years, and is especially so for patients with connective tissue disorders. 24 Among a recent group of large studies, 81À92% of re-intervention cases were elective, 5,13,24,25 perhaps contributing to a very low re-operative risk, which ranged from 0% to 12% (weighted average 4.7%) 1,3,5,7,11,13,22À24,26 Thus, in terms of the magnitude of the downstream problem: re-interventions are mostly elective, infrequent, low-risk events.…”