One-stage repair of extensive chronic aortic dissection using the arch-first technique and bilateral anterior thoracotomy.

Abstract

We evaluated a one-stage technique for extensive replacement of the thoracic aorta in patients with chronic aortic dissection. Fifty-one patients with chronic expanding thoracic aortic dissections (48 type A, 3 type B with proximal extension) were treated with a single procedure using a bilateral anterior thoracotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-six patients had previous operations: for acute type A aortic dissection (n = 36), aortic valve disease (n = 6), or coronary artery disease (n = 4). The ascending aorta and entire arch were replaced in all patients combined with varying lengths of the descending aorta. Hospital mortality was 3.9% (2 patients). Five patients (10%) required reoperation for bleeding. Two patients were discharged on ventilatory support and 2 on dialysis. No patient sustained a stroke, and paraplegia developed in one. The 5- and 7-year survival rates were 79% and 68%. Freedom from reoperation on the thoracic or abdominal aorta was 92% at 5 and 7 years postoperatively. Serial tomograms have documented substantial enlargement of the residual dissected aorta in only 2 patients (reoperated). The technique is a safe and suitable alternative to the two-stage (elephant trunk technique) and hybrid procedures for treatment of chronic dissection with aneurysm of the thoracic aorta. It eliminates the risk of rupture in the interval between staged procedures and the risks associated with a second thoracic aortic procedure, and is associated with a low rate of reoperation on the remaining aorta.