Reoperation for enlargement of the distal aorta after initial surgery for acute type A aortic dissection.

Abstract

We investigated the long-term outcomes of repair for acute type A aortic dissection on the basis of false lumen status and assessed treatment modalities for the enlarged downstream aorta. Between January 1990 and March 2013, 534 patients underwent surgery for acute type A aortic dissection. In-hospital mortality was 9.3% (50/534), and follow-up was 98% (472/484). Of the 472 hospital survivors, 451 (96%) underwent contrast-enhanced computed tomography within 1 month of surgery. Risk-adjusted survival and distal aortic events were investigated in these 451 patients. Surgical outcomes of distal reoperations were assessed in 37 patients. Postoperative false lumen patency was 62% (280/451). Eighteen patients died of aortic rupture, 17 (94%) with a patent false lumen. A patent false lumen decreased survival (hazard ratio [HR], 1.70; P = .012) and increased distal aortic events (HR, 4.11; P = .001). Other predictors identified were age (HR, 1.07; P < .001) and male sex (HR, 1.89; P = .002) for late mortality, and Marfan syndrome (HR, 6.6; P < .001), distal aortic diameter greater than 45 mm (HR, 4.4; P < .001), and nonresection of the primary entry (HR, 2.3; P = .005) for distal aortic events. Distal reoperations comprised open repair of the arch (n = 13), descending aorta (n = 16), or thoracoabdominal aorta (n = 7) or thoracic endovascular aortic repair (n = 7), with no in-hospital death or paraplegia. Although thoracic endovascular aortic repair yielded false lumen thrombosis around the stent graft in 80% of patients (4/5), complete false lumen thrombosis was achieved in 20% (1/5). False lumen patency influences the late outcomes of acute type A aortic dissection repair. Outcomes of distal reoperation were acceptable; thus, careful follow-up and timely reoperation may improve the late outcomes.