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The Annals of Thoracic Surgery, Vol 56, 259-268, Copyright © 1993 by The Society of Thoracic Surgeons
T Carrel, M Pasic, R Jenni, T Tkebuchava and MI Turina
Recurrent aortic aneurysms, persistent or new dissection, new onset of
valvular and coronary artery disease, graft infection, and prosthetic
endocarditis are not rare after thoracic aortic operations; they can be
difficult to diagnose and represent a formidable surgical challenge.
Between 1977 and 1991, 876 operations were performed on the thoracic aorta
in our institution: 340 in dissections, 299 in true aneurysms, 150 for
aortic remodeling and external wall support during aortic valve
replacement, and 87 for miscellaneous causes. During the same period, there
were 193 additional reoperations. Vascular reoperations on abdominal aorta
and peripheral arteries accounted for 73 cases and are not further
discussed in this study. The reasons for reoperation (n = 130) in 120
patients were: failure of biologic valves (n = 23); aneurysm recurrence in
a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at
suture lines (n = 13); new dissection or dilatation involving ascending
aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10);
aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n
= 5); and new onset of coronary disease (n = 5). Infected aortic graft and
prosthetic endocarditis accounted for 10 reoperations, and a planned
two-staged procedure was performed in 6 patients. Omitting the failed
biologic valves, reoperations were performed on the aortic segment
previously operated on in 69.3% of the cases and on other thoracic segments
in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A
significant decrease in operative mortality was observed in the most recent
period (3.0% between 1989 and 1991). Reoperations are technically
demanding, and some of them are preventable; therefore (1) graft inclusion
technique should be abandoned in ascending aortic operation due to
formation of false aneurysms; (2) in patients with Marfan syndrome,
complete repair of the diseased aorta should be attempted during the
initial operation; (3) aortic arch dissection should be repaired
definitively during the first operation in low-risk patients; (4)
biological valves should be avoided in aneurysm operations; and (5)
homograft replacement is the treatment of choice in prosthetic endocarditis
or in infected composite graft after an aortic valve or ascending aortic
operation.
ARTICLES
Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention
Clinic for Cardiovascular Surgery, University Hospital Zurich, Switzerland.
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