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Ann Thorac Surg 1998;66:1592-1599
© 1998 The Society of Thoracic Surgeons

Disadvantages of local repair in acute type A aortic dissection

^a Clinic for Cardiovascular Surgery, University Hospital Zürich and City Hospital Triemli, Zürich, Switzerland

Address reprint requests to Dr Niederhäuser, Clinic for Cardiovascular Surgery, City Hospital Triemli, CH- 8063 Zürich, Switzerland

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
Background. In acute type A dissection of the aorta, local repair with glue-aortoplasty was compared with aortic replacement.

Methods. Between 1992 and 1996, 106 consecutive patients (mean age, 59 years; 84 men) were operated on average 14.5 hours after onset of dissection. A local repair (gelatin-resorcine-formaldehyde/glutaraldehyde glue, Trigon AG, Mönchengladbach, Germany) without graft replacement was performed in 21 patients. Graft replacement and reinforcement of aortic stumps with gelatin-resorcine-formaldehyde/glutaraldehyde glue was performed in 85 patients (supracoronary graft, 68; aortic root replacement, 17).

Results. Survival was 79% after 30 days and 69% after 2 years. There was no difference in early mortality (p = 0.2240) and survival (p = 0.07649). Risk factors for early mortality were preoperative shock, neurologic disorder, duration of crossclamp, and extracorporeal circulation. The rate of reoperation on the proximal aorta was 31.6% (6 of 19) after local repair and 9% (6 of 64) after aortic replacement (p = 0.0157). Local repair was a significant predictor for reoperation (p = 0.0087), with decreased reoperation-free survival (p = 0.01164). In all reinterventions (four supracoronary grafts, including two valve replacements; two composite grafts; two arch replacements) breakdown of the aortoplasty was confirmed.

Conclusion. Local repair has satisfactory early results but an increased incidence of reoperations due to a breakdown of the glue-aortoplasty. Indications for local repair should be restricted to high-risk patients requiring a minimal emergency surgical procedure.

	Introduction

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
In acute ascending aortic dissection, emergency operation is the therapy of choice to prevent fatal intrapericardial rupture and to treat aortic regurgitation. The surgical treatment of an acutely dissected aorta is technically challenging and despite improving results over the last decades it still carries a considerable early mortality, ranging from 22% to 27% [1–3]. The principal aim of the operation is to obliterate the intimal tear and the dissected aortic wall layers and to reestablish antegrade, axial blood flow. The replacement of a proximal aortic segment, preferably including the entire intimal lesion, has evolved as standard method. In the literature numerous other techniques have been described (endovascular sutureless grafts [4], thromboexclusion [5], glue aortoplasty [6–11]) to achieve similar results with less mortality and morbidity. These techniques should simplify the operative procedure and reduce bleeding complications, a major concern in the surgery of acute aortic dissection. The construction of reliable anastomoses and suture lines is a prerequisite for the avoidance of intraoperative and postoperative hemorrhage. It is, however, difficult to achieve because of the friability of the dissected vessel wall, which in many patients is additionally weakened by a diffuse pathology (eg, media necrosis, Marfan disease, atherosclerosis). With gelatin-resorcin-formaldehyde/glutaraldehyde glue dissected aortic wall layers can be firmly readapted and with the biophysical properties of the adhesive the friable tissue is reinforced. The successful application of this glue at the level of proximal and distal aortic stumps, before suturing a prosthesis, has been described [10]. In this study we retrospectively analyzed our results of a local glue aortoplasty without graft replacement in comparison with a treatment containing graft replacement.

	Material and methods

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
Between May 1992 and February 1996, 106 consecutive patients were operated on at the University Hospital and the City Hospital Triemli of Zürich for peracute type A dissection of the ascending aorta according the Stanford classification. Dissections involving the ascending aorta were classified as type A and those without ascending aortic involvement as type B. The average interval between onset of symptoms and operation was 14.5 hours. Clinical data were obtained by retrospective review of hospital records. Postoperative follow-up data contain periodic follow-up reports of cardiologists and a combination of written and telephone communication with the patients or their physicians. A follow-up of more than 1 month was achieved in 73 of 83 early survivors (88%) with a mean duration of 22.4 months (maximum, 64 months), totaling 155 patient years. For the local repair group mean follow-up was 27.7 months and for the replacement group 20.9 months, respectively (p = 0.029715).

A glue-aortoplasty without graft interposition (local repair group) was performed in 21 patients (20%) and aortic replacement (replacement group) in 85 patients (80%). Demographic and preoperative clinical data of each patient group are depicted in Table 1. The mean age of all patients (± 1 standard deviation [SD]) was 59.5 ± 12.6 years (range, 17 to 80 years). There were 84 (79%) men and 22 women (21%). Pericardial effusion or tamponade were diagnosed via preoperative echocardiography and were confirmed intraoperatively without exception. Of the whole study population exact data on aortic diameters and left ventricular ejection fraction (LV EF) were available for 96 patients (91%).

The site of the entry tear was located with echocardiography and intraoperatively. In the aortoplasty group the intimal lesion was located in the ascending aorta in 15 patients (71%) and in the aortic arch in 4 patients (19%). For the replacement group localization was the ascending aorta in 57 patients (67%) and the aortic arch in 6 patients (7%). In 12 patients (14%) the entry tear extended from the arch to the descending aorta. In a total of 13 patients (12.3%) no intimal rupture could be found in the ascending aorta and arch. In these situations a retrograde dissection from the descending to the ascending aorta was assumed. The dissection process was confined to the ascending aorta in 3 patients (14%) with local repair and in 14 patients (16%) with graft replacement. It extended to the descending aorta in 18 and 56 patients of the respective groups and was confined to the arch in 15 patients of the replacement group. Echocardiographic information about aortic valve (AV) function and morphology was available for a total of 95 patients (90%). Regurgitation and degenerative changes were diagnosed as moderate to severe in 13 patients with local repair. In the graft replacement group these changes were moderate in 24 and severe in 19 patients.

A definite etiology was known in 23 of 106 patients (22%): Marfan, 3 (only occurred in the replacement group); media necrosis, 13; and mucoid degeneration, 7. Previous cardiac surgery occurred in the local repair group in 5 patients (24%) and in the replacement group in 17 patients (20%), including 4 AV replacements. An associated etiological event was only known in 1 patient.

	Surgical technique

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
In the following sections, numbers and values are indicated first for patients with local repair, followed by patients with aortic replacement.

A standard median sternotomy was performed and total cardiopulmonary bypass was instituted by cannulation of the femoral artery and the right atrium. For retrograde cerebral perfusion the superior vena cava was cannulated separately. During hypothermic circulatory arrest this vessel was occluded proximally and perfused distally with a target flow of 500 mL/min under controlled pressure not exceeding 40 mm Hg. This technique was applied in 6 patients of each group. Circulatory arrest was instituted in 18 patients (85.7%)/75 patients (88.2%) with a mean duration of 14.8 ± 7.8 minute/19.3 ± 7.3 minute (p = 0.059410) at a mean core temperature of 18.7° ± 2.4°C. In all study patients retrograde cold-blood cardioplegia with high potassium content was applied using a transatrial cannulation of the sinus venosus. The left heart was vented through a transmitral catheter.

Mean aortic crossclamp time was 40 ± 21 minute/70 ± 35 minute (p = 0.00003), mean extracorporeal circulation (ECC) time was 99 ± 29 minutes/150 ± 88 minutes (p = 0.08169), and mean circulatory arrest time was 12.7 ± 9 minutes/17.1 ± 9.3 minutes (p = 0.00100).

Local repair
Local repair with glue-aortoplasty was performed in 21 patients under the following conditions: In addition to dissection the visible aorta had a macroscopically normal appearance, ie, absence of Marfan disease, aneurysmatic dilatation, or impending rupture. The aorta was opened longitudinally to gain optimal access to the intimal surface and for assessment of the aortic root and the intimal rupture. Aortic valve replacement with a mechanical prosthesis was performed in 2 patients. Valve reconstruction with resuspending sutures was not performed in this group. In the group with glue aortoplasty, dissected valve commissures were anatomically repositioned and additionally fixed when intraluminal pressure was exerted after restitution of antegrade and central blood flow. The intimal tear was closed in 16 patients with a double-running suture using 5-0 polypropylene. In 5 patients the aortotomy could be placed directly into the course of the intimal tear and both were closed in one suture. The dissected wall layers were readapted with gelatin-resorcine-formaldehyde/glutaraldehyde (GRF) glue (Trigon AG, Mönchengladbach, Germany) that was warmed to 45°C. The adhesive was applied in two components on a dry and bloodless field if possible during hypothermic circulatory arrest. Care was taken not to contaminate the AV and the coronary ostia. A 40 mL Fogarty balloon (Baxter Healthcare Corp, Irvine, CA) was inflated inside the aortic lumen for application of pressure to the glued aorta. Corresponding wall segments were additionally fixed with small bulldog clamps. After reaching a core temperature of 18°C circulatory arrest was instituted and the aortic crossclamp was removed for inspection of the arch. An intimal lesion at the arch level was sutured in 4 patients and dissected wall layers were glued in the same manner as the proximal aortic portion. Great care must be taken to avoid embolization of glue through stitch holes or distal re-entry sites not reachable from this approach [12]. For this reason the inner wall was again controlled by an inflated balloon or swabs placed into the lumen. With a second balloon, placed several centimeters distal into the arch or into the proximal descending aorta, a disappearance of glue into an extended distal dissection was avoided. The aortotomy was closed with a double-running polypropylene suture without buttress. If the dissection extended into the aortic arch, the descending aorta, or both, antegrade reperfusion was performed to avoid retrograde redissection. For this reason recannulation was performed into the true lumen of the aorta through the aortotomy.

Graft replacement
In 85 patients a segment of the proximal aorta was replaced by a Dacron polyester tube graft (Vasculek Ltd, Inchiman, Scotland). The localization of the intimal tear together with the quality of the aortic wall were major determinants for the extent of aortic replacement. The arch was replaced when containing an entry site or in case of impending rupture or aneurysmal dilatation. In patients with Marfan’s disease or annuloaortic ectasia the aortic root was replaced with a composite graft. The inclusion technique [13, 14] (wrapping of the graft with the aorta) was used in 30 patients (35%). The open technique with resection of the diseased aortic segment and reimplantation of the coronary ostia with an aortic button in case of a composite graft [14] was performed in 55 patients (65%). In 8 of 30 patients (27%) receiving the inclusion technique the perigraft space was decompressed with a shunt to the right atrium [15]. A supracoronary graft was implanted in 68 patients (64%) including the aortic arch in 27 patients (32%). The entire arch was replaced only in 3 patients, whereas in 24 patients a hemiarch procedure was performed including only the concavity as prevalent site of arch dissection. Morphologic changes required the aortic valve to be replaced with a mechanical prosthesis in a total of 27 patients (composite grafts included). A resuspension of the valve commissures was performed with pledgetted sutures in 8 patients and with GRF glue in the remaining patients. The aortic root was replaced with a valved composite graft in 17 patients (20%). In this group 3 patients had a simultaneous hemiarch replacement. In the open technique group the aortic stumps were prepared with GRF glue, as described for local repair, in order to get a more secure anastomotic suture. This running suture was buttressed with an external Teflon felt strip (Impra Inc, subsidiary of L. R. Bard, Tempe, AZ). The distal anastomosis was tailored in the same way and was constructed in an open fashion using hypothermic circulatory arrest in 75 of 85 patients (88%).

Statistical analyses
The software package SPSS (SPSS Inc, Chicago IL) were used for statistical analysis. Continuous variables were summarized as mean ± SD. Predictors for mortality and reoperation were determined by univariate and multivariate analysis. In univariate analysis discrete variables were analyzed by the ² or Fisher’s exact test. Continuous variables were analyzed by the Mann-Whitney test. Statistical significance was associated with a p level of less than 0.05. Variables with a p value less than 0.2 in the univariate analysis were entered into multivariate analysis by a stepwise logistic regression or by Cox proportional hazard regression to determine independent predictors. Survival and event-free probabilities ± standard error were calculated by actuarial analyses [16]. The following variables were tested: age, gender, operation period, unstable preoperative hemodynamics, ischemia in ECG, preoperative renal failure, aortic regurgitation, dissection confined to ascending aorta, inclusion technique, local repair, graft replacement, aortic root replacement, arch replacement, valve replacement, Cabrol-shunt, hypothermia, hypothermic circulatory arrest, retrograde cerebral perfusion, reperfusion (antegrade/retrograde), extension of dissection to arch, localization of entry tear, dissection of coronary ostia, previous valve replacement, previous CABG, aortic cross-clamp time, ECC duration, duration of circulatory arrest, open thorax, postoperative neurology, perioperative myocardial infarction, use of inotropes, and rethoracotomy.

	Results

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
Survival
Operative mortality in all 106 patients was 21.7% (23 of 106 patients). In the local repair group operative mortality was 2 of 21 patients (9.5%) and in the replacement group 21 of 85 patients (24.7%) without significant difference (p = 0.1307). Overall survival was 79.3% ± 3.9% after 30 days, 70.8% ± 4.6% after 1 year, and 68.9% ± 4.9% after 2 years. After 2 years survival was 80.99% ± 8.5% in the local repair group and 66.0% ± 5.55%. in the replacement group (Fig 1). There was no significant difference between the two treatment methods (p = 0.07649). Survival after composite graft replacement was 71% ± 11.1% after 1 month and 64.7% ± 11.6% after 1 and 2 years. For supracoronary graft implantation the corresponding figures were 79.2% ± 3.9% after 1 month and 69.0% ± 4.9% after 1 and 2 years. Survival in the three treatment groups did not differ significantly (p = 0.22366). For aortic arch replacement survival was 79.7% ± 4.5% after 1 month and 69.6% ± 5.6% after 1 and 2 years. The corresponding figures for patients without arch replacement were 77.8% ± 8.0% and 68.1% ± 9.5%, respectively, without difference between the two groups (p = 0.47455).

View larger version (20K): [in this window] [in a new window]   Fig 1. Actuarial survival rates. SE = standard error.

Univariate significant predictors for early mortality were preoperative unstable hemodynamic situation (p = 0.0249), postoperative permanent or transitory neurologic disorder (p < 0.0001), aortic crossclamp time (p = 0.0167), ECC duration (p < 0.0001), circulatory arrest time (p = 0.0531), closed inclusion technique versus open resection technique (calculated only for the aortic replacement group [p = 0.0182]), and delayed closure of the thorax (p < 0.0001). Independent significant risk factors for early mortality determined by stepwise logistic regression were a preoperative unstable hemodynamic situation (p = 0.0158, relative risk = 10.8) and ECC duration (p = 0.0066, relative risk = 2.4, calculated for a time unit of 1 hour). Postoperative neurologic disorder was a significant predictor for late mortality in univariate (p = 0.0102) and multivariate analysis (p = 0.0006, relative risk = 1.4616).

Reoperation
A total of 14 early survivors (17%) needed another operation after a mean postoperative interval of 17.4 ± 13.4 months. In the repair group there were 6 local reoperations (31.6% of early survivors) at the level of the proximal aorta and in the replacement group there were 6 local reoperations (9.4% of early survivors) and two reinterventions (3.1%) at the distal aorta for aneurysmal dilatation (p = 0.0157 for local reoperations, p = 0.0512 for all reoperations). Freedom from reoperation (early deaths and reexplorations for hemorrhage excluded) was 91.9% ± 3.5% after 1 year and 77.8% ± 7.3% after 3 years with a significant difference (p = 0.0116) between the two treatment groups (Fig 2).

View larger version (21K): [in this window] [in a new window]   Fig 2. Actuarial freedom from reoperation. SE = standard error.

Histologic examinations of the glued aortic wall did not reveal foreign body reaction to the adhesive. In the medial layer and in the vicinity of the glue there was necrosis of soft tissue and small muscle cells. There were no signs of local inflammatory reactions and the necrotic tissue was not replaced by fibrotic tissue or scars. The tissue appeared "mummified" or fixed by chemical agents. This could be explained as a reaction to the glue components glutaraldehyde and formaldehyde, which are used in high concentrations of 25% and 18.5%, respectively.

Local reoperation in the replacement group of 5 patients consisted of composite graft insertion, including the arch for recurrent dissection and aneurysmatic dilatation in 3 and 2 patients, respectively. Supracoronary graft implantation was performed in 1 patient for aneurysmatic dilatation. In the whole study population early mortality after reoperation was 25% (3 of 12 patients).

Risk factors for reoperation were determined in 38 variables. Univariate significant risk factors were local repair (p = 0.0087), unstable preoperative hemodynamic situation (p = 0.0046), closed wrapping technique in the replacement group (p = 0.0527), and use of circulatory arrest (p = 0.0069). In the multivariate analysis, independent significant risk factors for reoperation were unstable preoperative hemodynamics (p = 0.0062, relative risk 5.4610) and use of circulatory arrest (p = 0.0201, relative risk 13.5040).

During the follow-up period 3 additional patients with local repair had recurrent dissection of the ascending aorta in control CT scans and TEE. Because of only minor aortic dilatation and absence of significant symptoms in all 3 patients, reoperation was delayed and regular monitoring of their aortas was continued as in all other patients.

	Discussion

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
Use of local repair
The handling of the dissected aortic wall and the construction of reliable graft-to-aorta anastomoses are major surgical concerns in acute type A aortic dissection. The first report about the use of GRF glue in aortic dissection was by Guilmet and coworkers [9]. It was soon followed by other publications concerning its biophysical properties [11] and clinical use [7–10]. Numerous arguments for local dissection repair with the aid of tissue adhesive include:

1. The operative procedure is simplified and the duration of organ ischemia and extracorporeal circulation is reduced.
   
2. Bleeding complications are prevented by avoidance of anastomotic sutures.
   
3. The tissue can be reinforced with the chemical properties of the glue.
   
4. The amount of implanted foreign material and consequently the risk of endocarditis are reduced.
   
5. The restoration of an intact aortic endothelial surface prevents thromboembolism and blood-flow disturbance.
   

Study design
We evaluated the outcome of a local GRF-glue-aortoplasty without graft replacement in 21 patients who all had acute aortic dissection type A. They were compared with a group of patients treated with graft replacement including GRF-glue application to reinforce the proximal and distal aortic stump. All operations were performed during the same period and in a peracute state of dissection with an average interval of 14.5 hours after onset of symptoms. The retrospective character of the study is responsible for certain limitations. A larger prospective and randomized study could provide more predictive and statistical power but may be questionable in view of the paucity of qualified patients and the fatality of the disease.

Differences between groups
Early mortality was 21.7% in the whole group and 24.7% in the replacement group, compared with 9.5% in the local repair group. By statistical calculation this difference appeared insignificant (p = 0.2240). In the local repair group more patients were hemodynamically unstable and their mean aortic diameter was smaller. Otherwise preoperative patient parameters and risk factors such as renal failure and neurologic disorders were comparable between the two groups. Duration of ECC, aortic cross-clamp, and circulatory arrest, however, were significantly prolonged in the more complex and time-consuming replacement procedure and they all were significant univariate risk factors for early mortality. Extracorporeal circulation duration was an independent risk factor, together with a reduced hemodynamic state preoperatively and neurologic disorders postoperatively. The high incidence of neurologic deficits may be explained by the inclusion of discrete and transitory findings without clinical relevance, such as cognitive dysfunctions or behavioral disorders. Late survival remained 70% after 1 and 2 years and there was no survival difference comparing local repair with aortic graft replacement.

Fabiani and coworkers [7] reported a similar technique of glue-aortoplasty without graft replacement and no perioperative mortality in 15 patients. The patients in their series, however, were younger and in better preoperative condition (only 2 patients in shock, no renal failure or neurologic disorders), which may explain a better early outcome. In the follow-up 20% of patients had recurrent dissection that was asymptomatic in two thirds of patients. A comparable group of patients without local repair was not contained in that study, which included 4 patients (31%) with Marfan disease. In accordance with other authors [18, 19] we consider Marfan disease to be a contraindication for local repair in view of the diffuse pathology of this disease, requiring complete aortic root replacement to avoid future aneurysm formation.

Bachet and associates [10] reported a series of 105 patients with aortic replacement and reinforcement of the dissected aortic stumps with GRF-glue. Preoperative patient parameters were similar to our study except for age (the Bachet group was younger). The treatment was also equal to our patients in the replacement group but a comparison with local repair was not performed. Overall early mortality was 23% and 30% when the arch was replaced. A local reoperation for recurrent dissection was necessary in 8 patients, with aortic regurgitation occurring in 1 patient. The safety of local GRF-glue application at the anastomotic site of dissected aorta could also be demonstrated by Schumacher and coworkers [20]. In their study GRF-glue application in 38 patients was compared to standard graft implantation without glue in 23 patients. In the GRF-glue group survival at 5 years was better (63% versus 43%), there was less increase in aortic diameter (7.9% versus 16.3%) and valve regurgitation (18.4% versus 34.7%), and the patency rate of the distal false lumen was decreased (42% versus 69%).

Postoperative morbidity was not different in our two treatment groups. With local repair transitory and permanent neurologic disorders, which represent significant predictors for mortality, could not be reduced.

In our series reoperations at the level of the proximal aorta were significantly (p = 0.0157) more frequent in the local repair group (28.6%) compared with aortic replacement (7.1%). Recurrent dissection of the glued aortic wall was diagnosed in all reoperations following GRF-aortoplasty and AV regurgitation was present in two thirds of them. These results are paralleled by a report by Jex and coworkers [19] documenting a 31% risk of recurrent ascending aortic dissection after local aortoplasty. In 3 additional patients in our series recurrent dissection is documented on CT scan and TEE. Reoperation was postponed because of minor aortic dilatation and absence of symptoms. Preoperative shock and circulatory arrest were significant predictors for reintervention. Overall freedom from reoperation was 77% after 2 years and was significantly decreased after local repair. In all redo procedures a complete breakdown of the glue aortoplasty was noted, leaving a severely decompounded and disintegrating aortic tissue with focal necrosis. At reoperation the surgeon was therefore exposed to a most challenging situation and the patient to a high operative risk.

The clinical observation of severely altered aortic tissue could be partly explained by the histologic findings. The GRF-glue causes a local reinforcement of the tissue at the cost of viability. It can be speculated that in case of local repair with extended application of the adhesive, the altered aortic tissue did not resist the mechanical forces, causing dilatation and recurrent dissection. Our observations are in contrast to the findings of Fabiani [8], who described good biological tolerance of the glue and massive sclerosis of the aortic layers. In graft replacement the glue was applied to a more limited portion of the aorta, allowing easy and secure anastomotic sutures. This technique proved to be reliable in a large number of patients and is our standard procedure in acute dissection.

Emergency surgery in acute type A dissection still remains palliative in most patients and carries a considerable risk of early mortality and morbidity. Local repair has satisfactory early results but an increased incidence of reoperations due to a complete breakdown of the glue-aortoplasty. This could be documented in all reoperations, which were technically most demanding and exposed the patient to a high operative risk. Reinterventions on the proximal aorta were significantly less frequent after aortic replacement.

We have abandoned local repair in acute dissection and advocate replacement of an aortic segment or composite graft replacement if the aortic root is involved in the disease. Reinforcement of the anastomosed aortic segments with GRF-glue is performed routinely. It simplifies the surgical procedure and has proved to be a reliable method.

Local repair should be restricted to patients in marginal and very critical condition or if life expectancy is reduced by other underlying diseases. In these situations a minimal emergency surgical procedure may be preferable [17].

	Acknowledgments

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 
We acknowledge the assistance of Burkhardt Seifert (Statistical Consultant) in manuscript preparation.

	References

Top Abstract Introduction Material and methods Surgical technique Results Discussion Acknowledgments References

 

1. DeBakey M.E., McCollum C.H., Crawford E.S., et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118-1134.[Medline]
2. Crawford E.S., Svensson L.G., Coselli J.S., Safi H.J., Hess K.R. Aortic dissection and dissecting aortic aneurysms. Ann Surg 1988;208:254-273.[Medline]
3. Fann J.I., Smith J.A., Miller D.C., et al. Surgical management of aortic dissection during a 30-year period. Circulation 1995;92(Suppl II):II-113-II-121.
4. Diehl J.T., Moon B., LeClerc Y., Wiesel R.D., Salerno T.A., Goldmann B.S. Acute type A dissection of the aorta: surgical management with the sutureless intraluminal prosthesis. Ann Thorac Surg 1987;43:502-507.[Abstract]
5. Carpentier A., Deloche A., Fabiani J.N., et al. New surgical approach to aortic dissection: flow reversal and thromboexclusion. J Thorac Cardiovasc Surg 1981;81:659-668.[Abstract]
6. Borst H.G., Laas J., Haverich A. A new look at acute type A dissection of the aorta. Eur J Cardiothorac Surg 1987;1:186-189.[Abstract]
7. Fabiani J., Jebara V.A., Deloche A., Stephan Y., Carpentier A. Use of surgical glue without replacement in the treatment of type A aortic dissection. Circulation 1989;80(Suppl I):I-264-I-268.
8. Fabiani J.N., Jebara V.A., Deloche A., Carpentier A. Use of glue without graft replacement for type A dissections: a new surgical technique. Ann Thorac Surg 1990;50:143-145.[Abstract]
9. Guilmet D., Bachet J., Goudot B., et al. Use of biological glue in acute aortic dissection. A new surgical technique. Preliminary clinical results. J Thorac Cardiovasc Surg 1979;77:516-521.[Abstract]
10. Bachet J., Goudot B., Teodori G., et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue: a twelve-year experience. J Cardiovasc Surg 1990;31:263-273.[Medline]
11. Albes J.M., Krettek C., Hausen B., Rohde R., Haverich A., Borst H.G. Biophysical properties of the gelatin-resorcin-formaldehyde/glutaraldehyde adhesive. Ann Thorac Surg 1993;56:910-915.[Abstract]
12. Carrel T., Maurer M., Tkebuchava T., Niederhäuser U., Schneider J., Turina M.I. Embolization of biologic glue during repair of aortic dissection. Ann Thorac Surg 1995;60:1118-1120.[Abstract/Free Full Text]
13. Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
14. Kouchoukos N.T., Wareing T.H., Murphy S.F., Perrillo J.B. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308-320.[Medline]
15. Cabrol C., Pavie A., Gandjbakhch I., et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309-315.[Abstract]
16. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
17. Laas J., Jurmann M.J., Heinemann M., Borst H.G. Advances in aortic arch surgery. Ann Thorac Surg 1992;53:227-232.[Abstract]
18. Haverich A., Miller D.C., Scott W.C., et al. Acute and chronic aortic dissections—determinants of long-term outcome for operative survivors. Circulation 1985;72(Suppl II):II22-II34.
19. Jex R.K., Schaff H.V., Piehler J.M., et al. Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results. J Thorac Cardiovasc Surg 1987;93:375-384.[Abstract]
20. Schumacher B., Keilich M., Pecher P., Schlaudraff K., Gunther H., Stegmann T. 5-Year follow-up of aorta dissection surgery: comparison of surgical methods with or without gelatine-resorcine-formaldehyde glue. Zentralbl Chir 1994;119(Suppl I):I-134-I-138.

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