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Ann Thorac Surg 2002;74:75-81
© 2002 The Society of Thoracic Surgeons
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
Accepted for publication March 12, 2002.
* Address reprint requests to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu, Japan
e-mail: tkazui{at}hama-med.ac.jp
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Abstract |
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Methods. From 1983 to 2000, a total of 130 patients underwent operation for acute type A aortic dissection. Extent of distal aortic resection included ascending aorta in 19 patients (15%), hemiarch in 29 (22%), and total arch in 82 (63%). In all, 31 preoperative and perioperative variables were analyzed using univariate and multiple logistic regression models for independent predictors of in-hospital mortality and risk of late reoperation. After excluding in-hospital deaths, risk factors for late death were analyzed by Cox proportional hazard analysis.
Results. In-hospital mortality was 19.2% (25 of 130 patients). Multivariable analysis indicated that renal/mesenteric ischemia and shock were independent predictors of in-hospital death. At 10 years, the actuarial survival rate including in-hospital mortality was 70.9% ± 4.7%, and the reoperation event-free rate was 73.5% ± 5.7%. Aortic valve resuspension was an independent predictor of proximal aortic reoperation, whereas nonresection of intimal tear and younger age were independent predictors for distal aortic reoperation. Chronic obstructive pulmonary disease was the only independent predictor for late death.
Conclusions. Patients’ preoperative dissection-related complications and comorbidities significantly affect early and late survival rates after surgical treatment of acute type A aortic dissection.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Aortography or digital subtraction angiography was performed to confirm the diagnosis of aortic dissection in the early period; later in the series, however, computed tomography or echocardiography including transesophageal Doppler technique was used to decide the indication for emergency operation.
By preoperative diagnostic measures together with observation during operation, primary intimal tear was detected at the ascending aorta in 52 patients (40%), between the ascending aorta and the aortic arch in 12 (9%), at the aortic arch in 29 (22%), and at the proximal descending aorta in 19 (15%). In the remaining 19 patients (15%), the primary intimal tear was not found at the above-mentioned aortic segments. Intimal tear in some of these patients might have been located more distally in the descending aorta, in which case the dissection extended retrogradely to the ascending aorta. Others might have had a thrombosed-type dissection.
All operations were performed on an emergency or urgent basis during the acute stage within 14 days after the onset of aortic dissection. Of the patients, 60 (40%) had their operations within 24 hours after onset.
Operative techniques
The operation was performed through a median sternotomy in most patients. A bilateral supraclavicular incision was added in the case of patients who required aortic arch repair. Extracorporeal circulation was established by cannulating the femoral artery or the right axillary artery, if indicated, with the venous drainage obtained through a single two-stage cannula placed in the right atrium. A left ventricular vent cannula was inserted through the right superior pulmonary vein. The myocardium was protected by cold crystalloid cardioplegia in the early period of the study, whereas antegrade blood cardioplegia was used for this purpose in most patients who underwent operation more recently. Operative techniques used in this series are listed in Table 2.
In the earlier part of this series, ascending aortic replacement (AAR) was performed in 19 patients (15%). The ascending aorta proximal to the origin of the innominate artery was cross-clamped, and the segment of the ascending aorta containing the intimal tear was resected. Both the proximal and distal dissected ends were then oversewn to reapproximate the dissected aortic wall and were reinforced with Teflon (Impra Inc, a subsidiary of L.R. Bard, Tempe, AZ) felt strips. A woven Dacron (C.R. Bard, Haverhill, PA) graft was interposed to reestablish aortic continuity.
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This technique facilitated the resection of intimal tear located in the minor curvature of the aortic arch or near the origin of the innominate artery. Total arch replacement (TAR) was performed in the recent 82 patients (63%). The detail of TAR using en-bloc repair or separated graft technique with the aid of antegrade selective cerebral perfusion (SCP) has been described previously [7, 8]. A brief account of our recent TAR technique with modified elephant trunk using aortic arch branched graft is as follows;
Proximal false lumen was obliterated with GRF glue during cooling by extracorporeal circulation. When the patient was cooled down to a rectal temperature of 22 C, systemic circulation was arrested, and antegrade SCP was started. With the descending aorta left open, a short segment of the graft was inserted into the true lumen of the descending aorta as a modified elephant trunk after obliterating the distal false lumen. Then the distal arch graft was sewn to the descending aorta, antegrade systemic circulation was started through the branch of the graft, the left subclavian artery was anastomosed to the third limb of the graft, and rewarming was started. The proximal graft was anastomosed to the stump of the ascending aorta, coronary circulation was started, and innominate and left common carotid arteries were anastomosed to the corresponding limbs of the graft in succession.
Resection of the primary intimal tear was performed in 108 patients (83%) in this series.
Concomitant procedures
As listed in Table 2, concomitant procedures were performed in 62 patients (48%); aortic valve resuspension in 42 (32%), composite graft replacement with coronary reimplantation in 20 (15%), aortic valve replacement (AVR) in 3 (2%), coronary artery bypass grafting (CABG) for either dissection-related coronary ischemia or coronary artery disease in 11 (8%), mitral annuloplasty in 2 (2%), and patch aortoplasty for supravalvular aortic stenosis in 1 (1%).
Follow-up
The patients were followed-up until December 2000 at the outpatient clinic or were contacted by telephone or letter. The follow-up was 98% complete. The mean follow-up period was 5.4 years, and the longest period was 17.9 years.
Statistical methods
The continuous data in this study are expressed as the mean ± standard deviation. Of the 31 preoperative and perioperative variables (Appendix), independent risk factors for in-hospital mortality and those for late dissection-related reoperation were examined by multivariable analysis using forward stepwise logistic regression model. Each variable that showed a significant difference (p < 0.05) by univariable analysis was examined by multivariable analysis. After excluding in-hospital deaths, risk factors for late death were analyzed by Cox proportional hazard analysis. Survival and freedom from reoperation were estimated by Kaplan-Meier method, and expressed as mean ± standard error of means (SEM). Differences in survival and freedom from reoperation were determined by log-rank analysis.
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Results |
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Table 3 shows the independent predictors of in-hospital death determined by multivariable analysis. Multivariable analysis indicated that renal/mesenteric ischemia and preoperative shock were significant independent predictors of in-hospital mortality, with myocardial ischemia/infarction being a possible third predictor.
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Causes of in-hospital mortality
The causes of in-hospital mortality were MOF in 8 patients, low cardiac output in 7, hemorrhage in 4, infection in 3, and rupture of the abdominal aorta in 1 and disseminated intravascular coagulopathy in 1.
Late survival
The 111 patients who survived the operation and were discharged from the hospital were followed up. Cox proportional hazards regression analysis showed that chronic obstructive pulmonary disease was the only independent predictor of late death (hazard ratio = 18.0, 95% CI = 3.27 to 98.9, p = 0.0009).
Figure 1 shows the actuarial survival curves estimated by Kaplan-Meier method. Survival for all patients at 5 and 10 years after the operation, including the in-hospital mortalities, were 76.0% ± 4.0% and 70.9% ± 4.7%, respectively (Fig 1A). The 10-year survival in the HAR and TAR groups tended to be better when compared with that in AAR group, but the difference did not reach statistical significance (61.6% ± 11.6% in AAR group, 73.4% ± 9.7% in HAR group, and 71.4% ± 6.4% in TAR group) (Fig 1B).
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Reoperation
A total of 21 patients (16%) required one to three reoperative procedures each in the late postoperative period. Although 18 of these patients had a single reoperative procedure, 2 patients required two, and 1 other patient required three procedures, accounting for a total of 25 reoperations. Indications for reoperation were severe aortic regurgitation in 1 patient, aortic root redissection with aortic regurgitation in 4, pseudoaneurysm in 5, aneurysmal dilatation of the false lumen in the distal aorta in 12, and ulcer-like projection in the descending aorta in 2. Surgical procedures used at reoperation included the following: AVR in 1 patient; aortic root replacement in 3; aortic root replacement with TAR in 2; AAR with TAR in 1; AAR, TAR, and descending aortic replacement in 1; TAR with descending aortic replacement in 1; descending aortic replacement in 1; and total thoracoabdominal graft replacement in 6.
Of the 21 patients who underwent reoperation, 6 eventually had total aortic graft replacement extending from the aortic valve to the aortic bifurcation. Three of the 21 patients (14%) died at reoperation: 1 due to bleeding after total thoracoabdominal graft replacement; 1 due to MOF after AAR, TAR, and descending aortic replacement; and the other due to low cardiac output after aortic root replacement with TAR.
Table 4 shows the independent predictors for proximal and distal aortic reoperation as determined by logistic regression analysis. Multivariable analysis indicated that aortic valve resuspension was the only independent predictor for proximal aortic reoperation, whereas nonresection of the intimal tear and younger age were independent predictors for distal aortic reoperation.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Significant independent risk factors for in-hospital mortality in acute type A aortic dissection in previous reports, as evaluated by univariable or multivariable analysis, were as follows: increasing age, preoperative conditions such as shock, dissection-related organ malperfusion, concomitant CABG, extent of aortic replacement, and period of operation [1–4, 10, 17, 18]. Risk factors for in-hospital death in our series were preoperative shock, renal/mesenteric ischemia due to organ malperfusion, and possibly myocardial ischemia/infarction requiring concomitant CABG. Thus, it was apparent that patients’ preoperative conditions were the main variables affecting the surgical outcome of acute aortic dissection. Although aortic arch repair did increase the risk of operative mortality in previous reports [1, 10, 18, 19], there was no significant difference in mortality between patients with and without TAR in our series. This is probably due to the learning curve in surgical technique as well as to patient selection. The AAR technique was performed in the early period, whereas extended TAR was performed in more recent cases. Our current indications for TAR are as follows: (1) acute aortic arch dissection with the intimal tear in the aortic arch, (2) acute aortic dissection with the intimal tear in the descending aorta, (3) rupture or massive false lumen of the aortic arch, (4) compromise of the arch vessels, (5) coexistent aortic arch aneurysm, and (6) young Marfan’s patients without serious preoperative complications such as shock or renal/mesenteric ischemia.
A conservative technique such as HAR was intended mostly for the more aged patients or for those with serious preoperative conditions. Chronic obstructive pulmonary disease was the only risk factor for late death in our series. The increasing age, reoperation, and period of operation that emerged as risk factors for late death in previous reports [2–5, 17] were not found to be risk factors in our series.
The reoperation event-free rate at 10 years after operation was 74%, which is comparable to the 60% to 80% reported previously [1, 5, 6, 20]. Risk factors for late reoperation were aortic valve resuspension for proximal aortic reoperation, and nonresection of intimal tear and younger age for distal aortic reoperation.
Biological glues such as GRF glue or Bioglue (Cryolife International Inc, Kennesaw, GA) have been applied to repair proximal aortic dissection and have facilitated meticulous aortic anastomosis. In our series, 4 patients who underwent aortic root repair with aortic valve resuspension using biological glues developed redissection of the aortic root associated with aortic regurgitation. The cause of redissection was aortic wall necrosis, probably due to the toxic effect of formaldehyde or glutaraldehyde [21].
In our series, risk factors for distal aortic reoperation were nonresection of intimal tear and younger age, which reconfirm the findings of previous reports [5, 6, 20].
Although an aggressive aortic arch repair has been advocated in some selected patients [1, 6, 8, 19, 20, 22–24], the big question that still remains to be answered is whether extended TAR could reduce the risk of reoperation in the late postoperative period and eventually improve the long-term results. It may be a significant finding that this aggressive approach did not emerge as a risk factor influencing surgical outcome in our series. Moreover, results for TAR in the present study suggest a trend towards improvement in the early and late outcome factors, although the differences with other approaches were not always statistically significant. This may suggest that, with increasing experience, it is possible to further improve the results of TAR.
Although 60% of the patients in our series had extended TAR, freedom from reoperation in this group was 78% at 10 years postoperation, which is roughly similar to outcomes in previous studies that adopted a more conservative approach. Two explanations may be put forward for this apparent lack of improvement in freedom from reoperation with TAR: namely, our recent meticulous follow-up protocol and our aggressive approach toward reoperation. However, the 10-year survival of 71% in our series is slightly better than the survival rates of 30% to 60% reported in previous studies [1–3, 5, 6, 17]. We believe that this improvement in late survival has, as an important contribution, our aggressive follow-up and reoperation strategy, and it reflects a relatively low incidence of death related to aortic rupture in the late postoperative period. Of the 5 patients who required operation on the aortic arch through median sternotomy in the late postoperative period, 2 died at reoperation, suggesting that TAR following the conservative approach might increase the risk of reoperation-related mortality.
In our series, we found that extended TAR could reduce the risk of reoperation on the aortic arch through median sternotomy when compared with AAR and HAR. Moreover, TAR with elephant trunk could facilitate reoperation for aneurysm formation of the distal thoracoabdominal aorta through left thoracotomy and could reduce mortality related to reoperation. We believe that the main advantage of TAR lies in the fact that it helps to avoid median resternotomy, which has been a well-known risk factor for reoperation-related mortality and morbidity.
In summary, in our series, patients’ conditions including preoperative dissection-related complications and comorbidities were independent determinants of overall mortality. Extended TAR could be justified in selected patients, particularly in those without serious preoperative complications or comorbidity.
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Appendix |
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Sex
Aortic regurgitation
Myocardial ischemia/infarction
Cerebral ischemia
Renal/mesenteric ischemia
Leg ischemia
Two or more organ ischemia
Shock
Endotracheal intubation
Pleural rupture
Marfan’s syndrome
Chronic obstructive pulmonary disease
Renal dysfunction
Hemodialysis
DeBakey classification
Previous cardiac operation
Interval between onset and operation
Extent of aortic replacement
Coronary artery bypass grafting
Composite graft replacement
Aortic valve replacement
Aortic valve resuspension
Entry-resection
Four-branched aortic arch graft
Elephant trunk
Emergency operation
Period of operation
Cardiopulmonary bypass time
Aortic cross-clamp time
Cerebral protection method
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References |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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