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Ann Thorac Surg 2004;78:2099-2105
© 2004 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Aortic Dissection After Previous Cardiovascular Surgery

Hitoshi Hirose, MDa, Lars G. Svensson, MD, PhDa,*, Bruce W. Lytle, MDa, Eugene H. Blackstone, MDa,b, Jeevanantham Rajeswaran, MSa,b, Delos M. Cosgrove, MDa

a Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic and Department of Thoracic and Cardiovascular Surgery
b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication May 14, 2004.

* Address reprint requests to Dr Svensson, The Cleveland Clinic Foundation, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave/Desk F25, Cleveland, OH 44195 (E-mail: svenssl{at}ccf.org).


   Abstract
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 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Appendix Variables Considered in...
 References
 
BACKGROUND: Risk of repairing aortic dissection after previous cardiovascular surgery has not been described clearly. This study assesses early and late outcomes of such reoperations.

METHODS: From January 1, 1990, to January 1, 2002, 108 patients with prior cardiovascular surgery (isolated coronary artery bypass grafting, 51%; isolated valve surgery, 21%; aortic aneurysm repair, 24%; and combinations of these in the remainder) underwent reoperation for aortic dissection (emergency operation for acute dissection in 24%). Mean age was 63 ± 13 years, and 85% were men. The interval since prior surgery ranged from 10 days to 22 years (median, 3.8 years). This was the third operation for 8%. Ascending aortic repair with or without aortic arch or descending aortic repair was performed in 40%, aortic valve replacement (n = 15) or repair (n = 17) with ascending aortic repair in 30%, aortic root replacement with or without aortic arch or descending aortic repair in 30%, and aortic arch with or without descending aortic repair in 1%. Circulatory arrest was used in 78%, with retrograde brain perfusion in 58%.

RESULTS: Hospital mortality was 6%, stroke 4%, renal failure 2%, and respiratory failure 7%. Survival at 30 days and 1, 3, 5, and 7 years was 93%, 85%, 74%, 63%, and 53%, respectively. Aortic reoperation was performed in 7 patients, with freedom from this event at 30 days and 1, 3, 5, and 7 years of 98%, 95%, 93%, 91%, and 89%., respectively

CONCLUSIONS: Aortic dissection after cardiovascular surgery is rare and can be managed with acceptable operative risks and good long-term survival. Need for subsequent aortic reoperation is uncommon.


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
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 Appendix Variables Considered in...
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The prevalence of aortic dissection occurring after previous cardiovascular surgery is unknown, and determining the prevalence would be difficult. Thus, we reviewed our patients who underwent reoperation for aortic dissection after previous cardiovascular surgery to assess early and late outcomes.


   Patients and Methods
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 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Appendix Variables Considered in...
 References
 
Patients
From January 1, 1990, to January 1, 2002, 108 consecutive patients with previous cardiovascular surgery underwent aortic dissection repair involving the ascending aorta or aortic arch at The Cleveland Clinic Foundation. Patients who underwent descending aortic dissection repair by means of a left thoracotomy only were excluded. If patients had more than two previous cardiovascular operations, the most recent one before aortic dissection was counted as the index operation. Perioperative data were prospectively entered into a structured database, the Cardiovascular Information Registry. The latter has been approved for use in research by the institutional review board. Medical records were reviewed to confirm perioperative data from the Cardiovascular Information Registry.

Follow-up information was collected by telephone interview or responses to mailed questionnaires. The common closing date for cross-sectional follow-up was December 2002. Follow-up was 100% complete, with a mean follow-up of 4.1 ± 2.9 years.

The study included 92 men (85%) and 16 women (15%), with a mean age of 63 ± 13 years at the time of aortic dissection repair; 6 (5.6%) had Marfan syndrome. Eight patients (8.3%) had more than one previous cardiovascular operation (two coronary artery bypass grafting [CABG] operations in 5, two mitral valve operations in 2, and combined CABG and ascending aorta replacement in 1). The previous operations were varied (Table 1). Operations for previous aortic dissection occurred in 20 patients (19%), including DeBakey type 1 or 2 in 17 patients and DeBakey type 3 in 3 patients. In addition, previous operation for true aneurysms was performed in 5 patients (4.6%), in the ascending aorta in 4 and in the aortic arch in 1. Other preoperative details are shown in Table 1.


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  		Table 1. Patient Characteristics and Clinical Details: Index Operation
 
Median interval between index operation and aortic dissection repair was 3.8 years (range, 10 days to 22 years). Distribution of the intervals is shown in Figure 1. Aortic dissections at the repeat operation were DeBakey type 1 in 62 patients (57%), type 2 in 45 patients (42%), and combination of type 1 and 3 in 1 patient (0.9%). Of the 108 patients, 47 (44%) had acute aortic dissection repair (within 2 weeks after onset of dissection), and 61 (57%) had chronic dissection repair. Twenty-six patients (24%) underwent emergency operation for either acute dissection or rupture of the aorta.



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  		Fig 1. Distribution of interval between index operation and aortic dissection repair. Plot is of probability density, analogous to a histogram.

 
Preoperative coronary angiography was performed in 80 patients (74%). Those with a previous CABG were more frequently evaluated by catheterization before surgery (87% [55 of 63] in the previous CABG group versus 67% [30 of 45] in the previous non-CABG group; p < 0.01). Catheterization was performed in 68% (32 of 47) with acute dissections and 79% (48 of 61) with chronic dissections (p = 0.2).

Operation
All patients underwent redo median sternotomy except one who had a clamshell incision. No cardiac or other structural injuries were documented during chest re-entry. Free rupture of aortic dissection was observed in 3 (2.8%): 1 into the pericardial space and 2 into the pleural space. An additional 2 patients were hemodynamically unstable at reoperation.

Cannulation site was the femoral artery in 46 (43%), axillary or subclavian artery in 48 (44%), aorta or innominate artery in 6 (5.6%), and undocumented in 8 (7.4%). Deep hypothermic circulatory arrest was used in 84 patients (78%), retrograde brain perfusion in 63 (58%), and antegrade brain perfusion in 5 (4.6%). Details of the operations are shown in Table 2. Ascending aortic repair with or without arch (n = 9) or descending (n = 3) aortic repair was performed in 43 (40%), aortic valve repair (n = 17) or replacement (n = 15) with ascending aortic repair with or without arch repair in 32 (30%), aortic root replacement (composite graft or valve-sparing) with or without aortic arch (n = 2) repair in 32 (30%), and arch with descending aortic repair in 1 (0.9%).


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  		Table 2. Patient Characteristics and Clinical Details: Reoperative Aortic Dissection Repair
 
Concomitant surgery included CABG in 65 patients (60%), mitral valve surgery in 5 (4.6%), tricuspid valve surgery in 2 (1.9%), elephant trunk procedure in 2 (1.9%), and fenestration of distal descending aorta in 2 (1.9%). Concomitant CABG was more frequent in patients who had previous CABG (84% [53 of 63] in the previous CABG group versus 27% [12 of 45] in the previous non-CABG group; p < 0.0001).

Previously repaired aortic valves (6 patients) were all replaced at the time of aortic dissection repair. Among 16 patients who had previously undergone subcoronary aortic valve replacement, 9 (56.3%) received a new aortic valve, including 5 who underwent composite grafting. None of 5 patients who had previous aortic root replacement required repeat aortic valve surgery at the time of aortic dissection repair.

Because of the retrospective nature of this study and difficulty of obtaining original operative reports from outside hospitals, we could not determine the influence of factors such as proximal CABG attachment methods, cannulation techniques, aortic size, presence of tricuspid aortic valves, and aortic dissection repair methods on risk of developing aortic dissection.

Aortic Operative Strategy
Most patients with acute dissection were transferred from outlying hospitals having undergone computed tomography, magnetic resonance imaging, or echocardiograms for chest pain. Coronary angiography was obtained if not already performed. Patients were then usually scheduled for surgery the next day unless a leak was present. Elective repairs were usually performed for patients presenting with asymptomatic incidentally found dissections after previous operation, evidence of growth of the dissected arch, size larger than 5.5 cm of the remaining aorta, or symptoms such as hoarseness, dysphagia, and stridor. Currently, most patients undergo operations with subclavian artery inflow with an attached side graft, transfemoral vein or direct right atrial venous drainage, and deep hypothermic circulatory arrest. Antegrade or retrograde brain perfusion was used on a selective basis [1, 2]. Most chronic dissection patients now undergo elephant trunk two-stage procedures or extended left thoracoabdominal incisions [3]. Biologic glue and aprotinin are usually not used.

Data Analysis
Descriptive statistics included the mean and standard deviation for continuous variables when the distribution was symmetrical; median and 25th and 75th percentiles when it was skewed; and frequencies and percentages for categorical variables (Appendix). Nonparametric estimates of time-related events were obtained using the Kaplan-Meier method. A parametric method was used to resolve the number of phases of instantaneous risk for each time-related end point (hazard function) and to estimate shaping variables [4]. To identify risk factors for all-cause mortality at any time after operation, multivariable analysis was performed in the hazard function domain using bootstrap bagging as the variable selection method, with p of 0.05 for retention of variables in the models [5, 6], following principles described previously [7].

Confidence limits of proportions and time-related depictions are accompanied by confidence limits equivalent to 1 standard error (68%).


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Appendix Variables Considered in...
 References
 
Hospital Mortality
There were 6 (5.6%,confidence limit 3.3% to 8.9%) hospital deaths, caused by bleeding complications in 3, stroke in 1, anoxic brain injury in 1, and perioperative myocardial infarction in 1. Among the patients who died, 3 had undergone emergency operation. Mortality for emergency operations was 12% (3 of 26), not statistically different from that for elective operations (3.6% [3 of 82]; p = 0.13). All 3 patients with ruptured aortic dissections died. Mortality for acute and chronic dissection was 11% (5 of 47) and 1.6% (1 of 61), respectively (p = 0.09). Mortality for second and third reoperations was 5.0% (5 of 100) and 12% (1 of 8), respectively (p = 0.4). There were no deaths among the 6 patients with Marfan syndrome. Mortality among patients with previous aortic valve surgery, previous CABG, and previous aortic surgery was 6.9% (2 of 29), 6.3% (4 of 63), and 3.6% (1 of 28), respectively. Preoperative coronary angiography did not affect mortality (5.0% [4 of 80] in the catheterization group versus 7.1% [2 of 28] in the noncatheterization group; p = 0.7), although it should be noted that 60% of the 108 patients required CABG procedures. The hazard multivariable analysis failed to identify any reliable risk factor for early death.

Postoperative Complications
The most common postoperative complications were bleeding and infection (Table 3). Strokes occurred in 4 patients (3.7%; confidence limit, 1.9% to 6.7%), 1 of whom died. Of the 4 patients who experienced strokes, deep hypothermic circulatory arrest with retrograde brain perfusion was used in 3 and was not reported in 1. Among hospital survivors, median intensive care unit and postoperative hospital stays were 3 and 13 days, respectively.


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  		Table 3. Postoperative Course
 
Late Survival
Follow-up revealed 32 postdischarge deaths, including 3 documented deaths as a result of aortic dissection or aneurysm. Other causes of death were not related to the aorta, although there were 4 sudden deaths from unknown cause among patients with known residual dissections.

Survival at 30 days and 1, 3, 5, and 7 years was 93%, 85%, 74%, 63%, and 53%, respectively (Fig 2). Risk factors for death in the late hazard phase were higher preoperative blood urea nitrogen level (p = 0.002) and longer circulatory arrest time (p = 0.0001), as shown in Figure 3.



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  		Fig 2. Survival after aortic dissection repair. Each circle represents an event; vertical bars are confidence intervals equivalent to one standard error (68% confidence limits); numbers in parentheses are patients at risk of death; solid line represents parametric estimates enclosed within 68% confidence limits (dashed lines).

 


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  		Fig 3. Five-year survival after aortic dissection repair according to risk factors. Solid line represents parametric estimates, and dashed lines are 68% confidence limits as a function of blood urea nitrogen (BUN) level (mg/dL) (a) and as a function of circulatory arrest time (b).

 
Late Aortic Reoperation
Seven late aortic reoperations were performed: 3 for endocarditis, 3 for aortic dissection (2 chronic and 1 acute), and 1 for perivalvular leak. Of the 3 reoperations for aortic dissection, 2 were for residual chronic dissection in the descending aorta, and the third was for a new acute dissection in the proximal aortic root and ascending aorta that developed 8.3 years after ascending aorta and arch replacement. Among the 6 patients with Marfan syndrome, 2 (33%) underwent reoperation: 1 for residual chronic descending aortic dissection and another for perivalvular leak.

Freedom from the aortic reoperation at 30 days and 1, 3, 5, and 7 years was 98%, 95%, 93%, 91%, and 89%, respectively (Fig 4). Five of the 7 aortic reoperations (71%) were performed within the first year of surgery.



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  		Fig 4. Aortic reoperation after aortic dissection repair. (a) Freedom from aortic reoperation. Presentation is as in Figure 2. (b) Hazard function for aortic reoperation. Solid line represents parametric estimates enclosed within dashed 68% confidence limits (dashed lines). (c) Magnification of early portion of hazard on an incidence per month scale.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Appendix Variables Considered in...
 References
 
Mortality for untreated DeBakey Type 1 or 2 aortic dissection is as high as 40% in the first 48 hours of onset, mostly as a result of free rupture of the aneurysm and hemodynamic compromise [8]. Rupture or tamponade is less likely in patients with adhesions from previous operation. Emergency surgery for aortic dissection is thus focused on preventing early death. In most cases, ascending aorta replacement is performed regardless of the extent of the dissection. Surgical mortality for acute aortic dissection after ascending aortic repair in one large study was 5% [9]. Freedom from reoperation after primary aortic dissection surgery was 96% at 1 year, 91% at 5 years, and 78% at 10 years [9]. Need for reoperation after aortic dissection repair has been reported to be from 15% to 35% at 10 years [10]. Kirsch and colleagues [10] found that the risk factors for proximal aortic reoperation after primary aortic dissection repair were residual regurgitation or new aortic regurgitation after primary surgery.

These authors note that reoperation after primary aortic dissection repair has increased in recent years [10], a trend mirrored in our series. However, because our study was limited to patients who underwent operation, this likely reflects referral bias and not an increase in the incidence of aortic dissection after cardiovascular surgery. Some patients may have refused referral for surgery, some may have died before referral to surgery, and some may have died before reaching the hospital. Thus, the true incidence of aortic dissection after cardiovascular surgery is unknown. We believe that the increase in reoperations could be related to increased referrals because of the relatively low postoperative mortality and morbidity; our hospital mortality (5.6%) is similar to that reported for primary aortic dissection repair [9]. We speculate that this low mortality is related to improved surgical techniques, circulatory arrest methods, cardiopulmonary bypass technologies, adjunctive brain perfusion methods, and axillary or subclavian cannulation strategies [1–3].

Aortic dissection after aortic valve operation was studied by von Kodolitsch and colleagues [11]. Late dissection occurred in 0.6%. Prevalence of previous aortic valve surgery was 9% in patients with aortic dissection. The authors found that fragility of the aortic wall, aortic regurgitation, and aortic wall thinning were risk factors for aortic dissection. However, in our study characteristics of the aortic wall at previous surgery were difficult to obtain owing to lack of documentation, or because most of the previous operations were performed at outside hospitals. In another study of aortic dissection after aortic valve replacement, dissection occurred more frequently in patients whose ascending aorta exceeded 50 mm in diameter at the time of valve replacement [12]. The authors recommended prophylactic ascending aorta replacement because of the risks of future dissection. McDonald and colleagues [13] found that the risk factors for late rupture (n = 15) after aortic valve procedures in 109 patients were older age and greater ascending aortic size indexed to body surface area. They also concluded that an enlarged ascending aorta required repair.

There are few studies of aortic dissection after previous cardiovascular operations [14, 15]. Gillinov and colleagues [14], in an earlier study from our institution, found 56 ascending aortic dissections after previous cardiovascular surgery, with a hospital mortality of 14%. They concluded that rupture of an aortic dissection after such surgery was infrequent because of adhesions. In our study, only 3 free ruptures occurred, but all the patients died. Once free rupture occurs before reoperation, salvage is less likely, because with emergency surgery, chest re-entry, cannulation, and exposure of the aorta are more complicated and time consuming than in primary operation for aortic dissection. Our study showed a higher mortality with emergency surgery, but this could be caused by chance.

Previous operation in our study was predominantly for coronary artery disease. Because hemodynamic instability or free rupture in redo aortic dissection patients is rare, patients should be considered for preoperative coronary angiography to evaluate native coronary artery disease and prior CABG surgery. Our study found that catheterization did not increase hospital mortality. Patients who have had previous CABG are more likely to require concomitant bypass surgery (87%; p < 0.0001) at the time of aortic dissection, mainly because of progression of the coronary artery disease, graft occlusion, or technical difficulties with reimplantation of previous grafts. Indeed, 27% without known coronary artery disease required CABG procedures.

During an average of 4.1 years of follow-up, there were 7 aortic reoperations. Among these, 3 were for endocarditis (2 infections occurred after composite graft placement and another after aortic valve repair), and they were performed in the first postoperative year. Reoperation for a new aortic dissection was observed in only 1 patient, and it occurred 8 years after surgery. Thus, new aortic dissection after redo dissection surgery is rare; furthermore, the most common cause of late deaths was not related to aortic dissection. The association of renal dysfunction and lengthy circulatory arrest with long-term mortality is not surprising.

In this study, stroke occurred in 3.7% of patients, comparable to its occurrence in primary aortic dissection repair [1]. This may reflect improved surgical technique, including use of the right subclavian or axillary artery for arterial infusion protocols for brain protection and adjunctive measures [1–3].

In summary, aortic dissection after cardiovascular surgery can be managed with acceptable operative risks. Long-term survival is good, and need for subsequent aortic reoperation is rare.


   Appendix Variables Considered in Multivariable Analysis
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Appendix Variables Considered in...
References
 
Preoperative Variables
DEMOGRAPHY
Sex, age (years), weight (kg), height (cm), body surface area (m2), body mass index (kg/m2).

SYMPTOMS
New York Heart Association functional class (I–IV), current dyspnea.

PATHOLOGY
Mitral regurgitation, aortic regurgitation, tricuspid regurgitation, pulmonary regurgitation, bicuspid aortic valve.

CARDIAC COMORBIDITY
Atrial fibrillation, complete heart block, ventricular arrhythmia, emergency cardiac surgery, number of previous cardiac operations, coronary artery disease by coronary artery territory (left main trunk, left anterior descending artery, left circumflex artery, right coronary artery).

NONCARDIAC COMORBIDITY
Treated diabetes, hypertension, history of peripheral vascular disease, presence of carotid disease, presence of chronic obstructive pulmonary disease, renal disease, history of smoking, creatinine (mg/dL), blood urea nitrogen (mg/dL), bilirubin (mg/dL), hemoglobin (g/dL), hematocrit (%), cholesterol (mg/dL), and triglyceride levels (mg/dL).

PREVIOUS OPERATIONS
Coronary artery bypass grafting, valve procedure, aneurysm repair.

EXPERIENCE
Date of surgery (date of operation from January 1, 1990).

Intraoperative Variables
PROCEDURE
Coronary artery bypass grafting, aortic valve replacement, aortic valve repair, ascending aorta procedure, aortic arch procedure, aortic valved conduit, descending aorta procedure.

SUPPORT
Aortic clamp time (min), circulatory arrest, circulatory arrest time (min), retrograde brain perfusion.


   References
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 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Appendix Variables Considered in...
 References
 

  1. Svensson LG, Nadolny EM, Kimmel WA. Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations Ann Thorac Surg 2002;74:2040-2046.[Abstract/Free Full Text]
  2. Svensson LG, Blackstone EH, Rajeswaran J. Does arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg 2004;78:1274–84..
  3. Svensson LG, Kim K-H, Blackstone EH. Elephant trunk procedure: newer indications and uses. Ann Thorac Surg 2004;78:109–16..
  4. Blackstone EH, Naftel DC, Turner Jr ME. The decomposition of time-varying hazard into phases, each incorporating a separate stream of concomitant information J Am Stat Assoc 1986;81:615-624.
  5. Breiman L. Bagging predictors Machine Learning 1996;24:123-140.
  6. Blackstone EH. Breaking down barriers: helpful breakthrough statistical methods you need to understand better J Thorac Cardiovasc Surg 2001;122:430-439.[Free Full Text]
  7. Blackstone EH, Rice TW. Clinical-pathologic conference: use and choice of statistical methods for the clinical study, "superficial adenocarcinoma of the esophagus" J Thorac Cardiovasc Surg 2001;122:1063-1076.[Free Full Text]
  8. Stanger O, Oberwalder P, Dacar D, et al. Late dissection of the ascending aorta after previous cardiac surgery: risk, presentation and outcome Eur J Cardiothorac Surg 2002;21:453-458.[Abstract/Free Full Text]
  9. Svensson LG, Crawford ES, Hess KR, et al. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results Circulation 1990;82(Suppl 4):IV-24-38.
  10. Kirsch M, Soustelle C, Houel R, et al. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection J Thorac Cardiovasc Surg 2002;123:318-325.[Abstract/Free Full Text]
  11. von Kodolitsch Y, Loose R, Ostermeyer J, et al. Proximal aortic dissection late after aortic valve surgery: 119 cases of a distinct clinical entity Thorac Cardiovasc Surg 2000;48:342-346.[Medline]
  12. Pieters FA, Widdershoven JW, Gerardy AC, et al. Risk of aortic dissection after aortic valve replacement Am J Cardiol 1993;72:1043-1047.[Medline]
  13. McDonald ML, Smedira NG, Blackstone EH, et al. Reduced survival in women after valve surgery for aortic regurgitation: effect of aortic enlargement and late aortic rupture J Thorac Cardiovasc Surg 2000;119:1205-1212.[Abstract/Free Full Text]
  14. Gillinov AM, Lytle BW, Kaplon RJ, et al. Dissection of the ascending aorta after previous cardiac surgery: differences in presentation and management J Thorac Cardiovasc Surg 1999;117:252-260.[Abstract/Free Full Text]
  15. Crawford ES, Crawford JL, Safi HJ, et al. Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch Ann Thorac Surg 1985;40:439-455.[Abstract]

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