Accepted Manuscript AATS 2014 #74: Acute Type A Aortic Dissection Extending Beyond Ascending Aorta: Limited or Extensive Distal Repair Bartosz Rylski , MD Friedhelm Beyersdorf , MD, PhD Fabian A. Kari , MD Julia Schlosser , BS Philipp Blanke , MD Matthias Siepe , MD PII:
S0022-5223(14)00595-9
DOI:
10.1016/j.jtcvs.2014.05.051
Reference:
YMTC 8636
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 7 January 2014 Revised Date:
12 March 2014
Accepted Date: 19 May 2014
Please cite this article as: Rylski B, Beyersdorf F, Kari FA, Schlosser J, Blanke P, Siepe M, AATS 2014 #74: Acute Type A Aortic Dissection Extending Beyond Ascending Aorta: Limited or Extensive Distal Repair, The Journal of Thoracic and Cardiovascular Surgery (2014), doi: 10.1016/j.jtcvs.2014.05.051. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
AATS 2014 #74: Acute Type A Aortic Dissection Extending Beyond Ascending Aorta: Limited or Extensive Distal Repair
RI PT
Bartosz Rylski, MD1; Friedhelm Beyersdorf, MD, PhD1; Fabian A Kari, MD1; Julia Schlosser, BS1; Philipp Blanke, MD2; Matthias Siepe, MD1
2
Heart Center Freiburg University, Freiburg, Germany
SC
1
Department of Diagnostic and Interventional Radiology, University Hospital Würzburg,
M AN U
Germany
This paper will be presented at the
American Association for Thoracic Surgery 94rd Annual Meeting
AC C
Word count: 2501
EP
TE D
Toronto, OW, Canada, April 26-28, 2014
Corresponding author: Bartosz Rylski, MD
Heart Center Freiburg University Hugstetter Str. 55 79106 Freiburg Germany Tel: +49 761 270 28180 Fax: +49 761 270 28670 E-mail: [email protected]
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Abstract Objective. The aim of this study is to delineate the impact of aortic arch surgery extension
RI PT
on outcome in acute Type A dissection extending beyond the ascending aorta.
Methods. Between 2001 and 2013, among 197 patients with Type A dissection, 153 (78%) with dissection extending beyond the ascending aorta (aged 61 (50; 69) years, 67% males)
SC
were identified. Aortic repair involved isolated ascending (n = 102), hemi- (n = 37) and total
M AN U
arch replacement (n = 14). Median follow-up was 4.9 (2.5; 7.6) years (733 patient-years).
Results. In-hospital mortality was 9.8%, 21.6% and 28.6% (P = .122) in patients with no, hemi- and total arch replacement. Age >80 years (OR: 9.37, P = .006), malperfusion syndrome (OR: 4.74, P = .004) and total arch replacement (OR: 6.47, P = .016) were
TE D
independent predictors of perioperative mortality. Freedom from distal re-intervention was 93 ± 3% vs 97 ± 3% vs 100% at 1 and 89 ± 3% vs 97 ± 3% vs 100% at 5 years in no, hemi- and
EP
total arch replacement patients (log rank, P = .440). Marfan syndrome (OR: 12.40, P = .038) and dissection of all aortic segments (OR 10.68, P = .007) predicted distal aortic re-
AC C
interventions. In-hospital mortality for elective re-intervention was 0%.
Conclusions. Limiting the extent of surgery for Type A aortic dissection to ascending aortic replacement is associated with low perioperative mortality. Aortic arch repair may be deferred, as it can be performed electively with lower risk of mortality.
Word count: 245
2
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Ultra-mini Abstract Complex aortic arch surgery in the setting of acute Type A aortic dissection is associated with high in-hospital mortality. Limiting the surgery to ascending aortic replacement results in low
RI PT
perioperative mortality. Aortic arch repair may be deferred, as it can be performed electively
AC C
EP
TE D
M AN U
SC
with lower risk of mortality.
3
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Introduction In the acute setting of Stanford Type A aortic dissection, emergency surgical intervention primarily aims at preserving life by preventing aortic rupture, correcting aortic valve
RI PT
insufficiency and restoring flow to dissected branch vessels [1]. In patients with dissection confined to the proximal aorta, the entire dissected aortic segment may be repaired by means of sole ascending aortic replacement [2, 3]. However, in the majority of patients the
SC
dissection process extends beyond the ascending aorta [4] and replacement of entire dissected tissue is usually not feasibly.
M AN U
Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are considered the standard in Type A dissection surgery. In patients with aortic arch aneurysm or intimal tear localized in the aortic arch, more extensive surgery with hemi- or total arch replacement is warranted [1]. However, the surgical strategy for patients with
TE D
dissection process extending into the aortic arch, but without arch aneurysm or an intimal tear within the arch remains controversial. Considering the still high perioperative mortality
EP
in Type A dissection patients of 8 to 34% [5, 6, 7], the increased perioperative risk associated with more extensive distal aortic repair has to be weighted against the risk of future re-
AC C
intervention and associated mortality.
In this study we sought to investigate the impact of aortic arch surgery extension on early and intermediate outcome in acute Type A dissection patients with the dissection process extending beyond the ascending aorta and to analyze the impact of more extensive aortic arch replacement onto prevention of subsequent distal aortic re-interventions.
4
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Methods Study Population and Definitions Between 2001 and 2013, among 197 patients operated on for acute Stanford Type A aortic
RI PT
dissection, 153 (78%) presented with dissection extending beyond the ascending aorta and involvement of at least the aortic arch. Patients with dissection process extending into the aortic arch were further analyzed and comprise the study population. They were divided into
SC
groups according to extension of aortic arch surgery, as follows: isolated ascending aortic, hemi- and total arch replacement groups. Demographics and clinical characteristics are
M AN U
presented in Table 1.
Acute aortic dissection was defined as a dissection operated on no later than 14 days after the symptom onset. Distal re-intervention was defined as an open or endovascular intervention on the aorta distal to the ascending aortic and/or arch prosthesis implanted by
TE D
the initial surgery. The institutional review committee approved this retrospective study.
EP
The need for informed consent was waived.
Surgical Management
AC C
According to our institutional policies, surgery on the aortic arch was routinely performed under hypothermic selective antegrade cerebral perfusion, using the right axillary artery for arterial inflow, with an open anastomosis technique. In case of dissected right axillary artery, we cannulated femoral and one or both carotid arteries. The aortic arch remained unreplaced in patients with non-aneurysmatic arch (5.0 cm) or intimal entry-tear localized along the small curvature. In patients with intimal entry-tear localized along the greater curvature and those with known connective tissue disorder total arch replacement was performed. Dissected layers of the aorta were sealed
RI PT
with BioGlue (CryoLife Inc, Kennesaw, GA).
Patients Follow-up
SC
Surveillance follow-up data were obtained from aortic clinic office visits, by contacting the patients’ primary care physician or the patients and their family members. Complete follow-
M AN U
up was available in 127 of 131 hospital survivors (97%). Patients were followed up a total of 733 patient-years, with a median follow-up among survivors of 4.9 (2.5; 7.6) years. Forty-five percent (n = 59) were followed for 5 or more years.
According to current guidelines [1], the follow-up protocol included postoperative computed
TE D
tomography (CT) angiography before discharge, clinical examination and CT angiography 6 and 12 months postoperatively, and annually thereafter at our institutional aortic outpatient
AC C
Statistical Analysis
EP
clinic or at their regional hospitals for patients living in remote areas.
Continuous data are presented as median (first quartile; third quartile); categorical variables are given as counts and percentages. For comparison of continuous variables the Student’s ttest was applied when normal distribution was present as tested by the KolmogorovSmirnov test. For not normally distributed variables, the Mann-Whitney rank sum test was employed. Categorical variables were compared using the χ2 Test. In case of small group sizes (n < 5), the Fisher’s exact test was used. The p-values are not presented for n = 0 in the subgroup. Survival was analyzed using the Kaplan-Meier method and log rank calculations.
6
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Multivariable logistic regression was applied to analyze the influence of age >80 years, cardiogenic shock, malperfusion of one or more organs, hemi- or total arch replacement on in-hospital mortality and age 80 years (OR: 9.37, P = .006), malperfusion of one or more organs (OR: 4.74, P = .004) and total arch replacement (OR:
RI PT
6.47, P = .016) were identified as independent predictors of in-hospital mortality (Table 2).
Distal Aortic Re-interventions
SC
Freedom from distal re-intervention was 93 ± 3% vs 97 ± 3% vs 100% at 1 year and 89 ± 3% vs 97 ± 3% vs 100% at 5 years in patients with isolated ascending aortic, hemi- and total arch
M AN U
replacement (log rank, P = .440; Figure 2). Twelve patients (8%) required secondary procedures at a median of 1.0 (0.4; 1.8) year as follows: 6 thoracic endovascular aortic repairs, 3 hybrid arch debranching, 2 total arch replacements and one descending thoracic aortic replacement (Table 3). Re-interventions were performed in 10 patients electively and
TE D
in 2 emergently. Two patients re-operated on emergently did not survive the secondary intervention: one died of multisystem organ failure after redo total arch replacement and one of ruptured descending thoracic aortic aneurysm one day after endovascular thoracic
AC C
EP
aortic repair. In-hospital mortality for elective distal re-intervention was 0%.
Distal Aortic Re-interventions Risk Factors Marfan syndrome (OR: 12.40, P = .038) and dissection of all aortic segments (OR 10.68, P = .007) were independent predictors of distal aortic re-interventions. Among 12 patients who underwent distal re-intervention, in 11 patients aortic dissection was involving all aortic segments and in 1 patient, the dissection primarily extended into the coeliac trunk. Age 80 years), malperfusion of one or more organs and total arch
EP
replacement as significant determinants of in-hospital mortality in patients with dissection extending beyond the ascending aorta. When stratified according to initial aortic repair, the
AC C
highest mortality was observed in those with total arch replacement. Similar observations as reported by others not only identified total arch replacement as a perioperative mortality risk factor [10, 11, 12, 13], but also as an independent risk factor for permanent neurologic injury [11].
Distal Aortic Re-interventions Patent false lumen is the major and well established risk factor for the need of reintervention on the aortic arch or descending aorta after Type A dissection repair [14]. 11
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Therefore, some groups advocate a more aggressive approach involving aortic arch repair to minimize the need for later re-interventions. Jacob et al. published their experience with 44 patients suffering aortic dissection limited to the ascending aorta and aortic arch [2]. They
RI PT
performed hemi-arch repair in 37% and complete arch replacement in 36% of patients with no need for distal aortic re-intervention over the median follow-up of 2 years. The Philadelphia group [15] routinely performs hemi-arch replacement in over 90% of all Type A
SC
dissection patients with 76% freedom from distal reoperation at 10 years. Griepp et al. reported in a cohort of 179 patients, with 54% hemi-arch and 6% total arch replacements, a
M AN U
total of 25 reoperations over 17 years [16]. Recently, several groups reported on even more aggressive approaches involving frozen elephant trunk implantation into the proximal descending thoracic aorta [17, 18] or antegrade endovascular descending aortic repair [2, 19], but data on long-term outcome is yet lacking.
TE D
In the present study, aortic arch replacement was performed to eliminate the intimal tear or to replace an aneurysmatic aortic arch. To minimize the risk of cerebral injuries and organ dysfunction related to longer duration of cardiac ischemia and circulatory arrest, our group
EP
does not routinely perform prophylactic arch replacement. In our series of patients with
AC C
dissected aortic arch, dissection extended beyond the arch in 76% of patients. Therefore routine arch replacement would not eliminate the entire dissected tissue in the majority of patients. Among 37 patients, with dissection terminating at the left subclavian artery, we chose a more conservative surgical strategy limited to isolated ascending aortic replacement in 22 patients since the resection of all dissected tissue in those patients would require total aortic arch replacement. We performed total aortic arch only if it was unavoidable due to arch aneurysm or intimal tear along the greater curvature.
12
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Marfan syndrome and dissection of all aortic segments were predictors of distal aortic reintervention. Incomplete resection of dissected aortic arch did not correlate with distal reinterventions. Interestingly, among patients who underwent distal reoperation, dissection
RI PT
extended to the coeliac trunk in 100% and to the iliac arteries in 92% at the initial presentation. This data underlies the fact, that extending the initial surgery to total arch replacement would not have eliminate the entire dissected tissue in none of these patients.
SC
However, it should be pointed out that none of the patients who had initially undergone total arch replacement required re-intervention in the follow-up period and none of Type A
M AN U
dissection surgery survivors died within 5 years after hospital discharge (9 patients remaining at risk). The downside of this favorable outcome is the high risk of perioperative mortality associated with the initial surgery. It is conceivable that younger patients will profit from more aggressive surgery. However, future studies with longer follow up are needed.
TE D
Especially, the frozen elephant technique might be favorable for the treatment of young patients or patients with connective tissue disorders to establish best possible replacement of dissected tissue and optimize long-term survival.
EP
Elective re-interventions were performed safely with no observed perioperative mortality.
AC C
These data suggest that limitating the surgery for Type A dissection to ascending aortic replacement results in low perioperative mortality (9.8%) and that distal aortic reintervention may be performed safely in the follow-up period, if secondary aortic pathology is diagnosed in time to allow for elective procedures. Shorter interval (
S0022-5223(14)00595-9
DOI:
10.1016/j.jtcvs.2014.05.051
Reference:
YMTC 8636
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 7 January 2014 Revised Date:
12 March 2014
Accepted Date: 19 May 2014
Please cite this article as: Rylski B, Beyersdorf F, Kari FA, Schlosser J, Blanke P, Siepe M, AATS 2014 #74: Acute Type A Aortic Dissection Extending Beyond Ascending Aorta: Limited or Extensive Distal Repair, The Journal of Thoracic and Cardiovascular Surgery (2014), doi: 10.1016/j.jtcvs.2014.05.051. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
AATS 2014 #74: Acute Type A Aortic Dissection Extending Beyond Ascending Aorta: Limited or Extensive Distal Repair
RI PT
Bartosz Rylski, MD1; Friedhelm Beyersdorf, MD, PhD1; Fabian A Kari, MD1; Julia Schlosser, BS1; Philipp Blanke, MD2; Matthias Siepe, MD1
2
Heart Center Freiburg University, Freiburg, Germany
SC
1
Department of Diagnostic and Interventional Radiology, University Hospital Würzburg,
M AN U
Germany
This paper will be presented at the
American Association for Thoracic Surgery 94rd Annual Meeting
AC C
Word count: 2501
EP
TE D
Toronto, OW, Canada, April 26-28, 2014
Corresponding author: Bartosz Rylski, MD
Heart Center Freiburg University Hugstetter Str. 55 79106 Freiburg Germany Tel: +49 761 270 28180 Fax: +49 761 270 28670 E-mail: [email protected]
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Abstract Objective. The aim of this study is to delineate the impact of aortic arch surgery extension
RI PT
on outcome in acute Type A dissection extending beyond the ascending aorta.
Methods. Between 2001 and 2013, among 197 patients with Type A dissection, 153 (78%) with dissection extending beyond the ascending aorta (aged 61 (50; 69) years, 67% males)
SC
were identified. Aortic repair involved isolated ascending (n = 102), hemi- (n = 37) and total
M AN U
arch replacement (n = 14). Median follow-up was 4.9 (2.5; 7.6) years (733 patient-years).
Results. In-hospital mortality was 9.8%, 21.6% and 28.6% (P = .122) in patients with no, hemi- and total arch replacement. Age >80 years (OR: 9.37, P = .006), malperfusion syndrome (OR: 4.74, P = .004) and total arch replacement (OR: 6.47, P = .016) were
TE D
independent predictors of perioperative mortality. Freedom from distal re-intervention was 93 ± 3% vs 97 ± 3% vs 100% at 1 and 89 ± 3% vs 97 ± 3% vs 100% at 5 years in no, hemi- and
EP
total arch replacement patients (log rank, P = .440). Marfan syndrome (OR: 12.40, P = .038) and dissection of all aortic segments (OR 10.68, P = .007) predicted distal aortic re-
AC C
interventions. In-hospital mortality for elective re-intervention was 0%.
Conclusions. Limiting the extent of surgery for Type A aortic dissection to ascending aortic replacement is associated with low perioperative mortality. Aortic arch repair may be deferred, as it can be performed electively with lower risk of mortality.
Word count: 245
2
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Ultra-mini Abstract Complex aortic arch surgery in the setting of acute Type A aortic dissection is associated with high in-hospital mortality. Limiting the surgery to ascending aortic replacement results in low
RI PT
perioperative mortality. Aortic arch repair may be deferred, as it can be performed electively
AC C
EP
TE D
M AN U
SC
with lower risk of mortality.
3
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Introduction In the acute setting of Stanford Type A aortic dissection, emergency surgical intervention primarily aims at preserving life by preventing aortic rupture, correcting aortic valve
RI PT
insufficiency and restoring flow to dissected branch vessels [1]. In patients with dissection confined to the proximal aorta, the entire dissected aortic segment may be repaired by means of sole ascending aortic replacement [2, 3]. However, in the majority of patients the
SC
dissection process extends beyond the ascending aorta [4] and replacement of entire dissected tissue is usually not feasibly.
M AN U
Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are considered the standard in Type A dissection surgery. In patients with aortic arch aneurysm or intimal tear localized in the aortic arch, more extensive surgery with hemi- or total arch replacement is warranted [1]. However, the surgical strategy for patients with
TE D
dissection process extending into the aortic arch, but without arch aneurysm or an intimal tear within the arch remains controversial. Considering the still high perioperative mortality
EP
in Type A dissection patients of 8 to 34% [5, 6, 7], the increased perioperative risk associated with more extensive distal aortic repair has to be weighted against the risk of future re-
AC C
intervention and associated mortality.
In this study we sought to investigate the impact of aortic arch surgery extension on early and intermediate outcome in acute Type A dissection patients with the dissection process extending beyond the ascending aorta and to analyze the impact of more extensive aortic arch replacement onto prevention of subsequent distal aortic re-interventions.
4
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT
Methods Study Population and Definitions Between 2001 and 2013, among 197 patients operated on for acute Stanford Type A aortic
RI PT
dissection, 153 (78%) presented with dissection extending beyond the ascending aorta and involvement of at least the aortic arch. Patients with dissection process extending into the aortic arch were further analyzed and comprise the study population. They were divided into
SC
groups according to extension of aortic arch surgery, as follows: isolated ascending aortic, hemi- and total arch replacement groups. Demographics and clinical characteristics are
M AN U
presented in Table 1.
Acute aortic dissection was defined as a dissection operated on no later than 14 days after the symptom onset. Distal re-intervention was defined as an open or endovascular intervention on the aorta distal to the ascending aortic and/or arch prosthesis implanted by
TE D
the initial surgery. The institutional review committee approved this retrospective study.
EP
The need for informed consent was waived.
Surgical Management
AC C
According to our institutional policies, surgery on the aortic arch was routinely performed under hypothermic selective antegrade cerebral perfusion, using the right axillary artery for arterial inflow, with an open anastomosis technique. In case of dissected right axillary artery, we cannulated femoral and one or both carotid arteries. The aortic arch remained unreplaced in patients with non-aneurysmatic arch (5.0 cm) or intimal entry-tear localized along the small curvature. In patients with intimal entry-tear localized along the greater curvature and those with known connective tissue disorder total arch replacement was performed. Dissected layers of the aorta were sealed
RI PT
with BioGlue (CryoLife Inc, Kennesaw, GA).
Patients Follow-up
SC
Surveillance follow-up data were obtained from aortic clinic office visits, by contacting the patients’ primary care physician or the patients and their family members. Complete follow-
M AN U
up was available in 127 of 131 hospital survivors (97%). Patients were followed up a total of 733 patient-years, with a median follow-up among survivors of 4.9 (2.5; 7.6) years. Forty-five percent (n = 59) were followed for 5 or more years.
According to current guidelines [1], the follow-up protocol included postoperative computed
TE D
tomography (CT) angiography before discharge, clinical examination and CT angiography 6 and 12 months postoperatively, and annually thereafter at our institutional aortic outpatient
AC C
Statistical Analysis
EP
clinic or at their regional hospitals for patients living in remote areas.
Continuous data are presented as median (first quartile; third quartile); categorical variables are given as counts and percentages. For comparison of continuous variables the Student’s ttest was applied when normal distribution was present as tested by the KolmogorovSmirnov test. For not normally distributed variables, the Mann-Whitney rank sum test was employed. Categorical variables were compared using the χ2 Test. In case of small group sizes (n < 5), the Fisher’s exact test was used. The p-values are not presented for n = 0 in the subgroup. Survival was analyzed using the Kaplan-Meier method and log rank calculations.
6
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Multivariable logistic regression was applied to analyze the influence of age >80 years, cardiogenic shock, malperfusion of one or more organs, hemi- or total arch replacement on in-hospital mortality and age 80 years (OR: 9.37, P = .006), malperfusion of one or more organs (OR: 4.74, P = .004) and total arch replacement (OR:
RI PT
6.47, P = .016) were identified as independent predictors of in-hospital mortality (Table 2).
Distal Aortic Re-interventions
SC
Freedom from distal re-intervention was 93 ± 3% vs 97 ± 3% vs 100% at 1 year and 89 ± 3% vs 97 ± 3% vs 100% at 5 years in patients with isolated ascending aortic, hemi- and total arch
M AN U
replacement (log rank, P = .440; Figure 2). Twelve patients (8%) required secondary procedures at a median of 1.0 (0.4; 1.8) year as follows: 6 thoracic endovascular aortic repairs, 3 hybrid arch debranching, 2 total arch replacements and one descending thoracic aortic replacement (Table 3). Re-interventions were performed in 10 patients electively and
TE D
in 2 emergently. Two patients re-operated on emergently did not survive the secondary intervention: one died of multisystem organ failure after redo total arch replacement and one of ruptured descending thoracic aortic aneurysm one day after endovascular thoracic
AC C
EP
aortic repair. In-hospital mortality for elective distal re-intervention was 0%.
Distal Aortic Re-interventions Risk Factors Marfan syndrome (OR: 12.40, P = .038) and dissection of all aortic segments (OR 10.68, P = .007) were independent predictors of distal aortic re-interventions. Among 12 patients who underwent distal re-intervention, in 11 patients aortic dissection was involving all aortic segments and in 1 patient, the dissection primarily extended into the coeliac trunk. Age 80 years), malperfusion of one or more organs and total arch
EP
replacement as significant determinants of in-hospital mortality in patients with dissection extending beyond the ascending aorta. When stratified according to initial aortic repair, the
AC C
highest mortality was observed in those with total arch replacement. Similar observations as reported by others not only identified total arch replacement as a perioperative mortality risk factor [10, 11, 12, 13], but also as an independent risk factor for permanent neurologic injury [11].
Distal Aortic Re-interventions Patent false lumen is the major and well established risk factor for the need of reintervention on the aortic arch or descending aorta after Type A dissection repair [14]. 11
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Therefore, some groups advocate a more aggressive approach involving aortic arch repair to minimize the need for later re-interventions. Jacob et al. published their experience with 44 patients suffering aortic dissection limited to the ascending aorta and aortic arch [2]. They
RI PT
performed hemi-arch repair in 37% and complete arch replacement in 36% of patients with no need for distal aortic re-intervention over the median follow-up of 2 years. The Philadelphia group [15] routinely performs hemi-arch replacement in over 90% of all Type A
SC
dissection patients with 76% freedom from distal reoperation at 10 years. Griepp et al. reported in a cohort of 179 patients, with 54% hemi-arch and 6% total arch replacements, a
M AN U
total of 25 reoperations over 17 years [16]. Recently, several groups reported on even more aggressive approaches involving frozen elephant trunk implantation into the proximal descending thoracic aorta [17, 18] or antegrade endovascular descending aortic repair [2, 19], but data on long-term outcome is yet lacking.
TE D
In the present study, aortic arch replacement was performed to eliminate the intimal tear or to replace an aneurysmatic aortic arch. To minimize the risk of cerebral injuries and organ dysfunction related to longer duration of cardiac ischemia and circulatory arrest, our group
EP
does not routinely perform prophylactic arch replacement. In our series of patients with
AC C
dissected aortic arch, dissection extended beyond the arch in 76% of patients. Therefore routine arch replacement would not eliminate the entire dissected tissue in the majority of patients. Among 37 patients, with dissection terminating at the left subclavian artery, we chose a more conservative surgical strategy limited to isolated ascending aortic replacement in 22 patients since the resection of all dissected tissue in those patients would require total aortic arch replacement. We performed total aortic arch only if it was unavoidable due to arch aneurysm or intimal tear along the greater curvature.
12
Rylski et al, Distal Aortic Repair in Type A Dissection
ACCEPTED MANUSCRIPT Marfan syndrome and dissection of all aortic segments were predictors of distal aortic reintervention. Incomplete resection of dissected aortic arch did not correlate with distal reinterventions. Interestingly, among patients who underwent distal reoperation, dissection
RI PT
extended to the coeliac trunk in 100% and to the iliac arteries in 92% at the initial presentation. This data underlies the fact, that extending the initial surgery to total arch replacement would not have eliminate the entire dissected tissue in none of these patients.
SC
However, it should be pointed out that none of the patients who had initially undergone total arch replacement required re-intervention in the follow-up period and none of Type A
M AN U
dissection surgery survivors died within 5 years after hospital discharge (9 patients remaining at risk). The downside of this favorable outcome is the high risk of perioperative mortality associated with the initial surgery. It is conceivable that younger patients will profit from more aggressive surgery. However, future studies with longer follow up are needed.
TE D
Especially, the frozen elephant technique might be favorable for the treatment of young patients or patients with connective tissue disorders to establish best possible replacement of dissected tissue and optimize long-term survival.
EP
Elective re-interventions were performed safely with no observed perioperative mortality.
AC C
These data suggest that limitating the surgery for Type A dissection to ascending aortic replacement results in low perioperative mortality (9.8%) and that distal aortic reintervention may be performed safely in the follow-up period, if secondary aortic pathology is diagnosed in time to allow for elective procedures. Shorter interval (
