Risk of late reoperations in patients with acute type A aortic dissection: Impact of a more radical surgical approach

Peppino Pugliese, Renzo Pessotto, Francesco Santini, Giuseppe Montalbano, Giovanni Battista Luciani, Alessandro Mazzucco

Research output: Contribution to journalArticle

65 Citations (Scopus)

Abstract

Objective: To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. Methods: From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 ± 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 ± 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 ± 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. Results: Nineteen patients (13%), 13 males and 6 females, aged 50 ± 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 ± 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 ± 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P <0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. Conclusions: Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

Original languageEnglish
Pages (from-to)576-581
Number of pages6
JournalEuropean Journal of Cardio-thoracic Surgery
Volume13
Issue number5
DOIs
Publication statusPublished - May 1998

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Reoperation
Aorta
Dissection
Tunica Intima
Thoracic Aorta
Aortic Valve
Incidence
Emergencies
Survival
Aortic Valve Insufficiency
Survival Rate
Transplants
Mortality

Keywords

  • Acute aortic dissection
  • Aortic surgery
  • Circulatory arrest
  • Reoperation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Risk of late reoperations in patients with acute type A aortic dissection : Impact of a more radical surgical approach. / Pugliese, Peppino; Pessotto, Renzo; Santini, Francesco; Montalbano, Giuseppe; Luciani, Giovanni Battista; Mazzucco, Alessandro.

In: European Journal of Cardio-thoracic Surgery, Vol. 13, No. 5, 05.1998, p. 576-581.

Research output: Contribution to journalArticle

Pugliese, Peppino ; Pessotto, Renzo ; Santini, Francesco ; Montalbano, Giuseppe ; Luciani, Giovanni Battista ; Mazzucco, Alessandro. / Risk of late reoperations in patients with acute type A aortic dissection : Impact of a more radical surgical approach. In: European Journal of Cardio-thoracic Surgery. 1998 ; Vol. 13, No. 5. pp. 576-581.
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abstract = "Objective: To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. Methods: From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 ± 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21{\%}. One hundred and forty-one patients (100 males and 41 females, aged 58 ± 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96{\%}) with extension to the transverse arch in 22 (16.2{\%}) and associated total root or aortic valve replacement in 31 (22.8{\%}) and 6 (4.4{\%}) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4{\%}). Total follow-up was 690 patient-years, mean 5.1 ± 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88{\%}, 73{\%} and 42{\%}, respectively. Results: Nineteen patients (13{\%}), 13 males and 6 females, aged 50 ± 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94{\%}, 64{\%} and 35{\%}, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84{\%}) cases, with total root replacement in 2 (12{\%}) and isolated aortic valve replacement in 1 (6{\%}). Three patients (16{\%}) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 ± 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11{\%}), aneurysmal evolution of the false lumen in 4 (21{\%}) or both in 13 (68{\%}). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68{\%}), isolated replacement of the ascending aorta in 3 (16{\%}), aortic valve in 2 (11{\%}) and aortic arch in 1 (5{\%}). There were 1 hospital (5{\%}) and 2 late (11{\%}) deaths at a mean follow-up of 2.5 ± 2.4 years, with an actuarial survival at 5 years of 88{\%}. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24{\%}) to 8/95 (8.4{\%}) (P <0.05). However, also with this strategy 8/73 (11{\%}) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60{\%}) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. Conclusions: Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.",
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TY - JOUR

T1 - Risk of late reoperations in patients with acute type A aortic dissection

T2 - Impact of a more radical surgical approach

AU - Pugliese, Peppino

AU - Pessotto, Renzo

AU - Santini, Francesco

AU - Montalbano, Giuseppe

AU - Luciani, Giovanni Battista

AU - Mazzucco, Alessandro

PY - 1998/5

Y1 - 1998/5

N2 - Objective: To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. Methods: From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 ± 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 ± 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 ± 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. Results: Nineteen patients (13%), 13 males and 6 females, aged 50 ± 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 ± 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 ± 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P <0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. Conclusions: Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

AB - Objective: To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. Methods: From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 ± 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 ± 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 ± 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. Results: Nineteen patients (13%), 13 males and 6 females, aged 50 ± 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 ± 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 ± 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P <0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. Conclusions: Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

KW - Acute aortic dissection

KW - Aortic surgery

KW - Circulatory arrest

KW - Reoperation

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