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J Thorac Cardiovasc Surg 2001;122:578-582
© 2001 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease (ACD)

Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique

From the Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis, Mo.

Received for publication Jan 16, 2001. Revisions requested Feb 13, 2001; revisions received March 1, 2001. Accepted for publication March 8, 2001. Address for reprints: Nicholas T. Kouchoukos, MD, 3009 N Ballas Rd, Suite 266C, St Louis, MO 63131 (E-mail NTKouch{at}aol.com).

Abstract

Objective: Management of the enlarged, chronically dissected aorta after previous repair of acute aortic dissection or after a previous cardiac operation may present a formidable technical challenge. Marked enlargement of the proximal descending thoracic aorta precludes safe use of staged procedures, including the elephant trunk technique.
Methods: Sixteen patients with chronic type A aortic dissection (mean age, 56 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. We used single-stage replacement, with perfusion of the aortic arch first to minimize the duration of brain ischemia, with a bilateral anterior thoracotomy (clamshell) incision. Eleven patients had undergone previous repair of acute type A dissection. Five patients had type A dissection after aortic valve replacement (2 patients) and coronary artery bypass (3 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a 2-stage repair. The mean interval between the initial and reoperative procedures was 62 months (range, 5-137 months).
Results: There was 1 (6.2%; 70% confidence limits, 0.3%-24.7%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Six patients required assisted ventilation for more than 72 hours, and 3 patients required a tracheostomy. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome.
Conclusion: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.

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