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J Thorac Cardiovasc Surg 2000;119:558-565
© 2000 Mosby, Inc.

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

EXTENDED TOTAL ARCH REPLACEMENT FOR ACUTE TYPE A AORTIC DISSECTION: EXPERIENCE WITH SEVENTY PATIENTS

From the First Department of Surgery, Hamamatsu University School of Medicine,^a Hamamatsu, and the Second Department of Surgery,^b Sapporo Medical University, Sapporo, Japan.

Address for reprints: Teruhisa Kazui, MD, First Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-Cho, Hamamatsu, Japan, 431-3192 (E-mail: surg1ss{at}hama-med.ac.jp ).

	Abstract

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 
Objective: We sought to report the clinical experience with extended total arch replacement for acute type A aortic dissection and to determine the factors that influence early mortality, late survival, and late reoperation.
Methods: Between December 1988 and August 1998, 70 patients underwent emergency graft replacement of both the ascending aorta and the total aortic arch for acute type A aortic dissection. All operations were performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral protection during aortic arch repair, and open distal anastomosis. Concomitant procedures included aortic valve resuspension in 18 patients, composite graft replacement in 10 patients, and coronary artery bypass grafting in 5 patients.
Results: The early mortality rate was 16% (11 of 70 patients). Multivariable analysis showed that renal-mesenteric ischemia and coronary artery bypass grafting were independent determinants for early death. Survival rates at 3 and 5 years postoperatively, including the early deaths, were 75% ± 5% and 73% ± 6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were independent determinants for late death. Freedom from reoperation was 91% ± 4% and 77% ± 8% at 3 and 5 years, respectively. Multivariable analysis showed that anastomotic leakage was the only significant determinant for late reoperation.
Conclusions: Extended total arch replacement for acute type A aortic dissection could be justified in properly selected patients.

	Introduction

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 
Ascending aortic replacement is the treatment of choice for acute type A aortic dissection. However, it still remains controversial whether to perform extended aortic replacement in these patients. With recent improvements in cerebral protection during aortic arch repair, extended aortic replacement has become an accepted surgical method for acute aortic arch dissection. ^1-8 We have used antegrade selective cerebral perfusion (SCP) for cerebral protection during operation of aortic arch aneurysm, including aortic dissection, and we have reported its usefulness. ^9-12

In this study we evaluated the operative results, late survivals, and reoperation rates in patients with acute aortic dissection who underwent extended total arch replacement under SCP.

	Materials and methods

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 
Patients’ profile
The subjects were 70 patients with acute type A aortic dissection who all underwent emergency extended total arch replacement (defined as total arch replacement simultaneously performed with ascending aortic replacement) by the senior author (T.K.) between December 1988 and August 1998. Forty-eight patients underwent only ascending aorta or hemiarch repair for acute aortic dissection, and another 69 patients underwent various operations for chronic aortic dissection during the same period.

The patients of the present study were 31 to 79 years of age (mean, 65 ± 8 years) and consisted of 47 men and 23 women. All patients had anterior chest pain, back pain, or abdominal pain at the onset of aortic dissection. Table I summarizes their preoperative complications. For confirmation of the diagnosis, aortography or digital subtraction angiography was performed in 27 (39%) of the 70 patients before surgery. In the remaining patients, computed tomography or echocardiography, including the transesophageal Doppler technique, was performed. By preoperative diagnostic examinations, together with observation during operation, a primary intimal tear was detected at the ascending aorta in 15 (21%) patients, between the ascending aorta and the aortic arch (near the origin of the innominate artery) in 9 (13%), at the aortic arch in 18 (26%), and at the proximal descending aorta (within 5 cm from the origin of the left subclavian artery) in 16 (23%). In the remaining 12 (17%) patients intimal tear was not found at the ascending aorta, aortic arch, and proximal portion of the descending aorta. In some of these patients, the tear might have been present in the more distal descending aorta, which could not be reached by the anterior approach. The rest of them had intramural hematoma-type dissection.

1. Acute aortic arch dissection with the intimal tear in the aortic arch (n = 28)
   
2. Acute aortic dissection with the intimal tear in the descending aorta (n = 16)
   
3. Rupture, massive false lumen (defined as true lumen being smaller than false lumen and which was significantly compressed by the false lumen), or both of the aortic arch (n = 5)
   
4. Compromised arch vessels (defined as dissection extending to the arch vessels and jeopardizing the cerebral circulation producing neurologic signs, n = 9)
   
5. Coexistent aortic arch aneurysm (n = 4)
   
6. Young age, particularly in patients with Marfan syndrome without serious preoperative complications (n = 8).
   

Operative techniques
Table II summarizes the operative techniques used. The details of hypothermic extracorporeal circulation, antegrade SCP, and the operative techniques used for aortic arch reconstruction, such as the en bloc repair technique and the separated graft technique have been described previously. ^7,9,10 Briefly, after systemic heparin administration, extracorporeal circulation was instituted, with the arterial return cannula placed in the femoral artery and a single 2-stage cannula for venous drainage in the right atrium. The heart was protected by blood cardioplegia. During the period of cooling by extracorporeal circulation, the proximal repair was performed. When the patient was cooled by extracorporeal circulation to a rectal temperature of 22°C, systemic circulation was arrested. Both the innominate artery and the left common carotid artery were cannulated through arteriectomy. SCP was then started at the rate of 10 mL · kg^–1 · min^–1. The left subclavian artery (LSA) was clamped during SCP. The distal graft anastomosis was performed while the systemic circulation was arrested. For aortic arch reconstruction, the en bloc repair technique was used in the first 4 patients, whereas the separated graft technique was used in the remaining 66 patients. For the latter, grafts with 3 limbs were used in the first 22 patients, and those with 4 limbs were used in the remaining 45 patients after 1993. Gelatin-resorcin-formaldehyde (GRF) glue (Laboratories Cardial, Saint-Etienne, France) was used to obliterate the false lumen in 43 patients, and a short segment of the graft was inserted into the true lumen as a modified elephant trunk to prevent leakage at the site of distal graft anastomosis in 8 patients. Fig 1 depicts the recent separated graft technique with modified elephant trunk.

View larger version (33K): [in this window] [in a new window]   Fig. 1. Schema of the recent surgical technique of the ascending aorta and aortic arch with modified elephant trunk technique by using a separated graft for acute type A aortic dissection. See details in text.

Concomitant procedures
Concomitant procedures were performed in 34 patients: aortic valve resuspension in 18 patients, composite graft replacement with coronary reimplantation for annuloaortic ectasia in 10, coronary artery bypass grafting (CABG) for myocardial ischemia related to dissection or coronary lesions in 5, and Doty’s extended aortoplasty for supravalvular aortic stenosis in 1 (Table I).

Follow-up
The patients were followed up until October 1998 at the outpatient clinic or were contacted by telephone or letter. The follow-up was 100% complete. The mean follow-up period was 3.3 years, and the longest period was 8.8 years.

Statistical methods
The continuous data in this study are expressed as means ± SD. From the 27 preoperative and perioperative variables (appendix), independent risk factors of early mortality (death within 30 days after operation) and those of late dissection-related reoperation were examined by multivariable analysis with the backward, stepwise, logistic regression model. Independent risk factors of late death were examined by using Cox proportional hazards regression analysis. Each variable showing a significant difference (P < .05) by univariable analysis was examined by multivariable analysis. Survival and freedom from reoperation were estimated by the Kaplan-Meier method and expressed as means ± SEM.

	Results

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 
Early mortality
The overall early (30-day) mortality rate was 16% (11 of 70 patients), and the in-hospital mortality rate was 21% (15 of 70 patients).

Table III shows the preoperative and intraoperative determinants of 30-day mortality, as determined by multivariable analysis. Multivariable analysis indicated that CABG and renal-mesenteric ischemia were significant predictors of early mortality. Early mortality rates in patients without CABG and renal-mesenteric ischemia were 12% and 11%, respectively.

Causes of early mortality
The causes of early death were multiorgan failure in 3 patients, hemorrhage in 2, low cardiac output in 2, suture line rupture due to infection in 1, rupture of the abdominal aorta into the retroperitoneal space in 1, and disseminated intravascular coagulopathy in 1.

Extracorporeal circulation data
The data of extracorporeal circulation for all patients are as follows: mean total pump time, 214.9 ± 55.3 minutes; mean cardiac ischemic time, 126.2 ± 50.9 minutes; mean SCP time, 97.4 ± 22.9 minutes; and mean open distal anastomosis time, 42.9 ± 45.4 minutes. There was not any relation between pump or SCP time and morbidity-mortality.

Late survival
The 59 patients who survived the early postoperative period were followed up. Table IV shows significant preoperative and intraoperative determinants of late death, as determined by the Cox proportional hazards regression analysis. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were significant risk factors of late mortality.

View larger version (22K): [in this window] [in a new window]   Fig. 2. Survival for the patients undergoing extended total arch replacement according to the presence or absence of risk factors.

Reoperation
In 7 patients reoperation was performed because of the development of lesions in the distal aorta. In 5 of these patients, total graft replacement of the thoracoabdominal aorta was performed for dilation of the false lumen in the distal aorta from 1 to 6 years after the initial operation. One patient died of bleeding at the time of reoperation, and the remaining 4 patients were discharged in good condition without paraplegia. Two other patients underwent graft replacement of the descending aorta: one was operated on for rupture of the descending aorta 2 months after the first operation, and the other was operated on for ulcer-like projection in the descending aorta 6 months after the first operation. Both of them survived the reoperation and were discharged in good condition.

One patient who underwent aortic valve resuspension for acute aortic regurgitation had aortic valve replacement for congestive heart failure because of recurrent aortic valve insufficiency 3 years after the initial operation and is now free from symptoms. Multivariable analysis showed anastomotic leakage (odds ratio, 3.27; 95% confidence interval, 1.21-8.83; P = .02) to be the only significant determinant of late dissection-related reoperation.

Fig 3 shows freedom from reoperation estimated by the Kaplan-Meier method. Freedom from reoperation for all the patients was 91% ± 4% and 77% ± 8% at 3 and 5 years after the operation, respectively.

View larger version (13K): [in this window] [in a new window]   Fig. 3. Freedom from reoperation after extended total arch replacement.

	Discussion

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

We used en bloc repair and separated graft techniques for reconstruction of the aortic arch. The advantages of the latter technique are that (1) the total pump time and SCP time are shorter than those of en bloc repair, ⁷ (2) anastomosis can be performed at the intact distal site of the arch vessel where dissection has not extended, (3) hemostasis at the posterior anastomosis of the arch vessel is easy, (4) there is no risk of dilation of the false lumen in the aortic arch in the late postoperative period.

Artificial grafts used for the separated graft technique were those with 3 limbs in the early period and those with 4 limbs in the later period. With the grafts with 3 limbs, reconstruction of LSA had to be performed after extracorporeal circulation was terminated. In one patient in whom complication of left cerebellar infarct developed because of ischemia of the left vertebrobasilar artery, we considered it necessary to shorten the duration of ischemia in the LSA region as much as possible. For this reason, we modified our technique and started to use the grafts with four limbs without cannulation of LSA. The LSA was reconstructed during the cooling period and then was perfused from the fourth limb to protect ischemia of LSA region.

It has been reported that the distal false lumen remained patent in 50% to 70% of patients who underwent ascending aortic replacement for acute type A aortic dissection. ^22,23 In young patients, ²⁴ and particularly patients with Marfan syndrome, ²⁵ reoperation is often required for dilation of the false lumen distal to the proximal aortic arch. Crawford and colleagues ²⁶ reported that previous operation on the ascending aorta or the aortic arch is a significant risk factor in patients requiring aortic arch repair. These facts indicate that it may be appropriate to perform aortic arch repair at the same time in the same surgical field during the first operation in young patients with acute type A aortic dissection, even if the primary intimal tear is located at the ascending aorta. However, the patients have to be free from serious preoperative complications.

There remains a problem with extended total arch replacement for acute type A aortic dissection as to whether it increases the risk of early mortality. It has been reported that simultaneous aortic arch replacement generally results in less satisfactory outcome compared with that of ascending aortic arch replacement. ^6,27,28 Recent reports by other investigators ^1-6 indicate that the early mortality rate after simultaneous aortic arch replacement is 20% to 55%. The early mortality rate of ascending aortic replacement for acute type A aortic dissection complicated with renal-mesenteric ischemia is reported to be about 70%. ²⁷ Thus it is clear that the severity of the patient’s condition before the operation considerably affects the outcome of the operation irrespective of whether simultaneous aortic arch replacement is performed. Crawford and colleagues ⁶ also reported a similarly high early mortality rate (50%) for total aortic arch replacement combined with CABG. Risk factors, such as visceral ischemia (eg, renal-mesenteric ischemia and myocardial ischemia), could be reduced by early surgical intervention. However, for patients with serious dissection-related complications, such as myocardial ischemia requiring CABG, a relatively conservative surgical procedure, such as ascending aortic replacement alone or partial arch replacement, will be preferable. In our study the early mortality rate for the low-risk patients without these two risk factors was 11%, which is almost identical to recently reported mortality rates of around 10% for patients who received ascending aortic replacement alone or partial arch replacement. ^6,29,30 These results suggest that recent technical improvements have made concomitant total arch replacement a safer technique that does not increase the operative risk in the patients with acute type A aortic dissection without serious complications.

It is necessary to evaluate whether extended total arch replacement for acute type A aortic dissection decreases the risk of reoperation. The reoperation event–free rate for patients with acute type A aortic dissection who have undergone ascending aortic replacement has been reported to be 70% to 80% at 5 years postoperatively. ^6,23 On the other hand, the Stanford group ⁴ reported that reoperation for patients with aortic arch dissection who received ascending aortic replacement without resection of intimal tear was as high as 30% at 1 year postoperatively. Ergin and colleagues ²⁴ reported that for patients in whom the distal false lumen remained patent, reoperation was higher and the long-term results were worse compared with those in whom the distal false lumen was closed. None of our patients required reoperation of arch lesions, and the overall reoperation event–free rate was 77% ± 8% at 5 years. These suggest that extended reconstruction for aortic arch dissection could reduce the risk of reoperation. Anastomotic leakage on the distal side of the graft (ie, leakage into the false lumen through the needle hole in the inner layer) was a risk factor for reoperation. Recent improvements of surgical technique by the introduction of GRF glue and modified elephant trunk eliminated leakage from the needle hole on the distal side of the graft. GRF glue had a favorable effect on the early results through its hemostatic effect on the suture line as it imparts a rigidity to the friable aortic wall, but it had no statistically significant effect on the late outcome, such as reoperation, in our series.

Finally, it is necessary to assess whether extended aortic replacement for acute type A aortic dissection improves the long-term results. The 5-year survival of patients with acute type A aortic dissection who received ascending aorta replacement has been reported to be 55% to 70%. ^6,23,30 In our series the 5-year survival was 72% for all patients and 85% for low-risk patients. It can be concluded from these results that extended aortic replacement carried out with advanced techniques improves long-term results if applied to properly selected patients.

In summary, we evaluated the results of extended total aortic arch replacement for acute type A aortic dissection and concluded that this surgical technique is justified for treatment of properly selected patients. The procedure is mainly indicated for type A dissection with a tear in the arch. However, it could also be applied to type A dissection with compromised arch vessels, massive false lumen of the aortic arch, and coexistent arch aneurysm and in young patients, particularly those with Marfan syndrome, despite the fact that the tear is located in the ascending aorta or the proximal descending aorta.

	Appendix. Preoperative and perioperative variables analyzed

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 

Sex

Age

Shock

Endotracheal intubation

Cardiac tamponade

Myocardial ischemia

Cerebral ischemia

Paraplegia

Renal-mesenteric ischemia

Leg ischemia

Two or more organ ischemias

Aortic regurgitation

Pleural rupture

Renal dysfunction

Chronic obstructive pulmonary disease

Marfan syndrome

Interval between onset and operation (3 days vs <3 days)

Site of intimal tear

Entry-resection

Aortic valve resuspension

Composite graft replacement

CABG

Technique of arch reconstruction (en bloc repair vs separated graft technique)

GRF glue

Elephant trunk

Period of reoperation (1988-1992 vs 1993-1998)

Anastomotic leakage

	References

Top Abstract Introduction Materials and methods Results Discussion Appendix. Preoperative and... References

 

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				T. Kazui, K. Yamashita, N. Washiyama, H. Terada, A. H. M. Bashar, T. Suzuki, and K. Ohkura Usefulness of antegrade selective cerebral perfusion during aortic arch operations Ann. Thorac. Surg., November 1, 2002; 74(5): S1806 - 1809. [Abstract] [Full Text] [PDF]

				T. Kazui, K. Yamashita, N. Washiyama, H. Terada, A. H. M. Bashar, T. Suzuki, and K. Ohkura Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection Ann. Thorac. Surg., November 1, 2002; 74(5): S1844 - 1847. [Abstract] [Full Text] [PDF]

				S. Ohtsubo, T. Itoh, K. Takarabe, K. Rikitake, K. Furukawa, H. Suda, and Y. Okazaki Surgical results of hemiarch replacement for acute type A dissection Ann. Thorac. Surg., November 1, 2002; 74(5): S1853 - 1856. [Abstract] [Full Text] [PDF]

				D. T. Lai, R. C. Robbins, R. S. Mitchell, K. A. Moore, P. E. Oyer, N. E. Shumway, B. A. Reitz, and D. C. Miller Does Profound Hypothermic Circulatory Arrest Improve Survival in Patients With Acute Type A Aortic Dissection? Circulation, September 24, 2002; 106(12_suppl_1): I-218 - I-228. [Abstract] [Full Text] [PDF]

				T. Shimono, N. Kato, F. Yasuda, T. Suzuki, U. Yuasa, K. Onoda, T. Hirano, K. Takeda, and I. Yada Transluminal Stent-Graft Placements for the Treatments of Acute Onset and Chronic Aortic Dissections Circulation, September 24, 2002; 106(12_suppl_1): I-241 - I-247. [Abstract] [Full Text] [PDF]

				M. Kato, T. Kuratani, M. Kaneko, S. Kyo, and K. Ohnishi The results of total arch graft implantation with open stent-graft placement for type A aortic dissection J. Thorac. Cardiovasc. Surg., September 1, 2002; 124(3): 531 - 540. [Abstract] [Full Text] [PDF]