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J Thorac Cardiovasc Surg 2002;123:318-325
© 2002 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease (ACD)

Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection

From the Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital Henri Mondor, Créteil, France.

Received for publication May 8, 2001. Revisions requested June 25, 2001; revisions received Aug 2, 2001. Accepted for publication Aug 9, 2001. Address for reprints: Matthias Kirsch, MD, Hôpital Henri Mondor, Service de Chirurgie Thoracique et Cardiovasculaire, 51, avenue du Mal de Lattre de Tassigny, 94010 Créteil Cédex, France (E-mail: loisance{at}univ-paris12.fr).

	Abstract

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
Objective: This study was undertaken to determine significant risk factors for proximal or distal reoperations after surgical correction of acute type A aortic dissection.
Methods: Between 1980 and 2000, a total of 160 consecutive patients (mean age 57.5 ± 13.3 years, 126 men) underwent surgery for acute type A aortic dissection. Proximal repair was performed by means of ascending aorta replacement with valve resuspension in 130 cases (81.3%), composite graft replacement in 19 cases (11.9%), separate aortic valve and ascending aorta replacement in 7 cases (4.4%), and aortic repair in 1 case (0.6%). Distal repair required arch replacement in 23 cases. Follow-up time averaged 4.51 ± 5.6 years per patient.
Results: Survival estimates after initial operation were 66.1% ± 3.8%, 57.7% ± 4.2%, 52.2% ± 4.6%, and 42.5% ± 5.8% at 1, 5, 10, and 15 years, respectively. Thirty patients required 37 reoperations at a mean interval of 5.7 ± 4.5 years after the initial operation. Freedoms from reoperation were 96.9% ± 1.8%, 74.7% ± 5.3%, 60.8% ± 6.8%, and 39.3% ± 9.1% at 1, 5, 10, and 15 years, respectively. Reoperations included procedures on the proximal aorta (aortic root or valve) in 21 cases and on the distal aorta or its side branches in 19 cases. Cox regression analysis distinguished severe preoperative aortic valve insufficiency as the only significant risk factors for proximal reoperation; younger patient age, more distal extent of dissection, and more recent operative date were found to be significant risk factors for distal reoperation.
Conclusion: Patients with acute type A aortic dissection who have severe aortic valve insufficiency are at increased risk for proximal reoperation. These patients should benefit from a more aggressive proximal repair at initial operation. Distal extent of aortic resection at initial operation did not significantly influence the risk of distal reoperation.

	Introduction

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
See related editorial on page 201.

The objectives of surgical treatment of acute type A aortic dissection are to prevent death of the patient from aortic rupture, to reestablish blood flow in areas that have been occluded by the dissection, and to correct aortic valvular regurgitation if present. ¹ These objectives are most frequently approached by prosthetic replacement of the supracoronary ascending aorta with proximal and distal reapproximation of the edges of the dissected aorta. Aortic valve resuspension represents the most often adopted technique to correct associated aortic valve incompetence. ² In case of a coexisting intrinsic pathologic condition of the aortic valve or root, the use of a composite graft is necessary. Distally, aortic replacement should be extended sufficiently to excise the segment of aorta containing the intimal tear.

These operations do not remove the entire extent of diseased aorta, however, so they remain palliative in most cases. ¹ The need for later reoperation therefore remains fairly common. As reviewed recently, ² several studies have reported various risk factors for reoperation after surgery for acute type A aortic dissection. Unfortunately, most of these studies examine the overall risk and do not differentiate the site of reoperation (proximal versus distal). This study was therefore undertaken to determine the incidences of and independent risk factors for proximal and distal reoperations after operations for acute type A aortic dissection.

	Patients and methods

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
Patients
Between January 1, 1980, and November 30, 2000, a total of 160 consecutive patients underwent operations for acute dissection involving the ascending aorta (Stanford classification type A) at Henri Mondor Hospital, Créteil, France. Acute dissection was defined by an onset of symptoms within 14 days of presentation. Mean patient age was 57.5 ± 13.3 years (range 21 to 87 years). Predisposing factors for aortic dissection and associated comorbidities are shown inTable 1. Hypertension was the most common predisposing medical disorder, occurring in 60.1% of cases.

Anatomy
The location of the primary tear was in the ascending aorta in 127 cases (79.4%), the arch in 20 (12.5%), and the upper descending thoracic aorta in 4 (2.5%). It was not specifically determined in 9 cases (5.6%). Dissections were classified according to the known distal extent of the dissection, as determined by preoperative testing and intraoperative findings. Because not all patients underwent imaging of the entire aorta, the known distal extent may have underestimated the actual distal extent of dissection. The aortic false channel was localized to the ascending aorta in 16 cases (10.1%) but reached the aortic arch in 54 (33.8%), the descending thoracic aorta in 36 (22.5%), and the abdominal aorta in 53 (33.1%).

Operative methods
Although operators and some minor aspects of the surgical technique varied during the study period, our general operative strategy remained the same. All operations were performed on an emergency basis as soon as the diagnosis had been ascertained. Cardiopulmonary bypass was established with retrograde femoral artery cannulation. After aortic crossclamping the ascending aorta was opened and the heart was arrested by direct antegrade administration of cold crystalloid cardioplegia into both coronary ostia. Cardiopulmonary bypass time averaged 155.4 ± 56.9 minutes, and mean aortic crossclamp time was 105.1 ± 46.7 minutes.

In 3 cases (1.8%) patients died peroperatively of aortic rupture before completion of the surgical procedure. In the remaining cases proximal aortic repair was performed with one of the following techniques(Table 2). Replacement of the supracoronary ascending aorta and aortic valve resuspension was performed in 130 cases (81.3%). This patient group included 1 patient with a bicuspid aortic valve and 7 patients with Marfan syndrome. Composite graft replacement of the aortic valve, sinuses, and ascending aorta with a modified Bentall technique ³ was performed in 19 cases (11.9%). Separate replacement of the supracoronary ascending aorta and aortic valve was performed in 7 cases (4.4%). In 1 case (0.6%) reconstruction of the ascending aorta was performed without aortic replacement. The distal extent of aortic replacement was determined by the location or extent of the intimal tear. If the intimal tear was localized to the ascending aorta, the distal anastomosis was constructed just proximal to the innominate artery. If the intimal tear originated in or extended into the aortic arch or proximal descending aorta, aortic replacement was extended to excise the segment of aorta containing the intimal tear. This was achieved with a hemiarch replacement in 13 cases (8.1%) and a total arch replacement in 10 cases (6.3%). Aortic arch replacement or inspection was performed with the patient under deep hypothermic circulatory arrest in 18 cases (11.3%). Mean duration of circulatory arrest was 24.8 ± 12.8 minutes at an average temperature of 19.0°C ± 3.8°C. In 16 cases additional cerebral protection was obtained with either selective antegrade (n = 10) or retrograde (n = 6) cerebral perfusion technique.

Time tendencies for patient-, dissection-, and procedure-related variables
A comparison of patient-, dissection- and procedure-related variables of patients operated on before January 1992 with those from the our more recent experience is depicted inTable 3. Patients who underwent operation after January 1992 were significantly older and tended to have a higher incidence of preoperative cerebral ischemic complications. Furthermore, significantly more patients underwent aortic arch replacement in the more recent period. These more complex procedures were associated with significantly longer cardiopulmonary bypass and aortic crossclamp times.

Statistical analysis
Statistical analysis was performed with SPSS Base 8.0 statistical software (SPSS Inc, Chicago, Ill). Continuous variables were expressed as the mean ± SD and were compared with an unpaired 2-tailed t test. Categoric variables, expressed as percentages, were analyzed with a ² test or a Fisher exact test. Survival data were analyzed with standard Kaplan-Meier actuarial techniques for estimation of survival probabilities and compared with log-rank tests.

Reoperations included any cardiac or vascular surgical intervention with an indication that could be related to complications occurring in the segments of aorta approached at first repair or to complications stemming from the spontaneous evolution of the dissection at sites not approached during the first operation. Reoperations were classified as proximal when they involved the aortic root or tubular ascending aorta and as distal when they involved the aortic arch or any aortic segment or great vessel distal to the aortic arch.

To determine risk factors for proximal and distal reoperations, univariate analysis of potential risk factors (see appendix) was performed by comparing different subsets of independent patients. Independent risk factors were subsequently discriminated by a multivariate proportional hazard regression analysis (Cox model) performed on significant or marginally significant (P .20) univariate risk factors. Coefficients were computed by the method of maximum likelihood.

	Results

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
Time-related survival
A total of 52 patients died during the initial hospitalization or within 30 days of the initial procedure, for an operative mortality of 32.5%. Overall survival estimates (including operative mortality) after the initial operation were 66.1% ± 3.8%, 57.7% ± 4.2%, 52.2% ± 4.6%, and 42.5% ± 5.8% at 1, 5, 10, and 15 years, respectively(Figure 1).

View larger version (18K): [in this window] [in a new window]   Fig. 1. Actuarial survival (including hospital mortality) after first operation. Error bars represent SEM.

View larger version (9K): [in this window] [in a new window]   Fig. 2. Bar graph representing absolutes number of reoperations performed during 4 periods.

View larger version (19K): [in this window] [in a new window]   Fig. 3. Actuarial freedom from reoperation after first operation. Error bars represent SEM.

View larger version (16K): [in this window] [in a new window]   Fig. 4. Actuarial freedom from proximal reoperation (squares) and actuarial freedom from distal reoperation (circles) after first operation. Error bars represent SEM.

Survival after proximal or distal reoperation
Four patients died in the hospital after the first reoperation (operative mortality 13.3%). Actuarial estimates for survival after the first operation were 75.3% ± 8.1% at 1 and 5 years and 34.4% ± 13.1% at 10 years. In-hospital mortality reached 28.6% (2 of 7 patients) after the second reoperation.

	Discussion

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
Survival
Despite major improvements in diagnosis, perioperative management, and operative techniques, acute type A aortic dissection remains a catastrophic event that still carries a high hospital mortality rate. The in-hospital mortality lies between 20% and 30% in most studies. ^5-12 The recently published data from the International Registry of Acute Aortic Dissection reports an in-hospital mortality rate of 26% after surgery for acute type A aortic dissection. ¹³ Long-term survival estimates at 10 years, including operative mortality, range between 37% and 53% in recently published series. ^5-12,14,15 The findings of this study are in close agreement with those results.

Reoperation
Late reoperations after surgical repair of acute type A aortic dissection are relatively common. Reported actuarial freedom from cardiac or aortic reoperations thus ranges from 65% to 85% at 10 years. ^5,10,12,14 The slightly lower freedom from reoperation reported in this study (61% at 10 years) is in part related to the fact that we included in the analysis all reoperations that had to be performed on the aortic root, aorta, and aortic side branches, as long as the indication could be related to aortic dissection. We believe that this means of analysis, although less gratifying, more accurately reflects the natural history of type A aortic dissection that has been operated on. Moreover, because an unknown number of patients die of aortic complications before they can undergo reoperation or refuse reoperation, the real incidence of patients needing reoperation is still underestimated.

Like others, ⁸ we have noted an increase of the absolute number of reoperations in more recent years. Furthermore, a more recent operative date was selected by univariate and multivariate analyses as a significant risk factor for proximal and distal reoperations, respectively. However, the incidence of patients undergoing reoperation and the interval to first reoperation significantly decreased in the more recent period; these findings appear to be related to a more careful postoperative follow-up and to increasing experience with complex aortic reoperations during the study period, which has allowed more timely reoperation in recent years. For the same reasons, the interval between initial repair and reoperation, usually reported between 5 and 6 years, ^8,16 overestimates the time to occurrence of an indication for reoperation. The latter is probably more accurately estimated by the time to reoperation of 3 years we have observed in recent years.

Proximal reoperation
There remains some controversy regarding the optimal surgical techniques used for proximal repair at initial operation. Among the several available surgical options, proximal aortic stump reconstruction with aortic valve resuspension (with or without the use of polytetrafluoroethylene felt bolsters or biologic glue) represents the most often adopted technique. ² This approach preserves the native aortic valve and avoids prosthesis-related and anticoagulation-related complications. Furthermore, avoidance of the long-term use of anticoagulation is believed to favor thrombosis of the false channel, thus preventing subsequent dilatation of the aorta. On the other hand, this conservative treatment exposes the patient to long-term changes of both aortic valve and aortic root, with these changes developing as a consequence of dissection or intrinsic preexisting aortic disease. Actuarial freedom from proximal reoperation after conservative treatment of the aortic root varies from 69% to 95% at 10 years. ^6,17 Patients with Marfan syndrome or annuloectasia have repeatedly been shown to be at increased risk for reoperation on the aortic root or valve after conservative proximal repair. ^16,17 There is now general agreement to use a more radical approach in these cases. In this series, although Marfan syndrome appeared as a significant risk factor at univariate analysis, the only significant and independent risk factor for proximal reoperation was severe preoperative aortic valve insufficiency. This finding confirms the impression of our first report, where 37% of patients with severe preoperative aortic valve insufficiency needed later proximal reoperation. ¹⁸ Similarly, Pessotto and coworkers ¹¹ have shown by multivariate analysis that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for the development of postoperative aortic valve regurgitation. Therefore patients presenting with significant aortic valve regurgitation appear to be at high risk for later proximal reoperation and might be best treated with a more radical approach at first operation, as has already been suggested by others. ¹⁹ In this series, however, aortic valve or sinus of Valsalva replacement during initial repair had no significant beneficial effect on the incidence of subsequent proximal reoperation. This finding is probably related to the relatively small proportion of patients treated with composite graft replacement or separate replacement of the supracoronary ascending aorta and aortic valve. Promising results with valve-preserving aortic root replacement for the treatment of acute type A aortic dissection have been published recently and might be an interesting alternative approach. ^20,21

Several recent studies have raised concerns about late complications related to the use of GRF-glue in aortic operations. ^22-25 In addition to the accidental occurrence of systemic embolism with GRF glue, ²⁴ the use of GRF glue has been held responsible for the occurrence of postoperative heart block ²⁵ and reinterventions because of redissection or false aneurysms. ^22,23 In contrast to these reports, the use of GRF glue in this study was not associated with a significant increase in rate of proximal reoperation.

Distal reoperation
The main objective of the distal surgical repair is obliteration of the false lumen redirect blood flow into the true lumen. ¹ However, distal surgical repair fails to achieve this objective in most cases. The reported incidence of patency and blood flow within the false lumen after surgical repair reaches up to 78%. ²⁶ Persistence of a patent false lumen exposes the patient to malperfusion syndromes and aortic aneurysmal dilatation. Even in the event of false channel thrombosis, the aorta becomes a fibrous cylinder, unadapted to withstand the internal aortic pressure, and is prone to subsequent dilatation. In agreement with this picture, we observed in this study that a more distal extent of the false channel at initial presentation was a significant risk factor for later distal reoperation.

There is now general agreement that the distal repair should be extended sufficiently to excise the segment of aorta containing the intimal tear. ^10,12 However, other groups advocate systematic extended or total aortic resection for the initial surgical management of acute type A aortic dissection, irrespective of the location of the intimal tear. ^27-29 Although these groups report satisfactory results, systematic extensive or total aortic replacement performed as an emergent procedure will necessarily increase an already high operative risk. We believe that this risk largely outweighs the relatively low incidence of reoperation (77% freedom of distal re-operation at 10 years in this series) and the associated operative risk.

The systematic use of circulatory arrest with "open-distal" repair in patients undergoing surgery for acute type A aortic dissection has been advocated by a number of surgeons. ^30-32 This technique allows aortic arch examination and avoids aortic crossclamp trauma but exposes the patient to the hazards of circulatory arrest and brain protection. With this technique, some groups have reported improved short- and long-term survivals, with reduced incidence of false channel dilatation or need for reoperation. ^30-32 In this series circulatory arrest with open-distal repair was performed only in cases of distal arch or proximal descending aortic replacement. In this group of patients the incidence of distal reoperation was not significantly different from that of the rest of our patient population. However, the number of patients in this group was small, and it is therefore possible that our more conventional "closed-distal" technique contributed to an increased incidence of distal reoperation.

Other groups have shown that the use of GRF glue for distal aortic stump reconstruction reduces the need for distal reoperation. ³¹ In contrast to Nguyen and colleagues, ³¹ we could not find any statistical difference in freedom of distal re-operation between patients whose defects were repaired with and without GRF glue.

Conclusion
Patients with acute type A aortic dissection and severe aortic valve insufficiency are at increased risk for proximal reoperation. These patients should benefit from a more aggressive proximal repair at initial operation. Distal extent of aortic resection at the initial operation did not significantly influence the risk of reoperation.

	Appendix

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 
Variables examined for association with proximal or distal reoperation
Demographic characteristics
Age and sex.

Comorbidities
Obesity, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic bronchopulmonary disease, and preoperative renal insufficiency.

Predisposing factors for dissection
Systemic arterial hypertension, known ascending aortic aneurysm, bicuspid aortic valve, Marfan syndrome, pregnancy, and previous cardiac surgery.

Preoperative status
Preoperative shock and ischemic complications (myocardial, cerebral, medullary, mesenteric, renal, lower extremity).

Aortic pathology
Location of intimal tear, known distal extent of dissection, and aortic valve regurgitation.

Procedure
Date of operation, type of proximal repair (aortic valve resuspension, aortic valve or root replacement), arch replacement, use of GRF glue, cardiopulmonary bypass time, aortic crossclamp time, and use of circulatory arrest.

	References

Top Abstract Introduction Patients and methods Results Discussion Appendix References

 

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