Is Less More? Outcomes of Reoperative Surgery after Type A Acute Aortic Dissection Repair

Background: Surgical repair of type A acute aortic dissection (AAAD) remains associated with high morbidity and mortality. For a variety of reasons, total aortic arch (TAR) and/or aortic root replacement (ARR) is not performed in all cases of AAAD, and some patients will require a second aortic procedure (SAP) due to progressive proximal and/or distal aortic dilatation or redissection. Characteristics and outcomes of SAP in patients operated primarily for AAAD are not widely investigated, and potential factors that may predict the need for SAP are not fully elucidated.

Method: Baseline characteristics, operative variables and early in-hospital outcomes for all patients undergoing surgical repair for AAAD between January 1, 2006, and December 31, 2018, were collected (Group A), and compared with baseline characteristics and outcomes of patients needing SAP during the follow-up (Group B). Group B was divided in two subgroups: the first includes patients undergoing SAP using cardiopulmonary bypass (ON-SAP), and the second patients undergoing off-pump secondary aortic procedure (Off-SAP) such as thoracic endovascular aortic repair (TEVAR), debranching or transcatheter aortic valve implantation (TAVI).

Results: Between January 1, 2006, and December 31, 2018, a total of 638 patients underwent emergency surgery for AAAD; 7.6% of patients required a SAP during the follow-up period. Compared with the whole cohort, the extent of surgery to the hemiarch was significantly lower in the SAP group at the first operation (52 vs. 44%, p = 0.043) and in the same group the rate of complete arch replacement was lower (7 vs. 16%, p = 0.049). The most frequent indication for SAP was the dehiscence of one or more suture lines (44%), followed by progressive arch dilatation (24%). In-hospital mortality for SAP was 12%. No difference was noted between root repair and root replacement rates at primary surgery. However, the majority of patients needing ON-SAP procedure underwent a proximal reoperation (75%) intended as root replacement or repair, with a mortality rate similar to that of the entire SAP group (14.2%). Thirty-two percent of patients requiring SAP underwent Off-SAP. In-hospital mortality for Off-SAP group was 7.7%.

Conclusion: A more aggressive surgical approach on the aortic root and a customized approach at the aortic arch in AAAD could be a reasonable option aiming at reducing the incidence and mortality of high-risk second aortic procedures after AAAD repair.

Publication History

Article published online:
28 January 2023