Postoperative Changes in the Distal Residual Aorta after Surgery for Acute Type A Aortic Dissection: Impact of False Lumen Patency and Size of Descending Aorta

Abstract

Objective In the present study, we retrospectively identified and analyzed the factors that influenced progressive dilatation of the residual distal aorta after surgical repair for acute type A aortic dissection (acute type A).

Methods A total of 477 patients underwent surgical repair for acute type A aortic dissection between 1995 and 2012. Postoperative and follow-up computed tomography (CT) scans of the descending aorta were available in 105 patients. We analyzed the maximum aortic diameter, total luminal area, and true luminal area of the descending thoracic and abdominal aorta.

Results The mean follow-up time was 4.5 ± 3 years, and the mean time interval between CT scan investigations was 2.0 ± 2.3 years. A residual dissection membrane was observed in 80 (76%) patients, with presence of a patent false lumen (FL) in 52 patients (50%) and a thrombosed FL in 28 patients (26%).

Progression of aortic disease with an increase in aortic diameter greater than 10 mm was observed in 14.3% (n = 15) of patients during follow-up. The independent predictors that influenced progressive dilation of the descending aorta by 10 mm or more were postoperative descending aortic diameter greater than 40 mm (p = 0.006; odds ratio [OR], 5.6; 95% confidence interval [CI], 1.6–19) and postoperative patent FL (p = 0.002; OR, 8.5; 95% CI, 2.2–32.3).

The unadjusted 1- and 5-year freedom from reoperation was 96.9 ± 2 and 80.1 ± 5%, respectively. Marfan syndrome (p = 0.006; OR, 5.2; 95% CI, 1.6–16.9) and postoperative descending aortic diameter greater than 40 mm (p = 0.07; OR, 4.1; 95% CI, 1.4–11.6) were independent predictors of aorta-related reoperations.

The mean survival at 1, 5, and 8 years was 90.7 ± 3, 82.5 ± 4, and 70 ± 6%, respectively. Previous cardiac surgery was independent predictor of midterm survival (hazard ratio, 3.6; 95% CI, 1.03–2.8; p = 0.04).

Conclusions A regular follow-up CT scan is mandatory to assess progressive dilatation of the distal residual aortic arch, descending thoracic, and abdominal aorta after surgical repair of acute type A dissection, particularly in patients with a patent FL, descending aortic diameter greater than 40 mm, and/or Marfan syndrome.

Keywords

type A aortic dissection - follow-up CT scan - progressive dilatation

• References

• 1 Trimarchi S, Nienaber CA, Rampoldi V , et al; International Registry of Acute Aortic Dissection Investigators. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005; 129 (1) 112-122
• 2 Heinemann M, Laas J, Karck M, Borst HG. Thoracic aortic aneurysms after acute type A aortic dissection: necessity for follow-up. Ann Thorac Surg 1990; 49 (4) 580-584
• 3 Bernard Y, Zimmermann H, Chocron S , et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001; 87 (12) 1378-1382
• 4 Song SW, Chang BC, Cho BK , et al. Effects of partial thrombosis on distal aorta after repair of acute DeBakey type I aortic dissection. J Thorac Cardiovasc Surg 2010; 139 (4) 841-7.e1 , discussion 847
• 5 Kim JB, Lee CH, Lee TY , et al. Descending aortic aneurysmal changes following surgery for acute DeBakey type I aortic dissection. Eur J Cardiothorac Surg 2012; 42 (5) 851-856 , discussion 856–857
• 6 Halstead JC, Meier M, Etz C , et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007; 133 (1) 127-135
• 7 Leontyev S, Borger MA, Legare JF , et al. Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. Eur J Cardiothorac Surg 2012; 41 (3) 641-646
• 8 Misfeld M, Leontyev S, Borger MA , et al. What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients. Ann Thorac Surg 2012; 93 (5) 1502-1508
• 9 Song JM, Kim SD, Kim JH , et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007; 50 (8) 799-804
• 10 Immer FF, Krähenbühl E, Hagen U , et al. Large area of the false lumen favors secondary dilatation of the aorta after acute type A aortic dissection. Circulation 2005; 112 (9, Suppl): I249-I252
• 11 Kazui T, Washiyama N, Muhammad BA , et al. Extended total arch replacement for acute type a aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000; 119 (3) 558-565
• 12 Urbanski PP, Siebel A, Zacher M, Hacker RW. Is extended aortic replacement in acute type A dissection justifiable?. Ann Thorac Surg 2003; 75 (2) 525-529
• 13 Hirotani T, Nakamichi T, Munakata M, Takeuchi S. Routine extended graft replacement for an acute type A aortic dissection and the patency of the residual false channel. Ann Thorac Surg 2003; 76 (6) 1957-1961
• 14 Gorlitzer M, Weiss G, Meinhart J , et al. Fate of the false lumen after combined surgical and endovascular repair treating Stanford type A aortic dissections. Ann Thorac Surg 2010; 89 (3) 794-799
• 15 Tsagakis K, Pacini D, Di Bartolomeo R , et al. Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry. Eur J Cardiothorac Surg 2011; 39 (1) 87-93 , discussion 93–94
• 16 Leontyev S, Tsagakis K, Pacini D , et al. Impact of clinical factors and surgical techniques on early outcome of patients treated with frozen elephant trunk technique by using EVITA open stent-graft: results of a multicentre study. Eur J Cardiothorac Surg 2016; 49 (2) 660-666
• 17 Fattouch K, Sampognaro R, Navarra E , et al. Long-term results after repair of type a acute aortic dissection according to false lumen patency. Ann Thorac Surg 2009; 88 (4) 1244-1250
• 18 Bachet JE, Termignon JL, Dreyfus G , et al. Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994; 108 (2) 199-205 , discussion 205–206
• 19 Kimura N, Tanaka M, Kawahito K, Yamaguchi A, Ino T, Adachi H. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2008; 136 (5) 1160-1166 , 1166.e1–1166.e3