Original Article
Late reoperations after acute aortic dissection repair: Single-center experience
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(7) 787–794 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315584523 aan.sagepub.com
Nicola Luciani1, Raphael De Geest2, Giuseppe Lauria1, Piero Farina1, Marco Luciani1, Franco Glieca1 and Massimo Massetti1
Abstract Background: After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. Methods: From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. Results: Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. Conclusions: When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.
Keywords Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Disease progression, Marfan syndrome, Reoperation
Introduction Acute type A aortic dissection (ATAAD) is a lifethreatening condition with a very poor prognosis unless surgery is performed on an emergency basis. The first operation prevents death from aortic rupture, malperfusion, and severe aortic valve regurgitation. Hospital or 30-day mortality after surgical procedures for ATAAD still remains around 20%.1–3 The surgical procedure is usually palliative, and the long-term evolution and prognosis are unpredictable. After hospital discharge, complications can occur both proximally and distally to the site of the primary repair. To date, a limited number of studies have focused on open redo aortic procedures in patients who previously underwent
ATAAD repair.4–12 Most single-center experiences have included less than 30 patients (Table 1).2,4,5,7,10,13–17 The aim of this retrospective study was to investigate the early and late outcomes in a cohort of 21 patients who needed 27 aortic reoperations following ATAAD repair.
1
Cardiac Surgery, Catholic University, Rome, Italy Thoracic and Cardiovascular Surgery, Onze Lieve Vrouw Clinic, Aalst, Belgium 2
Corresponding author: Piero Farina, MD, Cardiac Surgery, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy. Email: [email protected]
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Table 1. Previous reports of redo surgery following acute type A aortic dissection repair. Author
Year
No. of patients
No. of redo procedures
Hospital mortality
Current study Bekkerset20 Malvindi8 Kobuch4 Concistre`15 Halstead11 Zierer14 Geirsson7 Kirsch5 Moon16 Casselman2 Bachet17 Pugliese13
2015 2013 2012 2012 2012 2007 2007 2007 2002 2001 2000 1999 1998
21 43 104 23 25 16 26 21 30 9 12 25 19
27 47 154 30 25 25 28 24 37 11 12 33 22
3.7% 11.6% 7.7% 3% 4% 4% 7% 33.3% 13.3% 9.9% 33.3% 28% 5%
Patients and methods Bioethic committee approval was obtained for this retrospective follow-up study. Between September 2005 and July 2012, 21 patients were referred to the Cardiovascular Department at the Catholic University of Rome for late aortic complications following previous surgical repair of ATAAD. Demographic and clinical features are summarized in Table 2. Early and late results of 27 redo aortic procedures performed in this group of patients were investigated. In 14 (66.6%) patients, the primary operation had been carried out at our center, whereas the other 7 (33.3%) had been treated elsewhere. Exclusion criteria were: iatrogenic or traumatic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. ATAAD patients who had previously undergone open heart surgery were also excluded. The indication for surgery relies on the detection of complications occurring proximal or distal to the site of primary repair. Proximal complications are those involving the aortic root, aortic valve, and proximal suture lines anastomosis. Typically, the indications for surgery in this setting are severe valve regurgitation, pseudoaneurysm of the suture lines, endocarditis of the prosthetic or native valve, and graft infection. Distal complications are those involving the arch and/or the distal residual native aorta, distal anastomosis pseudoaneurysms, and graft or stent-graft infections. The main indications for redo procedures in our patients (Table 3) were progressive enlargement of the false lumen in the aortic arch and/or descending or thoracoabdominal aorta (n ¼ 18), severe aortic valve regurgitation with or without aneurysmal dilatation of the
Table 2. Clinical features of 21 patients undergoing redo aortic surgery. Variable
No. of patients
Mean body mass index (kg m1) Age (years) [range] Male sex Hypertension Chronic obstructive pulmonary disease Marfan syndrome Current smoker Chronic renal failure* Diabetes mellitus Cerebrovascular diseasey Coronary artery occlusive disease Congestive heart failurez Peripheral arterial occlusive disease Permanent dialysis Emergency status
27 3.2 59.48 11.49 [33–77] 17 (81%) 16 (76.2%) 6 (28%) 5 5 5 3 3 2 2 1 1 0
(23.8%) (23.8%) (23.8%) (14.3%) (14.3%) (9.5%) (9.5%) (4.7%) (4.7%)
*Glomerular filtration rate < 60 mL min1 1.73 m2. yStroke or transient ischemic attack. zLeft ventricular ejection fraction 48 h) was needed in 5 (18.5%) patients, although no tracheostomy was required. Time to extubation ranged from 8 to 219 h (mean 37 9.2 h). No major stroke or acute kidney failure was noted. Intensive care unit stay ranged from 1 to 25 days (mean 3.7 1.4 days), and total postoperative hospital stay ranged from 8 to 39 days (mean 12 5.7 days). The results are summarized in Table 5. Throughout the follow-up period, one death was registered. This occurred in a Marfan patient 2 years after the reoperation. As confirmed by necropsy, the fatal event was due to abrupt rupture of the native normal-sized (although dissected) descending thoracic aorta. Only one patient (also with Marfan syndrome) needed a further aortic reoperation due to pseudoaneurysm of the distal anastomosis after replacement of the thoracoabdominal aorta for a Crawford type II aneurysm. The overall survival rate at 3 years was 92.6%.
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Table 4. Details of cardiopulmonary bypass and cerebral protection strategies (when needed).
Case no. 1 2
3* 4 5 6 7
8 9* 10 11* 12 13 14 15 16 17 18 19* 20* 21
Redo procedure
Approach
Arterial cannulation site
Bentall þ arch replacement AAR þ arch replacement þ ET þ CABG TAAR Arch replacement þ ET TAAR DTAR Bentall þ arch replacement Bentall TAAR Bentall þ arch replacement þ ET þ CABG 1 TAAR TAAR Bentall TAAR AAR þ AV plasty þ CABG TAAR DTAR Bentall DTAR AAR Bentall Bentall (homograft) Arch replacement þ DTAR Distal DTAR DTAR AAR þ CAR Suture resuspension
Resternotomy Resternotomy
Femoral Femoral
231 225
167 158
67 62
TPL Resternotomy TPL LT Resternotomy Resternotomy TPL Resternotomy
Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral
325 333 289 165 256 218 68 245
15 125 25 135 103
15 63 20 23 74 39
155
62
TPL TPL Resternotomy TPL Resternotomy TPL LT Resternotomy LT Resternotomy Resternotomy Resternotomy Resternotomy LT LT Resternotomy Resternotomy
Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral
291 164 232 248 211 296 239 391 237 220 198 308 257 51 222 245 198
86 40 155 77 150 103 26 149 22 100 88 192 124 48 29 139 78
24 23 53 31 13 24 37 18 48 40 16
CPB time (min)
Crossclamp time (min)
DHCA time (min)
Cerebral perfusion time (min) 64 58
60 15 (R) 69 37 60
53 (R) 30 (R) 12 (R) 35 (R) 17 (R) 47 (R) 39 16
109
107
36
36 (R)
*Marfan syndrome. AAR: ascending aorta replacement; AV: aortic valve; AVR: aortic valve replacement; CABG: coronary artery bypass graft; CAR: coronary artery reimplantation; CPB: cardiopulmonary bypass; DHCA: deep hypothermic circulatory arrest; DTAR: descending thoracic aorta replacement; ET: elephant trunk; LT: left thoracotomy; R: retrograde delivery; TAAR: thoracoabdominal aorta replacement; TPL: thoracophrenolaparotomy;
Discussion Surgical treatment for ATAAD is mandatory at the time of presentation. Progressive dilatation of the residual aorta usually develops over time, both proximally and distally to the repair. Further complications should be taken into account: graft and/or valve infection (whether native or prosthetic) and pseudoaneurysms on the suture lines. These complications usually develop within 5–6 years,4,13,17 but they can appear even after 30 years.12 The actuarial freedom from cardiac or aortic reoperations at 10 years following
surgical treatment for ATAAD ranges from 85% to 65%.5,7,8,14,16,20 Several studies have identified risk factors for late aortic complications: elevated systolic blood pressure, residual false lumen patency, type of initial surgical procedure, and Marfan syndrome. Patency and flow within the false lumen appear to play important roles in residual aortic dilatation. Patency, reported to occur in a small proportion of patients, has been shown to reduce the rate of progression, without preventing aneurysmal evolution.11,11,15 The role of the primary surgical technique in late outcomes is a subject of active debate. In some reports,
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Table 5. Postoperative data of 21 patients undergoing redo aortic surgery. Variable
No. of patients
ICU stay (days) Hospital stay (days) Intubation time (h) Postoperative ARF* Postoperative paraplegia Reexploration for bleeding Postoperative AMI Postoperative stroke Postoperative coma Temporary dialysis Permanent dialysis
3.7 1.4 12.0 5.7 37 9.2 9 (42.8%) 2 (9.5%) 2 (9.5%) 0 0 0 0 0
*Creatinine 5 1.6 mg dL1. AMI: acute myocardial infarction; ARF: acute renal failure; ICU: intensive care unit.
a radical surgical approach at the primary procedure resulted in improved freedom from proximal and distal reoperations and better long-term survival.11,13,15–18 In contrast, other studies found that different surgical techniques and strategies at the primary operation did not influence the fate of the residual aorta or the time to reoperation.1,7,9,12,14 The role of antihypertensive medications in preventing aneurysmal evolution has been well established.14 We would like to highlight some factors concerning the Marfan patients in our series. First, the time interval between the primary procedure and first reoperation was shorter in Marfan patients (32.6 20.3 vs. 81.2 65.5 months in non-Marfan patients, p ¼ 0.03). Second, among the 6 patients who required 2-stage procedures, 3 were Marfan patients. If we include redo procedures performed outside our institution, the total number of procedures per patient was 3.2 for Marfan vs. 1.5 for non-Marfan patients, over a time span of 10 years for Marfan vs. 14 years for non-Marfan patients. Similar findings were reported by Moon and colleagues16 and Bachet and colleagues.17 Finally, on follow-up, the 2 aortic events (one death due to distal aortic rupture and one redo open surgical procedure) occurred in Marfan patients. Rupture can occur despite close surveillance.11 In our experience and according to other authors, Marfan syndrome appears to be the strongest risk factor for development of late complications, with a more rapid evolution.2,5,7,11,14,16,17 For this reason, the surgical treatment of ATAAD might be more aggressive and extensive, particularly at the level of the aortic root, when patients are affected by Marfan syndrome.2,13,16,17,18 In the last decade, studies have reported hospital mortality ranging from 3.5% to 7% (see Table 1).4,5,14
This is an excellent outcome if we consider the complex and challenging procedures performed. Our low mortality (3.7%) might be explained by the fact that no patient was operated on for graft and/or prosthesis infection and that all 27 procedures were carried out on an elective basis. Several published series have indeed shown that emergency status is the most important risk factor for intraoperative death.4 Overall morbidity was also acceptable; the neurologic outcomes (2 cases of paraplegia and 2 cases of vocal cord injury) were satisfying if we consider the extent of repairs and the fact that HCCA was used in 81% of patients. On the other hand, such complications occurred exclusively in the non-sternotomy group, for which the incidence was as high as 15.4%. The retrospective nature of this study prevents us from determining a more specific risk factor for paraplegia in this subset of patients. Advances in endovascular treatment have led to a rapidly expanding role for this technique, especially in unstable patients (e.g. acute complicated type B dissection). In the chronic setting, endovascular therapy appears to be indicated predominantly for nonoperable patients, and requires a shorter learning curve than surgery. Still, an endovascular approach can be extremely challenging under particular anatomical circumstances and exposes the patient to further long-term complications related to stent implantation. Whenever possible in the chronic setting, surgery allows treatment of any type of complication, with any anatomical configuration. Surgery, however, should be performed only by teams with longstanding expertise and if possible, in high-volume centers. This study does have limitations: retrospective analysis, small population size, and limited follow-up. The good outcomes are partly explained by the elective status of these patients in whom late complications were discovered thanks to close lifelong clinical and radiological follow-up. We concluded that surgical treatment for ATAAD can be followed by the onset of late proximal and distal aortic complications. Marfan syndrome appears to be the most important risk factor, whereas the role of the surgical technique of primary repair is still a matter of debate. Open reoperations can be performed with acceptable mortality and morbidity at all sites in the remaining aorta. Simultaneous proximal and distal complications can be treated by a 2-stage approach, with good results. In agreement with other authors, we strongly recommend close clinical and imaging follow-up for all patients who survive primary repair of ATAAD: computed tomography and echocardiography at least once a year to diagnose any aortic complication and allow reoperation on an elective basis, which is the key to an optimal surgical outcome.
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Acknowledgments Presented at the XXVII National Congress of the Italian Society for Cardiac Surgery, Rome, November 29, 2014.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Lai DT, Miller DC, Mitchell RS, et al. Acute type A aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair. J Thorac Cardiovasc Surg 2003; 126: 1978–1986. 2. Casselman FP, Tan ES, Vermeulen FE, Kelder JC, Morshuis WJ, Schepens MA. Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection. Ann Thorac Surg 2000; 70: 1227–33. 3. Chiappini B, Schepens M, Tan E, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J 2005; 26: 180–186. 4. Kobuch R, Hilker M, Rupprecht L, et al. Late reoperations after repaired acute type A aortic dissection. J Thorac Cardiovasc Surg 2012; 144: 300–307. 5. Kirsch M, Soustelle C, Houe¨l R, Hillion ML and Loisance D. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002; 123: 318–325. 6. Zoli S, Etz CD, Roder F, et al. Long-term survival after open repair of chronic distal aortic dissection. Ann Thorac Surg 2010; 89: 1458–1466. 7. Geirsson A, Bavaria JE, Swarr D, et al. Fate of the residual distal and proximal aorta after acute type a dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007; 84: 1955–1964. 8. Malvindi P, Van Putte B, Sonker U, Heijmen R, Schepens M and Morshuis W. Reoperation after acute type A aortic dissection repair: a series of 1004 patients. Ann Thorac Surg 2013; 95: 922–927.
9. Tan ME, Morshuis WJ, Dossche KM, Kelder JC, Waanders FG and Schepens MA. Long-term results after 27 years of surgical treatment of acute type A aortic dissection. Ann Thorac Surg 2005; 80: 523–529. 10. Immer FF, Hagen U, Berdat PA, Eckstein FS and Carrel TP. Risk factors for secondary dilatation of the aorta after acute type A aortic dissection. Eur J Cardiothorac Surg 2005; 27: 654–657. 11. 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: 127–135. 12. Estrera AL, Miller CC, Villa MA, et al. Proximal reoperations after repaired acute type A aortic dissection. Ann Thorac Surg 2007; 83: 1603–1608. 13. Pugliese P, Pessotto R, Santini F, Montalbano G, Luciani GB and Mazzucco A. Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach. Eur J Cardiothorac Surg 1998; 13: 576–580. 14. Zierer A, Voeller RK, Hill KE, Kouchoukos NT, Damiano RJ and Moon MR. Aortic enlargement and late reoperation after repair of acute type A aortic dissection. Ann Thorac Surg 2007; 84: 479–486. 15. Concistre` G, Casali G, Santaniello E, et al. Reoperation after surgical correction of acute type A aortic dissection: risk factor analysis. Ann Thorac Surg 2012; 93: 450–455. 16. Moon MR, Sundt TM, Pasque MK, et al. Does the extent of proximal or distal resection influence outcome for type A dissections? Ann Thorac Surg 2001; 71: 1244–1249. 17. Bachet J, Goudot B, Dreyfus GD, et al. Surgery for acute type A aortic dissection: the Hopital Foch experience (1977–1998). Ann Thorac Surg 1999; 67: 2006–2009. 18. Kazui T, Yamashita K, Terada H, et al. Late reoperation for proximal aortic and arch complications after previous composite graft replacement in Marfan patients. Ann Thorac Surg 2003; 76: 1203–1207. 19. Luciani N, Anselmi A, De Geest R, Martinelli L, Perisano M and Possati G. Extracorporeal circulation by peripheral cannulation before redo sternotomy: indications and results. J Thorac Cardiovasc Surg 2008; 136: 572–577. 20. Bekkers JA, Raap GB, Takkenberg JJ and Bogers AJ. Acute type A aortic dissection: long-term results and reoperations. Eur J Cardiothorac Surg 2013; 43: 389–396.
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Late reoperations after acute aortic dissection repair: Single-center experience
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(7) 787–794 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315584523 aan.sagepub.com
Nicola Luciani1, Raphael De Geest2, Giuseppe Lauria1, Piero Farina1, Marco Luciani1, Franco Glieca1 and Massimo Massetti1
Abstract Background: After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. Methods: From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. Results: Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. Conclusions: When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.
Keywords Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Disease progression, Marfan syndrome, Reoperation
Introduction Acute type A aortic dissection (ATAAD) is a lifethreatening condition with a very poor prognosis unless surgery is performed on an emergency basis. The first operation prevents death from aortic rupture, malperfusion, and severe aortic valve regurgitation. Hospital or 30-day mortality after surgical procedures for ATAAD still remains around 20%.1–3 The surgical procedure is usually palliative, and the long-term evolution and prognosis are unpredictable. After hospital discharge, complications can occur both proximally and distally to the site of the primary repair. To date, a limited number of studies have focused on open redo aortic procedures in patients who previously underwent
ATAAD repair.4–12 Most single-center experiences have included less than 30 patients (Table 1).2,4,5,7,10,13–17 The aim of this retrospective study was to investigate the early and late outcomes in a cohort of 21 patients who needed 27 aortic reoperations following ATAAD repair.
1
Cardiac Surgery, Catholic University, Rome, Italy Thoracic and Cardiovascular Surgery, Onze Lieve Vrouw Clinic, Aalst, Belgium 2
Corresponding author: Piero Farina, MD, Cardiac Surgery, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy. Email: [email protected]
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Table 1. Previous reports of redo surgery following acute type A aortic dissection repair. Author
Year
No. of patients
No. of redo procedures
Hospital mortality
Current study Bekkerset20 Malvindi8 Kobuch4 Concistre`15 Halstead11 Zierer14 Geirsson7 Kirsch5 Moon16 Casselman2 Bachet17 Pugliese13
2015 2013 2012 2012 2012 2007 2007 2007 2002 2001 2000 1999 1998
21 43 104 23 25 16 26 21 30 9 12 25 19
27 47 154 30 25 25 28 24 37 11 12 33 22
3.7% 11.6% 7.7% 3% 4% 4% 7% 33.3% 13.3% 9.9% 33.3% 28% 5%
Patients and methods Bioethic committee approval was obtained for this retrospective follow-up study. Between September 2005 and July 2012, 21 patients were referred to the Cardiovascular Department at the Catholic University of Rome for late aortic complications following previous surgical repair of ATAAD. Demographic and clinical features are summarized in Table 2. Early and late results of 27 redo aortic procedures performed in this group of patients were investigated. In 14 (66.6%) patients, the primary operation had been carried out at our center, whereas the other 7 (33.3%) had been treated elsewhere. Exclusion criteria were: iatrogenic or traumatic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. ATAAD patients who had previously undergone open heart surgery were also excluded. The indication for surgery relies on the detection of complications occurring proximal or distal to the site of primary repair. Proximal complications are those involving the aortic root, aortic valve, and proximal suture lines anastomosis. Typically, the indications for surgery in this setting are severe valve regurgitation, pseudoaneurysm of the suture lines, endocarditis of the prosthetic or native valve, and graft infection. Distal complications are those involving the arch and/or the distal residual native aorta, distal anastomosis pseudoaneurysms, and graft or stent-graft infections. The main indications for redo procedures in our patients (Table 3) were progressive enlargement of the false lumen in the aortic arch and/or descending or thoracoabdominal aorta (n ¼ 18), severe aortic valve regurgitation with or without aneurysmal dilatation of the
Table 2. Clinical features of 21 patients undergoing redo aortic surgery. Variable
No. of patients
Mean body mass index (kg m1) Age (years) [range] Male sex Hypertension Chronic obstructive pulmonary disease Marfan syndrome Current smoker Chronic renal failure* Diabetes mellitus Cerebrovascular diseasey Coronary artery occlusive disease Congestive heart failurez Peripheral arterial occlusive disease Permanent dialysis Emergency status
27 3.2 59.48 11.49 [33–77] 17 (81%) 16 (76.2%) 6 (28%) 5 5 5 3 3 2 2 1 1 0
(23.8%) (23.8%) (23.8%) (14.3%) (14.3%) (9.5%) (9.5%) (4.7%) (4.7%)
*Glomerular filtration rate < 60 mL min1 1.73 m2. yStroke or transient ischemic attack. zLeft ventricular ejection fraction 48 h) was needed in 5 (18.5%) patients, although no tracheostomy was required. Time to extubation ranged from 8 to 219 h (mean 37 9.2 h). No major stroke or acute kidney failure was noted. Intensive care unit stay ranged from 1 to 25 days (mean 3.7 1.4 days), and total postoperative hospital stay ranged from 8 to 39 days (mean 12 5.7 days). The results are summarized in Table 5. Throughout the follow-up period, one death was registered. This occurred in a Marfan patient 2 years after the reoperation. As confirmed by necropsy, the fatal event was due to abrupt rupture of the native normal-sized (although dissected) descending thoracic aorta. Only one patient (also with Marfan syndrome) needed a further aortic reoperation due to pseudoaneurysm of the distal anastomosis after replacement of the thoracoabdominal aorta for a Crawford type II aneurysm. The overall survival rate at 3 years was 92.6%.
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Table 4. Details of cardiopulmonary bypass and cerebral protection strategies (when needed).
Case no. 1 2
3* 4 5 6 7
8 9* 10 11* 12 13 14 15 16 17 18 19* 20* 21
Redo procedure
Approach
Arterial cannulation site
Bentall þ arch replacement AAR þ arch replacement þ ET þ CABG TAAR Arch replacement þ ET TAAR DTAR Bentall þ arch replacement Bentall TAAR Bentall þ arch replacement þ ET þ CABG 1 TAAR TAAR Bentall TAAR AAR þ AV plasty þ CABG TAAR DTAR Bentall DTAR AAR Bentall Bentall (homograft) Arch replacement þ DTAR Distal DTAR DTAR AAR þ CAR Suture resuspension
Resternotomy Resternotomy
Femoral Femoral
231 225
167 158
67 62
TPL Resternotomy TPL LT Resternotomy Resternotomy TPL Resternotomy
Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral
325 333 289 165 256 218 68 245
15 125 25 135 103
15 63 20 23 74 39
155
62
TPL TPL Resternotomy TPL Resternotomy TPL LT Resternotomy LT Resternotomy Resternotomy Resternotomy Resternotomy LT LT Resternotomy Resternotomy
Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral Femoral
291 164 232 248 211 296 239 391 237 220 198 308 257 51 222 245 198
86 40 155 77 150 103 26 149 22 100 88 192 124 48 29 139 78
24 23 53 31 13 24 37 18 48 40 16
CPB time (min)
Crossclamp time (min)
DHCA time (min)
Cerebral perfusion time (min) 64 58
60 15 (R) 69 37 60
53 (R) 30 (R) 12 (R) 35 (R) 17 (R) 47 (R) 39 16
109
107
36
36 (R)
*Marfan syndrome. AAR: ascending aorta replacement; AV: aortic valve; AVR: aortic valve replacement; CABG: coronary artery bypass graft; CAR: coronary artery reimplantation; CPB: cardiopulmonary bypass; DHCA: deep hypothermic circulatory arrest; DTAR: descending thoracic aorta replacement; ET: elephant trunk; LT: left thoracotomy; R: retrograde delivery; TAAR: thoracoabdominal aorta replacement; TPL: thoracophrenolaparotomy;
Discussion Surgical treatment for ATAAD is mandatory at the time of presentation. Progressive dilatation of the residual aorta usually develops over time, both proximally and distally to the repair. Further complications should be taken into account: graft and/or valve infection (whether native or prosthetic) and pseudoaneurysms on the suture lines. These complications usually develop within 5–6 years,4,13,17 but they can appear even after 30 years.12 The actuarial freedom from cardiac or aortic reoperations at 10 years following
surgical treatment for ATAAD ranges from 85% to 65%.5,7,8,14,16,20 Several studies have identified risk factors for late aortic complications: elevated systolic blood pressure, residual false lumen patency, type of initial surgical procedure, and Marfan syndrome. Patency and flow within the false lumen appear to play important roles in residual aortic dilatation. Patency, reported to occur in a small proportion of patients, has been shown to reduce the rate of progression, without preventing aneurysmal evolution.11,11,15 The role of the primary surgical technique in late outcomes is a subject of active debate. In some reports,
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Table 5. Postoperative data of 21 patients undergoing redo aortic surgery. Variable
No. of patients
ICU stay (days) Hospital stay (days) Intubation time (h) Postoperative ARF* Postoperative paraplegia Reexploration for bleeding Postoperative AMI Postoperative stroke Postoperative coma Temporary dialysis Permanent dialysis
3.7 1.4 12.0 5.7 37 9.2 9 (42.8%) 2 (9.5%) 2 (9.5%) 0 0 0 0 0
*Creatinine 5 1.6 mg dL1. AMI: acute myocardial infarction; ARF: acute renal failure; ICU: intensive care unit.
a radical surgical approach at the primary procedure resulted in improved freedom from proximal and distal reoperations and better long-term survival.11,13,15–18 In contrast, other studies found that different surgical techniques and strategies at the primary operation did not influence the fate of the residual aorta or the time to reoperation.1,7,9,12,14 The role of antihypertensive medications in preventing aneurysmal evolution has been well established.14 We would like to highlight some factors concerning the Marfan patients in our series. First, the time interval between the primary procedure and first reoperation was shorter in Marfan patients (32.6 20.3 vs. 81.2 65.5 months in non-Marfan patients, p ¼ 0.03). Second, among the 6 patients who required 2-stage procedures, 3 were Marfan patients. If we include redo procedures performed outside our institution, the total number of procedures per patient was 3.2 for Marfan vs. 1.5 for non-Marfan patients, over a time span of 10 years for Marfan vs. 14 years for non-Marfan patients. Similar findings were reported by Moon and colleagues16 and Bachet and colleagues.17 Finally, on follow-up, the 2 aortic events (one death due to distal aortic rupture and one redo open surgical procedure) occurred in Marfan patients. Rupture can occur despite close surveillance.11 In our experience and according to other authors, Marfan syndrome appears to be the strongest risk factor for development of late complications, with a more rapid evolution.2,5,7,11,14,16,17 For this reason, the surgical treatment of ATAAD might be more aggressive and extensive, particularly at the level of the aortic root, when patients are affected by Marfan syndrome.2,13,16,17,18 In the last decade, studies have reported hospital mortality ranging from 3.5% to 7% (see Table 1).4,5,14
This is an excellent outcome if we consider the complex and challenging procedures performed. Our low mortality (3.7%) might be explained by the fact that no patient was operated on for graft and/or prosthesis infection and that all 27 procedures were carried out on an elective basis. Several published series have indeed shown that emergency status is the most important risk factor for intraoperative death.4 Overall morbidity was also acceptable; the neurologic outcomes (2 cases of paraplegia and 2 cases of vocal cord injury) were satisfying if we consider the extent of repairs and the fact that HCCA was used in 81% of patients. On the other hand, such complications occurred exclusively in the non-sternotomy group, for which the incidence was as high as 15.4%. The retrospective nature of this study prevents us from determining a more specific risk factor for paraplegia in this subset of patients. Advances in endovascular treatment have led to a rapidly expanding role for this technique, especially in unstable patients (e.g. acute complicated type B dissection). In the chronic setting, endovascular therapy appears to be indicated predominantly for nonoperable patients, and requires a shorter learning curve than surgery. Still, an endovascular approach can be extremely challenging under particular anatomical circumstances and exposes the patient to further long-term complications related to stent implantation. Whenever possible in the chronic setting, surgery allows treatment of any type of complication, with any anatomical configuration. Surgery, however, should be performed only by teams with longstanding expertise and if possible, in high-volume centers. This study does have limitations: retrospective analysis, small population size, and limited follow-up. The good outcomes are partly explained by the elective status of these patients in whom late complications were discovered thanks to close lifelong clinical and radiological follow-up. We concluded that surgical treatment for ATAAD can be followed by the onset of late proximal and distal aortic complications. Marfan syndrome appears to be the most important risk factor, whereas the role of the surgical technique of primary repair is still a matter of debate. Open reoperations can be performed with acceptable mortality and morbidity at all sites in the remaining aorta. Simultaneous proximal and distal complications can be treated by a 2-stage approach, with good results. In agreement with other authors, we strongly recommend close clinical and imaging follow-up for all patients who survive primary repair of ATAAD: computed tomography and echocardiography at least once a year to diagnose any aortic complication and allow reoperation on an elective basis, which is the key to an optimal surgical outcome.
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Asian Cardiovascular & Thoracic Annals 23(7)
Acknowledgments Presented at the XXVII National Congress of the Italian Society for Cardiac Surgery, Rome, November 29, 2014.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
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