Aortic dissection with aortic side branch compromise: impact of malperfusion on patient outcome

Abstract

The purpose of this study was to review the management and clinical outcome of patients with aortic dissection and symptomatic or asymptomatic aortic branch compromise. We identified 104 patients (30.7%) with aortic branch compromise from a group of 339 patients who underwent surgical management of aortic dissection from January 1971 to May 2003. Patients were divided into 2 groups: symptomatic and asymptomatic aortic branch compromise, based on the presence or absence of cerebral, extremity, spinal, renal, and visceral ischemia. Clinical data and outcome were reviewed and compared in both groups. There were 74 male (77%) and 30 female patients with a mean age of 58.5 (range, 23-81) years. Aortic dissection was classified as Stanford type A in 58.7%, acute in 58.7%, and was associated with asymptomatic aortic branch compromise in 44 patients (42.3%) and symptomatic aortic branch compromise in 60 patients (57.7%). Asymptomatic and symptomatic aortic branch compromise, respectively, were distributed in the extremity (30 and 33), carotid (5 and 4), renal (21 and 28), visceral (13 and 8), and spinal (0 and 5) arteries. In the asymptomatic aortic branch compromise group, all patients had aortic graft replacement, and 9 had branch reconstructions. In the symptomatic aortic branch compromise group, treatment was aortic graft replacement (48), open fenestration (6), and endovascular treatment (6). Operative mortality rate was 9.1% (4 of 44) in the asymptomatic and 38.3% (23 of 60) in the symptomatic aortic branch compromise during the 30-year study period (P = .001), decreasing from 35.1% (20 of 57) prior to 1990 to 14.9% (7 of 47) since 1990 (P = .04). In the symptomatic group, operative mortality decreased from 56.7% (17 of 30) to 20% (6 of 30) in the same interval (P = .003). Patients treated in both treatment eras were similar except for less aortic graft replacements and more aortic fenestrations and direct branch reconstructions since 1990. Multivariate analysis revealed symptomatic aortic branch compromise group, treatment prior to 1990, Marfan syndrome, age greater than 70 years, and postoperative complications to be independently associated with increased operative mortality. Asymptomatic aortic branch compromise was not associated with increased operative mortality, but organ malperfusion was an independent risk factor for operative death. The operative mortality significantly decreased since 1990, mostly because of changes in our surgical approach, with less aortic graft replacements and more complication-directed procedures.