Aortic arch surgery after previous type A dissection repair: results up to 5 years

Abstract

Objectives: Open aortic arch surgery after type A dissection repair is challenging. We sought to review our surgical experience to analyse the causes and timing, establish the risk profile for this patient population, and better define outcomes.

Methods: From 2000 to 2014, we identified 55 patients who required aortic arch surgery after a previous type A dissection repair. Medical records were available for review including computerized tomographic angiograms, cerebral protection strategies and follow-up.

Results: The mean interval from previous type A dissection repair to aortic arch surgery was 5.7 ± 5.4 years. At reoperation 36 patients (65%) had total arch replacement and 19 (35%) had hemiarch replacement. Indications for reoperations were: enlarging aneurysm in 27 (49%), impending rupture in 12 (22%), chronic dissection in 10 (18%) and aneurysms in 6 (11%). Arterial peripheral cannulation was used in 80% of patients. Selective antegrade cerebral perfusion was used in 35 patients (64%) and retrograde perfusion in 2 (4%). There were 3 perioperative deaths (5%) and 4 cases of permanent stroke (7%). Survival rates were 90, 85 and 77% at the 1-, 3- and 5-year follow-up, respectively. The 5-year survival rate was 10% lower than that of an age- and sex-matched population (P < 0.001). The only predictor of the follow-up mortality was older age (odds ratio: 1.07, 95% confidence interval: 1.02-1.13, P = 0.007).

Conclusions: Aortic arch surgery after previous type A dissection repair can be performed with satisfactory early and mid-term results and acceptable risk of stroke. Cerebral perfusion strategies likely contribute to positive outcomes. Favourable mid-term survival justifies performing such difficult reoperations.

Keywords: Aortic arch reoperation; Cerebral protection; Type A dissection.