Imaging Surveillance After Proximal Aortic Operations: Is it Necessary?

Abstract

Background: Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance.

Methods: Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk.

Results: Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038).

Conclusions: Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.

Fig 1

Kaplan-Meier estimate of (A) overall freedom from aortic reintervention and (B) freedom from aortic reintervention stratified by aneurysm (Freestyle [Medtronic, Minneapolis, MN] excluded; solid line), Freestyle only (dashed line), and dissection (dotted line).

Fig 2

Smoothed hazard estimate for (A) the overall study cohort and (B) stratified by aneurysm (Freestyle [Medtronic, Minneapolis, MN] excluded; solid line), Freestyle only (dashed line), and dissection (dotted line).

Fig 3

Duke aortic surveillance protocol. DeBakey type I dissection, connective tissue disorder, or vasculitis/aortitis: computed tomography angiography of the chest, abdomen, and pelvis plus transthoracic echocardiography or cardiac magnetic resonance imaging/aortic magnetic resonance angiography. DeBakey type II dissection, degenerative (atherosclerotic) aneurysm, or bicuspid aortic valve: initial scan of the chest, abdomen, and pelvis but subsequent scans are of the chest only if no abdominal pathology is noted.