Acute aortic dissection with entry tear at the aortic arch: long-term outcome

Abstract

Objectives: The goal was to evaluate outcomes after conservative or surgical treatment of acute aortic arch dissections.

Methods: Between January 2009 and December 2018, patients with a diagnosis of acute aortic dissection were analysed. Aortic arch aortic dissection was defined as a dissection with an isolated entry tear at the aortic arch with no involvement of the ascending aorta.

Results: Aortic arch dissection was diagnosed in 31 patients (age 59 ± 11 years). Surgical intervention was performed in 13 (41.9%) cases. Overall in-hospital mortality was 3% (n = 1), and all deaths occurred in the conservative group (n = 1; 6%), whereas the overall stroke rate was 3% (n = 1), and all strokes occurred in the group treated surgically (n = 1; 8%). Surgical repair was necessary for the following conditions: end-organ malperfusion (n = 9; 69%), impending rupture (n = 3; 23%) and dilatation of the aorta with ongoing pain refractory to medical treatment (n = 1; 8%). Overall survival at the end of the follow-up period was 71%, with 77% in the surgical group and 63% in the conservative group (P = 0.91). Freedom from surgical intervention was 71%, with 82% in the surgical and 63% in the conservative group (P = 0.21), and freedom from a neurological event was 88%, with 89% versus 89% (P = 0.68) in the surgical and conservative groups, respectively.

Conclusions: Aortic arch dissection is a rare pathological condition that is one of the most challenging decision-making entities. Patients manifesting an uneventful course not requiring a surgical intervention during a hospital stay were at a higher risk for aorta-related intervention during the follow-up period. The treatment modality had no impact on survival or on the incidence of a neurological event.

Keywords: Aneurysm; Aortic arch; Aortic dissection.

Figure 1:

Aortic arch morphopathological division. The proximal segment of the aortic arch lies between the transition of the ascending aorta and the space between the InA and the LCCA (segment 2A). The middle segment (2B) is the part of the aortic arch with the origin of the LCCA as a central element. The distal segment of the aortic arch is defined as the area at the origin of the LSA, with its distal border at the level of the ligamentum arteriosum (segment 2C). InA: innominate artery; LCCA: left common carotid artery; LSA: left subclavian artery.

Figure 2:

Entry tear location in aortic arch dissection. According to the aortic arch segments (A), the entry tear may be (a) in the area between the transition of the ascending aorta and aortic arch and the space between the innominate artery and left common carotid artery (segment 2A, B); (b) at the middle segment (segment 2B, C) of the aortic arch; and at (c) the distal segment of the aortic arch proximal to the level of the ligamentum arteriosum (segment 2C, D).

Figure 3:

Kaplan–Meier survival curve. The 1-, 5- and 7-year survivals were 100%, 100% and 63% [95% confidence interval (CI) 14–89%] in the conservative group and 92% (95% CI 57–99%), 92% (95% CI 57–99%) and 77% (95% CI 31–94%); P = 0.91, respectively, in the surgical group.

Figure 4:

Kaplan–Meier curve for freedom from aortic-related reinterventions. The 1-, 5- and 7-year freedom from interventions was 83% [95% confidence interval (CI) 57–94%], 63% (95% CI 34–82%) and 63% (95% CI 34–82%) in the conservative group and 92% (95% CI 54–99%), 82% (95% CI 46–95%) and 82% (95% CI 46–95%), P = 0.21, respectively, in the surgical group.

Figure 5:

Kaplan–Meier curve for freedom from neurological events. The 1-, 5- and 7-year freedom from neurological events was 89% [95% confidence interval (CI) 62–94%], 89% (95% CI 62–97%) and 89% (95% CI 62–97%) in the conservative group and 100%, 89% (95% CI 43–98%) and 89% (95% CI 43–98%), P = 0.68, respectively, in the surgical group.