Survival and reinterventions after isolated proximal aortic repair in acute type A aortic dissection

Reinterventions After Repair of Acute Type A Aortic Dissection: Incidence, Outcomes, and Risk Factors

BACKGROUND

This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD).

METHODS

This was an observational study of aortic operations from 2010 to 2021. All patients with ATAAD undergoing open aortic arch reconstruction were included. Patients were dichotomized by the need for reintervention, which included reinterventions proximal to or distal to the index aortic repair. Propensity matching was used to determine the impact of reintervention on long-term outcomes. The cumulative incidence function for reintervention was estimated, and multivariable Fine-Gray analysis was performed to identify variables associated with reintervention, with death treated as a competing event.

RESULTS

We identified 601 patients undergoing surgery for ATAAD. An aortic reintervention was required in 71 (11.8%), comprising a proximal reintervention in 12 patients, a distal reintervention in 56, and both in 3. The cumulative incidence of reintervention was 11.6% (95% CI, 8.9%-14.6%) at 5 years and was 16.0% (95% CI, 12.2%-20.3%) at 10 years, with a median time to reintervention of 4.0 years (interquartile range, 0.9-7.5 years). Multivariable analysis using the Fine-Gray method showed no operative variables were associated with reinterventions. Among the 71 reinterventions, there were 4 (5.6%) operative deaths. After propensity matching, there was no difference in Kaplan-Meier survival estimates across each group (P = .138 by log-rank statistics).

CONCLUSIONS

The cumulative incidence of aortic reintervention after ATAAD repair was reasonably low (16% at 10 years), reinterventions were relatively safe (6% operative mortality), and reinterventions did not significantly impact long-term survival.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Surgical outcomes of DeBakey type I and type II acute aortic dissection: a propensity score-matched analysis in 599 patients

Background

The DeBakey classification divides Stanford acute type A aortic dissection (ATAAD) into DeBakey type I (D1) and type II (D2) according to the extent of acute aortic dissection (AAD). This retrospective study aimed to compare the early and late outcomes of D1-AAD and D2-AAD through a propensity score-matched analysis.

Methods

Between January 2009 and April 2020, 599 consecutive patients underwent ATAAD repair at our institution, and were dichotomized into D1 (n = 543; 90.7%) and D2 (n = 56; 9.3%) groups. Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 56 patients per group. The clinical features, postoperative complications, 5-year cumulative survival and freedom from reoperation rates were compared.

Results

In the overall cohort, the D1 group had a lower rate of preoperative shock and more aortic arch replacement with longer cardiopulmonary bypass time. The D1 group had a higher in-hospital mortality rate than the D2 group in overall (15.8% vs 5.4%; P = 0.036) and matched cohorts (19.6% vs 5.4%; P = 0.022). For patients that survived to discharge, the D1 and D2 groups demonstrated similar 5-year survival rates in overall (77.0% vs 85.2%; P = 0.378) and matched cohorts (79.1% vs 85.2%; P = 0.425). The 5-year freedom from reoperation rates for D1 and D2 groups were 80.0% and 97.1% in overall cohort (P = 0.011), and 93.6% and 97.1% in matched cohort (P = 0.474), respectively.

Conclusions

Patients with D1-AAD had a higher risk of in-hospital mortality than those with D2-AAD. However, for patients who survived to discharge, the 5-year survival rates were comparable between both groups.

Late Outcome after Surgery for Type-A Aortic Dissection

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.

Critical appraisal of multidimensional CT measurements following acute open repair of type A aortic dissection

INTRODUCTION

To identify patients with aneurysmal degeneration of the native aorta following type A aortic dissection (TAAD), reproducible serial measurements of aortic dimensions are critical. We used a systematic workflow for measuring aortic geometry following TAAD, using computed tomography angiography data, and test its reproducibility.

METHODS

The workflow for aortic measurements included centerline generation, luminal diameter, and area measurement at six anatomically defined locations along the aorta and luminal volumetric measurements in the descending aorta. Two independent observers measured the aortic geometry in 20 surgically repaired TAAD patients, preoperatively and at 3 months follow-up. To test reproducibility, intraobserver and interobserver agreement scores were analyzed using a concordance correlation coefficient (CCC).

RESULTS

The interobserver agreement scores of the diameter, area, and volumetric measurements in the descending aorta were acceptable. The agreement scores of the area measurements were highest, with CCCs ranging from 0.909 to 0.984. Luminal diameter measurements scored lower than luminal area measurements and were least reproducible at the mid aortic arch (CCC < 0.886). Overall, intraobserver agreement scores were better than interobserver agreement scores (SD of mean difference was 1.89 vs 1.94 for intraobserver vs interobserver diameter measurements, and 0.61 vs 0.66 for area measurements).

CONCLUSION

Although overall reproducibility was acceptable in descending aortic measurements, our results show that it remains challenging to reliably measure luminal diameters, compared with areas. To aid identification of early adverse remodeling following acute TAAD, novel two- and three-dimensional measurement techniques are needed that capture locoregional changes in the false lumen and true lumen morphology more accurately.