Aortic Enlargement and Late Reoperation After Repair of Acute Type A Aortic Dissection

doi:10.1016/j.athoracsur.2007.03.084

The Annals of Thoracic Surgery

Volume 84, Issue 2, August 2007, Pages 479-487

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.

https://doi.org/10.1016/j.athoracsur.2007.03.084 Get rights and content

Background

The natural history of the residual aorta after repair of acute type A aortic dissection is incompletely understood.

Methods

During a 22-year period, 201 patients underwent repair of acute type A dissection by 25 surgeons. For 168 operative survivors, mean late follow-up for reoperation or death was 6.5 ± 5.5 years and was 100% complete. Late blood pressure and medication history were available for 136 patients. Overall, 412 computed tomography scans were analyzed for segmental diameter and false lumen patency from 69 patients who underwent multiple follow-up imaging studies at our institution.

Results

Freedom from reoperation at 10 years (range, 1 to 170 months) was 74% ± 5% (28 reoperations in 26 patients). A nonresected primary tear (p = 0.05), Marfan syndrome (p < 0. 001), elevated systolic blood pressure at follow-up (p = 0.008), and absence of β-blocker therapy (p = 0.02) were independent predictors of late reoperation. Aortic growth between consecutive imaging studies was detected in 18% of intervals (62/343) affecting 49% patients (34/69), with mean yearly growth rate of 5.3 ± 4.5 mm. Onset of enlargement was unpredictable and occurred 59 ± 45 months postoperatively (range, 1 to 167 months). Risk factors for growth included aortic diameter (p < 0. 001), elevated systolic blood pressure (p = 0.04), and presence of a patent false lumen (p = 0.05). Maximum aortic diameter of less than 35 mm predicted growth in 11% of intervals, 35 to 49 mm in 22%, and more than 49 mm in 37% (p < 0.001). Different proximal or distal surgical strategies did not affect aortic growth or need for reoperation (p > 0.17).

Conclusions

Optimal long-term outcome of patients with acute type A dissection demands rigorous antihypertensive therapy and lifelong radiographic follow-up because aortic enlargement can begin more than a decade postoperatively.

Section snippets

Material and Methods

This retrospective review includes 201 consecutive patients that underwent surgical repair for acute type A aortic dissection between June 1984 and May 2006 at Washington University School of Medicine (Barnes-Jewish Hospital, Missouri Baptist Medical Center) by 25 different surgeons. The study was approved by the Washington University Institutional Review Board. There were 128 (64%) men and 73 (35%) women, with a mean age of 61 ± 16 years (range, 18 to 88 years).

Selected preoperative patient

Long-Term Survival

At late follow-up, 108 (64%) of 168 operative survivors were alive, a mean of 90 ± 68 months postoperatively. Actuarial survival rates for all operative survivors are demonstrated in Figure 2. For operative survivors, survival estimates were 90% ± 2% at 1 year (141 patients at risk), 76% ± 4% at 5 years (90 at risk), 59% ± 4% at 10 years (47 at risk), and 49% ± 5% at 15 years (18 at risk). Multivariate regression analysis identified five factors to be independent predictors of late death: (1)

Comment

Important studies on the natural history of descending thoracic and thoracoabdominal aneurysms have been published by the groups from Mount Sinai [20, 21, 22] and Yale [23, 24, 25]. These authors noted that late mortality from rupture was significantly higher in patients presenting with chronic dissections than in patients with atherosclerotic aneurysms. Several risk factors for secondary dilatation of aneurysms not associated with chronic dissection have also been described, including advanced

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Surgery for Stanford type A aortic dissection (TAAD) is associated with an increased risk of late aortic reoperations due to degeneration of the dissected aorta.
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After a mean follow-up of 4.2 ± 3.6 years, 60 patients underwent 85 distal aortic reoperations. Ten-year cumulative incidence of distal aortic reoperation was 9.6%. Multivariable competing risk analysis showed that the maximum preoperative diameter of the abdominal aorta (SHR 1.041, 95%CI 1.008–1.075), abdominal aorta dissection (SHR 2.133, 95%CI 1.156–3.937) and genetic syndromes (SHR 2.840, 95%CI 1.001–8.060) were independent predictors of distal aortic reoperation. Patients with a maximum diameter of the abdominal aorta >30 mm and/or abdominal aortic dissection had a cumulative incidence of 10-year distal aortic reoperation of 12.0% compared to 5.7% in those without these risk factors (adjusted SHR 2.076, 95%CI 1.062–4.060).
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Thoracic aortic aneurysm and dissection has a genetic predisposition and a variety of clinical manifestations. This study aimed to investigate the clinical and molecular characterizations of patients with thoracic aortic aneurysm and dissection and further explore the relationship between the genotype and phenotype, as well as their postoperative outcomes.
A total of 1095 individuals with thoracic aortic aneurysm and dissection admitted to our hospital between 2013 and 2022 were included. Next-generation sequencing and multiplex ligation-dependent probe amplification were performed, and mosaicism analysis was additionally implemented to identify the genetic causes.
A total of 376 causative variants were identified in 83.5% of patients with syndromic thoracic aortic aneurysm and dissection and 18.7% of patients with nonsyndromic thoracic aortic aneurysm and dissection, including 8 copy number variations and 2 mosaic variants. Patients in the “pathogenic” and “variant of uncertain significance” groups had younger ages of aortic events and higher aortic reintervention risks compared with genetically negative cases. In addition, patients with FBN1 haploinsufficiency variants had shorter reintervention-free survival than those with FBN1 dominant negative variants.
Our data expanded the genetic spectrum of heritable thoracic aortic aneurysm and dissection and indicated that copy number variations and mosaic variants contributed to a small proportion of the disease-causing alterations. Moreover, positive genetic results might have a possible predictive value for aortic event severity and postoperative risk stratification.
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The “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease” provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).
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Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD).
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.
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Original articleCardiovascularAortic Enlargement and Late Reoperation After Repair of Acute Type A Aortic Dissection

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Long-Term Survival

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Op Tech Thoarc Cardiovas Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

Am J Cardiol

Ann Thorac Surg

Evolving strategies for treatment of acute aortic dissection type A

Circulation

Original article
Cardiovascular
Aortic Enlargement and Late Reoperation After Repair of Acute Type A Aortic Dissection