Surgery for acute type a aortic dissection: comparison of techniques.

OBJECTIVE

In order to determine the optimal surgical strategy for acute ascending aortic dissection, the graft inclusion technique was compared with the open resection technique.

METHODS

Between 1985 and 1995 a consecutive series of 193 patients (77% male, mean age 58 years) had emergency surgery during a mean interval of 13.2 h after onset of symptoms. Graft replacement of the ascending aorta was performed in all patients (supracoronary graft 143/193=74%, aortic root replacement 50/193=26%, aortic valve replacement 73/193=38%, arch replacement 44/193=20%) The open resection technique was applied in 93 patients and the inclusion technique in 100 patients with a Cabrol-shunt in 26%. Preoperative risk factors were equally distributed between groups (inclusion technique vs. open technique): left ventricular ejection fraction<45% (13 vs. 2%, not significant (n.s.)), neurological deficit (31 vs. 25%; n.s.), systolic blood pressure<90 mm Hg (20 vs. 15%, n.s.) pericardial tamponade (25 vs. 9%, n.s.), renal failure (6 vs. 4%; n.s.).

RESULTS

The overall early mortality was 24%. Following graft inclusion it was 31% compared with 16% in the open technique group (P=0.0154). Postoperative complications (graft inclusion vs. open technique): myocardial infarction (9 vs. 12%, n.s.), low cardiac output (40 vs. 32%, n.s.), reexploration for hemorrhage (23 vs. 25%, n.s.). Survival at 8 years was significantly increased in the open technique group (P=0.0300). Pseudoaneurysm formation occurred in 3% of patients and only after graft inclusion. Freedom from reoperation was 80% at 8 years and did not differ between groups. Graft inclusion was an independent significant predictor of early (P=0.0069; relative risk=2.3673) and late mortality (P=0.0119; relative risk=2.0981).

CONCLUSIONS

Surgery of acute ascending aortic dissection still carries a considerable early mortality whereas the late outcome is satisfactory. The open resection technique is the method of choice showing superior early and late results and avoiding pseudoaneurysm formation. The inclusion technique may be indicated in situations with increased risk of bleeding. A consequent decompression of the perigraft-space could reduce the rate of pseudoaneurysms.