Proximal and Distal Reinterventions in Chronic Residual Aortic Type A Dissection

Objectives: In acute Type A aortic dissection (AAD), native aortic tissue remains proximal and distal to the prosthetic replacement in most cases. Together with residual dissections in the arch and the descending aorta, there is an increased risk for aneurysmal changes proximal and distally to the replacement. The aim of this retrospective study was to characterize reoperated patients due to a residual chronic type A dissection (rCAD) and to compare the short-term and long-term outcomes of different techniques.

Methods: Between May 2007 and June 2019, a total of 94 patients initially operated for DeBakey Type I (n = 86, 91.5%) and Type II (n = 8, 8.5%) were reoperated for proximal or distal aneurysmal changes and aortic valve insufficiency. Previous operations were isolated replacement of the ascending aorta (42%), combined with hemiarch replacement (51%), or complete arch replacement (7%). 17% of these patients were initially operated elsewhere. Patients were identified and retrospectively analyzed for their demographics, comorbidities, operative details, reintervention rates, and short- and long-term outcome.

Results: Mean age at the time of reoperation was 61.7 ± 12.1; 68% were male. Significantly more DeBakey Type I (91 vs. 9%, p < 0.001) patients were reoperated. The mean interval between the initial operation for AAD and the reoperation for rCAD was 3.7 ± 5.2 years. Proximal reinterventions (n = 29, 31%) were root replacement or remodeling (72%) and isolated valve replacements (28%). Distal reinterventions (n = 65, 69%) included 29 arch replacements (86% FET) and 36 TEVAR procedures (42% zone 0 after debranching). New neurological events occurred in 3.5% in the proximal group, 6.9% in the open, and 8.6% in the endovascular distal group (p = 0.8). Overall in-hospital mortality was 7.5%, 3.5% in the proximal group, 3.5% in the open, and 14% in the endovascular distal group (p = 0.148). The 3-year survival rate was 93% in the proximal and 67% in both distal groups (p = 0.79).

Conclusion: About 75% of all reinterventions were necessary within the first 5 years after AAD. Close postoperative surveillance is crucial after AAD. Reoperations in rCAD can be performed safely, with low mortality and morbidity. Even though open reoperations seem superior in terms of early mortality, the medium-term results of endovascular and open procedures are similar.

No conflict of interest has been declared by the author(s).