Is Concomitant Total Arch Replacement Justified for Acute Type A Dissection?

Abstract

Between December 1988 and August 1998,118 patients underwent operation for acute type A dissection on an emergency basis. Seventy of them had total arch replacement concomitantly performed with ascending aortic replacement. Indication for this extended operation included acute aortic arch replacement, acute aortic dissection with the tear in the descending aorta, rupture and/or massive false lumen of the aortic arch, compromised arch vessels, coexistent aortic arch aneurysm, and young patients, particularly Marfan’s patients without serious preoperative complications. All operations were performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral protection during aortic arch repair, and circulatory arrest during distal graft anastomosis (open distal anastomosis). Concomitant procedures included aortic valve resuspension in 18 patients, composite graft replacement with coronary reimplantation in 10, and CABG in 5. The early mortality was 16% (11 of 70 patients). Multivariable analysis showed that renal/mesenteric ischemia and CABG were independent determinants for early death. Survival at 3 and 5 years postoperatively including the early deaths were 75 ± 5%, and 73 ± 6%, respectively. Freedom from reoperation were 91 ± 4%, and 77 ± 8% at 3, and 5 years, respectively. The present data indicates that concomitant total arch replacement could be justified in properly selected patients.