Surgical treatment of acute aortic dissection type A: long-term outcomes and mortality predictors

Abstract

Background & Aims: Acute aortic dissection (AD) of the ascending aorta (type A) is a severe condition that generally prompts emergent surgical repair due to its associated life-threatening complications. Debate continues regarding the optimal approach to treating this condition. We sought to analyse the perioperative outcomes and long-term surgical results as well as to determine predictors of mortality.Patient population and methods: From January 1989 to October 2018, a total of 213 patients aged 20-85 years (mean 61.1±12.6 years), 70.4% (n=150) of which males, underwent surgery for acute Stanford type A AD. Of these, 87.3% (n=186) had DeBakey type I AD. Survival curves were plotted using Kaplan-Meier methods and early and late mortality predictors were determined by logistic regression or Cox regression models, respectively. Average follow-up time was 8.1±6.7 years (median 6.7 years, maximum 29.9 years). Results: Perioperative mortality was 8%, with the most frequent causes being acute myocardial infarction and abdominal ischemia. Haemorrhage was the most common postoperative complication. Chronic renal failure (HR, 26.90; 95% CI, 1.77-408.50; p=0.02) and extracorporeal (ECC) time (HR, 1.03; 95% CI, 1.01-1.04; p=0.001) were the two found predictors of early mortality. Death after hospital discharge occurred in 34.7% (n=68) of patients, mostly due to sudden death and cerebrovascular accident (CVA). Median survival time was 13.53±1.99 (95% CI, 9.63-17.43). At the completion of this study 60.1% (n=128) of patients were alive. Patients with AD showed a 2-fold decrease in life expectancy (Standard mortality rate: 2.11; 95% CI, 1.65-2.69; p<0.0001) relatively to the age- and gender-adjusted general population. Age (HR, 1.07; 95% CI, 1.05-1.10; p<0.001), chronic renal failure (HR, 11.62; 95% CI, 3.38-39.99; p<0.001), aortic valve homograft surgery (HR, 8.22; 95% CI, 2.29-29.51; p=0.001), ECC time (HR, 1.01; 95% CI, 1.01-1.02; p<0.001) and postoperative acute renal failure (HR, 5.22; 95% CI, 1.82-15.00; p=0.002) were the definitive independent predictors of overall mortality in our study population. Residual patent false lumen was present in 59.4% (n=82) of the 138 patients that had follow-up CT records. Conclusions: Surgery for acute type A AD is associated with an acceptable mortality. However, these patients have impaired late survival in comparison with the general population and an important percentage still carries residual disease over time. Regular postoperative follow-up is mandatory for early detection and treatment of late complications and alternative surgical procedures should be pursued to keep improving long-term outcomes.

Background & Aims: Acute aortic dissection (AD) of the ascending aorta (type A) is a severe condition that generally prompts emergent surgical repair due to its associated life-threatening complications. Debate continues regarding the optimal approach to treating this condition. We sought to analyse the perioperative outcomes and long-term surgical results as well as to determine predictors of mortality.Patient population and methods: From January 1989 to October 2018, a total of 213 patients aged 20-85 years (mean 61.1±12.6 years), 70.4% (n=150) of which males, underwent surgery for acute Stanford type A AD. Of these, 87.3% (n=186) had DeBakey type I AD. Survival curves were plotted using Kaplan-Meier methods and early and late mortality predictors were determined by logistic regression or Cox regression models, respectively. Average follow-up time was 8.1±6.7 years (median 6.7 years, maximum 29.9 years). Results: Perioperative mortality was 8%, with the most frequent causes being acute myocardial infarction and abdominal ischemia. Haemorrhage was the most common postoperative complication. Chronic renal failure (HR, 26.90; 95% CI, 1.77-408.50; p=0.02) and extracorporeal (ECC) time (HR, 1.03; 95% CI, 1.01-1.04; p=0.001) were the two found predictors of early mortality. Death after hospital discharge occurred in 34.7% (n=68) of patients, mostly due to sudden death and cerebrovascular accident (CVA). Median survival time was 13.53±1.99 (95% CI, 9.63-17.43). At the completion of this study 60.1% (n=128) of patients were alive. Patients with AD showed a 2-fold decrease in life expectancy (Standard mortality rate: 2.11; 95% CI, 1.65-2.69; p<0.0001) relatively to the age- and gender-adjusted general population. Age (HR, 1.07; 95% CI, 1.05-1.10; p<0.001), chronic renal failure (HR, 11.62; 95% CI, 3.38-39.99; p<0.001), aortic valve homograft surgery (HR, 8.22; 95% CI, 2.29-29.51; p=0.001), ECC time (HR, 1.01; 95% CI, 1.01-1.02; p<0.001) and postoperative acute renal failure (HR, 5.22; 95% CI, 1.82-15.00; p=0.002) were the definitive independent predictors of overall mortality in our study population. Residual patent false lumen was present in 59.4% (n=82) of the 138 patients that had follow-up CT records. Conclusions: Surgery for acute type A AD is associated with an acceptable mortality. However, these patients have impaired late survival in comparison with the general population and an important percentage still carries residual disease over time. Regular postoperative follow-up is mandatory for early detection and treatment of late complications and alternative surgical procedures should be pursued to keep improving long-term outcomes.