Eastern Cardiothoracic Surgical Society

Which Patients are at Risk for Distal Aortic Pathology Following Conservative Repair of Acute Type A Aortic Dissection?
Kellianne Kleeman, Himanshu Patel, Donald Likosky, Bo Yang, Matthew Romano, Elise Woznicki, Michael Paulsen, Kevin Schmidt, Zhyldyz Kabaeva, Michael Ranella, Theron Paugh, G. Michael Deeb,  University of Michigan, Ann Arbor, MI USA.


Objective: Conservative repair (ascending resection, arch reconstruction, and open distal anastomosis) of acute Type A aortic dissection (ATAAD) treats the primary source of mortality and offers excellent survival, but results in a risk of late death or reoperation on the distal dissected aorta. Therefore, we sought to define the cohort of patients at higher risk of late mortality or reoperation–those that may benefit from prophylactic intervention on the descending aorta (i.e. frozen elephant trunk) during the initial operation.

Methods: We reviewed 384 ATAAD patients. All underwent conservative repair. All had hemiarch replacement, except those with: primary arch tear, diameter >4.5cm, or dissection into head vessels, who underwent complete arch replacement. The primary endpoint was distal aortic pathology causing death or reoperation at 10yrs.

Results: Outcomes were equivalent irrespective of distal anastomosis (hemiarch vs. complete arch). Early mortality (7%) correlated with tobacco use. Ten-year survival was 76%. Risk factors for all-cause mortality were increasing age and no family history of aortic dissection. Distal aortic pathology necessitated reoperation in 13% and caused 10% of late deaths. Risk factors for distal aortic pathology causing death or reoperation were African American race and connective tissue disorders (Table SA18-1).

Conclusions: Conservative repair of ATAAD yields excellent early and late survival with low rates of distal reoperation. However, newer approaches which intervene on the descending aorta (i.e. frozen elephant trunk) may add benefit in African American patients or those with known/suspected connective tissue disorders, to reduce the risk of late death or reoperation on the distal dissected aorta.

Table 1 – Risk Factors for Distal Aortic Pathology Resulting in Death or Reoperation at 10 Years
  Odds Ratio CI (95%)    p-value
African American race    3.44 1.56,    7.58 0.002
Connective Tissue Disorder (Genetic syndrome such as Marfan, Ehlers-Danlos, or familial)    3.26 1.03,    10.34 0.044