title: Aortic dissection resulting from tear of transverse arch: is concomitant arch repair warranted?
abstract: Forty-seven patients with aortic dissection resulting from a primary tear located in the transverse aortic arch underwent surgical treatment. Twenty-six patients had acute type A, 7 had acute type B, 7 had chronic type A, and 7 had chronic type B aortic dissections. Of the 33 patients with acute dissections, 11 (7 acute type A and 4 acute type B) underwent concomitant arch repair with an operative (less than or equal to 30 days) mortality rate of 55% (35% to 73%, +/- 1 asymmetric 70% confidence limit) (2 of 7 acute type A and 4 of 4 acute type B). Concomitant arch repair was omitted in 22 patients with acute dissections (19 acute type A and 3 acute type B); the operative mortality rate was 41% (29% to 54%) (7 of 19 acute type A and 2 of 3 acute type B) (p = not significant versus arch repair). The overall survival rate for those with arch repair was 45% +/- 15% (+/- 1 standard error of the estimate) at 4 years, compared with 43% +/- 11% for patients without arch repair (p = not significant). Considering the type of dissection, the 4-year survival estimate for patients with acute type A dissections who underwent arch repair (5 hemiarch and 2 total arch) was 71% +/- 17% (versus 44% +/- 12% for acute type A patients without arch repair). There were no survivors among the 4 patients with acute type B dissections who had an arch repair (1 hemiarch and 3 total arch), whereas patients with acute type B dissections who did not undergo concomitant arch repair had a 4-year survival estimate of 33% +/- 27% (p = not significant versus arch repair). Four other patients with acute type B dissections resulting from an arch tear were managed medically and tended to have a slightly better prognosis (2-year survival estimate of 75% +/- 22% versus 14% +/- 13% for all surgically treated acute type B patients), but again this difference was not statistically significant. Multivariate analysis of the 47 surgical patients revealed that advanced age (p = 0.0008), preoperative dissection complications (p = 0.02), and other coexistent medical problems (p = 0.03) were the only significant, independent determinants of overall mortality. Initial arch repair was not a significant predictor. Nine percent (2/22) of patients with acute type A dissections who initially underwent isolated ascending aortic replacement required subsequent arch replacement; 1 died after reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)
authors.affiliation: Department of Cardiovascular Surgery, Stanford University School of Medicine, Calif. 94305-5247.
authors.forename: K L
authors.initials: KL
authors.lastname: Yun
authors.forename: D D
authors.initials: DD
authors.lastname: Glower
authors.forename: D C
authors.initials: DC
authors.lastname: Miller
authors.forename: J I
authors.initials: JI
authors.lastname: Fann
authors.forename: R S
authors.initials: RS
authors.lastname: Mitchell
authors.forename: W D
authors.initials: WD
authors.lastname: White
authors.forename: J S
authors.initials: JS
authors.lastname: Rankin
authors.forename: W G
authors.initials: WG
authors.lastname: Wolfe
authors.forename: N E
authors.initials: NE
authors.lastname: Shumway
mesh_terms: D000206:Actuarial Analysis; D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000209:etiology* / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000209:etiology* / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000601:surgery; D012086:Reoperation; D012307:Risk Factors; D015996:Survival Rate