title: Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique.
abstract: OBJECTIVE
  Management of the enlarged, chronically dissected aorta after previous repair of acute aortic dissection or after a previous cardiac operation may present a formidable technical challenge. Marked enlargement of the proximal descending thoracic aorta precludes safe use of staged procedures, including the elephant trunk technique.
  
  
  METHODS
  Sixteen patients with chronic type A aortic dissection (mean age, 56 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. We used single-stage replacement, with perfusion of the aortic arch first to minimize the duration of brain ischemia, with a bilateral anterior thoracotomy (clamshell) incision. Eleven patients had undergone previous repair of acute type A dissection. Five patients had type A dissection after aortic valve replacement (2 patients) and coronary artery bypass (3 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a 2-stage repair. The mean interval between the initial and reoperative procedures was 62 months (range, 5-137 months).
  
  
  RESULTS
  There was 1 (6.2%; 70% confidence limits, 0.3%-24.7%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Six patients required assisted ventilation for more than 72 hours, and 3 patients required a tracheostomy. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome.
  
  
  CONCLUSIONS
  The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis, Mo, USA. NTKouch@aol.com
authors.forename: N T
authors.initials: NT
authors.lastname: Kouchoukos
authors.forename: P
authors.initials: P
authors.lastname: Masetti
authors.forename: C K
authors.initials: CK
authors.lastname: Rokkas
authors.forename: S F
authors.initials: SF
authors.lastname: Murphy
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D001027:Aortography; D002908:Chronic Disease; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000601:surgery; D012086:Reoperation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D012720:Severity of Illness Index; D013908:Thoracotomy / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome