title: Single-stage reoperative repair of chronic type A aortic dissection using the arch-first technique.
abstract: BACKGROUND
  Management of the enlarged, chronically dissected aorta after previous repair of acute ascending aortic dissection or after a previous cardiac operation may present a formidable technical challenge and the optimal method of management is not clearly established.
  
  
  METHODS
  Twenty-one patients with chronic type A aortic dissection (mean age 57 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. Single-stage replacement with perfusion of the aortic arch first to minimize the duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision were used. Fourteen patients had undergone previous repair of acute type A dissection. Seven patients had type A dissection after aortic valve replacement (3 patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a two-stage repair. The mean interval between the initial and reoperative procedures was 69 months (range, 5 to 249).
  
  
  RESULTS
  There was 1 (4.8%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Ten patients required assisted ventilation for more than 48 hours. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. There has been 1 late death (mean follow-up 2 years).
  
  
  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, USA. ntkouch@aol.com
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Kouchoukos
authors.forename: Paolo
authors.initials: P
authors.lastname: Masetti
authors.forename: Chris K
authors.initials: CK
authors.lastname: Rokkas
authors.forename: Suzan F
authors.initials: SF
authors.lastname: Murphy
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery; D001026:Coronary Artery Bypass; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012086:Reoperation / Q000379:methods / Q000401:mortality; D015996:Survival Rate; D016896:Treatment Outcome