Twenty-year experience with acute distal thoracic aortic dissections.
BACKGROUND
There are few large studies in the literature that document the clinical outcome of an acute dissection of the distal thoracic aorta (ADDA), particularly since the advent of percutaneous techniques for therapeutic and prophylactic treatment of complications of ADDA. The goal of this study was to evaluate the outcome of ADDA with respect to medical, surgical, and percutaneous treatment over a 20-year period, and to use this information to estimate the benefit that future prophylactic therapy may yield.


METHODS
The hospital records of all patients admitted with ADDA during the period of the study were reviewed retrospectively.


RESULTS
There were 119 patients who fit the criteria of ADDA. Medical management was performed in 92 patients, with an overall mortality in this group of 13% (12/92 patients). Major morbidity occurred in 34 of the 83 surviving patients managed nonoperatively. Percutaneous interventions consisting of aortic fenestration and branch vessel stenting in 5 patients had a mortality rate of 40% and was only effective in the treatment of isolated renal artery malperfusion. Twenty-two patients underwent aortic surgery for complications or risk of impending rupture. Postoperative mortality was 18% (4/22 patients). Significant risk factors for death were rupture, acute renal failure, mesenteric ischemia, and age >70. No patient who had surgical fenestration required reoperation on the tailored segment. On the basis of clinical outcomes, we estimate that a maximum of 37% of patients could benefit acutely from prophylactic treatment of ADDA with aortic stent grafts, and an additional 13% could benefit chronically from such prophylactic treatment.


CONCLUSIONS
ADDA remains a challenging clinical problem with many failures of medical, surgical, and percutaneous therapy. Surgery remains an effective therapeutic option in the treatment of complications of acute dissection of the distal thoracic aorta, and surgical aortic fenestration is a durable treatment for malperfusion. A minority of patients may benefit from prophylactic treatment of ADDA with thoracic stent grafts.
Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287-8611, USA. gsrosebo@jhmi.edu
Glen
G
Roseborough
John
J
Burke
Jason
J
Sperry
Bruce
B
Perler
Jose
J
Parra
G Melville
GM
Williams
D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000601:surgery*; D017130:Angioplasty / Q000379:methods; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome