title: Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management.
abstract: OBJECTIVE
  Controversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting.
  
  
  METHODS
  From 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n = 88) or thoracoabdominal (n = 81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention.
  
  
  RESULTS
  Thirty-day mortality was 8% (n = 14). Serious complications included neurologic (n = 12 [spinal cord n = 4, 2.4%]), respiratory (n = 32), and renal failure (n = 1 descending thoracic artery only vs 17 thoracoabdominal, P < .001). Chronic obstructive pulmonary disease predicted early mortality (hazard ratio 8.0, P = .005). Survival at 1, 2, and 5 years was 76%, 69%, and 55%, respectively; 23 patients (14%) required reintervention. Event-free survival at 5 years was 51% and 47% after descending thoracic artery only or thoracoabdominal repair, respectively. Greater maximum aortic diameter (hazard ratio 1.9, P = .03) and greater diameter at the diaphragm (hazard ratio 3.7, P = .01) or renal segment (hazard ratio 4.3, P = .03) predicted poor outcome.
  
  
  CONCLUSIONS
  Early outcomes are good and late outcomes are less than desirable after open repair of chronic distal aortic dissection, regardless of the extent of repair. High-risk and late-stage patients with larger and more extensive aneurysmal degeneration warrant further investigation, including the use of newer, less-invasive techniques. Select patients at risk for aneurysmal degeneration should undergo a more aggressive initial approach with aortic dissection repair.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Akshat C
authors.initials: AC
authors.lastname: Pujara
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.forename: Adrian V
authors.initials: AV
authors.lastname: Hernandez
authors.forename: Lina M
authors.initials: LM
authors.lastname: Vargas Abello
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Burke
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002908:Chronic Disease; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D021621:Imaging, Three-Dimensional; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009820:Ohio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000628:therapy; D016016:Proportional Hazards Models; D011857:Radiographic Image Interpretation, Computer-Assisted; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome