Impact of perfusion strategy on outcome after repair for acute type a aortic dissection.
BACKGROUND
The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial.


METHODS
We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90).


RESULTS
Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups (p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% (p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009).


CONCLUSIONS
Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge.
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany. Electronic address: christian.etz@med.uni-leipzig.de.
Christian D
CD
Etz
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Konstantin
K
von Aspern
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Jaqueline
J
da Rocha E Silva
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Felix F
FF
Girrbach
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Sergey
S
Leontyev
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Maximilian
M
Luehr
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Martin
M
Misfeld
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Michael A
MA
Borger
Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Saxony, Germany.
Friedrich W
FW
Mohr
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D000792:Angiography / Q000379:methods; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D001366:Axillary Artery; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D002315:Cardiopulmonary Bypass / Q000379:methods; D002404:Catheterization / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005263:Femoral Artery; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010477:Perfusion / Q000379:methods*; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods
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