Distal aortic interventions after repair of ascending dissection: the argument for a more aggressive approach.
OBJECTIVE
Survivors of ascending aortic dissection repair frequently require downstream aortic interventions. Because of a paucity of data, we assessed early and long-term outcomes, and risk factors, of these distal procedures.


METHODS
From January 1993 to January 2011, 305 patients underwent 429 distal aortic interventions after acute type A (95% DeBakey type I) dissection repair performed 3.8 years earlier (median); 11% of interventions used an endovascular approach. Maximum aortic size was 5.9 ± 1.3 cm. Median follow-up was 3.6 years.


RESULTS
Hospital mortality was 6.1%. Risk factors included graft infection, concomitant coronary artery bypass grafting, combined open arch and descending procedures, and lower distal anastomotic site. Within 10 years, the probability of patients undergoing a reintervention was 38%, with a cumulative incidence of 55 per 100 patients; however, 40 (9.3%) were stage-II elephant trunks. Patients with larger aortic diameters distal to the initial repair, and a stage-I elephant trunk, were more likely to undergo distal interventions. Survival was 65% at 10 years. Higher body mass index, a longer time between reinterventions, graft infection, combined open arch and descending procedures, and lower distal anastomosis sites were risk factors. The extent of aorta replaced was not associated with increased morbidity or mortality, unless it involved a combined open arch and descending aorta procedure.


CONCLUSIONS
Distal interventions after ascending aortic dissection repair are feasible, but they are associated with early morbidity and subsequent reinterventions. Rigorous follow-up with early reintervention is important for improving short- and long-term outcomes. An extended hybrid endovascular repair for initial dissection warrants study.
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
Eric E
EE
Roselli
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Gabriel
G
Loor
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Jiayan
J
He
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Aldo E
AE
Rafael
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Jeevanantham
J
Rajeswaran
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Penny L
PL
Houghtaling
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Lars G
LG
Svensson
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Eugene H
EH
Blackstone
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Bruce W
BW
Lytle
D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome