title: Aortic arch surgery after previous type A dissection repair: results up to 5 years.
abstract: OBJECTIVE
  Open aortic arch surgery after type A dissection repair is challenging. We sought to review our surgical experience to analyse the causes and timing, establish the risk profile for this patient population, and better define outcomes.
  
  
  METHODS
  From 2000 to 2014, we identified 55 patients who required aortic arch surgery after a previous type A dissection repair. Medical records were available for review including computerized tomographic angiograms, cerebral protection strategies and follow-up.
  
  
  RESULTS
  The mean interval from previous type A dissection repair to aortic arch surgery was 5.7 ± 5.4 years. At reoperation 36 patients (65%) had total arch replacement and 19 (35%) had hemiarch replacement. Indications for reoperations were: enlarging aneurysm in 27 (49%), impending rupture in 12 (22%), chronic dissection in 10 (18%) and aneurysms in 6 (11%). Arterial peripheral cannulation was used in 80% of patients. Selective antegrade cerebral perfusion was used in 35 patients (64%) and retrograde perfusion in 2 (4%). There were 3 perioperative deaths (5%) and 4 cases of permanent stroke (7%). Survival rates were 90, 85 and 77% at the 1-, 3- and 5-year follow-up, respectively. The 5-year survival rate was 10% lower than that of an age- and sex-matched population (P < 0.001). The only predictor of the follow-up mortality was older age (odds ratio: 1.07, 95% confidence interval: 1.02-1.13, P = 0.007).
  
  
  CONCLUSIONS
  Aortic arch surgery after previous type A dissection repair can be performed with satisfactory early and mid-term results and acceptable risk of stroke. Cerebral perfusion strategies likely contribute to positive outcomes. Favourable mid-term survival justifies performing such difficult reoperations.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA Division of Cardiovascular Surgery and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Pietro
authors.initials: P
authors.lastname: Bajona
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Eduard
authors.initials: E
authors.lastname: Quintana
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Daly
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Greason
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA pochettino.alberto@mayo.edu.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
mesh_terms: D000367:Age Factors; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D005260:Female; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D008910:Minnesota; D016017:Odds Ratio; D018579:Patient Selection; D010477:Perfusion / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Aortic arch reoperation; Cerebral protection; Type A dissection