title: The impact of surgical strategy on survival after repair of type A aortic dissection.
abstract: OBJECTIVE
  A diverse group of operative strategies are utilized for treatment of acute Stanford type A aortic dissection. We hypothesized that a surgical strategy to prevent cross-clamp injury or false lumen pressurization would be associated with reduced morbidity, mortality, persistent false lumen patency, and improved survival. This study was designed to determine the differences in outcomes between operative techniques.
  
  
  METHODS
  Outcomes and postoperative imaging were compared in patients who underwent surgery for acute type A aortic dissection. Two groups were compared, based on operative strategy. The surgical strategy for group 1 consisted of no aortic cross-clamp use, use of deep hypothermic circulatory arrest, and use of only antegrade perfusion after aortic replacement. The surgical strategy for group 2 consisted of any other combination that lacked 1 of these 3 technical steps.
  
  
  RESULTS
  Between January 1, 1996, and December 31, 2012, a total of 196 patients underwent surgery for acute type A aortic dissection. Operative mortality and postoperative morbidity were not statistically different between groups. Mean follow-up time was 3.95 (range: 0-15.4) years. Persistence of a false lumen was not statistically different between groups (P = .78). Overall survival was significantly better in group 1, versus group 2 (P = .0020). Multivariate Cox regression identified preoperative renal failure, chronic lung disease, greater number of packed red blood cells transfused, and being in group 2 as risk factors for poor long-term survival.
  
  
  CONCLUSIONS
  The operative strategy of group 1 (no cross-clamp, use of DHCA and antegrade perfusion) was associated with a highly significant improvement in survival, despite a lack of statistical difference in the incidence of persistent false aortic lumen between groups.
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo. Electronic address: lawtonj@wustl.edu.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Lawton
authors.affiliation: Department of Biostatistics, Washington University School of Medicine, St Louis, Mo.
authors.forename: Jingxia
authors.initials: J
authors.lastname: Liu
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kulshrestha
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Marc R
authors.initials: MR
authors.lastname: Moon
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: Damiano
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Hersh
authors.initials: H
authors.lastname: Maniar
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Pasque
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D016009:Chi-Square Distribution; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003250:Constriction; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008923:Missouri; D015999:Multivariate Analysis; D010477:Perfusion; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D055815:Young Adult
keywords: Aorta; dissection; operative technique; outcomes; survival