title: Surgical outcomes for acute type A aortic dissection with aggressive primary entry resection.
abstract: OBJECTIVE
  An entry located at aortic arch in acute type A aortic dissection (AAAD) is uncommon. It remains controversial whether or not aggressive primary entry resection should be routinely performed in such patients. We have adopted an aggressive strategy of entry site resection, including total arch replacement (TAR) in patients with arch tears. The purpose of this study was to investigate the efficacy of our surgical management approach, using aggressive primary entry resection.
  
  
  METHODS
  Between January 2000 and December 2014, we retrospectively reviewed the records of 334 patients with AAAD who underwent emergent surgery. The mean age was 67 ± 13 years (range, 20-95 years). Ninety-five patients (28%) presented with shock vital status, and 84 patients (25%) manifested malperfusion of branched arteries. Primary entry resection was achieved in 95% of patients under an aggressive surgical strategy [hemiarch replacement for 173 (52%) patients and TAR for 161 (48%) patients] concomitant with 22 coronary artery bypass grafts and 38 root replacements. Ninety-six percent of hospital survivors (298/311) were followed for a median of 39 months (range, 0-179 months).
  
  
  RESULTS
  Operation, cardiopulmonary bypass, cardiac arrest, antegrade cerebral perfusion and lower body circulatory arrest times were 447 ± 170, 236 ± 93, 112 ± 74, 115 ± 81 and 54 ± 18 min, respectively. The 30-day mortality rate was 5.4%. The in-hospital mortality rate was 8.4% (6.9% at our hospital). Incidences of postoperative permanent neurological dysfunction, tracheotomy and newly permanent haemodialysis were 6.9, 8 and 2%, respectively, with no spinal cord injuries observed. Complete false lumen thrombosis was achieved in 57% of patients as visualized by postoperative computed tomography angiography. After 3, 5 and 10 years, overall survival rates were 81, 74 and 65%, respectively, and the percentages of patients free from downstream dissection-related reoperation were 89, 86 and 80%, respectively. Multivariable analysis demonstrated that the risk factors for downstream aortic reoperation were patent false lumen, residual primary entry tear and connective tissue disorder.
  
  
  CONCLUSIONS
  The surgical outcomes following aggressive treatment of AAAD are satisfactory. False lumen thrombosis can be achieved in a relatively high proportion of patients using this technique, resulting in a low rate of subsequent downstream aortic reoperations.
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Yosuke
authors.initials: Y
authors.lastname: Inoue
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan minatoya@ncvc.go.jp.
authors.forename: Kenji
authors.initials: K
authors.lastname: Minatoya
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Oda
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Itonaga
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Yoshimasa
authors.initials: Y
authors.lastname: Seike
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Tanaka
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Sasaki
authors.affiliation: Department of Cardiovascular surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Junjiro
authors.initials: J
authors.lastname: Kobayashi
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D015996:Survival Rate / Q000639:trends; D055815:Young Adult
keywords: Aortic dissection; Frozen elephant trunk; Outcome; Primary entry resection