Imaging Surveillance After Proximal Aortic Operations: Is it Necessary?
BACKGROUND
Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance.


METHODS
Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk.


RESULTS
Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038).


CONCLUSIONS
Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.
Section of Cardiac Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Alexander
A
Iribarne
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Jeffrey
J
Keenan
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Ehsan
E
Benrashid
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Hanghang
H
Wang
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
James M
JM
Meza
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Asvin
A
Ganapathi
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Jeffrey G
JG
Gaca
Division of Cardiology, Duke Cardiovascular Magnetic Resonance Center, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Han W
HW
Kim
Department of Radiology, Duke University Medical Center, Durham, North Carolina.
Lynne M
LM
Hurwitz
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina. Electronic address: gchad.hughes@duke.edu.
G Chad
GC
Hughes
D000368:Aged; D001018:Aortic Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging*; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
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