SURGERY FOR AORTIC DISSECTION WITH INTIMAL TEAR IN THE TRANSVERSE AORTIC-ARCH

Objectives. This study reports surgical experience of 72 cases of aort ic dissection with intimal tear in the transverse aortic arch. Methods . Of 335 patients with aortic dissection, 72 (22.2%) had a tear in the arch, including 27 with acute dissection and 45 with chronic dissecti on, Mean age at surgery was 60.8+/-14.1 years, The dissection was loca lized from the ascending aorta to the arch in 30 patients and extensiv e from the ascending aorta to the descending aorta in 42. Surgeries co nsisted of total arch replacement in 50 patients, hemiarch replacement in 20, and extra-anatomical bypass in 1. In the initial series, cardi opulmonary bypass for brain protection during arch procedures was sele ctive cerebral perfusion (61 patients), but since July 1993 deep hypot hermic circulatory arrest with retrograde cerebral perfusion was exclu sively utilized (8 patients). Results. Hospital mortality was 9.7%, 11 .1% of the patients who had acute dissection and 8.8% with chronic dis section, There has been no mortality since February 1993. The mean fol low-up period was 51+/-37 months, and there were 3 late deaths. The 5 and 10 year survival rate was 85.3+/-4.8 in all patients, 84.3+/-8.9% with acute dissection, and 85.5+/-5.7% with chronic dissection. The 5 and 10 year survival was 79.8+/-7.1 with extensive dissection, and 93. 5+/-6.5% with localized dissection, During follow-up, 6 patients under went subsequent aortic surgeries, The freedom from reoperation at 5 ye ars and at 10 years was 91.4+/-4.8% and 65.6+/-14.4%, respectively. In patients with acute dissection it was 92.3+/-7.4% and 61.5+/-25.6% at 5 years and 10 years; while with chronic dissection it was 87.0+/- 7. 0% and 44.0+/-17.3% at 5 years and 10 years, respectively (n.s.). The freedom from subsequent reoperation for the aorta in all patients was 91.4+/-4.8% at 5 years and 10 years was 65.6+/-14.4%. With acute disse ction it was 92.3+/-7.4% at 5 years and 61.5+/-25.6% at 10 years, whil e that with chronic dissection it was 91.3+/-5.9% and 65.7+/-16.8% at 5 years and 10 years respectively (n.s.). The freedom from all reopera tions with extensive dissection at 5 years and 10 years was 86.6%+/-7. 2% and 34.2+/-17.3%, respectively, moreover, the freedom fro tn reoper ations with localized dissection at 5 and at 10 years was 90.0+/-9.5% (n.s.). However, the freedom from subsequent aorta reoperation with ex tensive dissection at 5 years and 10 years was 86.6+/-7.2% and 56.0+/- 16.0%, respectively, while with localized dissection it was 100% at 10 years (P<0.01). Conclusion. Early and]ate surgical result for arch di ssection was satisfactory with a surgical principle of resecting the a ortic segment that contains the initial intimal tear and graft replace ment.