AORTIC DISSECTION - PREVALENCE, CAUSE, AND RESULTS OF LATE REOPERATIONS

From January 1977 to September 1992, 143 patients underwent an emergen cy operation for type A acute aortic dissection. Because of the locati on of the intimal tear, the replacement of the ascending aorta was ext ended to the transverse arch in 42 patients (29.3%). One hundred ten p atients (78%) survived the operation. During the same period, 32 patie nts had to be reoperated on once (n = 24) twice (n = 6), or three time s (n = 2) for a total of 42 reoperations. Nineteen patients had had th e initial repair in our institution, and 13 had been operated on elsew here. Reoperation was indicated for aortic valve disease (n = 4), recu rring dissection (n = 7) threatening aneurysmal evolution of a persist ing dissection (n = 28), or false aneurysm (n = 3). The redo procedure involved the aortic root and/or ascending aorta in 15 cases (group I) , the transverse arch alone in 7 cases (group II), the transverse arch and the descending aorta or the descending aorta alone in 10 cases (g roup III), or the thoracoabdominal aorta in 10 cases (group IV). The r isk factors for reoperation have been analyzed in the 110 survivors in itially operated on in our institution. Seven of 18 patients with Marf an's syndrome (38.8%) versus 12 of 92 without Marfan's syndrome (13%) were reoperated on (p = 0.023), None of the 30 patients surviving arch replacement at initial repair required a reoperation, versus 19 of 80 (23.7%) patients surviving a replacement limited to the ascending aor ta (p = 0.013). The overall mortality rate of reoperation was 21.8% (7 /32) with a risk of 16.6% (7/42) at each procedure (group I, 13.3%; gr oup II, 0%; group III, 20%; group IV, 30%). Hospital mortality,vas inf luenced by emergency operation (5/10) (p < 0.005) and thoracoabdominal replacement (3/10) (p < 0.035). The late survivals after reoperation are 65.1% +/- 17.6% at 1 year and 55% +/- 19.63% at 5 years (Kaplan-Me ier, confidence interval 95%). The late survivals, after the initial r epair, of the patients undergoing reoperation are 89.6% +/- 11.0%, 79. 3% +/- 14.7%, 53.9% +/- 18.1%, and 35.9% +/- 21.8% at 1, 5, 10, and 12 years, respectively. In conclusion, aortic dissection is an evolving process that may require one or several reoperations after the initial repair. At initial emergency operation, the resection of the entry si te, when located on or extending to the transverse arch, has reduced t he risk of reoperation, in our experience, Elective reoperation must b e considered before the occurrence of complications, especially in pat ients with Marfan's syndrome. It entails a relatively low risk, except in case of thoracoabdominal replacement, and allows a satisfactory lo ng-term survival.