LATE REOPERATIONS IN PATIENTS WITH AORTIC DISSECTION

Aortic dissection is an evolving process that may require one or sever al reoperations after the initial emergency repair. From January 1977 to September 1993, 148 patients underwent emergency surgery for type A acute aortic dissection. The replacement of the ascending aorta was e xtended to include the transverse arch in 43 patients (29%). One hundr ed fifteen patients (78%) survived surgery. During the same period, 37 patients required reoperation once (28), twice (7), or three times (2 ), for a total of 48 reoperations. Twenty-one patients had undergone i nitial repair in our institution; 16 patients had been operated on els ewhere. Reoperation was indicated for: aortic valve disease (4); a new dissecting process (7); threatening aneurysmal evolution of a persist ing dissection (34); or false aneurysm (3). The re-do procedure involv ed: the aortic root and/or ascending aorta in 12 cases (group I); the ascending aorta and the transverse arch in 6 cases (group II); the tra nsverse arch alone in 8 cases (group III); the transverse arch and des cending aorta, or the descending aorta alone in 11 cases (group IV); a nd the thoracoabdominal aorta in 11 cases (group V). Risk factors for reoperation were analyzed in the 115 survivors initially operated on a t our institution. Seven of 20 Marfan patients (35%) versus 12 of 95 n on-Marfan patients (12.6%) required reoperation (p < 0.02). None of th e 31 patients surviving arch replacement at initial repair required a reoperation, versus 21 of 84 (25%) patients surviving replacement limi ted to the ascending aorta (p < 0.01). The overall mortality rate of r eoperation was 18.9% (7/37), with a risk of 14.5% (7/48) at each proce dure (group I 8.3%, group II 0%, group III 20%, group IV 18%, group V 27%). Hospital mortality was influenced by whether the operation was d one as an emergency (5/10) (p < 0.005), and whether thoracoabdominal r eplacement was required (3/11) (p < 0.03). The late survival rate afte r reoperation is 67.1% +/- 17.6% at 1 year, and 57% +/- 19.6% at 5 yea rs (Kaplan-Meier Cl 95%). The late survival rate, after initial repair , of reoperated patients is 89.6% +/- 11.0% at 1 year, 79.3% +/- 14.7% at 5 years, 53.9% +/- 18.1% at 10 years, and 35.9% +/- 21.8% at 12 ye ars. In conclusion, elective reoperation should be considered before t he occurrence of complications, especially in patients with Marfan syn drome. It entails a relatively low risk, except in the case of thoraco abdominal replacement, and allows satisfactory long-term survival. In our experience, resection of the entry site at initial emergency opera tion, when it is located on or extends to the transverse arch, reduces the incidence of reoperation.