Extended total arch replacement for acute type a aortic dissection: Experience with seventy patients

Objective: We sought to report the clinical experience with extended total arch replacement for acute type A aortic dissection and to determine the fa ctors that influence early mortality, late survival, and late reoperation. Methods: Between December 1988 and August 1998, 70 patients underwent emerg ency graft replacement of both the ascending aorta and the total aortic arc h for acute type A aortic dissection. All operations were performed with hy pothermic extracorporeal circulation, selective cerebral perfusion for cere bral protection during aortic arch repair, and open distal anastomosis. Con comitant procedures included aortic valve resuspension in 18 patients, comp osite graft replacement in 10 patients, and coronary artery bypass grafting in 5 patients. Results: The early mortality rate was 16% (11 of 70 patient s). Multivariable analysis showed that renal-mesenteric ischemia and corona ry artery bypass grafting were independent determinants for early death. Su rvival rates at 3 and 5 years postoperatively, including the early deaths, were 75% +/- 5% and 73% +/- 6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were independent determi nants for late death. Freedom from reoperation was 91% +/- 4% and 77% +/- 8 % at 3 and 5 Sears, respectively, Multivariable analysis showed that anasto motic leakage was the only significant determinant for late reoperation. Co nclusions: Extended total arch replacement for acute type A aortic dissecti on could be justified in properly selected patients.