Surgery for acute type a aortic dissection: comparison of techniques

Objective: In order to determine the optimal surgical strategy for acute as cending aortic dissection, the graft inclusion technique was compared with the open resection technique. Methods: Between 1985 and 1995 a consecutive series of 193 patients (77% male, mean age 58 years) had emergency surgery during a mean interval of 13.2 h after onset of symptoms. Graft replacement of the ascending aorta was performed in all patients (supracoronary graft 143/193 = 74%, aortic root replacement 50/193 = 26%, aortic valve replaceme nt 73/193 = 38%, arch replacement 44/193 = 20%) The open resection techniqu e was applied in 93 patients and the inclusion technique in 100 patients wi th a Cabrol-shunt in 26%. Preoperative risk factors were equally distribute d between groups (inclusion technique vs. open technique): left ventricular ejection fraction < 45% (13 vs. 2%, not significant (n.s)), neurological d eficit (31 vs. 25%; n.s.), systolic blood pressure < 90 mmHg (20 vs. 15%, n .s.) pericardial tamponade (25 vs. 9%, n.s.), renal failure (6 vs. 4%; n.s. ). Results: The overall early mortality was 24%. Following graft inclusion it was 31% compared with 16% in the open technique group (P = 0.0154). Post operative complications (graft inclusion vs. open technique): myocardial in farction (9 vs. 12%, n.s.), low cardiac output (40 vs. 32%, n.s.), reexplor ation for hemorrhage (23 vs. 25%, n.s.). Survival at 8 years was significan tly increased in the open technique group (P = 0.0300). Pseudoaneurysm form ation occurred in 3% of patients and only after graft inclusion. Freedom fr om reoperation was 80% at 8 years and did not differ between groups. Graft inclusion was an independent significant predictor of early (P = 0.0069; re lative risk = 2.3673) and late mortality (P = 0.0119; relative risk = 2.098 1). Conclusions: Surgery of acute ascending aortic dissection still carries a considerable early mortality whereas the late outcome is satisfactory. T he open resection technique is the method of choice showing superior early and late results and avoiding pseudoaneurysm formation. The inclusion techn ique may be indicated in situations with increased risk of bleeding. A cons equent decompression of the perigraft-space could reduce the rate of pseudo aneurysms. (C) 2000 Elsevier Science B.V. All rights reserved.