The Fate Of The Thoracoabdominal Aorta After Ascending Aortic Repair For Type A Aortic Dissection: Worse Than Previously Reported
Tomaz Mesar1, Christopher Barreiro2, Hosam F. El-Sayed1, Animesh Rathore1, David Dexter1, Jean M. Panneton1.
1eastern virginia medical school, Norfolk, VA, USA, 2Sentara Heart Hospital, Norfolk, VA, USA.
INTRODUCTION:Long-term disease progression of the descending thoracic and abdominal aorta in acute Debakey type I aortic dissection (DT1AD) is poorly understood and generally thought as needing low intervention rate after open ascending aortic repair (oAOR). We sought to determine disease progression of the distal aorta after oAOR and determine risk factors associated with disease progression.METHODS: We performed a retrospective chart review of all patients without connective tissue disorders treated with open repair of acute DT1AD from January 2008 to December 2018. CT measurements of aortic segments were performed preoperatively and postoperatively, then 3-6 months, 6-12 months, 1-2 years, 2-3 years, and 3-5 years. Primary endpoints were aortic adverse events or mortality (AREM): aortic enlargement of the descending thoracic (DTA) to at least 55 mm, aortic rupture, surgical intervention on the DTA. DTA/TL ratio was defined as the smallest cross-section diameter of the true lumen (TL) of the DTA divided by diameter of DTA.
RESULTS:We identified 128 patients with acute DT1AD; 124 underwent oAOR. Eight of these had also an intervention on the descending thoracic aorta for malperfusion. Of the 116 remaining patients, 102 survived to their discharge and 3-months follow-up was available for 99 patients. Twenty-one patients underwent delayed DTA repair (mean time to intervention 13.6±13.7 months), 4 patients
met criteria for repair but were never intervened upon and 2 patients died from DTA rupture, yielding an AREM of 27.3%. DTA enlargement was most significant within the first 6 months, increasing from 35.8±7.5mm to 40.5±8.7 mm at 3-6 months (p=0.003). Subsequent growth was small and peaked at 2-3 years. Change in perivisceral aorta was pronounced in the first 12 months, peaking at 2-3 years. There was no statistical change in infrarenal aorta average diameter. On multivariate analysis for risk factors for AREM, DTA diameter at 6 to 12 months most reliably predicted both need for DTA intervention (OR:1.200, 95%CI:1.058–1.251,p=0.004;AUROC=0.865,p<0.001) and aneurysmal degeneration (OR:1.370, 95%CI:1.117-1.680,p=0.003;AUROC=0.977,p<0.001). Lower DTA/TL ratio was associated with a higher need for intervention on DTA (OR: 37.797 95%CI:1.168–851.417,p=0.022). CONCLUSION:The rate of intervention and adverse events on the thoracoabdominal aorta after open DT1AD repair appears higher than previously reported. DTA diameter at 6-12 months and persistent true lumen compression of the DTA reliably predict worse outcomes.
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