Abstract 3540: Evolving Surgery for Acute A Aortic Dissection Using Selective Cerebral Perfusion and with Aggressive Total Arch Repair
Objectives: To assess our current surgical strategy for acute type A aortic dissection (AAAD).
Methods: Between 1997 and 2006, 137 patients underwent emergency surgery for AAAD. For 92 patients since 2001, has been applied the following current strategy;
routine adjunct of right axillary artery perfusion in conjunction with femoral artery perfusion for establishment of cardiopulmonary bypass,
brain protection using selective antegrade cerebral perfusion with profound or moderate hypothermia,
prompt attempt of extended total arch replacement with a modified elephant trunk procedure at the distal anastomosis for secure anastomosis and early closure of the false channel.
The primary purpose of the surgery was for resection of the intimal tear. Extended total arch replacement with individual arch-vessel reconstruction was then carried out according to the following settings; A) with the intimal tear on the transverse arch or the proximal descending aorta, B) with massive arch dissection, C) with Marfan syndrome. The outcome of recent consecutive 92 patients since 2001was compared with that of the other 45 patients before 2001. Forty-nine (53.3%) of the recent 92 patients were in shock status due to cardiac tamponade/rupture or coronary malperfusion. The incidence of total arch replacement was 56.5% since 2001, while 42.2% before 2001 (P= 0.001). Concomitant aortic root surgeries were carried out in 3 patients (6.7%, composite graft replacement in all) before 2001 and in 9 patients (9.8%, composite graft replacement in 3 and valve sparing in 6) since 2001.
Results: In the recent series since 2001, only two patients died from low cardiac output syndrome, who had developed cardiac arrest preoperatively due to rupture or left coronary artery malperfusion. The mortality rate was 2.2%, which significantly improved compared with 17.8% before 2001 (p= 0.0007). Of 92 patients, no late death was found and 3 patients required redo surgery for proximal anastomosis stenosis in 1 and pseudoaneurysm in 2 patients.
Conclusions: Current surgical strategy including selective cerebral perfusion with right axillary artery perfusion and prompt extended total arch replacement can provide stable outcome in emergency surgery for AAAD.