Does Operative Technique of Performing Distal Anastomosis in

Acute type A Dissection Affect Early And Late Clinical Outcomes?

Does Operative Technique of Performing Distal Anastomosis in

Acute type A Dissection Affect Early And Late Clinical Outcomes?

Sotiris C. Stamou, MD, Ph.D, Nicholas T. Kouchoukos, MD, Robert C. Hagberg, MD, Kamal Khabbaz, MD, Robert M.

Stiegel, MD, Mark K. Reames, MD, Eric Skipper, MD, Marcy Nussbaum, MS, Francis Robicsek, MD, Kevin W. Lobdell, MD

Divisions of Thoracic and Cardiovascular Surgery Missouri Baptist Medical Center, St. Louis, MO

Beth Israel Deaconness Medical Center, Harvard Medical School, Boston, MA

Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC

Sotiris C. Stamou, MD, Ph.D, Nicholas T. Kouchoukos, MD, Robert C. Hagberg, MD, Kamal Khabbaz, MD, Robert M.

Stiegel, MD, Mark K. Reames, MD, Eric Skipper, MD, Marcy Nussbaum, MS, Francis Robicsek, MD, Kevin W. Lobdell, MD

Divisions of Thoracic and Cardiovascular Surgery Missouri Baptist Medical Center, St. Louis, MO

Beth Israel Deaconness Medical Center, Harvard Medical School, Boston, MA

Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC

Objective Objective

To evaluate the early and late clinical outcomes of two different surgical techniques for repair of acute type A dissection:

1. open distal anastomosis under deep hypothermic circulatory arrest (DHCA) and

2. distal aortic clamping on moderate hypothermic cardiopulmonary bypass (ACPB)

To evaluate the early and late clinical outcomes of two different surgical techniques for repair of acute type A dissection:

1. open distal anastomosis under deep hypothermic circulatory arrest (DHCA) and

2. distal aortic clamping on moderate hypothermic cardiopulmonary bypass (ACPB)

Acute Aortic Dissection Acute Aortic Dissection Type A (Stanford)Type A (Stanford)

Inspection of the arch for Inspection of the arch for additional intimal tearadditional intimal tear

Yes Yes

Patient Patient ExclusionExclusion

No No

Study Study GroupGroup

DHCA DHCA (n=82)(n=82)

ACPB ACPB (n=42)(n=42)

Preoperative CharacteristicsPreoperative Characteristics

DHCA ACPB P

N (n=82) (n=42)

Females 35% 29% 0.55

Diabetes 10% 5% 0.49

Hypertension 83% 81% 0.81

Renal Failure 15% 3% 0.06

Instability 21% 10% 0.18

DHCA ACPB P

N (n=82) (n=42)

Females 35% 29% 0.55

Diabetes 10% 5% 0.49

Hypertension 83% 81% 0.81

Renal Failure 15% 3% 0.06

Instability 21% 10% 0.18

Operative Characteristics IOperative Characteristics I

DHCA ACPB P

N (n=82) (n=42)

CABG 17% 21% 0.63

Aortic Valve Procedure

Resuspension 58% 68% 0.33

Replacement 17% 5% 0.09 Composite root 6% 19% 0.06 Nothing 19% 7% 0.11

DHCA ACPB P

N (n=82) (n=42)

CABG 17% 21% 0.63

Aortic Valve Procedure

Resuspension 58% 68% 0.33

Replacement 17% 5% 0.09 Composite root 6% 19% 0.06 Nothing 19% 7% 0.11

Operative Characteristics IIOperative Characteristics IIDHCA ACPB P

N (n=82) (n=42)Arterial Cannulation

Axillary a 16% 10% 0.70 Femoral a 76% 83% Other 8% 7%ACP 22% ------RCP 10% ------Circ Arrest Time 23+15 <1min <0.001

(Mean/SD)

DHCA ACPB PN (n=82) (n=42)Arterial Cannulation

Axillary a 16% 10% 0.70 Femoral a 76% 83% Other 8% 7%ACP 22% ------RCP 10% ------Circ Arrest Time 23+15 <1min <0.001

(Mean/SD)

(ACP= Antegrade cerebral perfusion, RCP= retrograde cerebral perfusion)

Postoperative CharacteristicsPostoperative Characteristics

DHCA ACPB PN (n=82) (n=42)Reop for Bleeding 20% 34% 0.16Renal Failure 20% 19% 0.99Atrial Fibrillation 27% 36% 0.31Stroke 16% 24% 0.33Length of Stay 16+13 18+15 0.68Operative mortality 17% 21% 0.63

DHCA ACPB PN (n=82) (n=42)Reop for Bleeding 20% 34% 0.16Renal Failure 20% 19% 0.99Atrial Fibrillation 27% 36% 0.31Stroke 16% 24% 0.33Length of Stay 16+13 18+15 0.68Operative mortality 17% 21% 0.63

Time to Death (in years)

1.0

0.8

0.7

0.52 4 5

Freedom from Death at 5 YearsD

eath

Fre

e P

rob

abil

ity

Log Rank p = 0.99

30 day 1 year 2 years 3 years 4 years 5 years

DHCA (N=42) 34 (81%) 31 (74%) 31 (74%) 31 (74%) 31 (74%) 31 (74%) ACPB (N=82) 67 (82%) 62 (76%) 61 (74%) 60 (73%) 60 (73%) 60 (73%)

0.6

1 3

0.9

DHCAACPB

ConclusionConclusion

• No significant differences in operative mortality, major morbidity and actuarial 5-year survival were observed between DHCA and ACPB.

• However, there are some practical technical advantages if the distal anastomosis is performed with an open manner

• More studies are required to determine the fate of the false lumen and the incidence of dissecting aneurysms with the two techniques.

• No significant differences in operative mortality, major morbidity and actuarial 5-year survival were observed between DHCA and ACPB.

• However, there are some practical technical advantages if the distal anastomosis is performed with an open manner

• More studies are required to determine the fate of the false lumen and the incidence of dissecting aneurysms with the two techniques.