Acute type A dissection without intimal tear in arch: Proximal or extensive repair?

Objective: For acute type A dissection without an intimal tear in the arch, the optimal surgical strategy is unknown. The present study was designed to clarify the issue by comparing the early and late outcomes of proximal (PR) and extensive repair (ER).Methods: From January 2002 to June 2010, 331 patients with acute type A dissection were treated surgically at our institute. Of these 331 patients, 197 were identified without an arch tear on the preoperative imaging examination and by intraoperative inspection. Of these 197 patients, 74 underwent proximal repair, including the aortic root, ascending aortic, or hemiarch repair, and 88 underwent extensive repair, including proximal repair, total arch replacement and a stented elephant trunk technique. The perioperative variables and late results were statistically analyzed.Results: No significant difference was found in the rates of early mortality and morbidity between the 2 groups, despite the shorter duration of circulatory arrest in the PR group. During long-term follow-up (mean, 55.7 +/- 33.1 months; maximum, 129), the overall survival rate in the whole cohort was 100%, 90.8%, and 71.1% at 1, 5, and 8 years, respectively. No difference was found in survival between the 2 groups (P > .05). However, complete thrombosis of the false lumen in the proximal descending aorta was achieved in 100% of the ER group and 24.6% of the PR group (P < .001). For patients with a patent false lumen in the PR group, distal anastomosis leakage and unclosed small intimal tears were identified in 53.3% and 35.6% patients, respectively. The reintervention rate was also lower in the ER group than in the PR group (4.9% vs 15.9%, P < .05) during follow-up. Moreover, the reintervention rate for patients with Marfan syndrome was 9.5% in the ER group and 38.5% in the PR group (P < .05).Conclusions: For patients with acute type A dissection without an intimal tear in the arch, extensive repair could promote the occlusion of distal false lumen and decrease the reintervention rate without increasing the operative risk.

目的：对于弓部无内膜撕裂的急性A型夹层，最佳手术策略尚不明确。本研究旨在通过比较近端修复（PR）和广泛修复（ER）的早期和晚期结果来阐明这一问题。 方法：2002年1月至2010年6月，我院对331例急性A型夹层患者进行了手术治疗。在这331例患者中，通过术前影像学检查和术中探查确定197例无弓部撕裂。在这197例患者中，74例接受了近端修复，包括主动脉根部、升主动脉或半弓修复，88例接受了广泛修复，包括近端修复、全弓置换和带膜支架象鼻技术。对围手术期变量和晚期结果进行了统计学分析。 结果：尽管PR组体外循环阻断时间较短，但两组早期死亡率和发病率无显著差异。在长期随访期间（平均55.7±33.1个月；最长129个月），整个队列在1年、5年和8年的总体生存率分别为100%、90.8%和71.1%。两组生存率无差异（P>0.05）。然而，近端降主动脉假腔完全血栓形成在ER组为100%，在PR组为24.6%（P<0.001）。对于PR组假腔仍通畅的患者，分别有53.3%和35.6%的患者存在远端吻合口漏和未闭合的小内膜撕裂。随访期间ER组再次干预率也低于PR组（4.9%对15.9%，P<0.05）。此外，马凡综合征患者的再次干预率在ER组为9.5%，在PR组为38.5%（P<0.05）。 结论：对于弓部无内膜撕裂的急性A型夹层患者，广泛修复可促进远端假腔闭塞，降低再次干预率，且不增加手术风险。