Distal Reoperations after Repair of Acute Type A Aortic Dissection-Incidence, Causes and Outcomes

Background and aim of the study: In patients with acute type A aortic dissection (A-AAD) whether initial repair should include also aortic arch replacement is still debated. We aimed to assess if extensive aortic repair prevents from reoperations patients with A-AAD.

Methods: Outcomes after distal reoperation following repair of A-AAD (n = 285; 1977 to 2018) were analysed in 22 of 226 who underwent ascending aorta/hemiarch replacement (Group $1^{\text{R}}$ ) and 7 of 59 who had ascending aorta/arch replacement (Group $2^{\text{R}}$ ).

Results: Distal reoperation was more common in Group $1^{\text{R}}$ (n = 22) than in Group $2^{\text{R}}$ (n = 0) (p $<$ 0.001) while thoracic endovascular stenting was more frequent in Group $2^{\text{R}}$ (7 vs 3, p $<$ 0.001). Indications for reoperation were pseudoaneurysm at distal anastomosis (n = 4, 18%) and progression of aortic dissection (n = 18, 82%) in Group $1^{\text{R}}$ . Indication for thoracic endovascular stenting was progressive aortic dissection in 3 patients of Group $1^{\text{R}}$ and in 6 of Group $2^{\text{R}}$ . Second reoperation was required in 2 patients from Group $1^{\text{R}}$ (2%) during a mean follow-up of 5 years. Median follow-up was 4 years in Group $1^{\text{R}}$ and 7 years in Group $2^{\text{R}}$ (p = 0.36). Hospital mortality was 14% in Group $1^{\text{R}}$ and 0% in Group $2^{\text{R}}$ (p = 0.3). Actuarial survival is 68 $\pm$ 10%, and 62 $\pm$ 11% for Group $1^{\text{R}}$ and 100% for Group $2^{\text{R}}$ at 5 and 10 years (p = 0.076).

Conclusions: Distal reoperations after A-AAD repair have an acceptable mortality. An extensive initial repair has lower rate of reoperation and better mid-term survival and should be indicated especially for young patients in experienced centers.