Emergency Surgery for Acute Type A Aortic
Dissection in Octogenarians
Motomi Shiono, MD, PhD, Mitsumasa Hata, MD, PhD, Akira Sezai, MD, PhD,
CARDIOVASCULAR
Mitsuru Iida, MD, PhD, Shinya Yagi, MD, PhD, and Nanao Negishi, MD, PhD
Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
Background. Emergency surgery for acute type A dis-
section is associated with a high mortality rate in aged
patients. This study was designed to explore periopera-
tive risk factors and prognosis in octogenarians with
acute type A aortic dissection.
Methods. Twenty-four octogenarians, of 134 consecu-
tive patients with acute type A dissection between 1995
and 2005 who underwent emergency surgery, were re-
viewed. The median age was 82 years (80 to 90); the
patients were 10 men and 14 women. All 24 patients
underwent conservative tear-oriented surgery under
deep hypothermic circulatory arrest with cerebral perfu-
sion; the procedures were 23 ascending aortic replace-
ments and one entire arch replacement.
Results. The hospital mortality rate was 13% (3 of 24
patients), without statistical significance compared with
6% in patients younger than 80 years. The late mortality
A cute type A aortic dissection is a lethal aortic disease
with an extremely poor prognosis unless surgical
intervention is performed in a timely manner. Many pre-
dictors of death have been evaluated for patients in acute
aortic dissection with or without surgery [1 4]. Most studies
indicate that older age is a risk determinant of early death
[2, 4 6]. With progressive aging of the population, many
physicians are increasingly faced with this medical emer-
gency in these high-risk patients. Controversy still exists as
to whether surgical intervention should be avoided in
elderly patients who have little chance of survival. How-
ever, recent progress in emergency surgery for acute aortic
dissection has resulted in a significant decline in operative
and hospital mortality. This study was undertaken to ana-
lyze a consecutive series of patients aged 80 years or older
with acute type A aortic dissection, aiming to improve
outcome in these high-risk patients, with a comparison to
younger patients.
Patients and Methods
Patients
Twenty-four consecutive patients aged 80 years or older,
who underwent emergency surgery for acute type A
Accepted for publication Dec 13, 2005.
Address correspondence to Dr Shiono, Department of Cardiovascular
Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-
kamimachi, Itabashi-ku, Tokyo 173-8610, Japan; e-mail: mshiono@
med.nihon-u.ac.jp.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
rate was 38% (9 of 24 patients), with significance com-
pared with 9% in the other patients. Five- and 10-year
survivals ware 55% and 42%, respectively, compared
with 83% and 73%, respectively (p 0.0013), in the other
patients. Univariate and multivariate analysis demon-
strated that age 80 or greater was not an independent risk
factor of hospital death. Risk factors of late death in
younger-aged patients were pneumonia and reoperation.
Conclusions. Emergency surgery for octogenarians
with acute type A aortic dissection was successfully
performed using a conservative intimal tear-oriented
procedure, resulting in satisfactory early and late sur-
vival. Aggressive surgical treatment is mandatory for
improving the outcome of this medical emergency in
octogenarians.
(Ann Thorac Surg 2006;82:554 9)
2006 by The Society of Thoracic Surgeons
aortic dissection at our institution from July 1995 to June
2005, were reviewed retrospectively and compared with
patients younger than 80 years. Institutional review
board approval was provided before publication of this
manuscript and report of the information. The older
patients represented 17.9% of a total of 134 consecutive
patients who underwent emergency surgery for acute
type A aortic dissection in the same period. Forty-one
octogenarians who presented with acute type A dissec-
tions were observed during the same period. Ten pa-
tients were not offered surgery because the false channel
revealed thrombosed occlusion without pericardial effu-
sion or tamponade. Seven patients refused surgery be-
cause of age or concomitant disease, and 6 patients died
in hospital. None of the patients younger than 80 years
refused operation. After obtaining the informed consent,
all of the operations were performed within 72 hours of
onset, with a mean of 16.5 hours after onset. One hun-
dred eleven patients (82%) were operated on within 24
hours after onset, 13 patients (10%) between 24 and 48
hours, and 9 patients (8%) between 48 and 72 hours. The
clinical characteristics and perioperative variables of the
older patients, consisting of 10 men and 14 women, are
presented in Table 1. Their age ranged from 80 to 90
years, with a mean of 82.0 years. Pain in the chest and
back was the common presenting symptom. Computed
tomography scan and echocardiography were the com-
mon diagnostic modalities before emergency surgery.
When the false channel revealed thrombosed occlusion,
the operation was postponed, unless pericardial effusion
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.12.048
Ann Thorac Surg SHIONO ET AL 555
2006;82:554 9 TYPE A DISSECTION IN OCTOGENARIANS

Table 1. Patient Characteristics, Surgery Data, and was not detected. When the diagnosis was confirmed by
Postoperative Data these diagnostic modalities, the patient was transferred
80 Years 80 Years
to the operating room as soon as possible.
Variable (n 24) (n 110) p Value

CARDIOVASCULAR
Clinical characteristics Surgery and Follow-Up
Age (y) 82.0 2.4 61.9 12.6 0.0001 Cardiopulmonary bypass was initiated by means of
Gender: female 14 (58.3%) 58 (52.7%) 0.61 femorofemoral cannulation for patients in preoperative
DeBakey shock. After a median sternotomy was performed, a
Type I 16 (66.7%) 79 (71.8%) 0.61 venous cannula was inserted through the right atrium, in
Type II 7 (29.2%) 25 (22.7%) 0.50 the cases with stable hemodynamic condition. In all of
Type III 1 (4.2%) 6 (5.5%) 0.63 the patients of both age groups, deep hypothermic cir-
Marfan syndrome 0 8 (7.3%) 0.20 culatory arrest and antegrade selective cerebral perfu-
Smoking 8 (33.3%) 53 (48.2%) 0.19 sion were used, and the heart was arrested with cold
Hypertension 23 (95.8%) 96 (87.2%) 0.20
crystalloid cardioplegia. Under deep hypothermia less
CAD 4 (16.7%) 8 (7.2%) 0.14
than 20C, the aortic segment that included the intimal
tear was resected. Gelatin-resorcin-formalin glue was
Aortic valve 4 (16.7%) 33 (30.0%) 0.14
regurgitation applied to both the proximal and distal dissected ends of
Thrombosed 6 (25.0%) 27 (24.5%) 0.96 the false lumen, and then the glued stumps were rein-
occlusion forced with felt strips, and the resected aorta was re-
Temporary ischemic 6 (25.0%) 18 (16.4%) 0.32 placed with a presealed woven polyethylene terephtha-
attack late fiber (Dacron) graft (Boston Scientific, Inc, Natick,
Stroke 2 (8.3%) 10 (9.1%) 0.64 MA). Antegrade arterial circulation was established
Unconsciousness 3 (12.5%) 6 (5.5%) 0.20 through a side branch of the Dacron graft, after comple-
Tamponade 11 (45.8%) 46 (41.8%) 0.72 tion of an open distal anastomosis. In cases in which the
Cardiopulmonary 2 (8.3%) 2 (1.8%) 0.15 intimal tear could not be found, only ascending aortic
resuscitation replacement was performed to avoid serious
ECG change 1 (4.2%) 8 (7.3%) 0.49 complications.
Limb ischemia 1 (4.2%) 2 (1.8%) 0.45 We examined the patients at our outpatient clinic or
Visceral ischemia 1 (4.2%) 0 0.18 contacted the physicians treating them for follow-up. The
Surgery data retrospective postoperative follow-up rate was 100% for
Ascending/hemiarch 23 (95.8%) 82 (74.5%) 0.01 up to 10 years (419.7 patient-years).
replacement
Entire arch 1 (4.2%) 28 (25.5%) 0.01
replacement Statistical Analysis
Concomitant 1 (4.2%) 18 (16.4%) 0.09 Statistical analysis was performed with StatView soft-
procedure ware (SAS Institute Inc, Cary, NC). All pertinent periop-
Root replacement 0 9 (8.2%) 0.16 erative risk factors for death were examined by 2 test or
CABG 1 (4.2%) 8 (7.3%) 0.49 Fishers exact test, as appropriate; continuous variables
AVR/AVP 0 2 (1.8%) 0.67 were examined by Students t test, and the results were
No entry resection 1 (4.2%) 10 (9.1%) 0.68 expressed as percentage and the mean standard devi-
Cardiopulmonary 185 35.2 218 60.1 0.02 ation, respectively. Univariate analysis was followed by
bypass multiple logistic regression to determine independent
time (min)
risk factors. Actuarial survival and freedom rates from
Myocardial ischemic 112 34.1 137 50.6 0.06 events were calculated by the KaplanMeier method, and
time (min)
the log-rank test (MantelCox test) was used for compar-
Postoperative data and
morbidity ison between the two age groups. A value of p less than
Reexploration 3 (12.5%) 6 (5.5%) 0.20 0.05 was considered statistically significant.
Postoperative stroke 2 (8.3%) 8 (7.3%) 0.57
Postoperative 4 (16.7%) 8 (7.3%) 0.14
pneumonia Results
Tracheostomy 1 (4.2%) 9 (8.2%) 0.43
Patients and Surgery Data
Postoperative 3 (12.5%) 16 (14.5%) 0.55
hemodialysis The two age groups (80 years or older, and younger than
Hospital stay (days) 32.2 16.0 33.4 19.9 0.83 80 years) examined were not significantly different from
Hospital death 3 (12.5%) 6 (5.5%) 0.20 each other with respect to the majority of perioperative
False lumen: open 3 (12.5%) 20 (18.2%) 0.56 variables, except for age, the extent of aortic replacement,
Reoperation 0 8 (7.3%) 0.35 and cardiopulmonary bypass time. Although the hospital
Late death 9 (37.5%) 10 (9.1%) 0.0003 mortality rate (3 of 24 patients; 13%) was not statistically
different, the late mortality rate (9 of 24 patients; 38%) and
AVP aortic valvuloplasty; AVR aortic valve replacement;
CABG coronary artery bypass grafting; CAD coronary artery
disease; ECG electrocardiogram.
 556 SHIONO ET AL Ann Thorac Surg
TYPE A DISSECTION IN OCTOGENARIANS 2006;82:554 9

the two age groups were significantly different (p

0.0004).
Major events, including late deaths, occurred in 25
patients after discharge from the hospital, in both
groups of patients. In the older patients, all of such
CARDIOVASCULAR

major events, including pneumonia (3 patients), spon-

taneous death by senility (2 patients), stroke (1 pa-
tient), cancer (1 patient), arrhythmia (1 patient), and
ileus (1 patient), were lethal. In the younger patients,
10 deaths and eight reoperations occurred during fol-
low-up. Reoperations were performed because of en-
largement of the distal false lumen in 5 patients,
enlargement of the aortic root in 2 patients, and aortic
valve regurgitation in 1 patient.

Actuarial Survival and Event-Free Rates

Actuarial survival rates (including hospital mortality) of
the older patients at 5 and 10 years after surgery were
Fig 1. Actuarial survival curve for the two age groups (80 years or
older, and younger than 80 years) after emergency surgery for acute 55% and 42%, respectively. In the younger patients,
type A aortic dissection. actuarial survival rates at 5 and 10 years were 83%, and
73%, respectively. Log-rank test indicated a significant
difference in the actuarial survival rates between the two
groups (p 0.0013). The actuarial survival curves for the
nonvascular-related mortality (6 of 24 patients; 25%) were two groups are shown in Figure 1.
significantly worse in the older age group (p 0.0003 and Actuarial event-free rates at 5 and 10 years after
0.0001, respectively). surgery were 55% and 41%, respectively, in the older
In the older patients, the operation was mostly limited patients, and 78% and 48%, respectively, in the younger
to replacement of the ascending or hemiarch aorta in 23 patients. Log-rank analysis indicated a significant differ-
patients (96%), and entire replacement of the aortic arch ence in the actuarial freedom rates between the two
was necessary in 1 patient (4%), although replacement of groups (p 0.017). The event-free curves for the two
the entire aortic arch was performed in 28 patients (26%) groups are shown in Figure 2.
in the younger patients (p 0.03). Cardiopulmonary
bypass time was shorter in the older patients (p 0.02). Risk Factor Analysis on Hospital and Late Mortality
There were no significant differences in concomitant In the older patients, univariate and multivariate anal-
procedures, impossible entry resection, and myocardial ysis of perioperative risk factors demonstrated no
ischemic time (Table 1). independent factors that were associated with hospital
mortality (Table 2). In the younger patients, the inde-
Mortality and Events pendent risk factor was postoperative hemodialysis (p
The hospital mortality rate was 13% (3 of 24 patients) in
the older patients; causes of deaths were multiple-
organ failure (2 patients) and pneumonia (1 patient).
The hospital mortality rate in the younger patients was
6% (6 of 110 patients); their causes of death were low
cardiac output syndrome (2 patients), multiple-organ
failure (1 patient), hepatic failure (1 patient), bleeding
(1 patient), and pulmonary hypertensive crisis (1 pa-
tient). There was no significant difference in the hos-
pital mortality between the two age groups (p 0.36).
The late mortality rate in the older patients was 38% (9
of 24 patients) after discharge from the hospital. The
causes of late deaths were pneumonia (3 patients),
spontaneous death by senility (2 patients), stroke (1
patient), gallbladder cancer (1 patient), arrhythmia (1
patient), and ileus (1 patient). The causes of deaths in
the younger patients were reoperation (2 patients),
mediastinitis (1 patient), stroke (1 patient), pancytope-
nia (1 patient), pneumonia (1 patient), rupture of the
thoracic aorta (1 patient), sepsis (1 patient), rupture of Fig 2. Event-free curve for the two age groups (80 years or older,
an abdominal aortic aneurysm (1 patient), and spinal and younger than 80 years) after emergency surgery for acute type A
cord tumor (1 patient). The late mortality rates between aortic dissection.
Ann Thorac Surg SHIONO ET AL 557
2006;82:554 9 TYPE A DISSECTION IN OCTOGENARIANS

Table 2. Univariate Analysis on Hospital Death

Age 80 (n 24) Age 80 (n 110)

Variable Death (n 3) Alive (n 21) p Value Death (n 6) Alive (n 104) p Value

CARDIOVASCULAR
Age (y) 81.6 4.3 81.9 6.1 0.57 62.0 10.6 61.7 12.7 0.47
Sex: female 3 11 0.18 3 58 0.55
DeBakey type I 2 14 0.75 4 77 0.81
Marfan syndrome 0 0 - 0 8 0.63
Thrombosed 0 6 0.40 1 26 0.54
Tamponade 2 9 0.43 2 44 0.51
Aortic regurgitation 1 3 0.44 2 31 0.58
Resuscitation 1 1 0.24 1 1 0.11
Stroke 1 1 0.24 1 9 0.44
Unconsciousness 1 2 0.34 1 6 0.33
Renal failure 0 0 - 0 2 0.89
Arch replacement 0 1 0.88 2 26 0.48
Root replacement 0 0 - 0 9 0.59
Entry resection 3 20 0.88 5 95 0.91
Postoperative stroke 0 2 0.76 1 8 0.41
Postoperative dialysis 1 2 0.34 3 13 0.03
CPB time (min) 178 13 187 37 0.81 218 85 220 62 0.52
Anoxic time (min) 118 15 112 35 0.40 141 59 139 54 0.47

CPB cardiopulmonary bypass.

0.04; odds ratio, 1.98; 95% confidence interval, 1.02 to
35.4). In the older patients, the independent risk factor
that was associated with late mortality was female sex
(p 0.04; odds ratio, 2.10; 95% confidence interval, 1.18
to 122.3; Table 3). In the younger patients, postopera-
tive pneumonia (p 0.0007; odds ratio, 3.41; 95%
confidence interval, 3.54 to 108.2) and reoperation (p
0.0007; odds ratio, 3.54; 95% confidence interval, 4.09 to
134.7) were independent risk factors associated with
late mortality.

Table 3. Univariate Analysis on Late Death

Age 80 (n 21) Age 80 (n 104)

Variable Dead (n 9) Alive (n 12) p Value Dead (n 10) Alive (n 94) p Value

Age (y) 82.6 3 81.5 2.5 0.17 59.8 14.5 61.9 12.6 0.69
Sex: female 8 3 0.006 6 50 0.68
DeBakey type I 6 8 0.68 8 68 0.24
Marfan syndrome 0 0 - 2 6 0.17
Thrombosed 3 3 0.52 2 24 0.52
Tamponade 3 6 0.38 4 40 0.58
Aortic regurgitation 2 1 0.39 4 27 0.34
Resuscitation 1 0 0.43 1 0 0.09
Stroke 0 1 0.57 2 6 0.17
Unconsciousness 2 0 0.17 1 5 0.46
Renal failure 0 0 - 0 2 0.82
Arch replacement 0 0 - 3 23 0.48
Root replacement 0 0 - 2 7 0.21
Entry resection 9 11 0.57 9 86 0.79
Postoperative stroke 2 0 0.17 2 6 0.17
Postoperative dialysis 2 0 0.06 3 10 0.11
Pneumonia 3 0 0.06 4 6 0.007
Reoperation 0 0 - 4 5 0.004
CPB time (min) 190 44 184 33 0.36 232 87 219 59 0.29
Anoxic time (min) 124 37 99 30 0.08 116 42 131 43 0.75

CPB cardiopulmonary bypass.

 558 SHIONO ET AL
TYPE A DISSECTION IN OCTOGENARIANS
Comment
According to the International Registry of Acute Aortic
Dissection (IRAD) database, logistic regression identified
age 70 years and older as one predictor of death in type
CARDIOVASCULAR
A dissection [1], and mortality of patients managed
surgically was 26% [2]. Most articles consistently report
hospital mortality exceeding 15% in Western countries [2,
4 6]. Recent technical improvements in emergency sur-
gery for acute aortic dissection have resulted in a marked
decline in hospital mortality.
In this study, the hospital mortality rate was remark-
ably low, and older age was not associated with an
increase in the hospital mortality rate in acute type A
aortic dissection, as Hagl and Griepp [7] have reported.
Postoperative hemodialysis was found to be a statistically
significant risk factor for hospital death in our younger
population. Although cardiac tamponade was not a sig-
nificant risk factor in this study, protracted dissection-
related complications, such as tamponade or shock and
visceral ischemia, are a major concern that would have an
effect on hospital mortality and morbidity [2, 8 10]. Early
recognition of the disease with noninvasive diagnostic
modalities, such as computed tomography scans and
echocardiography, and earlier referral to surgical units
have been improving the surgical results before dissec-
tion-related complications become irreversible. In our
series of patients, 82% of patients (n 110) underwent
emergency surgery within 24 hours of onset, which has
been considered one of the key factors of success. Post-
operative hemodialysis also contributes to hospital mor-
tality as a result of hemodynamic instability during
dialysis, consequently resulting in multiple-organ
failure.
Transverse arch replacement, which required longer
cardiopulmonary bypass time, was performed in only 1
patient in our older group (4%), whereas it was per-
formed in 28 of the younger patients (25%). In the
majority of patients, a partial or hemiarch replacement is
sufficient, as the intimal tear is generally located in the
ascending aorta or the proximal aortic arch [3]. In this
study, resection of the primary intimal tear was per-
formed successfully in 23 patients (96%). The extent of
aortic replacement and period of surgery have been
reported as significant risk factors for hospital mortality
in previous reports [3, 11, 12]. All of our patients under-
went glue-aided repair for the dissected aortic wall and
the aortic valve because glue-aided repair is simple and
time-saving. Because the principal object of emergency
surgery for acute dissection is saving the patients life,
conservative tear-oriented procedure, which reduces the
time of surgery, may be appropriate [13], especially in
older patients.
Since hypothermic circulatory arrest was successfully
introduced for aortic surgery and modified [14], circula-
tory arrest provides easier and more extensive aortic
repair. However, hypothermic circulatory arrest alone
without providing for cerebral perfusion could not di-
minish high rates of brain damage and mortality rates
[15]. In this study, we have adopted antegrade cerebral
Ann Thorac Surg
2006;82:554 9
perfusion because of its physiology and time limitation
for brain protection. Because of antegrade cerebral per-
fusion, longer and more extended repair can be per-
formed as a safe and easily reproducible surgical proce-
dure [9, 16, 17]. Dissection-related organ malperfusion as
a major concern refers to organ malperfusion that will
have an effect on hospital mortality and morbidity [2,
8 10]. Antegrade arterial perfusion provides a better
solution for intraoperative malperfusion by femoral ar-
tery perfusion. There were no serious complications
owing to organ malperfusion in all of our patients who
underwent antegrade aortic perfusion after the open
distal anastomosis. We could dramatically reduce the
surgical mortality because we have benefited greatly
from these improvements, including open distal anasto-
mosis using hypothermic circulatory arrest with ante-
grade cerebral perfusion, gelatin-resorcin-formalin glue,
and antegrade arterial perfusion. Also, tear-oriented con-
servative surgery has provided satisfactory surgical re-
sults, especially in older patients.
The late survival in our older patients was considered
acceptable, but it was significantly poorer compared with
the younger patients (p 0.0016). The results are com-
parable with previous reports describing 5-year survival
rates of 50% to 80% in all age groups [5, 11, 16, 18]. In this
study, three independent risk factors for late death were
female sex in the older patients, and pneumonia and
reoperation in the younger patients. A high prevalence of
aspiration pneumonia was observed even after discharge
from the hospital, and therefore strict long-term respira-
tory care and prevention of pneumonia are required to
improve late results. The critical influence of older age as
an important risk factor for late death was demonstrated
in our study; however, significant improvement in long-
term mortality is considered difficult because this factor
of older age includes physiologic and pathologic factors
related to the normal degenerative process of senes-
cence. There were no reoperations in the older group,
although 8 patients required reoperation in the younger
patients. Reoperation is a major risk factor for late death
in all patients, even when initial emergency operation
has been successfully performed.
Our long-term survival rate of octogenarians is com-
parable to those in other types of elective coronary and
valve procedures [19, 20]. Among 12 survivors, follow-
ups have been continued in the outpatient clinic (n 6),
nursing homes (n 4), and care at home (n 2).
Assessment of postoperative quality of life revealed that
half of the patients remained autonomous; however,
currently dementia (n 6) and depression (n 2) have
been observed in the survivors. Impaired autonomy or
bedridden status after emergency operation is another
concern, and therefore fully informed consent that de-
scribes the prognosis after emergency operation is man-
datory for aggressive surgical treatment.
In conclusion, the hospital mortality could be reduced
dramatically in octogenarians with acute type A aortic
dissection because of earlier operation and use of a
tear-oriented procedure; however, late mortality re-
mained unsatisfactory compared with younger patients.
Ann Thorac Surg
2006;82:554 9
Aggressive emergency surgery is the only option that will
provide a reasonable chance of survival for these high-
risk patients with an otherwise dismal prognosis. In older
patients, a conservative tear-oriented approach is
recommended.
The authors are grateful to Kaname Hirayanagi, PhD, for his
statistical review for this study.
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