Consequences of incomplete repair of acute type A aortic dissection

Vitaly Aleksandrovich Sorokin, Theo Kofidis, Felix Woitek, Eliana Cecilia Martinez,
Chuen Neng Lee and Uwe Klima
Interact CardioVasc Thorac Surg 2008;7:1121-1123; originally published online Aug
21, 2008;
DOI: 10.1510/icvts.2008.183418

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://icvts.ctsnetjournals.org/cgi/content/full/7/6/1121

Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association
for Cardio-thoracic Surgery (EACTS) and the European Society for Cardiovascular Surgery
(ESCVS). Copyright © 2008 by European Association for Cardio-thoracic Surgery. Print ISSN:
1569-9293.

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doi:10.1510/icvts.2008.183418

Interactive CardioVascular and Thoracic Surgery 7 (2008) 1121–1123

www.icvts.org

Negative results - Aortic and aneurysmal

Consequences of incomplete repair of acute type A aortic dissection
Vitaly Aleksandrovich Sorokin, Theo Kofidis*, Felix Woitek, Eliana Cecilia Martinez,
Chuen Neng Lee, Uwe Klima
Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road,
Level 2, 119074 Singapore

Received 21 May 2008; received in revised form 29 July 2008; accepted 30 July 2008

Abstract

During emergency repair of acute Stanford type A aortic dissections, surgical compromises in the form of incomplete arch replacement
are made due to the unstable condition of the patient and safety issues of the performing team. We report a case of delayed reoperation
after previous incomplete surgery for acute type A aortic dissection in a young patient with Marfan’s syndrome. He presented again with
repetitive chest pain five years after initial surgical treatment. Extensive aneurysmal dilatation of the aorta and remaining dissection led
to the decision to replace the ascending aorta and the aortic arch. After a good progress during the first days after surgery, the patient
died due to a ruptured thoraco-abdominal aneurysm on the fifth postoperative day. Extensive surgical reconstruction including aortic arch
replacement should be considered in patients with Marfan’s syndrome who present with aortic dissections type A to avoid unnecessary
reoperations and their complications.
䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Aortic dissection; Surgical treatment; Aortic arch replacement; Marfan’s syndrome

1. Introduction the procedure. A control CT-scan three months after surgery

Aortic dissection is a common complication in Marfan’s
syndrome patients. Surgery in this cohort of patients often
requires extensive resection of the dissected aorta and
reconstruction of the aortic root. Compromise in surgical
strategy endangers the patient’s life and may result in
unnecessary repetition of surgical intervention. We report
a case of delayed reoperation after previous incomplete
surgery for acute type A aortic dissection with fatal out-
come.
2. Presentation and clinical course
A 24-year-old male patient with known history of Marfan’s
syndrome was admitted to our hospital in 2001 with an
acute type A aortic dissection extending to the infrarenal
abdominal aorta without formation of an aneurysm (dia-
meter of the ascending aorta was 3.1 cm and the descend-
ing aorta was 2.9 cm). The patient underwent an
emergency repair of his ascending aorta on the same day
of admission, with replacement of aortic root and proximal
ascending aorta with a 23-mm sized valve conduit. During
surgery the aortic arch was cannulated and aortic cross
clamp was used without hypothermic circulatory arrest
(closed distal anastomosis technique). The entry site was
found in the ascending aorta and the tear resected. The
patient recovered well and was discharged 12 days after
*Corresponding author. Tel.: q65 6772 2065y5214; fax: q65 6776 6475.
E-mail address: surtk@nus.edu.sg (T. Kofidis).
䊚 2008 Published by European Association for Cardio-Thoracic Surgery
showed persistence of a dissection in the aortic arch and
descending thoracic aorta with a large false lumen com-
pressing the true lumen. Additionally, there was evidence
of false aneurysm formation at the level of the previous
distal anastomosis between the graft and the ascending
aorta (Fig. 1). The option to repeat surgery and replace
the ascending aorta and aortic arch was offered to him but
he denied any surgical intervention.
In 2006 the patient was readmitted to the hospital with
repetitive chest pain and progressive dilatation of the
ascending aorta, the aortic arch and the thoraco-abdominal
aorta was visible on the CT thorax scan (Fig. 2). He
consented and underwent the second operation almost six
years after the first procedure. Replacement of the ascend-
ing aorta and the aortic arch was planned as a first stage
procedure. A median sternotomy was performed and the
femoral vessels cannulated. The residual distal ascending
aorta and the total arch were replaced under circulatory
arrest with antegrade cerebral perfusion technique for
brain protection. We proceeded with the next planned
stage of surgery on the thoraco-abdominal aorta using the
elephant trunk technique and a 24-mm Dacron graft. The
arch island was anastomosed to the proximal part of the
graft after completion of the elephant trunk procedure.
The patient recovered well, but on the fifth day after
surgery he collapsed, did not respond to resuscitation, and
passed away. Post-mortem evaluation revealed thoraco-
abdominal aneurysm rupture.

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Fig. 1. Contrast enhanced computer tomography study three months after
emergency Bentall operation with false aneurysm formation at the level of
distal anastomosis (arrow), measuring 3.1 cm=3.9 cm in the ascending and
4.7 cm=5.3 cm in the descending aorta.
Fig. 2. Contrast enhanced computer tomography study five years after emer-
gency Bentall operation. The ascending aorta is measuring 4.1 cm=4.0 cm
and the false lumen represents half of the lumen. The aorta’s diameter in
the descending part is 6.5 cm=5.8 cm and in the false lumen is
5.1 cm=5.8 cm in extension.
3. Discussion
Surgical treatment for Stanford type A dissections can
prevent fatal complications such as cardiac tamponade,
myocardial infarction, heart failure, aortic rupture and
significantly decreases early mortality w1–3x. However, late
results have been disappointing even after an initial suc-
cessful operation w2, 4x. The remaining aortic dissection
that was not primarily replaced is responsible for the
considerable number of postoperative complications and
deaths w1, 2x. Aggressive surgical approach involving exten-
sive resection of dissected aorta for patients with aortic
dissection became more popular over the recent years w3x.
According to the authors, extensive replacement of dis-
sected aorta can improve long-term results and decrease
requirement for a second intervention. In the presented
case, the first operation was limited to the aortic root and
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proximal part of ascending aorta only and was not optimal
for the patient with Marfan’s syndrome. Additionally, there
is an increasing trend to aortic-valve-sparing surgeries, such
as the recent David procedure w5x.
Open distal anastomosis has been introduced to increase
safety and adequacy of arch surgery w2, 3x. Despite contro-
versy, this technique has the advantage of the aortic lumen
revision and leads to a more radical resection of dissected
aortic wall. In our case the aortic arch was not revised and
the dissected aortic wall was not adequately resected.
Furthermore, the first surgery with incomplete resection
of ascending aorta made total replacement of the dissected
aorta via left thoracotomy impossible.
Surgical treatment is advocated for patients with persist-
ent false lumen and development of aneurysm formation
after the first operation w1, 2, 6x. Acute rupture of an
existing aneurysm has a rate of 3–5% per five years and it
is especially frequent with large and persistently growing
aneurysms w1, 4x. In our case, anastomotic aneurysm for-
mation occurred in the first three months after first oper-
ation and was not repaired for five years due to defaulted
follow-up.
Kouchoukos et al. have shown in non-Marfan patients with
extensive aortic disease and with a variety of entities, that
an extensive first surgical approach is similar to the first
surgery of a two-stage procedure considering complications
and follow-up. Aggressive surgical approach can be an
option since in Marfan’s patients the risk of rupture com-
plications is even higher. However, as stated, aneurysmal
enlargement of the aorta distal to the anastomosis and the
extent of bilateral anterior thoracotomy can be deterring
factors or limiting factors that have to be assessed individ-
ually w7x.
The rapid endovascular approach and stent grafting of the
aneurysmal enlarged aorta has proven to be safe and useful
in non-Marfan patients, but for patients with Marfan’s
syndrome bigger studies and especially long-term follow-
up data are not available yet and a general recommenda-
tion cannot be given w8x.
This case demonstrates the importance of complete sur-
gical resection of ascending aorta. Extensive surgical recon-
struction including aortic arch replacement should be
considered in patients with Marfan’s syndrome who present
with aortic dissections type A to avoid unnecessary reoper-
ations and their complications w9x. Furthermore, conse-
quent regular follow-up with CT-scan after surgery must be
mandatory in these patients.
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 Consequences of incomplete repair of acute type A aortic dissection
Vitaly Aleksandrovich Sorokin, Theo Kofidis, Felix Woitek, Eliana Cecilia Martinez,
Chuen Neng Lee and Uwe Klima
Interact CardioVasc Thorac Surg 2008;7:1121-1123; originally published online Aug
21, 2008;
DOI: 10.1510/icvts.2008.183418
This information is current as of April 19, 2011

Updated Information including high-resolution figures, can be found at:

& Services http://icvts.ctsnetjournals.org/cgi/content/full/7/6/1121
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http://icvts.ctsnetjournals.org/cgi/content/full/7/6/1121#BIBL
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