Total arch replacement for distal enlargement after ascending aortic replacement for acute type A aortic dissection.

OBJECTIVE Distal reoperations for aortic dissection are associated with high morbidity rates. We describe distal aortic enlargement that was treated using our surgical strategy. PATIENTS AND METHODS From January 1997 to April 2008, 63 patients underwent ascending aortic replacement for acute type A aortic dissection. Four patients (7.4%; 3 males, 1 female; mean age, 67.8 +/- 4.6 years) required reoperation for distal enlargement after long-term follow-up. Individual 5- and 10-year rates of those remaining free of reoperation after the initial procedure were 94.9% and 83.0%, respectively. At reoperation, a median sternotomy with left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. RESULTS Mechanical ventilation was required after surgery for 3.0 +/- 1.4 days. No new phrenic or left recurrent laryngeal nerve palsy or permanent neurological dysfunction occurred in this series. Although the surgical duration and relative mechanical circulation time were significantly elongated, all patients recovered uneventfully. CONCLUSION We postulate that the surgical principle involved in treating aortic dissection is a resection of the aortic segment containing the initial intimal tear and graft replacement, especially in acute dissection. Our results showed that total arch replacement through a median sternotomy and left anterolateral thoracotomy seem to be helpful for extended replacement of the thoracic aorta, as well as in the distal reoperation for dissecting type A. Moreover, our results suggested that perfusion from bilateral axillary arteries is useful to prevent cerebral damage.