The impact of surgical strategy on survival after repair of type A aortic dissection

Objective: A diverse group of operative strategies are utilized for treatment of acute Stanford type A aortic dissection. We hypothesized that a surgical strategy to prevent cross-clamp injury or false lumen pressurization would be associated with reduced morbidity, mortality, persistent false lumen patency, and improved survival. This study was designed to determine the differences in outcomes between operative techniques. Methods: Outcomes and postoperative imaging were compared in patients who underwent surgery for acute type A aortic dissection. Two groups were compared, based on operative strategy. The surgical strategy for group 1 consisted of no aortic cross-clamp use, use of deep hypothermic circulatory arrest, and use of only antegrade perfusion after aortic replacement. The surgical strategy for group 2 consisted of any other combination that lacked 1 of these 3 technical steps. Results: Between January 1, 1996, and December 31, 2012, a total of 196 patients underwent surgery for acute type A aortic dissection. Operative mortality and postoperative morbidity were not statistically different between groups. Mean follow-up time was 3.95 (range: 0-15.4) years. Persistence of a false lumen was not statistically different between groups (P = .78). Overall survival was significantly better in group 1, versus group 2 (P = .0020). Multivariate Cox regression identified preoperative renal failure, chronic lung disease, greater number of packed red blood cells transfused, and being in group 2 as risk factors for poor long-term survival. Conclusions: The operative strategy of group 1 (no cross-clamp, use of DHCA and antegrade perfusion) was associated with a highly significant improvement in survival, despite a lack of statistical difference in the incidence of persistent false aortic lumen between groups.