Early and late risk factors in surgical treatment of acute type A aortic dissection.

BACKGROUND: Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. METHODS: A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. RESULTS: The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. CONCLUSIONS: Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

[Spinal cord protection in surgery of the thoracic, descending, and thoraco-abdominal aorta. Comparison of methods]. / La protezione midollare nella chirurgia dell'aorta toracica, discendente e toraco-addominale. Metodiche a confronto.

The authors compare the strategus needed for the elimination of paraplegia and for protection of abdominal organs after replacement of descending thoracic or thoraco-abdominal aorta. They analyse single technique considering the advantages and the controindications; furthermore they compare these properties and those of possible variants in the light of the presentation; type of disease and general conditions of the patient. These considerations are in agreement with later literature as well as the attitude of the surgeon.

Aortic arch aneurysms: surgical results and follow up in 56 patients.

From January 1989 to December 1994, 56 patients, 43 male and 13 female, mean age 61.21 +/- 10.05 years, underwent surgical procedures on the aortic arch at our institution. Forty-six patients underwent emergency or urgent operations, fourty-four of them presented acute aortic dissections involving the aortic arch. All operations were performed in cardiopulmonary by-pass, 39 operations in deep hypothermic circulatory arrest, 10 in deep hypothermic circulatory arrest and hypothermic retrograde cerebral perfusion. The overall hospital mortality was 17.9% (10 patients). The main causes of hospital mortality were: multiorgan failure (3 patients) and major neurological damage (2 patients). In the group of patients that underwent hypothermic retrograde cerebral perfusion there was no major neurological damage. In the follow up there were no deaths and 4 reoperations related to the aortic pathology. The cerebral protection represents the main problem in the aortic arch surgery. The deep hypothermic circulatory arrest is an effective method to reduce the cerebral and visceral ischemia, in particular in acute dissection; nevertheless this method leads to more bleeding complications and lengthening of the cardiopulmonary bypass in time. In our experience, the hypothermic retrograde cerebral perfusion associated with deep hypothermic circulatory arrest appears to be a useful method to prevent cerebral damage. However this procedure needs further investigation.