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Redo total arch replacement with frozen elephant trunk for patients with previous proximal aortic replacement for acute type A dissection
Markian Bojko, Maylis Basturk, Serge Kobsa, *Fernando Fleischmann
Surgery, University of Southern California Keck School of Medicine, Pasadena, California, United States
Objective: The extent of aortic arch replacement at the time of acute DeBakey type I dissection remains controversial. In the absence of an intimal tear in the aortic arch, many advocate for a limited hemiarch replacement to keep the operation as simple as possible in the emergency setting. Although most would agree that this is an acceptable strategy in centers with low aortic surgery volume, hemiarch replacement leaves the residually dissected arch and descending thoracic aorta at risk for aneurysmal degeneration and the potential need for redo arch replacement in the future. Outcomes for patients undergoing redo total arch replacement after a previous proximal aortic repair in this context remain understudied. Therefore, the purpose of this study was to investigate patients undergoing redo sternotomy for total arch replacement with frozen elephant trunk in the setting of a previously repaired DeBakey type I dissection.
Methods: Between 2012 and 2024, 80 patients underwent redo sternotomy and total arch replacement with frozen elephant trunk after previous proximal aortic repair for acute dissection. Aortic pathology and the indication for surgery was confirmed by direct review of the operative reports. Baseline characteristics, operative details, and postoperative outcomes were obtained from the institutional database.
Results: The median age (years) [IQR] in the cohort was 56 [50, 62]. 63/80 (79%) patients were male, 77/80 (96%) had hypertension, 14/80 (18%) had peripheral vascular disease, and 14/80 (18%) had preoperative cerebrovascular disease (Table1). The median [IQR] ejection fraction (%) was 62 [57, 62], and 10/80 (13%) had congestive heart failure. There was one patient undergoing second time redo sternotomy (previous type A repair and subsequent redo root replacement) while the remaining patients underwent first time redo sternotomy. 39/80 (49%) patients underwent surgery on an elective basis, 36/80 (45%) underwent urgent surgery, and 5/80 (6%) underwent emergent surgery. 54/80 (68%) cases were performed by the senior aortic surgeon. The median [IQR] cardiopulmonary bypass time (min) was 201 [168, 245], aortic cross clamp time (min) was 78 [62, 109], and circulatory arrest time (min) was 18 [13, 25]. The median lowest temperature (Celsius) was 28 [26, 29]. The median [IQR] total operating room time (hours) was 9.3 [8.3, 10.8]. The median [IQR] number of red blood cell units transfused was 5 [3, 7], and 5/80 (6%) patients required mediastinal re-exploration for bleeding. The operative mortality rate was 3/80 (3.8%), the postoperative stroke rate was 8/80 (10%), and the postoperative paraplegia rate was 4/80 (5%). The median [IQR] length of stay in the ICU (hours) was 107 [67, 214] and 5/80 (6%) patients needed readmission to the ICU. The median postoperative mechanical ventilation time (hours) was 19 [11,64], and 4/80 (5%) patients required tracheostomy.
Conclusions: Redo total arch replacement with frozen elephant trunk in the setting of a previously repaired acute DeBakey type I dissection can be performed with acceptable morbidity and a low mortality rate at a high-volume aortic surgery center. These results may help inform surgical decision making at the time of acute type A dissection repair.
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