Reoperative Arch-First Total Aortic Arch Repair After Prior Acute Type A Aortic Dissection Repair

S. Ohira, R. Malekan, J. Shimamura, S. Lansman, D. Spielvogel
Westchester Medical Center, Valhalla, New York

Purpose: A subset of patients develop aortic growth of downstream aorta after acute type A aortic dissection (ATAD) repair where there is perception that arch reoperation is a high-risk procedure. We sought to review the outcomes of our arch-first total aortic arch repair (TAR) technique utilizing a trifurcated graft.

Methods: From February 2006 to June 2024, 62 patients had reoeprative TAR for residual dissection after ATAD repair. The two-staged procedures were standard. The first-stage TAR includes: direct right axillary artery cannulation, minimal dissection of the mediastinal structures without aortic cross-clamping, myocardial protection utilizing systemic potassium and retrograde blood cardioplegia, an arch-first technique with deep hypothermia (bladder temperature, 20 ºC), creation of fenestration and construction of a classical elephant trunk through a partial transverse incision distally in the old graft (Technique I) or in the aorta just distal to the old graft (Technique II) depending on the length of ascending graft.
The second-stage repair was performed via left thoracotomy utilizing femoro-femoral partial cardiopulmonary bypass (bladder temperature, 32 ºC). Intercostal arteries were sacrificed from the outside. After draining venous blood, aorta was longitudinally incised and the elephant trunk was manually grabbed and clamped. Open distal anastomosis was performed above the celiac axis.

Results: The median age at reoperative TAR was 63.5 years. The median interval from initial ATAD repair to reoperative TAR was 3 years [IQR: 1,8] with maximal aortic diameter of 6.0 cm. Right axillary artery was cannulated in 60 patients (96.8%) including 34 redo axillary cannulations. Concomitant procedure was performed in 20 patients (32.3%). The median cardiopulmonary bypass, myocardial ischemic and lower body circulatory arrest times were 227.5, 102, and 97 minutes, respectively. The median lowest nasopharyngeal and bladder temperature were 16.9°C and 20.0°C, respectively. Operative mortality was for reoperative TAR was 1.6% (N=1/62), as was the incidence of stroke (1.6%, N=1/62) and renal replacement therapy (1.6%, N=1/62). There was no spinal cord injury after reoperative TAR. There was no mortality while waiting for stage II repair.
The Stage II repair was performed or planned in 48 patients (open repair, N=41; endovascular repair, N=3; endovascular followed by open repair, N=2; and two patients waiting for open repair). Mean interval between staged procedures was 63 days [IQR: 36,134]. Mortality of stage II procedure was 4.3% (N=2/46) with no spinal cord injury.
Median follow-up was 4.1 years. Kaplan-Meier analysis showed that estimated survival at 1 and 5 years were 93.1±3.3% and 82.8±5.8%, respectively.

Conclusion: Our reoperative TAR is safe in the setting of residual dissection after ATAD repair that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects organs including the brain, heart, kidney and spinal cord. Insertion of classical elephant trunk followed by staged distal intervention showed favorable outcomes.

Identify the source of the funding for this research project: No