Total aortic arch grafting for acute type A dissection: analysis of residual false lumen

In surgery for acute type A dissection, an unresected dissection and residual false lumina are causes of the progression of aneurysms and ruptures. We grafted the ascending aorta and total arch, the maximum grafting possible through a median sternotomy alone, in all patients with type A dissection extending to the descending aorta, wherever initial tears existed in the arch.

A total of 37 consecutive patients with acute type A dissection underwent ascending and total arch grafting between August 1994 and December 2000. Cerebral protection was achieved by selective cerebral perfusion. The distal anastomosis was conducted using the "Elephant Trunk" technique. Patent false lumina were evaluated using computed tomography 3 months after the operation.

The hospital mortality was 8.1%. No major cerebral complications were observed. The incidence of residual thoracic patent false lumina was 26.5%. Univariate analyses showed Marfan syndrome and preoperative extension of false lumina to be statistically significant determinants of residual thoracic false lumina. On multivariate analysis, no other significant independent predictor of residual false lumina in the thoracic aorta was found.

Outcomes of our strategy were satisfactory. However, residual thoracic false lumina could not be prevented in 26.5% of the patients. Thus, this extended operation is indicated in patients with initial tears in the aortic arch or distal arch, those with Marfan syndrome, and young patients with preoperative patent false lumina extending to the abdominal aorta.