Surgery extended into the aortic arch in acute type A dissection. Indications, techniques, and results

From May of 1979 to September of 1990, 106 patients underwent emergency surgery for acute type A aortic dissection. In 29 patients (27.3% of total; mean age, 53 years) surgery was extended into the aortic arch. In 19 cases the proximal entry reached or began beyond the aortic cross-clamping site, which prevented proper reconstruction of the distal aorta. In six cases an aortic perforation was located in the arch. In four others the dissection occurred within a preexistent arch aneurysm. Operative techniques consisted of eight arch reconstructions, 17 proximal arch replacements, and four total arch replacements. Repair was performed during deep hypothermia (mean nasopharyngeal temperature, 17.8 degrees C) and circulatory arrest (mean, 24.2 minutes). Operative mortality was 20.6% (six of 29), dropping to 10.5% (two of 19) during the past 4 years. There were no late deaths in the 23 survivors, with one patient suffering from neurological sequelae. Nineteen underwent either computed tomography and digital subtraction angiography or magnetic resonance imaging without pathological findings in the ascending aorta or arch. In acute type A aortic dissection the site of the intimal tear and/or perforation, as well as preexistent aneurysmatic disease, may require primary aortic arch repair. This can be accomplished during deep hypothermia and circulatory arrest, with acceptable early and satisfactory late results.