A Study on Outcome in Stanford Type A Aortic Dissection Focusing on Neurological Outcome and New Surgical Techniques

Background: Today, surgical repair of aortic type A dissections is routinely mandatory but some complications remain despite technical advances over several decades. The most important complications are neurological deficits that have been quantified with an incidence of up to 25% in international trials. In this study, we focused on the postoperative outcome over a ten year period after surgical repair of type A dissections. A special focus has been put on specific complications, neurological outcome and technical advances with modern surgical techniques including cannulation strategy.

Methods: A cohort of 147 patients undergoing surgery since 2004 was studied in a retrospective analysis with 10 year follow-up. Analysis was performed using Cox-proportional hazard model focusing on more than 30 variables.

Results: Survival after 1y (5, 10y) was 98% (88%, 50%). Early mortality of all patients declined to 14% in the last years. 27% were female, with a higher age than men (+10y, mean, 64+10y). Gender did not influence survival. Survival probability (Log rank test) for the first postoperative year was 0.82/0.77 (female/male) for 5 years 0.70/0.71, and 0.46/ 0.50 for 10 years.

Preoperatively, the carotid arteries were compromised in 25% of patients. Neurological deficits were preoperatively present in 11% of patients. Of those, a percentage of one third (33%) was reversible. Postoperatively, major and minor neurological deficits could be seen in 22% of all patients. Over the time, the incidence of postoperative complications could be reduced (from nearly 27% to 10%). The vascular access via truncal cannulation technique showed a significant lower risk vs. all other cannulation sites (p=0.0168).

Conclusions: The incidence of neurological complications could be reduced, either as reversible preoperative deficits or postoperative new complications.

Neurological disorders with concomitant carotid obstructions should lead clinicians to an extensive diagnostic approach, i.e. spreading the diagnostic look towards supraaortic/brachiocephalic branches of the aorta. By establishing technical modifications and surgical advancements, we could achieve a 50% reduction of postoperative neurological deficits from nearly 20% to below 10% and also of mortality rates from nearly 30% to about 15%. This is reflected by a growing number of longtime survivors. Adopting modern perfusion techniques helps reducing the incidence of those disabilities that bear an enormous subjective medical and also economic burden.