Distal Remodeling After Operations for Extensive Acute Aortic Dissection

BackgroundThe clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood.MethodsFrom 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n = 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n = 25), and total endovascular repair (n = 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up.ResultsAt 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up.ConclusionsAfter distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management. The clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood. From 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n = 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n = 25), and total endovascular repair (n = 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up. At 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up. After distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management.