Original article
Adult cardiac
Imaging Surveillance After Proximal Aortic Operations: Is it Necessary?

Presented at the Sixty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 4–7, 2015.
https://doi.org/10.1016/j.athoracsur.2016.06.085Get rights and content

Background

Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance.

Methods

Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk.

Results

Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038).

Conclusions

Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.

Section snippets

Study Design and Patients

An institutional database was used to identify all patients who underwent proximal aortic operations at a single referral aortic center (Duke University Medical Center, Durham, NC) from June 2005 to March 2014. Proximal aortic operations were defined as ascending aortic replacement with or without aortic root replacement, with or without aortic valve repair or replacement, or with or without aortic arch replacement. Patients who underwent reoperations after having undergone an index proximal

Patient Characteristics

From June 1, 2005, to March 15, 2014, 869 patients at our institution underwent proximal aortic operations. Reinterventions occurred in 4.3% of patients (n = 37). Baseline characteristics of all patients at the time of the index proximal aortic operation are reported in Table 1, stratified by whether patients ultimately went on to have a reintervention. Among patients who subsequently required reinterventions, there was a higher frequency of baseline hypertension, history of stroke or transient

Comment

In the current analysis we demonstrate that thoracic aortic surgical reinterventions among patients who undergo proximal aortic operations are uncommon, occurring at a frequency of 4.3% over a 9-year study period. For both patients with an index proximal aneurysm operation or type A dissection repair, the most common indication for surgical reintervention was the metachronous development of an aneurysm of the descending or thoracoabdominal aorta, which occurred at an overall median time of 2.8

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