Early and late outcome of operated and non-operated acute dissection of the descending aorta.

Objective: At present debate continues concerning the optimal mode of treatment for type B dissections. Controversies are mainly due to discordant results regarding survival following medical or surgical treatment. We assessed early and long-term outcome of acute dissection of the descending aorta treated by emergency aortic replacement, medical treatment or delayed surgery.

Methods: Between 1980 and 1995, 225 patients were hospitalized in the medical or surgical department of our institution with the diagnosis of acute type B aortic dissection. A total of 38 patients (16.8%) underwent replacement of the descending aorta within the first week after hospital admission. Primary indications for immediate surgery were: rupturing aneurysm (n = 15), diameter of the descending aorta (n = 13), malperfusion of the thoracoabdominal aorta (n = 8) and pseudocoarctation syndrome with uncontrollable hypertension (n = 2). All other patients (n = 187) underwent primary conservative treatment on the intensive care unit, including appropriate anti-hypertensive medication. In 12 of them, surgery was denied because of age or significant concomitant diseases.

Results: Hospital mortality after urgent or emergency surgery was 21% (8/38 patients) for the overall time period. There has been a significant decrease in hospital mortality during the last 5 year-period (12% versus 30% between 1980 and 1994). Causes of death were: cardiac failure in 3, bleeding complications in 2, postoperative mesenteric ischemia in 2 and septicemia in one patient. From the 30 operative survivors, 9 (30%) patients required further surgery on the native aorta after a mean follow-up of 48 +/- 13 months. Hospital mortality during conservative treatment was 17.6% (33/187 patients). Main causes of death were rupture in 14, thoraco-abdominal malperfusion in 13 and cardiac failure in 3 patients, whereas in 3 patients, the cause of death could not be evaluated. In this group, 9 patients had to be shifted to early surgery during the initial hospitalization because of impending rupture (n = 4), rapidly increasing diameter (n = 2) and suspicion of intestinal ischemia (n = 3). After hospital discharge, surgery for chronic dissection was performed in 47 patients, mainly because of expanding descending aortic aneurysm. Hospital mortality was 8% (4/47 patients). Actuarial survival rates after surgery during the first admission were 85 +/- 6% at 5 years and 61 +/- 8% at 10 years, versus 76 +/- 5 and 50 +/- 7% respectively, following conservative treatment (P < 0.001).

Conclusion: Nowadays, acute type B dissection can be treated surgically with a reasonable perioperative risk. Despite aggressive anti-hypertensive treatment, hospital mortality of primary conservative treatment is still high and a substantial percentage of patients requires surgery during initial hospitalization. Main causes of death in both groups are rupture and abdominal malperfusion: therefore, closed clinical and radiologic assessment of the whole thoraco-abdominal aorta is of utmost importance. Long-term results are satisfying; unlimited radiographic follow-up allows for detection of potential severe complications and for proper planning of elective reoperations when indicated.