Realistic expectations of surgical treatment of aortic dissections: The stanford experience

Over a 16‐year span, 125 unselected patients with acute and chronic aortic dissections underwent uniform surgical treatment. Fifty‐three had acute type A(Ac‐A), 29 had chronic type A(Ch‐A), 20 had acute type B(Ac‐B), and 23 had chronic type B(Ch‐B) dissections. Major preoperative complications were encountered frequently; 14% of dissections had ruptured. All patients underwent aortic replacement with tubular grafts; concomitant aortic valve replacement (AVR) was performed in 11% of the Ac‐A patients and 38% of Ch‐A patients. The primary intimal tear was resected in 78% of operations. Follow‐up averaged 4.5 years and extended beyond 13 years. Overall operative mortality rate was 34% for Ac‐A, 14% for Ch‐A, 45% for Ac‐B, and 22% for Ch‐B patients. Between January, 1974 and October, 1979 these mortality rates (63 patients Ac‐A, 17 Ch‐A, 7 Ac‐B, 12 Ch‐B) declined to 22%, 18%, 14%, and 17%, respectively. Actuarial survival rates (± SEM) for the entire series were 54±5% at 5 years and 26±7% at 10 years. Excluding operative deaths, these were 76±5% and 37±10% at similar intervals. Multiple preoperative variables correlated with both operative risk and long‐term survival, but the survival rate appeared not to be influenced by whether AVR was performed (type A patients) or by whether the primary intimal tear was resected (all patients). No differences in long‐term survival were evident between the 4 subgroups of patients. Survivors generally sustained satisfactory functional results and experienced good rehabilitation. The results of this investigation argue for immediate operative treatment of acute type A dissections and, possibly, of acute type B dissections as well. Furthermore, surgical resection of symptomatic and/or expanding chronic type A and chronic type B dissections ameliorates symptoms and provides satisfactory long‐term survival. Surgical treatment does not “cure” the disease. However, as evidenced by the declining operative risk, acceptable durability of repair, and improved long‐term survival, surgical therapy can result in salvage of a substantial majority of patients with life threatening dissection of the aorta.