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Interact CardioVasc Thorac Surg 2009;9:693-697. doi:10.1510/icvts.2009.213405 © 2009 European Association of Cardio-Thoracic Surgery
Is reduction aortoplasty (with or without external wrap) an acceptable alternative to replacement of the dilated ascending aorta?Department of Cardio-thoracic Surgery, James Cook University Hospital, Middlesbrough, TS4 3BW, UK Received 8 June 2009; accepted 10 June 2009
*Corresponding author. Tel./Fax: +44 191 3862526.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether reduction aortoplasty is an acceptable alternative to ascending aorta replacement. From 925 potential papers, 13 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that aortoplasty seems to be a safe procedure which gives good postoperative outcomes in selected patients. Our literature review documents 716 patients from 13 papers, with only 25 patients that on follow-up suffered redilatation (3%). Thus, reduction aortoplasty is a viable alternative to conventional aortic root replacement or interposition tube grafting in some patients. In particular, an aortoplasty in elderly patients with post-stenotic dilatation, or in patients with significant co-morbidities is attractive. It should be acknowledged that only one study directly compares the technique with conventional replacement and that replacement remains the ‘gold standard’ technique. It should also be acknowledged that the external wrap is not without risk and wrap dislocation, erosion or fistula formation are recognised complications.
Key Words: Ascending aorta; Aneurysm; Aortoplasty
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
In patients with an [ascending aortic aneurysm] is [reduction aortoplasty] an acceptable alternative to [ascending aorta replacement] to prevent [ascending aortic rupture]?
During an aortic valve replacement (AVR), a 76-year-old patient was found to have an ascending aortic aneurysm measuring 5.4 cm diameter. As this was a high-risk case, an ascending aorta replacement was not performed but instead a reduction aortoplasty created and a Dacron tube graft placed outside the aorta. The procedure was much more straightforward than aortic root replacement or a conventional tube graft, but after the operation we elected to check in the literature that this alternative procedure had acceptable long-term results.
The following search engines were used to obtain the relevant papers: Medline 1950 to May 2007 using Dialog Datastar interface using the term [aortoplasty.mp] Embase 1980 to February 2008 using Dialog Datastar interface using the term [aortoplasty] and in addition the National Library for Health and the British Medical Journal search engines were also searched.
From the above search 440 papers were found in Medline and 485 papers found in Embase. Thirteen papers were selected that provided the best evidence to answer the question. These are presented in Table 1.
Carrel et al. [2] retrospectively reviewed patients undergoing AVR and ascending aortic aneurysm repair. One hundred and sixty-four of these underwent aortic remodelling with external wall support, 81 had composite graft replacement and 46 had supracoronary graft. Compared to the graft replacement and supracoronary graft, the aortoplasty group had the lowest early mortality rates (1.8% vs. 9.8% vs. 6.4%) and best 10-year survival rates (83.8% vs. 67% vs. 73%). There were six redilatations in the aortoplasty group, of which five were due to the wrap slipping distally. Barnett et al. [3] operated on 17 fusiform ascending aorta aneurysms, nine of which had tailoring aortoplasty alone, eight with external Dacron wrap support. Twelve patients were followed-up (mean 4.4 years) none of whom showed subsequent dilatation. The range of follow-up was from 2 to 120 months, which may have been too short to detect re-enlargement in a number of patients. In Mueller et al.'s [4] study, 17 consecutive patients who underwent aortoplasty without external support were reviewed. Four patients were diagnosed with aortic enlargement at 45, 59, 67 and 81 months. Baumgartner et al. [5] performed S-shaped aortoplasties in 23 patients with no external support. Mean preoperative aorta diameter was 5.0±0.7 cm, reduced to 3.1±0.6 cm (P<0.01). Sixteen patients were followed-up at 9.9±12.6 months where their mean diameter rose from 2.9±0.65 cm to 3.1±0.45 cm (P=NS). Seven patients were followed-up >1 year with an intra-operative diameter rising from 2.9± 0.5 cm to 3.1±0.35 cm (P=NS, mean follow-up 22.1 months). Bauer et al. [6] reviewed 115 patients with bicuspid aortic valves of which 106 underwent aortoplasty without support and nine with external Dacron support. Mean preoperative diameter was 4.87±0.51 cm reduced to 3.69±0.36 cm early post-surgery. After mean follow-up of 40 months, aorta diameter was 3.8±0.45 cm (P=0.37) with no statistical difference between those who had external support or not (P=0.37). During late follow-up, nine patients without external support were found to have a significant increase in diameter (>0.4 cm). This patient group was found to have suboptimal diameter reduction in theatre (mean 4.14±0.31 cm). In the study by Ogus et al. [7], 22 high-risk patients underwent AVR with aortoplasty and external wrap. CT scans showed a mean preoperative diameter of 5.12± 0.38 cm with a 3-month postoperative diameter of 3.19±0.25 cm (P<0.0001). At 1 year, diameter rose to 3.32±0.3 cm (P=0.03) which did not change significantly on 3rd and 4th year review. Kamada et al. [8] performed 10 aortoplasties along with AVR. Mean preoperative diameter was 5.2±0.48 cm which was reduced to 3.61±0.41 cm. Teflon felt strips were used in five patients, Teflon pledgets in four and none in one patient. There was one case of redilatation, attributed to suboptimal reduction intra-operatively (4.5 cm). At mean follow-up of 38 months, aorta diameter was 3.6±0.64 cm. Cotrufo et al. [9] analysed 61 patients undergoing AVR and ‘waistcoat’ (dual layer) aortoplasty. Measurements were taken using echocardiography at three different levels. In 53 patients at mean follow-up of 33.8+10.2 months, there was no significant enlargement compared to 48 h postoperatively (P=0.32, P=0.15, P=0.38, respectively). Olearchyk [10] operated on 10 patients with bicuspid aortic valves who underwent aortoplasty, four patients with distal external wrap, complete wrap in two and no wrap in three. After 47±45.1 months follow-up, there were no cases of migration of the wrap or re-enlargement of the aorta. Arsan et al. [11] retrospectively reviewed 62 patients who underwent aortoplasty with the use of an external wrap, along with concomitant operations. Fifty patients were followed-up with the postoperative diameter rising from 3.04±0.05 cm early post-surgery to 3.2±0.5 cm at a mean follow-up of 39.6±18 months. Although this shows a statistically significant increase (P<0.0005), the authors argue that the diameter is still within normal range. Polvani et al. [12] analysed the results of 68 patients who underwent aortoplasty with a concomitant procedure and without external reinforcement. At >1 year, of 58 patients, five (7.5%) suffered redilatation, all had a preoperative diameter of >5.5 cm (P=0.001 on univariate analysis, P=0.038 on multivariate stepwise logistic regression). In the study by Walker et al. [13], 91 patients were reviewed post-aortoplasty with Teflon felt strips and without external support. Of 54 patients, there was a mean increase in diameter of 0.17±0.27 cm (confidence interval 0.09–0.25 cm) with a preserved physiologic elasticity of the aorta (Windkessel function). Feindt et al. [14] retrospectively reviewed 50 patients who underwent aortoplasty with external reinforcement. Of the 31 (at 56 months) patients followed-up, there was a persistent significant reduction in aortic diameter. Mortality was 8%.
Aortoplasty seems to be a safe procedure that gives good postoperative outcomes in selected patients. Our literature review documents 716 patients from 13 papers, with only 25 patients that on follow-up suffered redilatation (3%). Thus, reduction aortoplasty is a viable alternative to conventional aortic root replacement or interposition tube grafting in some patients. In particular, an aortoplasty in elderly patients with post-stenotic dilatation, or in patients with significant co-morbidities is attractive. It should be acknowledged that only one study directly compares the technique with conventional replacement and that replacement remains the ‘gold standard’ technique. It should also be acknowledged that the external wrap is not without risk and wrap dislocation, erosion or fistula formation are recognised complications. Recommendations for suitable patient groups are made in Table 2, in part based on the work by Robicsek et al. [17].
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Abstract
1. Introduction
