The History of Stanford Type A Aortic Dissection Experience Over Five Decades

Description

Objective: Since the establishment of aortic dissection classification by Stanford in 1968, this categorization has been widely adopted. The objectives of this study were to analyze Stanford type A aortic dissection repair history and evaluate outcomes over 50 years.
Methods: From 1967 through August 2019, 1,251 patients presented to Stanford University with type A aortic dissection. Of these patients, 1,218 patients were offered surgical repair. The cohort was further stratified by decades. The continuous variables were compared using ANOVA, and categorical variables were assessed using χ2 test. Kaplan-Meier survival analyses and Cox proportional-hazards model were used to investigate overall survival. The primary endpoint was all cause mortality.
Results: Patient age at presentation was 60.2 ± 15.1 years, which increased over the decades (p = .0001). Four hundred seven patients (32.5%) were female. Recent patients were more likely to have hypertension (729, 63.2%), hyperlipidemia (292, 25.3%), diabetes (79, 6.9%), coronary artery disease (70, 6.1%), heart failure (160, 13.9%), chronic obstructive pulmonary disease (67, 5.8%), stroke (91, 7.9%), and require dialysis (70, 6.1%) or mechanical support (16, 1.4%) preoperatively (p ≤ .02). Cardiopulmonary bypass time (222.7 ± 146.5 minutes) and aortic cross-clamp time (126.8 ± 62.4 minutes) increased over the decades (p ≤ .002), and the lowest bladder temperature (23.5 ± 4.4°C) increased over time (p < .0001). Circulatory arrest time remained stable over the years (41.1 ± 143.4 minutes, p = .5), and antegrade cerebral perfusion was the most common protection method (501, 63.3%). Valve sparing aortic root replacement (12, 2.1%) and total arch replacement (74, 8.8%) were first utilized after 1999, but composite valve graft was the most common root replacement technique (227, 33.7%). Recent patients were more likely to receive hemi-arch repair (572, 60.4%, p < .0001). The overall median survival was 9.5 vs. 1 years for those who were offered surgical vs. medical management (p < .0001) (Figure A). The median survivals from year 1967–1988, 1989–1998, and 1999–2008 were 11.5, 8.3, and 8.5 years with a 10-year survival of 66.7% from year 2009–2019 (p = .003) (Figure B). The hazard ratios adjusted for patient age and gender from year 1989–1998, 1999–2008, and 2009–2019 referenced to year 1967–1988 were 1.07 [0.78–1.5], 0.93 [0.68–1.3], and 0.62 [0.44–0.88] (p = .0008).
Conclusions: In this over half-century retrospective study, long-term survival after Stanford type A aortic dissection significantly improved during the recent decade, despite worsening preoperative patient status and increased technical complexity. Patients with Stanford type A aortic dissection should be considered for transfer to a high-volume, experienced center to ensure the best chance of receiving surgical management and survival.