The surgical management of acute type A aortic dissection (ATAAD) has improved considerably over recent decades, with operative mortality now reduced to approximately 10–20%. However, patients remain exposed to late aortic complications that may require further intervention. The main surgical goals are to remove the primary intimal tear, restore true lumen flow, and prevent false lumen expansion, although the fragility of dissected aortic tissue makes anastomotic construction particularly challenging.
While distal anastomotic new entry tears (DANE) have been extensively studied because of their effect on aortic remodelling, complications involving the proximal anastomosis have received less attention. In particular, proximal anastomotic new entry tear (PANE), a complication defined by residual dissection or pseudoaneurysm formation at the proximal anastomotic site on contrast-enhanced computed tomography, may promote persistent false lumen perfusion, progressive aortic root dilatation, recurrent aortic regurgitation, and the need for reintervention. This study aimed to determine the incidence and anatomical location of PANE, identify its perioperative risk factors, and assess its impact on long-term survival and proximal reoperation rates.
A total of 532 patients with acute type A aortic dissection (ATAAD) who underwent open surgical repair at Kurashiki Central Hospital between 2003 and 2023 were analysed. Patients without postoperative follow-up CT or those who underwent aortic root procedures were excluded, leaving 425 patients for the final analysis.
Among the 425 included patients, 50 (11.8%) developed PANE within the first six months after surgery, whereas 375 (88.2%) did not. Patients who developed PANE were, on average, predominantly male, younger, and had a larger body surface area. They also had a higher prevalence of preoperative severe aortic regurgitation.
With regard to the surgical procedure, the use of biological glue at the proximal anastomosis was significantly less frequent among patients who developed PANE. In addition, operations performed by less experienced surgeons showed a higher incidence of this complication. Multivariable analysis identified three independent factors associated with PANE development: preoperative severe aortic regurgitation (OR = 3.69), surgery performed by less experienced surgeons (OR = 3.75), and, as a protective factor, the use of biological glue at the proximal anastomosis (OR = 0.37).
From an anatomical standpoint, most PANE cases were located in the noncoronary sinus of Valsalva, either in isolation or in combination with adjacent sinuses. In 96% of cases, the site of PANE exactly matched the preoperative dissection site, suggesting that this complication usually arises in areas already weakened by the underlying disease.
Follow-up was available in 94.6% of patients, with a median of 8.4 years in the no-PANE group and 11 years in the PANE group. Although survival rates at 5, 10, and 15 years were lower in patients with PANE (76%, 63%, and 30%) than in those without PANE (85%, 68%, and 45%), no statistically significant difference in overall survival was found. However, the presence of PANE was associated with a significantly higher 10-year incidence of proximal aortic reoperation (14.2% vs 2.2%; p < .001). A total of 17 patients required proximal reoperation, mainly because of anastomotic complications (64.7%). In addition, time to reoperation was longer in the PANE group (3.38 vs 0.38 years; p = .038). Risk analysis identified PANE as a strong predictor of proximal reoperation (sHR = 8.39), together with younger age and male sex as factors associated with an increased risk of further surgery.
The authors conclude that PANE is a relatively frequent complication after surgical repair of acute type A aortic dissection. Although it does not appear to significantly affect long-term survival, it substantially increases the risk of future reintervention. Surgeon experience, the presence of preoperative severe aortic regurgitation, and specific intraoperative technical strategies seem to play an important role in its development.
COMMENTARY:
This study reports long-term outcomes in patients undergoing surgery for acute aortic dissection and compares survival according to the development of a new entry tear at the proximal anastomotic site. The data provide a practical perspective on the triggers, management, and outcomes of PANE.
The analysis shows that this complication is closely linked both to the pathophysiology of the original aortic dissection, as reflected by the anatomical continuity between the initial dissection site and subsequent PANE location, and to the experience of the surgeon performing the initial acute dissection repair. These findings reinforce the importance of both pre-existing tissue fragility and technical surgical factors in the development of this complication.
One of the issues raised by this study is the role of biological sealants, which remain important in haemostasis during cardiac surgery but are probably underestimated in daily practice. Some of these agents have, in fact, been viewed unfavourably because of their potential association with complications such as pseudoaneurysm formation, particularly in relation to compounds such as glutaraldehyde, which is included in some formulations to denature biological agents such as bovine albumin. These products are widely used to adhere the layers of the false lumen and create a neo-intima, a concept that appears particularly relevant in light of the findings of this study.
Although survival among patients who develop this complication is lower, probably in relation to the high surgical risk of reintervention, the differences were not statistically significant. These results reflect the clear improvement in therapeutic management and surgical technique.
After reading this study, several practical objectives can be considered: highlighting the importance of surgical experience to optimize both short- and long-term postoperative outcomes, and emphasizing the value of haemostatic strategies during the operation. Haemostasis should not be regarded as a mere final step before closure, but rather as a determinant of the patient’s subsequent course.
Overall, this study suggests that although PANE is a serious complication, clinically relevant and strongly associated with late reintervention, and relatively frequent, affecting almost 1 in 9 patients, current outcomes remain acceptable when technical control of the anastomosis and selective use of biological adhesives are taken into account. Regarding the excluded patient population, the study also underlines the need for close imaging follow-up, since PANE increases the long-term risk of reintervention by more than 8-fold.
REFERENCE:
Yamashita G, Yaegashi K, Takauchi T, Nakano S, Sakai J, Hirao S et al. Proximal Anastomotic New Entry Tear Following Surgical Repair of Acute Type A Aortic Dissection: Anatomical Location, Risk Factors, and Impact on Long-Term Outcomes. Eur J Cardiothorac Surg 2026; doi:10.1093/ejcts/ezag144.
