Total Arch Replacement with Concomitant Retrograde Stent Graft Deployment via Ministernotomy in Acute Aortic Dissection
DOI:
https://doi.org/10.1532/hsf.2829Abstract
Background: Acute aortic dissection is one of the most fatal conditions, with high surgical risks and severe postoperative complications. Treatment modalities vary from center to center, and a total arch replacement sometimes is not sufficient to provide a good result. Frozen elephant trunk (FET) offers a good option for a more complete repair. Because of its complexity and expense, however, this excellent technique is not always available. In this article, we present our hybrid technique including total arch replacement and retrograde thoracic endovascular aortic repair (TEVAR) for acute aortic dissection via a ministernotomy.
Objective and methods: Our study aimed to estimate the safety, early results, and some midterm outcomes of total arch replacement in combination with retrograde TEVAR for acute aortic dissection from August 2013 to May 2017. We analyzed the intraoperative variables (duration of cross-clamp, circulatory arrest, ventilation, and intensive care unit stay), 30-day mortality, and early complications as well as the midterm results of these patients.
Results: From August 2013 to May 2017, 22 patients (17 male) diagnosed with acute aortic dissection were treated with total arch replacement and concomitant retrograde endovascular repair via an upper ministernotomy. Mean age (± SD) was 60.8 ± 10.7 years. Thirty-day mortality was 4.5%: 1 patient died of acute renal failure. One patient had a postoperative stroke. The average number of stents used intraoperatively was 1.83. Midterm mortality was 1 patient (4.5%). Complete thrombosis of the false lumen in the thoracic aorta was achieved in 18 patients (90%).
Conclusions: Retrograde TEVAR in combination with total arch replacement via an upper ministernotomy might be safe and effective in treating acute type A aortic dissection, with fairly low mortality and perioperative complications, and a very good rate of total false lumen thrombosis in midterm follow up.
References
Black JH III, Manning WJ. Management of acute aortic dissection. UpToDate, Collins KA, ed. UpToDate, Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/management-of-acute-aortic-dissection (Accessed on January 11, 2018).
Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg 2002;73:460-465; discussion 465-466.
Criado FJ. Aortic dissection: A 250-year perspective. Tex Heart Inst J 2011;38:694-700.
Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-247.
Di Bartolomeo R, Leone A, Di Marco L, Paciniet D. When and how to replace the aortic arch for type A dissection. Ann Cardiothorac Surg 2016;5:383-388.
Di Bartolomeo R, Murana G, Di Marco L, et al., Frozen versus conventional elephant trunk technique: application in clinical practice. Eur J Cardiothorac Surg 2017;51(suppl 1):i20-i28.
Fattori, R., Bacchi-Reggiani L, Bertaccini P, et al. Evolution of aortic dissection after surgical repair. Am J Cardiol 2000;86:868-872.
Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine (Baltimore) 1958;37:217-279.
Hofferberth SC, Newcomb AE, Yii MY, Yap KK, Boston RC, Nixon IK, Mossop PJ. Hybrid proximal surgery plus adjunctive retrograde endovascular repair in acute DeBakey type I dissection: Superior outcomes to conventional surgical repair. J Thorac Cardiovasc Surg 2013;145:349-354; discussion 354-355.
Kato M, Ohnishi K, Kaneko M, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(9 suppl):II188-II193.
Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-Year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol 2015;66:350-358.
Perrotta S, Lentini S. Ministernotomy approach for surgery of the aortic root and ascending aorta. Interact Cardiovasc Thorac Surg 2009;9:849-858.
Shrestha M, Martens A, Kaufeld T, et al. Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years. Eur J Cardiothorac Surg 2017;52:858-866.
Uchida N, Shibamura H, Katayama A, Shimada N, Sutoh M, Ishihara H. Operative strategy for acute type a aortic dissection: Ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. Ann Thorac Surg 2009;87:773-777.
Vallabhajosyula P, Szeto WY, Pulsipher A, et al., Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate. J Thorac Cardiovasc Surg 2014;147:942-948.
Yamamoto H, Kadohama T, Yamaura G, et al. Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection. J Thorac Cardiovasc Surg 2019:S0022-5223(19)30360-5.
Zierer A, Voeller RK, Hill KE, Kouchoukos NT, Damiano RJ Jr, Moon MR. Aortic enlargement and late reoperation after repair of acute type A aortic dissection. Ann Thorac Surg 2007;84:479-486; discussion 486-487
