Abstract
Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD.
Highlights
Despite improvements in surgical techniques for acute Type A aortic dissection (ATAAD), the most recent large registry data published in 2015 suggests a persistently high operative mortality of 15-20% [1, 2]
The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting
There is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia
Summary
Despite improvements in surgical techniques for acute Type A aortic dissection (ATAAD), the most recent large registry data published in 2015 suggests a persistently high operative mortality of 15-20% [1, 2]. The potential benefits of extended arch surgery in patients with ATAAD are 1) resection of primary intimal tears beyond the ascending aorta, 2) exclusion of re-entry tears in the descending aorta, 3) facilitation of re-expansion of the distal true lumen, and 4) promotion of false lumen obliteration This approach aims to reduce early malperfusion, improve late aortic remodeling, and decrease late mortality without increasing perioperative morbidity and mortality. The overall population showed an aorta-related survival of 93% at 100 months, stable thoracic and abdominal aortic dimensions over a mean follow-up of 57.3 months, and complete false lumen thrombosis in 23% of cases [16] This was followed by another report from the same group comparing the shortterm outcomes of this technique compared with treatment by proximal aortic intervention only.
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