Reply to Urbanski

Abstract

We thank Dr Urbanski for his kind comments and demonstration of his personal results [1]. There is an obvious misunderstanding in the interpretation of our surgical principles in assuming that a complete resection of all dissected aortic walls was not performed in all patients. On the contrary, all dissected aortic walls were removed in all Type II patients according to our modification of DeBakey’s original classification with extension to the end of the aortic arch, as indicated in the ‘Surgical management’ section [2]. This means that, in 44 patients with Type II dissection, complete removal of the dissected aortic wall was achieved by the sole ascending aortic replacement in 12 (27%), by hemiarch in 16 (36%) and total arch replacement in another 16 (36%) patients. Beyond this, the intention of our article is to demonstrate, that after removal of all dissected tissue, none of the survivors faced any late complications of the downstream aorta. Reiteration of the data pool of the presented Type II patients by January 2012, with continuing complete follow-up from now up to 10 years (mean ± SD 2.8 ± 2 years), confirms the observation from our article that none of the patients developed later downstream aortic dissection or associated pathologies, besides one isolated, infrarenal aortic aneurysm. This indicates that DeBakey’s original assumption that ‘complete resection of the dissected (ascending) aorta could be curative’ holds true for the aortic arch as well [3]. Dr Urbanski’s plea for a different classification, taking into consideration the extent of dissection and the location of the intimal tear, is in good company with several historic attempts to better conceive the anatomical and pathophysiological situation, as described by Dr Kirsch in his thoughtful editorial comment on our article [4]. What all those alternative classifications have in common is their complexity or even impracticability for daily use. In our opinion, the Stanford classification remains the keystone classification in fast clinical decision making, and the DeBakey classification, in its upgraded version based on today’s knowledge and imaging capacities, is the best tool for prognostic judgement after surgical repair. The major intention of our article is to provoke other established groups in the field of thoracic aortic surgery to check with their data bases and ascertain whether or not our, as well as Dr Urbanski’s, observation holds true, that the resection of all dissected aortic tissue renders a very favourable prognosis in regard to cure of the aortic disease. Since up to 40% of all thoracic aortic dissection cases are included in this subgroup, long-term follow-up studies should be undertaken by separating this large subgroup from the Type A patients, which represent the vast preponderance of all publications worldwide. This, however, would mean that up to 40% of those Type A patients would not expect late complications like patients with Type I dissection and persisting false lumen. The consequence would be that there is an enormous underestimation of late risk for downstream complications as judged today. Attempts to treat a dissected descending aorta simultaneously with the ascending aorta and/or arch would be even more justified than today.