Acute DeBakey Type Research Articles

Acute DeBakey Type I aortic dissection without intimal tear in the arch: is total arch replacement the right choice?

Surgical management of acute DeBakey Type I aortic dissection without intimal tear in the aortic arch is controversial. This study compared short- and long-term outcomes of total arch replacement (TAR) versus limited ascending aorta/hemiarch replacement (no-TAR) in a consecutive series of patients. Between January 1998 and December 2015, 220 consecutive patients were operated for DeBakey Type I acute aortic dissection; 135 cases did not exhibit an intimal entry tear in the aortic arch and were subsequently selected to comprise the primary study cohort. A secondary subgroup analysis was made within these 135 cases, which comprised patients who received antegrade cerebral perfusion as the neuroprotective strategy of choice (n = 45). Mean follow-up period was 5 ± 4 years. Among the patients selected, 21 (16%) underwent TAR. Thirty-day mortality was higher in the TAR group (38% vs 21%, P = 0.04). Postoperative complication rates were similar between the groups (61% vs 73%, P = 0.31). Long-term mortality and late aortic reintervention rates were also similar (7% vs 30%, P = 0.36 and 27% vs 14%, P = 0.32, respectively). From the subgroup of patients with antegrade cerebral perfusion, 14 (31%) underwent TAR and 31 (69%) had no-TAR. Mean follow-up-time was 3 ± 2 years. Thirty-day mortality was higher in the TAR group (50% vs 16%, P < 0.01), postoperative complications, long-term mortality and late aortic reintervention rates were similar (64% vs 69%, P = 0.73; 0% vs 19%, P = 0.22; 29% vs 8%, P = 0.17, respectively). TAR was associated with higher 30-day mortality compared with the less extensive hemiarch replacement. In the long term, TAR showed a trend of improved survival and higher reintervention rate.

Extended versus limited arch replacement in acute Type A aortic dissection.

The recommended extent of surgical resection and reconstruction of the arch in acute DeBakey Type I aortic dissection is an ongoing controversy. However, several recent reports indicate a trend towards a more extensive arch operation in several institutions. We have analysed the recent data from the International Registry of Acute Aortic Dissection to assess the choice of procedure over time and to evaluate the surgical outcome in a 'real-world' database. Our aim was to compare short- and mid-term outcomes of limited repairs versus complete arch surgery. Of the 1241 patients included in the 'Interventional Cohort' of the International Registry of Acute Aortic Dissection from March 1996 to March 2015, 907 underwent ascending aortic or hemiarch replacement (Group A) and 334 had extended arch replacement (Group B). An extended resection was a surgeon's 'judgement call'. Logistic regression analysis, propensity-adjusted multivariable comparisons and Kaplan-Meier curves were used for analyses. Overall in-hospital mortality was 14.2% with no difference between groups (Group A 13.1%, Group B 17.1%). Coma/altered consciousness (odds ratio 3.16, 95% confidence interval 1.60-6.25, P = 0.001), hypotension, tamponade or shock (2.03, 1.11-3.73, P = 0.022) and any pulse deficit (1.92, 1.04-3.54, P = 0.038) were predictors of in-hospital mortality in a propensity score-adjusted multivariable analysis. Overall 5-year survival was 69.4% in the ascending group and 73.1% in the total arch group (P = 0.83 by Kaplan-Meier analysis). For survivors of the index hospitalization, the 5-year freedom from death, aortic rupture and reintervention were 71.1% in Group A and 76.4% in Group B (P = 0.54 by Kaplan-Meier analysis). Selective, or 'surgeon's choice', extended arch replacement had no discernible acute downside compared with less extensive surgery. Whether extended arch replacement improves the prognosis beyond 5 years remains to be settled.

Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.

In patients with acute aortic dissection involving the arch and the descending aorta (AADA DeBakey type I), performing a total aortic arch replacement with the frozen elephant trunk (FET) procedure for supposedly better long-term results is still controversial. From February 2004 to April 2016, 94 patients with AADA DeBakey type I had an FET procedure (80% men, age 58 ± 12 years). During the early period (Group 1, 2004-10), the FET technique was performed using non-branched grafts. Thirty-two percent (9/28) underwent concomitant aortic valve-sparing root procedures. More recently (Group 2, 2010-16), branched FET grafts were used in 66 patients (76% men, age: 56 ± 12 years). Fifty-six percent (37/66) underwent concomitant aortic valve-sparing root procedures. Patients showed a high rate of malperfusion syndrome (Group 1: 29% vs Group 2: 38%, P = 0.48). In-hospital mortality was 12% (Group 1: 21% vs Group 2: 9%, P = 0.17). Stroke and rethoracotomy for bleeding occurred in 15% (Group 1: 11% vs Group 2: 17%) and 20% (Group 1: 21% vs Group 2: 20%; P = 1.00) of patients, respectively. Postoperative recurrent nerve palsy and spinal cord injury rates were 18% (Group 1: 14% vs Group 2: 20%) and 5% (Group 1: 7% vs Group 2: 5%; P = 0.63). During follow-up, 11 patients (12%) required reoperation on the downstream aorta (open surgical: n = 6/94, 6%, endovascular: n = 5/94; 5%). Survival tended to be superior in Group 2 (5 years: Group 1: 68% vs Group 2: 80%; P = 0.17). The FET procedure improves short- and long-term outcome, especially for AADA DeBakey I with malperfusion.

Acute DeBakey Type I Dissection Repair Using Frozen Elephant Trunk: The Cleveland Clinic Technique.

Over the past 3 decades, the standard surgical management for acute DeBakey type I aortic dissection has not significantly changed. Most patients undergo ascending aortic replacement with an interposition graft under hypothermic circulatory arrest with selective root replacement. Nevertheless, with the improvement in overall patient care, acute surgical outcomes continue to improve. The frozen elephant trunk (FET) technique was introduced as a modification to conventional elephant trunk to treat extensive degenerative and chronic dissecting aneurysms involving the aortic arch and the proximal descending aorta. The FET technique converts the conventional elephant trunk procedure-an inherently 2-stage operation-into a 1-stage repair in selected patients and greatly facilitates more distal aortic repair, for others. The surgical strategy is tailored to address individual pathology, based on each patient's aortic anatomy and disease. FET technique in acute DeBakey type I aortic dissection extends the surgical repair into and beyond the arch with the potential to address some of the limitations of the conventional type I aortic dissection repair, but it has not been widely adopted yet. Only a limited number of institutions have embraced this modality during the acute phase of aortic dissection out of concern that it may be too complicated during an emergency situation. We have developed a simplified technique that has evolved over the past several years and the purpose of this report is to describe it.

Acute Type A Aortic Dissection Treated Using a Tubular Stent-Graft in the Ascending Aorta and a Multibranched Stent-Graft in the Aortic Arch

Purpose: To describe the combined use of a tubular stent-graft for the ascending aorta and an inner-branched arch stent-graft for patients with acute type A aortic dissection. Technique: The technique to deploy these modular, custom-made stent-grafts is demonstrated in 2 patients with acute DeBakey type I aortic dissections and significant comorbidities precluding open surgery. Both emergent procedures were made possible by the availability of suitable devices manufactured for elective repair in other patients. After preliminary carotid-subclavian bypass, a long Lunderquist guidewire was introduced from the right femoral artery to the left ventricle for delivery of the Zenith Ascend and Zenith Branched Arch Endovascular Grafts under inflow occlusion. Bridging stent-grafts were delivered to the innominate and left common carotid arteries to connect to the 2 inner branches; the left subclavian artery was occluded. Both cases were technically successful and resulted in exclusion of the false lumen in the ascending aorta. The operating and fluoroscopy times did not exceed those of comparable elective procedures. The patients were rapidly extubated shortly after the procedure and without serious immediate complications. One patient survived 11 months with a satisfactory repair; the other succumbed to complications of recurrent pneumonia after 23 days. Conclusion: Endovascular treatment of patients with acute type A aortic dissection using a combination of tubular and branched stent-grafts in the ascending aorta is feasible and offers an alternative strategy to open surgery.

Ascending Aorta and Hemiarch Replacement Combined With Modified Triple-Branched Stent Graft Implantation for Repair of Acute DeBakey Type I Aortic Dissection

To simplify extensive repair of acute DeBakey type I aortic dissection, ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation was developed. The descriptions and early results of this technique are reported. From August 2014 to September 2015, 116 patients with acute DeBakey type I aortic dissection underwent ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation. Clinical data of all patients were retrospectively reviewed. Survivors were followed up prospectively by computed tomography angiography. The cardiopulmonary bypass time was 131.5 ± 10.7 minutes, the aortic cross-clamp time was 50.0 ± 9.9 minutes, and the selective cerebral perfusion and lower body arrest time was 17.2 ± 2.2 minutes. The in-hospital mortality rate was 3.4%. Two patients were lost during follow-up. One patient died of a cerebrovascular accident 2 months after discharge, and another died of chronic renal failure 5 months after discharge. At the 3-month postoperative scans, complete thrombus formation of the false lumen around the implanted modified triple-branched stent graft occurred in all survivors, at the diaphragmatic level in 69.7% patients, and at the superior mesenteric arterial level in 8.3% patients. Extensive thoracic aorta repair of acute type I aortic dissection can be performed simply by combining ascending aorta and hemiarch replacement with modified triple-branched stent graft implantation. This technique can reduce the risk and technical difficulty of extensive thoracic aorta repair to levels close to those seen with ascending aorta and hemiarch graft replacement with open distal anastomosis.

Long-Term Changes in the Distal Aorta after Aortic Arch Replacement in Acute DeBakey Type I Aortic Dissection.

BackgroundWe analyzed the long-term results of ascending aortic replacement and arch aortic replacement in acute DeBakey type I aortic dissections to measure the differences in the distal aortic changes with extension of the aortic replacement.MethodsWe reviewed 142 cases of acute DeBakey type I aortic dissections (1996–2015). Seventy percent of the cases were ascending aortic replacements, and 30% of the cases underwent total arch aortic replacement, which includes the aorta from the root to the beginning of the descending aorta with the 3 arch branches. Fourteen percent (20 cases) resulted in surgical mortality and 86% of cases that survived had a mean follow-up period of 6.6±4.6 years. Among these cases, 64% of the patients were followed up with computed tomography (CT) angiograms with the duration of the final CT check period of 4.9±2.9 years.ResultsThere were 15 cases of reoperation in 13 patients. Of these 15 cases, 13 cases were in the ascending aortic replacement group and 2 cases were in the total arch aortic replacement group. Late mortality occurred in 13 cases; 10 cases were in the ascending aortic replacement group and 3 cases were in the total arch aortic replacement group. Eight patients died of a distal aortic problem in the ascending aortic replacement group, and 1 patient died of distal aortic rupture in the total arch aortic replacement group. The follow-up CT angiogram showed that 69.8% of the ascending aortic replacement group and 35.7% of the total arch aortic replacement group developed distal aortic dilatation (p=0.0022).ConclusionThe total arch aortic replacement procedure developed fewer distal remnant aortic problems from dilatation than the ascending aortic replacement procedure in acute type I aortic dissections.

Aortic valve reimplantation using Kuban Cuff modification in a patient with acute type A aortic dissection and aortic valve insufficiency

The corresponding video is an aortic valve (AV) reimplantation using the Kuban Cuff modification technique (Video 1). The patient is a 36-year-old male with acute (3 days) DeBakey type I aortic dissection. He has Marfan syndrome, aortic root aneurysm of 65 mm, tricuspid aortic valve with aortic grade 3 insufficiency. The patient had a previous abdominal aortic replacement without any other significant comorbidities. The left ventricular function and coronary arteries are normal. AV reimplantation was chosen by reason of young age.

Abstract No. 542 - Does ascending aorta and hemiarch replacement for acute Debakey type I dissection alter true lumen geometry distally?

Abstract No. 542 - Does ascending aorta and hemiarch replacement for acute Debakey type I dissection alter true lumen geometry distally?

Results of Open Surgical Repair in Patients With Marfan Syndrome and Distal Aortic Dissection

In patients with Marfan syndrome (MFS), distal aortic dissection can necessitate thoracoabdominal aortic aneurysm (TAAA) repair in survivors of acute DeBakey type I dissection and those with DeBakey type III dissection. We examined outcomes of surgical repair of TAAA in patients with MFS with distal aortic dissection. Data were analyzed for 127 consecutive TAAA repairs performed between January 2004 and June 2014 in patients with MFS and distal aortic dissection-DeBakey types I (n= 73) and III (n= 54). The median time from dissection onset to TAAA repair was 5.2 years (interquartile range [IQR]: 2.1 to 9.8 years) for the overall group and was longer in patients with DeBakey I (6.5 years, IQR: 3.5 to 13.9 years) than patients with DeBakey III (2.9 years, IQR: 0.6 to 6.0 years, p < 0.001). Eleven patients (9%) had acute or subacute dissection at the time of repair. Sixty-six patients (52%) underwent Crawford extent II TAAA repair. A composite end point, adverse event, was defined as operative death or permanent stroke, renal failure, paraplegia, or paraparesis. Eight patients had adverse events (6%), including 5 operative deaths (4%). There was no permanent stroke and 1 case each of permanent paraplegia andparaparesis. At discharge, 2 early survivors (2%) had renal failure. Extent II repairs did not have substantially different outcomes from other repairs. In these patients with MFS with aortic dissection, open TAAA repair incurred reasonable operative risk, but improvements are needed to reduce rates of renal failure. Extent II TAAA repair does not appear to increase operative risk in patients with MFS.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required.

Ascending aortic and aortic arch replacement after previous surgery for acute aortic dissection DeBakey type I

Ascending aortic and aortic arch replacement after previous surgery for acute aortic dissection DeBakey type I

Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement

ObjectiveThe present study aimed to determine the impact of the extent of graft replacement on early and late outcomes in acute DeBakey type I aortic dissection. MethodsBetween October 1999 and July 2014, 197 consecutive patients were surgically treated for acute DeBakey type I aortic dissection. The extent of graft replacement (hemiarch, partial, or total arch replacement) was mainly determined by the location of the primary entry. Early and late results were compared in patients after total arch replacement (n = 88) and combined hemiarch and partial arch replacement: non–total arch replacement (n = 109). ResultsThe in-hospital mortality rates of the total arch replacement and non–total arch replacement groups were 10.2% and 14.7%, respectively (P = .47). Multivariate analysis revealed preoperative cardiopulmonary resuscitation and visceral organ malperfusion as significant risk factors for in-hospital mortality, but not total arch replacement. During a mean follow-up period of 60 ± 48 months, the 5-year survivals in the total arch replacement and non–total arch replacement groups were 88.6% ± 4.2% and 83.8% ± 4.4%, respectively (P = .54). Rates of distal aortic events (defined as freedom from surgery for distal aorta dilation or distal arch diameter expanding to 50 mm) at 5 years were significantly better in the total arch replacement group than in the non–total arch replacement group (94.9% ± 3.5% vs 83.6% ± 4.9%, P = .01). ConclusionsThe operative mortality of patients with acute DeBakey type I aortic dissection treated by total arch replacement was acceptable with good long-term survival after both total arch replacement and non–total arch replacement. The frequency of distal aortic events might be reduced in patients after total arch replacement compared with non–total arch replacement.

DOES STANDARD SURGICAL REPAIR OF DEBAKEY TYPE I DISSECTION ALTER TRUE LUMEN GEOMETRY DOWNSTREAM?

After successful surgical repair of DeBakey Type I dissection using contemporary standard surgical techniques, patients are generally left with a dissection flap in the descending aorta. Recent evidence suggests that a narrowed true lumen in the distal aorta may lead to early end-organ malperfusion if vital branch vessels arise off the narrowed true lumen. Furthermore, an effaced true lumen may also be associated with poor long term outcomes. The effect of standard surgery involving cardiopulmonary bypass, replacement of the ascending aorta and an open distal anastamosis on the true lumen size in the distal aorta has not been investigated. Pre- and post-op CT scans of patients who had emergency repair for acute aortic syndrome at a single centre between 2006 and 2013 were reviewed. Patients with Debakey Type 2 Dissection, intramural hematoma, hybrid arch repair, total arch repair, and those patients that did not have adequate imaging were excluded. Using a TeraRecon workstation, double oblique surface area measurements of the true lumen and total aortic lumen at the level of the subclavian artery, pulmonary artery bifurcation and diaphragmatic hiatus were obtained. A total of 128 patients underwent operative repair. Inclusion criteria were met by 45 patients (34 males and 11 females) with a mean age of 56 (range 26-79). The median interval between scans was 11 days. The average pre-op and post-op true lumen area in the descending aorta was 2.43 cm2 (0.98-4.25) and 2.70 cm2 (0.82-4.90) respectively. Preoperatively, the true lumen constituted 36% of the total aortic area in the descending thoracic aorta. Postoperatively, this ratio was 38% (p=NS). The true:total ratio improved in 44% of the study population and worsened in 56%. In the group that showed improvement, the average increase in true:total aortic ratio was 42% (median 35%, range: 3%- 121%). In the group that showed worsening of the average ratio, the average decrease was 18%(median 17%, range 49% - 2%). Standard surgical repair in patients with acute De Bakey type I dissection may not improve true lumen morphology in the descending thoracic aorta. When malperfusion is clinically suspected perioperatively and the true lumen is effaced, consideration should be given to adjunctive modalities that may expand true lumen area. Further research is required to understand if adjunctive surgical strategies to expand the true lumen distally will mitigate long term complications.

Outcomes of open distal aortic aneurysm repair in patients with chronic DeBakey type I dissection

In patients with acute DeBakey type I dissection, endovascular repair of the descending thoracic aorta during proximal aortic repair is an increasingly popular approach to preventing distal aortic sequelae and subsequent repair. To better define the risks and outcomes associated with these secondary operations, we examined our contemporary experience with open distal aortic repair in patients with chronic type I aortic dissection. Data were collected between January 2005 and June 2013 regarding 198 consecutive open descending thoracic (n = 27) or thoracoabdominal (n = 171) aortic repairs performed in patients with chronic type I dissection. The median interval between the dissection onset and the subsequent distal operation was 5.0 years (interquartile range, 2.4-10.5 years). A total of 110 repairs (56%) were performed in patients with genetic disorders. There were 14 early deaths (7%). Permanent paraplegia developed in 2 patients (1%), 5 patients (3%) had permanent stroke, and 9 patients (5%) had permanent renal failure. Factors associated with early death included greater age (P = .01), chronic obstructive pulmonary disease (P = .01), clamping proximal to the left subclavian artery (P = .004), and use of hypothermic circulatory arrest (P = .002). The use of cold renal perfusion (P < .001) was associated with early survival. Early death was not associated with genetic disorders, emergency surgery, or extent of aortic repair. There were 36 late deaths, yielding an actuarial 8-year survival of 65.6% ± 5.9%. At 7 years, freedom from repair failure was 95.7% ± 1.7%, and freedom from subsequent repair for disease progression was 84.8% ± 4.6%. In survivors of DeBakey type I aortic dissection with distal aneurysm, open repair of the descending thoracic or thoracoabdominal aorta can be performed with excellent early survival, acceptable morbidity, and relatively few late aortic events.

Risk Factors for Prolonged Mechanical Ventilation After Total Aortic Arch Replacement for Acute DeBakey Type I Aortic Dissection

EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation. Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation. The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p<0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p<0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 10⁹/L (p<0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75). EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation.

Simplified total arch repair with a stented graft for acute DeBakey type I dissection

A novel technique for total arch repair was developed, and the safety and feasibility of this simplified technique were compared with those of total arch replacement. With the use of a self-designed stented graft, of which the proximal 10 cm is free of stent, 54 patients with acute type I dissection underwent ascending aorta replacement combined with total arch repair (simplified group). The stented part was implanted into the descending aorta as an elephant trunk, and the part free of stent was sutured inside the arch with exposure of the orifices of 3 arch vessels. A total of 41 patients with acute type I dissection undergoing ascending aorta and total arch replacement with stented elephant trunk (total arch group) were enrolled as controls. There was no permanent neurologic dysfunction or paraplegia in both groups. The incidence of postoperative transient neurologic dysfunction and prolonged ventilation was lower in the simplified group (P<.05). The hospital mortality was 3.7% (2/54) in the simplified group and 7.3% (3/41) in the total arch group (P=.44). No significant difference was detected in survival between the 2 groups (P=.78). Complete thrombosis in the false lumen of the residual arch was found in all patients undergoing simplified aortic repair. The rate of complete thrombosis in the false lumen of the distal aorta was similar between the 2 groups (P>.05). The risks of aortic event were comparable for both groups (P=.84). The simplified technique of total arch repair is an easy and effective surgical strategy for acute type I dissections.

Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate

Previously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair. DeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained. Preoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P<.001). In-hospital/30-day mortality (10% vs 14%; P=.51), stroke (5% vs 8%; P=.6), and paraplegia (0% vs 1%; P=1) were similar in the stented versus standard groups. Mean follow-up was 2.7 ± 2.3 and 2.2 ± 2.1 years. Actuarial survival in stented versus standard groups at 1 and 7 years was 86% versus 81% and 76% versus 60% (P=.5). Thoracic aorta false lumen obliteration was improved in the stented group (82% vs 39%; P<.001), along with improved freedom from open distal aortic reoperation rate (98% vs 90% at 6 years, P=.1). Endovascular distal aortic reintervention rate was higher in the stented group (18% vs 3%; P=.008), with zero mortality. Antegrade stent graft deployment during acute DeBakey type I dissection repair is safe method to promote distal aortic remodeling without increasing postoperative or midterm mortality. This technique provides increased freedom from open distal aortic reoperations compared with standard open repair.

Early and midterm outcomes of hemiarch replacement combined with stented elephant trunk in the management of acute DeBakey type I aortic dissection: Comparison with total arch replacement

For patients with acute DeBakey type I aortic dissection without an intimal tear in the arch, the early and midterm outcomes of hemiarch replacement with stented elephant trunk were compared with those of total arch replacement. From January 2006 to December 2011, 197 patients with acute type I aortic dissection were identified without an intimal tear in the arch. Of the 197 patients, 71 underwent hemiarch replacement with stented elephant trunk implantation (hemiarch group) and 84 underwent ascending aorta and total arch replacement with stented elephant trunk implantation (total arch group). The incidence of postoperative transient neurologic dysfunction, low cardiac output syndrome, and prolonged ventilation was lower in the hemiarch group (P<.05 for all). The hospital mortality was 4.2% and 5.9% for the hemiarch and total arch groups, respectively (P=.91). No difference was detected in survival between the 2 groups (P=.56). Complete thrombosis in the false lumen of the residual arch was found in 92.1% of those undergoing hemiarch replacement. The rate of complete thrombosis in the false lumen of the distal aorta was similar between the 2 groups (P>.05). The risk of an aortic event was similar for both groups (P=.62). For patients with acute DeBakey type I dissection without an intimal tear in the arch, hemiarch replacement with stented elephant trunk implantation was easily performed, with satisfactory early and midterm outcomes. For these selective patients, total arch replacement with the stented elephant trunk technique did not improve the late surgical results further.

Should the dissected aortic arch be replaced in acute type A dissection? The Mayo Clinic perspective.

Should the dissected aortic arch be replaced in acute type A dissection? The Mayo Clinic perspective.