Stented Elephant Trunk Procedure Research Articles

Comparison of Open Repair vs. the One-Stage Hybrid Extra-Anatomic Technique for Distal Aortic Arch Disease Treatment: Mid-term Outcomes With a Risk-Adjusted Analysis.

Objective: This study aims to compare the short- and mid-term outcomes of the stented elephant trunk (SET) procedure combined with supra-arch branch reconstruction and one-stage hybrid arch repair combined thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in the management of distal arch disease.Methods: From January 2009 to January 2019, 97 patients underwent one-stage hybrid arch repair combined with TEVAR with extra-anatomic bypass (HAR group), and 206 patients underwent the SET procedure with supra-arch branch reconstruction (SET group). We used inverse-probability-of treatment weighting (IPTW) to adjust baseline differences.Results: Before IPTW adjustment, there was no significant difference in operative mortality between the two groups (5.2 vs. 1.0%, P = 0.064). The incidences of stroke, spinal cord injury (SCI), acute kidney injury (AKI), and endoleak also showed no significant differences (4.1 vs. 0.5%, P = 0.066; 2.1 vs. 1.5%, P = 1.000; 0 vs. 1.0%, P = 0.831; 6.2 vs. 1.9%, P = 0.113, respectively). After IPTW adjustment, the incidences of stroke, SCI, and AKI showed no significant differences between the two groups (1.8 vs. 1.1%, P = 0.138; 0.8 vs. 1.6%, P = 0.448; and 0 vs. 0.7%, P = 0.148, respectively). However, the HAR group tended to have higher operative mortality and incidence of endoleak than the SET group (12.4 vs. 1.3%, P = 0.01; 9.9 vs. 1.8%, P = 0.031, respectively). In the multivariate analysis, open repair decreased the risks of endoleak (odds ratio [OR], 0.171, 95% CI, 0.060–0.401; P < 0.001) and operative mortality (OR, 0.093, 95% CI, 0.027–0.238; P < 0.001). The overall survival and event-free survival of the HAR group were significantly lower than those of the SET group (P < 0.001).Conclusion: One-stage hybrid arch repair combined TEVAR with extra-anatomic bypass and the SET procedure with supra-arch branch reconstruction both provided good postoperative treatment outcomes for distal arch disease. However, hybrid arch repair increased the risks of endoleak and operative mortality. The SET procedure provided better mid-term survival than hybrid arch repair without increasing operative mortality. Carefully selecting the indications for the procedure, while receiving close long-term follow-up, may improve the survival rate of patients undergoing hybrid arch repair.

Application of the modified stented elephant trunk procedure in type B aortic dissection.

BackgroundConsidering the progressive nature of complicated Stanford type B aortic dissection (TBAD), operation must anticipate the need for later interventions. Recently we have used a modified stent elephant trunk (SET) procedure to treat these patients. And we review the indications, considerations for planning, and operative details for this this modified SET procedure.MethodsTen patients (seven males and three females) with complicated TBAD underwent a modified SET procedure in Anzhen Hospital, Beijing in the period between January 2019 and December 2019. The patients, whose ages ranged from 29–52 (42±7.23), suffered complications with hypertension. Under deep hypothermic circulatory arrest, all the patients received SET implantation via an incision of the aortic arch. Before the patients were discharged, a computed tomography angiography (CTA) was performed to ensure the safety and accuracy of the procedure.ResultsThe average surgery time was 4.0–5.5 (4.65±0.47) hours, cardiopulmonary bypass (CPB) time was 115–163 (138.6±15.64) minutes, aortic cross-clamping time was 32–59 (42±7.72) minutes, and selective cerebral perfusion (SCP) time was 15–32 (21.7±5.56) minutes. The SCP flow and nasopharyngeal temperature were 5–8 (6.8±1.23) mL/kg/min and 23.5–26.8 (25.22±0.96) °C, respectively. During SCP, the blood pressure of the left upper limb was 20–31 (25.5±3.81) mmHg. Aorta cannulation position: vascular graft was anastomosed to the innominate artery (IA) and left subclavian artery (LSA) in seven cases, and with IA, LSA, and the right femoral artery in three cases. Ventilation time was 5–15 (8.8±2.94) h, retention time in ICU was one day, and post-operative hospitalization time was 6–8 (6.9±0.74) days. None of the patients died, or experienced endoleakage or neurological complications.ConclusionsThe application of a modified stented elephant trunk procedure in the treatment of TBAD is safe and efficient.

Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition With Stented Elephant Trunk in the Hybrid Repair Era

Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51±14 (range 20-69) years. There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33±21months, one patient died. Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.

The repair of a type Ia endoleak following thoracic endovascular aortic repair using a stented elephant trunk procedure

BackgroundType Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent-graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. MethodsFrom July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. ResultsAll cases of type Ia endoleak (100%) were repaired successfully. There were no in-hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow-up. During follow-up, there were 3 deaths. ConclusionsAcceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion.

Repair of complicated type B dissection with an aberrant right subclavian artery.

An aberrant right subclavian artery (ARSA) is one of most common congenital anomalies, but the coexistence of type B dissection and an ARSA is extremely rare. Repair of type B dissection poses a technical challenge due to an ARSA. We retrospectively reviewed our experience of surgical treatment of a complicated type B dissection with an ARSA. From August 2010 to March 2014, 7 patients with chronic type B dissection with an ARSA underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass in our centre. The mean age was 45 ± 7 (range, 32-54) years. Total arch replacement was performed in 2 patients. Revascularization of the ARSA was done in 5 of 7 patients. There were no in-hospital deaths. The mean time of mechanical ventilation and stay in the intensive care unit was 22 ± 11 and 53 ± 11 h, respectively. Neurological deficit, visceral ischaemia or injury to the spinal cord was not observed. Right upper-limb ischaemia was not observed in patients without ARRA revascularization during follow-up. In patients not undergoing descending aortic replacement, the stented elephant trunk method is our preferred procedure for this anomaly via a median sternotomy. Repair of type B dissection and revascularization of the ARSA were achieved in a single stage using this technique. Satisfactory surgical results and follow-up outcomes were obtained. There was no right upper-limb ischaemia or neurological deficit in patients without ARSA revascularization, but revascularization of the ARSA is recommended for this vessel anomaly.

One-Stage Repair of Acute Type B Dissection With Ascending Thoracic Aortic Dilatation Using a Stented Elephant Trunk Procedure.

Acute type B dissection with ascending thoracic aortic dilatation (ATAD) is very common, but remains surgically challenging with the use of the conventional single-stage procedure via median sternotomy or lateral thoracotomy. We report our experience with repair of acute type B dissection with ATAD using a one-stage stented elephant trunk procedure. We retrospectively reviewed the medical records of 16 patients (13 males and 3 females) with acute type B dissection with ATAD who underwent ascending thoracic aortic reconstruction combined with a stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion between February 2009 and February 2013. ATAD included ascending aortic aneurysm in four patients, ascending aortic enlargement + aortic regurgitation in three, and ascending aortic aneurysm + aortic root aneurysm in nine. Lower limb ischemia occurred in one case. There was no in-hospital mortality. Drainage of the pericardial sac was indicated for two patients with pericardial effusion. The median durations of ventilator support and intensive care unit stay were 25 ± 18 and 48 ± 7 hours, respectively. Lower limber ischemia was alleviated after implantation of a stented elephant trunk. One patient received thoracoabdominal aortic replacement during follow-up and encountered no postoperative complications. Satisfactory surgical results and follow-up outcomes can be achieved using the proposed one-stage stented elephant trunk procedure for acute type B dissection with ATAD.

Stented elephant trunk procedure with left subclavian artery transposition for acute type B dissection with distal arch involvement

ObjectiveComplete or partial supra-aortic debranching, after thoracic endovascular aortic repair, is appealing treatment for complicated acute type B dissection (ABAD) with aortic arch involvement (AAI) because of reduced surgical trauma. However, unsatisfactory outcomes have been reported. We retrospectively reviewed our experience of left subclavian artery (LSCA) transposition with stented elephant trunk (SET) implantation for complicated ABAD with distal AAI. MethodsFrom April 2011 to December 2014, 19 patients (all men; mean age: 44 years) who had complicated ABAD and distal AAI underwent LSCA transposition with SET implantation via a median sternotomy under hypothermic cardiopulmonary bypass with selective cerebral perfusion. Preoperative renal dysfunction was observed in 3 patients, visceral ischemia in 2 patients, and lower-limb ischemia in 1 patient. ResultsNo in-hospital deaths occurred. Seventeen patients required mechanical ventilation for <24 hours, and 2 cases for <48 hours. The mean time of mechanical ventilation and duration of stay in the intensive care unit was 18 ± 6 hours and 44 ± 16 hours, respectively. Ischemia of the viscera and lower limbs after surgery was ameliorated. Continuous renal replacement therapy was not required in 3 patients who had preoperative renal dysfunction. Complete thrombosis of the false lumen at the distal end of the SET was observed in 17 of 18 (94.4%) patients during follow-up. ConclusionsThis method preserves autologous brachiocephalic vessels, excludes the false lumen, promotes thrombosis and remodeling of the distal aorta, and repairs proximal aortic lesions simultaneously. Satisfactory surgical outcomes and follow-up results were achieved using LSCA transposition with SET implantation.

Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique

The presence of an isolated left vertebral artery (ILVA) remains a challenging issue for thoracic endovascular aortic repair (TEVAR) of type B dissection if the proximal landing zones are inadequate. We retrospectively reviewed our experience of the surgical management of complicated type B dissection with an ILVA using the stented elephant trunk technique. Between February 2009 and May 2013, 7 patients with complicated type B dissection (acute = 2 and chronic = 5) underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All the patients were males with a median age of 53 ± 6 (range 42-59) years. Preoperative lower limb ischaemia was observed in 1 patient, renal dysfunction in 1 patient and visceral ischaemia in 1 patient. There were no in-hospital deaths. The median ventilator support time was 16 ± 3 (range 11-20) h. Ischaemia of the lower limb and viscera was ameliorated after surgical stent-graft implantation. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurological deficits were observed in any patients prior to hospital discharge. One patient underwent TEVAR due to distal aortic dilatation within the mean follow-up period, which was 44 ± 19 months. Repair of complicated type B dissection with an ILVA using the stented elephant trunk technique was associated with satisfactory surgical results in patients with inadequate proximal fixation zones. This technique is an alternative to TEVAR for complicated type B dissection with inadequate proximal landing zones.

Intraoperative platelet transfusion is associated with increased postoperative sternal wound infections among type A aortic dissection patients after total arch replacement.

Blood transfusion and its impact upon clinical outcomes of cardiac surgery have been extensively discussed, especially in the post-aprotinin era. This study compared clinical outcomes and perioperative blood utilisation among acute type A aortic dissection (AAD) patients with or without intraoperative platelet transfusion during total arch replacement, thus intending to investigate prognostic value of platelet transfusion during major aortic surgeries. Acute AAD patients undergoing total arch replacement and stented elephant trunk procedure under hypothermic circulatory arrest with and without intraoperative platelet transfusion at our institute from January 2008 to December 2012 were retrospectively included. Patients were categorised into PLT (n = 74) and non-PLT (n = 85) groups to compare the in-hospital mortality and complications, as well as blood components utilisation. Baseline characteristics and operational features were all comparable between two groups. In PLT group, in-hospital survival was not improved and intraoperative utilisation of red blood cell RBC, fresh frozen plasma (FFP) and cryoprecipitate was not reduced. Postoperative RBC transfusion [2.0(0-4.0) vs 0(0-4.0) U, p = 0.026; 64.9 vs 43.5%, p = 0.007] was significantly increased in PLT group, parallel with the prolonged postoperative hospitalisation time [(24.0 ± 12.7) vs (20.8 ± 10.9) days, p = 0.093] and elevated incidence of sternal wound infections (16.2 vs 5.9%, p = 0.035). Intraoperative platelet transfusion [odds ratio (OR): 3.10, 95% confidence interval (CI): 1.04-9.25, p = 0.043] was identified as independent risk factor of postoperative sternal wound infections by multivariate logistic regression analysis. Intraoperative platelet transfusion did not improve in-hospital prognosis among AAD patients after total arch replacement. The incidence of postoperative sternal wound infections increased among those who received intraoperative platelet transfusion.

Invited Commentary

Invited Commentary

Concomitant frozen elephant trunk procedure and pulmonary embolectomy

The antegrade stented (frozen) elephant trunk procedure and pulmonary embolectomy are complex cardiac surgical operations for extensive aortic and pulmonary arterial disease, respectively. We report the first known case of concomitant antegrade stented elephant trunk and pulmonary embolectomy in order to highlight pre- and intra-operative management strategies for this uncommon disease combination.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

The stented elephant trunk procedure combined total arch replacement for Debakey I aortic dissection: operative result and follow-up

The stented elephant trunk technique in aortic arch replacement combined with transaortic stented graft implantation into the descending aorta has been introduced as a means of eliminating the residual false lumen in the descending thoracic aorta and improving long-term outcomes of surgical intervention for Debakey I aortic dissection. This report summarizes the operative and follow-up data with this new procedure. Between August 2004 and May 2009, 28 stented elephant trunk operations were performed for Debakey I aortic dissection at Nanjing First Hospital. A 10 cm long woven Dacron graft was implanted through the aortic arch during hypothermic circulatory arrest. Patent false lumina were evaluated using computed tomography three months after the operation. Mean cardiopulmonary bypass time was 213.2±47.2 min, and selected cerebral perfusion time was 38.8±9.7 min. Hospital mortality was 14.3% (4/28). Thrombus obliteration of the residual false lumen in the descending aorta was observed in 91.7% of the aortic dissections three months postoperatively. The survival rate was 87.5% at five years and the freedom from reoperation rate was 91.7%. Total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta is an effective treatment for Debakey type I aortic dissection.

Early Influence of Valve-Related Anticoagulation on False Lumen Thrombosis in Aortic Dissection Patients after Stented Elephant Trunk Surgery

Aim of the study was to assess the influence of anticoagulation on the false lumen after a stented elephant trunk procedure with mechanical valve replacement for aortic dissection patients. Between 2003 and 2008, 181 out of 232 aortic dissection patients undergoing stented elephant trunk procedure concomitant with arch and/or proximal surgery were enrolled in this study. Fifty-five patients received an aortic valve replacement (AVR) with mechanical prosthesis. Patients were divided into two groups: with and without AVR. The aorta was evaluated by CT, and the diameter ratios between the true lumen and the aorta were calculated and the extent of thrombosis of the false lumen was quantified. Follow-up CT study at one year showed a significant difference between groups, mainly in the diameter ratios of the stent and aorta at the same level (P=0.003, at the stent end). Accordingly, CT data after hospital discharge differed significantly with regard to the extent of false lumen thrombosis at the carina level (P=0.020, at one year). Over one year after surgery, the residual false lumen around the stent-graft achieved complete thrombosis obliteration in 87.3% of patients with AVR and in 98.4% without AVR (P=0.005). Valve-related anticoagulation is associated with delay in false lumen thrombosis around the stent-graft.

Repair of Chronic Type B Dissection With Aortic Arch Involvement Using a Stented Elephant Trunk Procedure

A conventional single-stage procedure, staged procedures, or debranching of the supraaortic vessels, followed by immediate transfemoral stenting of the aortic arch, have been introduced to treat chronic type B dissection with aortic arch involvement. The best method for surgical repair of chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions is not known. Between October 2003 and December 2008, 19 patients underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion through a median sternotomy. Thirteen patients had proximal aortic lesions. Postoperative computed tomography was used to evaluate thrombosis and absorption of the false lumen. Concomitant proximal aortic lesions were repaired in all patients. Thirty-day mortality was 5.26% (1/19). There was one late death at a mean follow-up of 36 +/- 12 months. There was no spinal cord injury or visceral malperfusion. One patient with Marfan syndrome with chronic dissection underwent thoracoabdominal aortic replacement 6 months later. Obliteration of the false lumen around the stented elephant trunk was observed in 16 patients (94.1%, 16/17) during follow-up. This technique is safe, effective, and economical. Replacement of aortic arch dissection and thrombosis of the dissected descending aorta was achieved simultaneously. Concomitant proximal aortic lesions were repaired. Favorable surgical outcomes and postoperative results using this technique were obtained in patients with chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions.

Chronic Debakey I aortic dissection in Marfan syndrome and hypertensive patients with modified stented elephant trunk surgery: a post-operative CT assessment

To assess the outcome of stented elephant trunk surgery for chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients by CT. Between 2003 and 2008, 54 patients underwent the modified stented elephant trunk procedure and total arch replacement for chronic DebakeyIaortic dissection. Twenty-two patients were made a diagnosis of Marfan syndrome and the other 32 patients of hypertension. Aortic evolvement was evaluated with CT angiography by calculating the diameter ratios between the stent graft/true lumen and the aorta at the same level. CT study one year after discharge showed no difference in the diameter ratios of the stent and aorta at the carina level between groups (0.84 +/- 0.16 vs 0.80 +/- 0.23, P = 0.472), but had significant difference before and after surgery (0.29 +/- 0.16 vs 0.72 +/- 0.21, P < or = 0.001). And significant difference occurred at the different periods after discharge (0.72 +/- 0.21 vs 0.81 +/- 0.20, 0.81 +/- 0.20 vs 0.77 +/- 0.20, P < or = 0.001). The residual false lumen in the proximal descending aorta reached complete thrombosis in 59% of Marfan and 78% of hypertension. The modified stented elephant trunk technique is effective for closing the false lumen in the proximal descending aorta of chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients.

Clinical application of stented elephant trunk technique for complicated Stanford type B aortic dissection

To summarize the experience of the application of stented elephant trunk procedure in the treatment of the patients with complicated Stanford type B aortic Dissection. Between January 2004 and March 2009, 33 patients (27 male and 6 female) underwent stented elephant trunk implantation in the descending aorta for complicated type B dissection. Right auxiliary artery cannulation was routinely used for cardiopulmonary bypass and selected cerebral perfusion. The stented elephant trunk was implanted through the aortic arch under hypothermic circulatory arrest. Complications were recorded to evaluate the immediate and mid-term results. Cardiopulmonary bypass time was 174 +/- 29 min, and average selective cerebral perfusion and lower body arrest time was 24 +/- 9 min. The in-hospital mortality was 6.0% (2/33). No paraplegia was observed after surgery. During follow-up CT-scans thrombus formation was observed within the descending aortic false lumen excluded by the stented graft in the acute and chronic aortic dissections. There was one death during follow-up. The stented elephant trunk procedure could be an effective treatment for complicated type B dissection; it also could close the false lumen of the descending aorta and in preventing expansion of the descending aorta.

Total Arch Replacement with Stented Elephant Trunk Technique: A Proposed Treatment for Complicated Stanford Type B Aortic Dissection

The treatment of Stanford type B aortic dissections involving the arch or associated with proximal aortic aneurysms remains a surgical challenge. We report our results with total arch replacement with the stented elephant trunk (SET) procedure for these complicated Stanford type B aortic dissections. Between December 2003 and June 2008, 31 patients were admitted for complicated type B dissection (12 acute, 19 chronic). The mean age at operation was 44.3 +/- 10.6 years (range: 22-68 years). The surgeries were performed by using total arch replacement combined with SET implantation. Enhanced computed tomography (CT) was performed before discharge as well as 3 months and annually to evaluate the condition of the graft and the residual false lumen. The procedure was successful in all but two patients; two patients died of multiple organ failure following surgery. No paraplegia was observed after surgery. Follow-up was completed in 27 of 29 patients and the mean follow-up period was 18.4 +/- 12.3 months (range: 6-54 months). During follow-up CT scans, thrombus formation was observed in the descending aortic false lumen excluded by the stented graft in most patients. One patient died during follow-up while two patients with Marfan syndrome underwent successful operations for replacement of the remaining descending and abdominal aorta. Total arch replacement with the SET procedure has emerged as a viable option for complicated type B dissections and is associated with low morbidity and mortality. At mid-term follow-up, most patients have either thrombosed or have had no further increase in the false lumen of the descending aorta.

Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure

Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure. Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography. Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up. Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.

Invited Commentary

Invited Commentary