Aortic arch replacement with prophylactic aortic arch debranching during type A acute aortic dissection repair: initial experience with 23 patients

• Published in: European journal of cardio-thoracic surgery Vol. 40; no. 2; pp. 418 - 423
• Main Authors: Glauber, Mattia, Murzi, Michele, Farneti, Pierandrea, Bevilacqua, Stefano, Mariani, Massimiliano, Tognarelli, Andrea, Gasbarri, Tommaso, Berti, Sergio
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Science B.V 01.08.2011; Oxford University Press
• Subjects: Acute Disease; Acute Kidney Injury - etiology; Adult; Aged; Aneurysm, Dissecting - surgery; Aorta, Thoracic - diagnostic imaging; Aorta, Thoracic - surgery; Aortic Aneurysm - surgery; Aortic Aneurysm, Thoracic - surgery; Aortography - methods; Biological and medical sciences; Blood and lymphatic vessels; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - methods; Cardiology. Vascular system; Diseases of the aorta; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Follow-Up Studies; Humans; Male; Medical sciences; Middle Aged; Patient Selection; Pneumology; Recurrence; Reoperation - methods; Stents; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Tomography, X-Ray Computed; Treatment Outcome; Re-operation; Endovascular techniques; Aortic dissection; Human; Corrective surgery; Acute; Cardiovascular disease; Patient; Endovascular route; Replacement; Operation; Arterial disease; Vascular disease; Dissecting aneurysm; Experience; Treatment; Aortic arch; Aorta; Circulatory system; Technique; Cardiology; Repair; Aortic disease; Pneumology
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2010.12.012

Objective: To improve the long-term results of acute type A dissection repair, we developed a technique that combines radical surgical resection, and, at the same time, creates a safe and long landing zone for subsequent endovascular procedure on the descending aorta. Methods: Since November 2006, 23 patients (62 ± 13 years) underwent aortic arch replacement concomitant with prophylactic debranching of the supra-aortic vessels, with a specially designed arch graft. The technique consists of replacing the ascending aorta and the aortic arch, and, at the same time, relocating the origin of the supra-aortic vessels just above the sinotubular junction creating a long and safe proximal landing zone for subsequent stent-graft deployment. Perfusion was antegrade through the ascending aorta during cooling and through the vascular prosthesis during rewarming. Distal arch anastomosis was performed under moderate hypothermic circulatory arrest for 25 ± 7 min and antegrade selective cerebral perfusion (46 ± 14 min). Cardiopulmonary bypass and aortic cross-clamp time were 138 ± 46 and 63 ± 22 min. Results: Hospital mortality was 4.3% (1/23). Postoperative morbidity includes five acute renal failures and four lung failures. No major neurological complications were observed. At follow-up (22 ± 10 months), survival was 100% and two patients required an endovascular thoracic aorta repair for aneurysmal enlargement. In both cases, the stent grafts were successfully released in the landing zone created at the time of primary repair. Conclusions: Our technique extends the suitability of endovascular therapies during type A acute dissection repair, creating a long and stable landing zone that allows safe performance of a second endovascular step if needed, both in the short- and long term.