Intimal re-layering technique for type A acute aortic dissection—reconstructing the intimal layer continuity to induce remodeling of the false channel

Abstract

Background: Residual false channel is common after repair of type A acute aortic dissection (TAAAD).Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions.Methods: Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 ℃) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation.Results: No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions:This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

Arch replacement with collared elephant trunks: The Siena approach

“…Beyond the debate about more extensive arch approach, the principal reason is that in dissections requiring arch replacement we prefer to use 2 different grafts, one for the ET and one for the arch, given that the collar offers no technical advantage in small and fragile aortas; more recently, we have adopted other techniques such as intimal relayering for arch repair dissection. 30 Number . Kaplan-Meier estimates for overall survival after elephant trunk procedure comparing endovascular, surgical, and unstented ("soft") techniques; the "soft" approach was adopted mainly in dissection patients (16 dissection vs 3 aneurysm); this group does not include lost to follow up (1 patient), unfit (3 patients), pending treatment (1 patient), and died waiting completion (3/11 patients: beyond 30 days from the index procedure).…”

“…Beyond the debate about more extensive arch approach, the principal reason is that in dissections requiring arch replacement we prefer to use 2 different grafts, one for the ET and one for the arch, given that the collar offers no technical advantage in small and fragile aortas; more recently, we have adopted other techniques such as intimal relayering for arch repair dissection. 30 …”

False lumen rotational flow and aortic stiffness are associated with aortic growth rate in patients with chronic aortic dissection of the descending aorta: a 4D flow cardiovascular magnetic resonance study

“…Type A AD is more prevalent and requires a more aggressive management, most often replacement of the diseased part of the aorta containing the dominant entry tear, whereas for type B AD, pharmacological treatment or endovascular repair in case of complications [ 1 ] is conventionally used. Although emergent surgery for acute type A AD has significantly improved survival, most patients persist with a residual dissection of the descending aorta (surgically-treated type A with residual descending AD) [ 3 ], thereby increasing the number of patients with a chronic type B AD.…”