Is extended aortic replacement in acute type A dissection justifiable?

Urbanski, Paul P.; Siebel, Alexander; Zacher, Michael; Hacker, Robert J.

doi:10.1016/s0003-4975(02)04378-3

Cited by 56 publications

(40 citation statements)

References 17 publications

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“…In accordance with the results of previous studies, in which aortic arch replacement was performed in selected patients, [9][10][11][12][13] other groups, which used aortic arch grafting in all patients with AAAD, reported a 27%-46% incidence of a residual patent false lumen. 3,[6][7] It is possible that the low percentage of aortic arch replacements in the present series (12%, 28/243) led to the relatively high rate of residual, false lumen patency. 8) Crawford et al recommended replacement of the aortic arch, only when it is aneurysmic and there is a risk for impending or actual rupture of the false lumen.…”

Section: Discussionmentioning

confidence: 83%

“…3,[5][6][7] The main benefit of this approach is the complete resection of a small, invisible entry site located in the aortic arch. 6) We have recently reported that the patent false lumen of the distal aorta were associated with late, distal aortic enlargement.…”

Section: Discussionmentioning

confidence: 99%

“…3,[6][7] A routine approach for extended aortic arch replacement may decrease the incidence of a residual, patent false lumen. However, groups not following the routine use of an extended aortic arch, including our institution, had similar reoperation-free rates.…”

Section: Discussionmentioning

confidence: 99%

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In-hospital and Long-Term Results of Surgery for Acute Type A Aortic Dissection: 243 Consecutive Patients

Tanaka

Kimura

Yamaguchi

et al. 2012

ATCS

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Background: Our surgical strategies for acute type A aortic dissection (AAAD) are prompt establishment of cardiopulmonary bypass and primary entry resection. We investigated our experience with surgery for AAAD. Methods: Between January 1997 and December 2006, 243 consecutive patients with AAAD underwent emergency surgery. Clinical and diagnostic data of these patients were analyzed retrospectively. Results: Surgical procedures included ascending aorta or hemiarch replacement (n = 212) and total or partial arch replacement (n = 31), and those for proximal reconstruction included modified Bentall procedure (n = 8), and aortic valve replacement (n = 3). Hospital mortality was 6.9%, and entry resection was performed in 74% of patients. Actuarial survival rate at 5 and 10 years was 86% ± 14% and 77% ± 23%, respectively. A total of 13 patients required re-operation: 5, an aortic root; 3, an aortic arch; and 5, a descending aorta. Actuarial freedom from re-operation at 5 and 10 years was 95% ± 5%, and 81% ± 18%, respectively. Conclusions: Our surgical strategy for AAAD seems to be pertinent with acceptable shortand long-term results. Since we lost 8 patients due to rupture of false lumen postoperatively, careful follow-up for a residual false lumen may improve the patients' prognosis.Keywords: aortic dissection, aortic operation, outcomes, aortic reoperation Ann Thorac Cardiovasc Surg 2012; 18: 18-23 doi: 10.5761/atcs.oa.11.01704 have shown that a more aggressive technique, such as the routine replacement of a total arch, have resulted in better long-term outcomes by the elimination of the residual, patent false lumen. 3,5-7)However, we believe that priority of the patient with AAAD is immediate survival, which may be accomplished by simple and less invasive operative procedures, rather than risking further aggression for already risky patient through extended surgery. Simple and less invasive operative procedures that we recommend include prompt establishment of cardiopulmonary bypass to prevent malperfusion, preservation of the aortic valve whenever possible, and aortic arch replacement in patients with an entry site located in or extending into the aortic arch. This study investigated our early and late surgical results of AAAD to validate our surgical strategy for AAAD.

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Section: Discussionmentioning

confidence: 83%

Section: Discussionmentioning

confidence: 99%

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In-hospital and Long-Term Results of Surgery for Acute Type A Aortic Dissection: 243 Consecutive Patients

Tanaka

Kimura

Yamaguchi

et al. 2012

ATCS

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“…Because the residual dissection flap in the aortic arch and descending aorta carries risks of progressive aortic dilation and rupture and the need for secondary intervention, several groups have suggested immediate extensive surgery that involves the aortic arch, although concomitant distal aortic manipulation has been associated with an increased risk of morbidity and death. [4][5][6][7][8][9][10][11][12][13] In this situation, 2 different surgical strategies have been proposed: total arch replacement or hemiarch replacement (a more conservative repair limited to the ascending aorta and proximal arch). 4,[9][10][11][12] We evaluated the early and intermediate outcomes of aortic arch surgery in patients with type A AAD, investigating the effect, upon postoperative results, of aortic arch extension.…”

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confidence: 99%

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

Lio¹,

Nicolò²,

Bovio³

et al. 2016

Texas Heart Institute Journal

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T he surgical mortality rate for type A acute aortic dissection (AAD) still remains high (8%-34%), despite improvements in perioperative and postoperative management during the last decade.1-3 Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are still considered the standard of care for type A dissection surgery. Because the residual dissection flap in the aortic arch and descending aorta carries risks of progressive aortic dilation and rupture and the need for secondary intervention, several groups have suggested immediate extensive surgery that involves the aortic arch, although concomitant distal aortic manipulation has been associated with an increased risk of morbidity and death. [4][5][6][7][8][9][10][11][12][13] In this situation, 2 different surgical strategies have been proposed: total arch replacement or hemiarch replacement (a more conservative repair limited to the ascending aorta and proximal arch). 4,[9][10][11][12] We evaluated the early and intermediate outcomes of aortic arch surgery in patients with type A AAD, investigating the effect, upon postoperative results, of aortic arch extension. Patients and MethodsWe undertook a retrospective, observational study of prospectively collected data on consecutive patients who had presented with type A AAD at our institution. This cohort study was approved by our local ethics committee, and individual consent was obtained by each patient's physician. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent surgery at our institution. For the purposes of this study, we did not consider 109 AAD patients who underwent isolated replacement of the ascending aorta. We included only the 92 patients who underwent

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“…Some surgeons advocate a more conservative tear oriented approach (hemiarch replacement) to reduce postoperative mortality and morbidity (1). On the other hand, other authors support a more aggressive approach for AAAD, mainly consisting of total arch replacement with or without the use of the frozen elephant trunk (FET) or classic elephant trunk (ET) technique (2)(3)(4)(5). The rationale behind this more invasive operation is to mitigate the risk of late aneurysm formation at the distal aorta and to avoid distal malperfusion due to the compression of the true lumen.…”

Section: Introductionmentioning

confidence: 99%

When and how to replace the aortic arch for type A dissection

Bartolomeo

Leone

Marco

et al. 2016

Ann. Cardiothorac. Surg.

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Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high.The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.

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Is extended aortic replacement in acute type A dissection justifiable?

Cited by 56 publications

References 17 publications

In-hospital and Long-Term Results of Surgery for Acute Type A Aortic Dissection: 243 Consecutive Patients

In-hospital and Long-Term Results of Surgery for Acute Type A Aortic Dissection: 243 Consecutive Patients

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

When and how to replace the aortic arch for type A dissection

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