Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumens

Abstract

OBJECTIVES: Surgical management of chronic aortic dissection is controversial, especially when the dissection extends into the abdominal aorta in which the visceral arteries originate from different lumens and is combined with aortic arch pathology necessitating surgery. The aim of the study was to evaluate the results of open surgery in this complex aortic pathology. METHODS:Between June 2002 and 2015, a total of 17 patients (median age 57, range 32-76 years) necessitating complete arch replacement presented complex chronic dissection of the thoraco-abdominal aorta with the visceral arteries originating from different lumens. Fourteen patients (82%) had had previous cardiac surgery, which was performed on the proximal aorta in all but one because of acute type A dissection. Nine patients without considerable dilatation of the descending aorta received aortic arch replacement with distal resection of the dissection membrane, and 8 patients with progressive dilatation of the thoracic aorta underwent aortic arch and descending aorta replacement via clamshell approach. RESULTS:No early (defined as 30-day, 90-day and in-hospital period) deaths, strokes or spinal cord injuries occurred. Only 1 patient (6%) presented temporary neurological dysfunctions (delirium, agitation), which resolved completely before discharge, and an injury of the recurrent laryngeal nerve was documented in 2 patients (12%). Temporary dialysis was necessary in 1 case. The follow-up was complete for all patients. All but one patient, who died due to leukaemia 23 months after surgery, were alive at the last follow-up (median duration 33 months, range 2-118 months). No patient needed a reoperation or an intervention on the thoracic and/or abdominal aorta. Moreover, no noticeable progression of the chronic dissection in the downstream aorta was documented in any patient. CONCLUSIONS:The results after conventional aortic arch repair with distal resection of the dissection membrane and, if necessary, with replacement of the progressively dilated chronic dissected thoracic aorta can offer excellent results in experienced hands and, therefore, this technique may be considered as a preferable option for surgical treatment of chronic aortic dissection with involvement of the aortic arch and the visceral arteries originating from different lumens.

Intraoperative angiography for visceral arteries originating from false lumen

“…However, obliteration of the false lumen in aortic dissection can be catastrophic in patients with VA and/or spinal cord-supplying arteries originating from a false lumen. 2,3 In our patient, visceral perfusion was almost dependent on the false lumen's downstream blood flow from the large proximal entry. Therefore, we confirmed the patency of the VA by performing intraoperative angiography immediately after the circulatory arrest was terminated,…”

“…Although total arch replacement (TAR) with a frozen elephant trunk (FET) has been reported to be useful in chronic aortic dissection, 1 obliteration of the false lumen can be catastrophic in cases with visceral arteries (VA) originating from the false lumen. 2,3 Herein, we report the TAR with FET of chronic aortic dissection, in which the VA originated from the false lumen, using intraoperative angiography.…”

Clinical outcomes and rates of aortic growth and reoperation after 1-stage repair of extensive chronic thoracic aortic dissection

“…Urbanski and colleagues 29 treated 17 patients with extensive chronic aortic dissection with arch replacement or arch and DTA replacement via a clamshell approach combined with distal resection of the dissection membrane to establish distal flow into both the true and false lumens. 29 There were no early deaths and 1 late death due to leukemia. During the follow-up interval that extended to 118 months, no noticeable progression of the chronic dissection in the downstream aorta was documented in any patient.…”

Infrarenal aortic repair with or without false lumen intentional placement of endografts for hybrid management of complex aortic dissection

“…If thrombosis of the false lumen occurs in such patients, blood flow to important end organs may be compromised, resulting in complications such as paraplegia, stroke, bowel ischemia, extremity ischemia, renal failure, and death. 5,6 Traditional open surgery for thoracoabdominal aortic disease carries significant risk of complications despite the advances in anesthetic management. 7 Accessing two visceral cavities simultaneously in these patients, many of them being high surgical risk patients, can be complicated by cerebrovascular accidents, renal failure, and prolonged respiratory failure.…”