The results of total arch graft implantation with open stent-graft placement for type A aortic dissection

Abstract

Our preliminary review of the total arch graft implantation with a stent graft suggests that this new procedure for type A aortic dissection might provide better results in both the acute and the chronic phase, especially with regard to the outcome for the false lumen and dissected aorta.

Descending endografts for type A dissections: con

“…In-hospital mortality after hybrid therapy for type A aortic dissection is documented as 4.2-14.3% (9,12,(18)(19)(20)(22)(23)(24)(25)(26), which is comparable to conventional open repair. Moreover, there is not enough data demonstrating survival benefits of the hybrid therapy in mid-term.…”

“…Although the false lumen thrombosis is observed in 80-100% in the stented segment of the proximal descending aorta (18,21,22,25), complete false lumen thrombosis rate after hybrid type A dissection repair is limited to 17-50% (9,12,20,23), which is similar to that of total arch replacement with elephant trunk (43-63%) (3,5). Despite the fact that the history of the hybrid approach in the type A dissection is relatively short, the reported distal reoperation rate is 0-14% (9,12,(18)(19)(20)(22)(23)(24)(25)(26) and has no superiority to total arch replacement with elephant trunk (0-13%) (2,3,5,16). In addition to the distal reinterventions, adjunctive procedures such as branch vessel intervention or additional stenting to cover endoleak or SINE, are often performed after the hybrid approach.…”

“…Moreover, most centers have added selective antegrade cerebral perfusion (9,12,(18)(19)(20)(21)(22)(23)(24)(25)(26) to their procedure to avoid stroke due to the longer open distal time compared to the conventional arch repair. Thus, hybrid procedures may be performed with acceptable risk of stroke when proper cerebral protection is provided in a selected patient group.…”

Initial Experience of Modified Four-Branched Graft Technique and Antegrade TEVAR in Acute Type A Aortic Dissection

“…Although the technique of open antegrade thoracic stent-graft deployment under circulatory arrest had been reported with good results, 5,6) antegrade deployment of thoracic stent-graft after the distal anastomosis and circulatory restoration is more advantageous. First, the stentgraft landed in the distal aortic graft across the anastomosis into the descending aorta and consequently would secure the distal anastomosis from bleeding.…”

“…5) In their method, under CPB at 24°C with right axillary artery and femoral artery return and cardioplegic arrest, the proximal anastomosis of the ascending aorta has been completed first, and then supra-aortic bypass anastomoses from the four-branched graft to the left carotid artery and left subclavian artery are performed. The arterial return cannula is shifted form the femoral artery to the fourbranched graft and the perfusion of cervical branches is restarted.…”