The stented elephant trunk procedure combined total arch replacement for Debakey I aortic dissection: operative result and follow-up

Abstract

The stented elephant trunk technique in aortic arch replacement combined with transaortic stented graft implantation into the descending aorta has been introduced as a means of eliminating the residual false lumen in the descending thoracic aorta and improving long-term outcomes of surgical intervention for Debakey I aortic dissection. This report summarizes the operative and follow-up data with this new procedure. Between August 2004 and May 2009, 28 stented elephant trunk operations were performed for Debakey I aortic dissection at Nanjing First Hospital. A 10 cm long woven Dacron graft was implanted through the aortic arch during hypothermic circulatory arrest. Patent false lumina were evaluated using computed tomography three months after the operation. Mean cardiopulmonary bypass time was 213.2±47.2 min, and selected cerebral perfusion time was 38.8±9.7 min. Hospital mortality was 14.3% (4/28). Thrombus obliteration of the residual false lumen in the descending aorta was observed in 91.7% of the aortic dissections three months postoperatively. The survival rate was 87.5% at five years and the freedom from reoperation rate was 91.7%. Total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta is an effective treatment for Debakey type I aortic dissection.

Total Arch Replacement with Stented Elephant Trunk in DeBakey Type I Acute Aortic Dissection

“…According to a German study in 2008, the hybrid operation of total arch replacement with an SET was found to be equivalent to the conventional operation (total arch replacement only) with respect to in-hospital mortality and morbidity. The results of other studies on the use of SET grafts were similar [1,3,4]. The SET procedure has advantages such as false lumen obliteration of the descending aorta.…”

Descending endografts for type A dissections: con

“…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.…”

“…Cerebral spinal drainage, perfusion of left subclavian artery and distal perfusion with balloon occlusion technique are utilized by some groups to avoid SCI in hybrid approach (22)(23)(24). In fear of SCI, the commonly used length of endograft is around 10-15 cm (9,(19)(20)(21)25), which is shorter than the average length of endografts used in type B dissection. This shorter endograft may be controversial in terms of positive aortic remodeling.…”

“…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.…”

“…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.…”