Total Arch Replacement Combined With Stented Elephant Trunk Implantation

Abstract

Background-Appropriate surgical management of type A dissection is a critical factor for achieving satisfactory outcome, but the choice of optimal procedure is controversial. We retrospectively reviewed our experience with aortic arch replacement for type A dissection involving the arch. Methods and Results-Excluding 14 cases of subtotal or total aortic replacement, 411 of 544 patients with type A dissection (stented elephant trunkϭ291, conventional surgical repairϭ120) underwent aortic arch replacement between January 2003 and September 2008. In-hospital mortality was 3.09% (9 of 291) for stented (acuteϭ4.73%, 7 of 148; chronicϭ1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acuteϭ6.06%, 4 of 66; chronicϭ3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stentedϭ2.41%, 7 of 291; conventionalϭ0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stentedϭ1 and conventionalϭ4; Pϭ0.031) and 3.05% (6 of

Dr. Sun's Procedure for Type A Aortic Dissection: Total Arch Replacement Using Tetrafurcate Graft With Stented Elephant Trunk Implantation

“…This is one of the lowest recorded in the literature, three-to four-fold lower than most contemporary reports [25]. Complete thrombus formation around the stented graft is observed in 93% of patients, extending to the diaphragmatic level in 70% [16].…”

“…Sun's procedure encompasses several technical details in terms of cannulation, cardiopulmonary bypass, cerebral protection, and surgical skills [12][13][14][15][16]. It is performed via a median sternotomy under total cardiopulmonary bypass (CPB) and selective cerebral perfusion (SCP) with cannulation of the right axillary artery (RAA).…”

“…As our team has gained vast experience since its introduction, the indications of Sun's procedure have evolved considerably [12][13][14][15][16][17][19][20][21][22][23][24]. This, in part, may be ascribed to an algorithm dictating the surgical strategies based on our subcategorization of the Stanford system that divides type A dissections into subtypes according to the aortic root diameter, degree of aortic insufficiency, competency of the sinotubular junction, and the dissection process in the arch and beyond [17].…”

“…In 2002, the senior author (L.Z.S. ), then the chief of Aortic Surgery in Fu Wai Hospital, designed a new stented graft and proposed a modified technique of total arch replacement using a four-branched graft with implantation of this stented elephant trunk as a treatment for type A aortic dissection [12], which has produced satisfactory early and long-term results [13][14][15][16][17]. Owing to its ingenious design, widespread usage, and excellent outcomes, this technique was named after Dr. Sun by domestic and international colleagues in 2008, hence the term "Sun's procedure," i.e., total arch replacement using a tetrafurcate graft with stented elephant trunk implantation [18].…”

Open repair techniques in the aortic arch are still superior

“…In particular the false lumen in the descending aorta thromboses in a large proportion of patients, reducing the risk for further late distal malperfusion syndromes. Several groups have, indeed, published quite satisfactory results with the use of this method, in particular after surgery for acute or chronic aortic dissection (43)(44)(45)(46).…”