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Eur J Cardiothorac Surg 2009;35:921-922. doi:10.1016/j.ejcts.2009.02.002
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Prophylactic aortic arch debranching during type A aortic dissection repair

Mattia Glauber*, Michele Murzi, Andrea Farneti

Department of Adult Cardiac Surgery, G. Paquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Via Aurelia Sud 54100, Massa, Italy

Received 7 January 2009; accepted 2 February 2009.

* Corresponding author. Tel.: +39 0585493604; fax: +39 0585493604. (Email: Glauber{at}ifc.cnr.it).

Key Words: Aorta • Aortic dissections • Endovascular procedure

We read with interest the article of Uchida and co-workers [1] on their experience with a combined surgical and endovascular procedure in patients with acute type A aortic dissection. The aim of their hybrid approach is to obtain the thrombosis of the residual false lumen and in doing so, prevent the development of aneurysmatic dilatation of the dissected thoraco-abdominal aorta. However, when regarding the literature, many studies demonstrated that even though the residual dissected aorta tends to dilate, a long time is necessary for the development of a large aneurysm requiring surgery [2,3]. In a recent paper, Kimiura and co-workers [4] showed that the presence of a residual patent lumen does not affect the long-term outcome in patients who underwent standard surgical repair of type A aortic dissection. In addition their result demonstrated that a residual patent lumen is not necessarily associated with faster aortic growth rate.

Taking these data into consideration, probably only a few patients of Dr Uchida's series will really benefit from this hybrid single stage approach while all patients, on the contrary, receive a supplementary risk related to the insertion of the thoracic stent-graft.

In our hands, a solution to overcome the problems related to possible enlargement of the residual dissected aorta has been represented by the use of a standard aortic arch replacement in concomitant with a prophylactic supra-aortic vessels debranching with a specially designed trifurcated vascular prosthesis (Vascutek, GelweaveTM Plexus Graft, Terumo Inc., USA). The use of this prosthesis allows, at the same time the replacement of the ascending aorta and arch and to relocate the origin of the supra-aortic vessels very proximally just above the sino-tubular junction, creating a safe and long proximal stent landing zone. In case of further descending thoracic aorta enlargement, if indicated, this preventing of debranching during acute surgery allows a safe and effective endovascular treatment.

References

  1. Uchida N, Shibamura H, Katayama A, Shimada N, Sutoh M. Total arch replacement with an open stent graft for acute type A aortic dissection: fate of the false lumen. Eur J Cardiothorac Surg 2009;35:83-88.[Abstract/Free Full Text]
  2. Halsted JC, Meier M, Etz C, Spielvogel D, Bodian C, Wurm M, Shahani R, Griepp RB. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007;133:127-135.[Abstract/Free Full Text]
  3. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 2000;104:46-59.
  4. Kimiura N, Tanaka M, Kawahito K, Yamaguchi A, Ino T, Adachi H. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2008;136:1160-1166.[Abstract/Free Full Text]



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Home page
 Eur. J. Cardiothorac. Surg.Home page
N. Uchida and K. Akira
Reply to Glauber et al.
Eur. J. Cardiothorac. Surg., May 1, 2009; 35(5): 922 - 922.
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