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Ann Thorac Surg 1997;63:1081-1084
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Surgical Treatment of Acute Type B Aortic Dissection Using an Endoprosthesis (Elephant Trunk)

Divisions of Cardiovascular Surgery and Cardiology, Escola Paulista de Medicina, São Paulo, Brazil

Accepted for publication November 2, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates.

Methods. Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures.

Results. The mean arrest time was 31.4 ± 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line.

Conclusions. The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 1084.

In 1965 Wheat and associates [1] recommended medical therapy for the management of an acute type B aortic dissection. Surgical means of treating this condition that have been used in the past have included fenestration of the abdominal aorta [2, 3], thromboexclusion [4], and the interposition of a graft in the thoracic aorta [5, 6]. The latter procedure is the most recommended one, because it deals with the intimal tear, which is the important pathophysiologic mechanism that leads to the development of the complications of this condition. Fenestration and thromboexclusion do not prevent expansion of the false lumen, and vascular compression and medical management are associated with a high rate of late complications and an acquired pathologic condition stemming from progression of the dissection and leading to aortic rupture or vascular obstruction.

We report here our total experience in the management of 70 patients with an acute type B aortic dissection who underwent an elephant trunk procedure during a short period of deep hypothermic circulatory arrest through a median sternotomy.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
From May 1988 to December 1995, 70 consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure performed through a me-dian sternotomy during deep hypothermic circulatory arrest. There were 57 male and 13 female patients ranging in age from 31 to 80 years. Diagnosis was confirmed in all patients by aortography, contrast-enhanced computed tomographic scanning, and transthoracic or transesophageal echocardiography. Ten patients had retrograde arch involvement, 2 of whom also had coronary artery disease. Preoperative complications included severe refractory pain (all patients), pulmonary hemorrhage (3 patients), cerebral ischemia (2 patients), acute myocardial infarction (3 patients), cardiac arrest (2 patients), aortic insufficiency (8 patients), hemopericardium (2 patients), renal ischemia (16 patients), abdominal pain (7 patients), and limb ischemia (2 patients).

After a median sternotomy was made and the patient was heparinized (4 mg/kg), the heart was cannulated via the right atrium. Arterial inflow was accomplished via the ascending aorta (proximal to the innominate artery) when it was not involved or by means of femoral artery cannulation when the ascending aorta was involved. Cooling to a core temperature of 18°C (pharyngeal temperature) was begun immediately after the initiation of cardiopulmonary bypass. It usually took 30 minutes to achieve this temperature. Barbiturates were administered immediately before the initiation of deep hypothermic circulatory arrest. An incision was then made in the anterior wall of the ascending aorta that was extended into the arch. The inside of the ascending aorta and arch was then inspected to determine whether there was a proximal intimal tear. These tears were usually found distal to the left subclavian artery and outside the surgeon's view. After the aorta at the left subclavian origin was sized, an appropriately sized Dacron prosthesis was placed inside the distal aorta using gentle finger manipulation. The Dacron prosthesis was then sutured to the aortic wall distal to the origin of the left subclavian artery using a running 4-0 Prolene suture (Ethicon, Somerville, NJ) (Fig 1). To verify the proper position of the graft, aortoscopy was performed in 2 patients using a sterile fiberoptic bronchoscope. The diameter of the Dacron prosthesis varied from 22 to 24 mm, and the median length was 12 cm. The aortotomy was then closed with a 4-0 running Prolene suture, and after the evacuation of air, cardiopulmonary bypass was reinstituted slowly with the patient in the Trendelenburg position. In the last 2 patients, stented Dacron tubes were inserted under direct vision by means of the arch (Fig 2). Four patients underwent transesophageal echocardiography before rewarming to confirm that the graft was correctly positioned and blood was flowing through the true lumen (Fig 3). The remainder of the operation was performed in the same way as any cardiac procedure.

View larger version (117K): [in this window] [in a new window]   Fig 1. . Endoprosthesis applied to the descending aorta and occluding the intimal tear.

View larger version (153K): [in this window] [in a new window]   Fig 2. . Stented Dacron prosthesis applied to the descending aorta in a case of acute type B dissection.

View larger version (67K): [in this window] [in a new window]   Fig 3. . Transesophageal echocardiogram obtained just after cardiopulmonary bypass showing blood flow in the true lumen only. The flow to the false lumen through the intimal tear was clearly interrupted.

View larger version (110K): [in this window] [in a new window]   Fig 4. . Aortogram obtained in the postoperative period showing flow through the endoprosthesis only.

View larger version (77K): [in this window] [in a new window]   Fig 5. . Computed tomographic scan showing the elephant trunk endoprosthesis and no flow through the false lumen.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Late deaths occurred in 4 patients (5.7%). In 1 patient this was due to rupture of the abdominal aorta and rupture of the thoracic aorta distal to the elephant trunk. In a second patient it was due to an undiagnosed distal intimal tear, and in the remaining 2 patients it occurred after reoperation and was due to complications of a thoracoabdominal aneurysm procedure. Two patients who died during their hospital stay underwent autopsy, which revealed that the endoprosthesis was firmly adherent to the intima of the aorta and completely occluded the false lumen in both. The actuarial 5-year survival rate was 62.5%.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Since the mid-1960s and early 1970s when Wheat [1] and Daily [7] and their colleagues recommended that patients with a type B dissection be treated with medical therapy, surgical treatment has been reserved for patients with complications of the dissection, such as rupture, an aneurysm, or organ ischemia. However, medical therapy is associated with a high incidence of complications stemming from expansion of the false lumen and ischemic injury to different organs, with a 5-year mortality rate of 65% in such patients [8]. As a result, several authors have begun to recommend the use of surgical treatment for a type B dissection, performed early and on an elective basis when the condition is detected clinically [9, 10]. Crawford and associates [6] used a left thoracotomy approach and interposed a graft in the descending thoracic aorta in their patients. However, this procedure is associated with a significant risk of paraplegia and high mortality rates.

On the basis of the work of Borst and colleagues [11], who utilized an elephant trunk endoprosthesis in the treatment of aneurysms that involved the thoracic and abdominal aorta, we decided to try this technique in the management of an acute type B dissection. The procedure was performed on an elective basis and with the intention to obliterate the intimal tear and prevent progression of the false lumen [12]. It was our practice to operate on patients with a type B dissection using the elephant trunk procedure as a primary therapy after the initiation of medical treatment following the patient's admission to the hospital. The early mortality of 20% reflects the complicated clinical condition of our patients, all of whom had refractory pain and who may have been improperly selected to undergo operation during our initial experience with this procedure. We have found that such an endoprosthesis can be inserted and sutured into the descending aorta by means of the arch during less than 20 minutes of deep hypothermic circulatory arrest, thereby minimizing cerebral ischemia. Recently, in the last 2 patients, we implanted a stented Dacron endoprosthesis, which can be achieved in less than 5 minutes. It may be possible in the near future to implant an endoprosthesis percutaneously in special cases of acute type B aortic dissection, as has been attempted in patients with true aortic aneurysms [13, 14].

In summary, we performed an elephant trunk procedure in 70 consecutive patients presenting with an acute type B aortic dissection in whom the graft was sutured to the aorta distal to the origin of the left subclavian artery during deep hypothermic circulatory arrest. The hospital mortality rate was 20%, and this included all deaths due to conditions that existed preoperatively. The actuarial 5-year survival rate was 62.5%. These results compare favorably with those of medical therapy.

At our institution we now consider surgical treatment in patients with an acute type B aortic dissection, even in noncomplicated cases. In the past this involved the use of an elephant trunk endoprosthesis, but more recently we have begun to use a stented Dacron prosthesis. The technique is not used in chronic cases because of the very disproportionate difference in the size of the true (minor) and false (larger) lumens, mainly stemming from an acquired pathologic condition consisting of vascular obstructions or distal tears.

We consider dissection of the descending thoracic aorta with retrograde progression a very good indication for use of this technique. One can replace the ascending aorta with a Dacron tube and insert an stented Dacron tube in the descending aorta to occlude the tear.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Buffolo, Escola Paulista de Medicina, Rua Borges Lagoa, 783-5° andar, Vila Clementino, São Paulo, Brazil.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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