Ann Thorac Surg 1997;64:1331-1332
© 1997 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Local Transverse Arch Repair for Type A Aortic Dissection
Fritz J. Baumgartner, MD,
Bassam O. Omari, MD,
Andy Pandya, BS,
Avni Pandya, BS,
Daniel M. Bethencourt, MD
Harbor–UCLA Medical Center, Torrance, and Lakewood Regional Medical Center, Lakewood, California
Accepted for publication May 16, 1997.
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Abstract
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Background. The management of retrograde dissections originating from the transverse arch is controversial. Although replacing the ascending aorta is clearly beneficial, the appropriate approach to the management of the arch tear is not as apparent and ranges from no intervention to total arch replacement.
Methods. Three patients presented with acute (n = 2) or subacute (n = 1) aortic dissection, with tears involving the transverse arch. All underwent local transaortic pledgeted suture repair of the arch tears during hypothermic circulatory arrest, as well as graft replacement of the ascending aorta.
Results. Circulatory arrest times ranged from 12 to 15 minutes (transaortic arch repairs alone) to 48 minutes (transaortic arch repair and open distal graft anastomosis). Postoperatively all patients awoke within 12 hours and subsequently did well neurologically.
Conclusions. In the face of a type A dissection with an entry in the transverse arch, local transaortic repair with concomitant ascending aortic replacement represents a viable middle ground between no arch intervention and lengthy arch replacement. Huge entry tears or aneurysmal arch enlargement would preclude such an approach.
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Introduction
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An acute aortic dissection arising from a transverse arch intimal tear is among the most lethal problems encountered in cardiovascular surgery. Although controversial and not valid in all circumstances, definitive treatment involving ascending and arch replacement is recommended for the repair of retrograde type A aortic dissections originating in the transverse arch [1–3]. Because of the considerably higher operative mortality associated with concomitant arch repair at most centers, "simple" graft replacement of the ascending aorta without transverse arch repair has been suggested in some instances [4].
A method of transaortic closure of the entrance tear with replacement of the ascending aorta for patients with dissection of the descending thoracic aorta extending into the ascending aorta has been reported [5]. Svensson and Crawford [6] have also suggested that small intimal tears in the transverse arch can be oversewn with polypropylene, provided this portion of the arch is not aneurysmal and the ascending aorta is replaced. We have successfully used this technique in 3 patients with acute or subacute type A dissections originating in the transverse arch. For the management of selected tears, the technique may represent a viable compromise between leaving a recognized arch tear untreated and prolonged arch replacement procedures.
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Patients and Methods
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Three patients with an acute (n = 2) or subacute (n = 1) type A aortic dissection with transverse arch tears are described (Table 1
). The dissection in all patients was diagnosed preoperatively on the basis of transesophageal echocardiographic findings. All then underwent cardiopulmonary bypass, systemic hypothermia, and circulatory arrest. One patient (No. 1) underwent retrograde cerebral perfusion. Transverse arch repair was accomplished using interrupted transaortic 4-0 pledgeted polypropylene sutures.
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Table 1. . Surgical Findings, Low Temperature, and Circulatory Arrest Times in Patients With Transverse Arch Tears With Ascending Aortic Dissection
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Results
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All patients had chest pain or cardiac tamponade, or both, and patient 2 also had limb ischemia at the time of presentation. All 3 had entry tears in the aortic arch between the innominate and left common carotid arteries that measured between 1 and 3 cm. Two patients had additional aortic tears, one in the mid ascending aorta anteriorly (patient 3) and one in the distal ascending aorta in the lesser curve (patient 1). Transaortic pledgeted suture repair of the arch tears was done under hypothermia and circulatory arrest (see Table 1
). There was no compression or narrowing of the orifices of the great vessels. All patients underwent concomitant graft replacement of the ascending aorta (Fig 1).
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Fig 1. . Completed transaortic pledgeted suture repair of transverse arch tear between the innominate and left common carotid arteries extending anteriorly, as well as ascending aortic graft replacement (patient 2).
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The circulatory arrest times ranged from 12 to 15 minutes (transaortic arch repairs alone) to 48 minutes (local arch repair between the innominate and left common carotid arteries and open distal graft anastomosis incorporating the concavity of the arch). All patients had aortic insufficiency, and all underwent successful valve resuspension. Postoperatively all patients awoke within 12 hours and subsequently did well neurologically. No further sequelae have resulted from their residual arch and distal dissection between 5 and 20 months postoperatively.
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Comment
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A large percentage of patients with type A aortic dissections have tears arising in the transverse arch [1]. There is little argument that graft replacement of the ascending aorta should be done to prevent the life-threatening complications of tamponade or aortic valve or coronary insufficiency. However, the appropriate approach to the management of the arch remains controversial. Recommendations include replacing the arch if it has an intimal tear [1–3, 5]; replacing the arch if it has a false lumen, regardless of the presence of an intimal tear [7]; and not replacing the arch [4, 8].
The most compelling reason to replace the arch in patients with a type A dissection with arch tears is to prevent aneurysmal dilation of the distal false channel. The frequency of this complication appears to be higher if only the ascending aorta is replaced, with no reoperations required in patients who have the arch replaced as well [2, 5]. Nonetheless, the higher morbidity and mortality associated with arch replacement factors significantly in the decision-making process. The question of whether the aortic arch should be included in the operation on the ascending aortic dissection may have many answers, and what may be right at one institution may be disastrous at a less experienced center. The transaortic local repair of transverse arch tears with ascending dissection performed in the 3 patients described here has been shown to be effective in the short term. Although unlikely to serve well for the repair of huge transverse arch tears, it may prove useful for the management of smaller tears in the transverse arch, such as those in our patients.
Local transaortic repair with concomitant ascending aortic replacement is a viable alternative to arch replacement in a patient with a type A dissection with an entry point in the transverse arch. The attendant decreases in the circulatory arrest times may have profound implications from the standpoint of neurologic recovery and operative mortality. The technique may be a middle ground between no arch intervention and a lengthy arch replacement.
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Footnotes
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Address reprint requests to Dr Baumgartner, Division of Cardiothoracic Surgery, Harbor–UCLA Medical Center, 1000 W Carson St, Bin 423, Torrance, CA 90509.
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References
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- Carrel T, Pasic M, Vogt P, et al. Retrograde ascending aortic dissection: a diagnostic and therapeutic challenge. Eur J Cardiothorac Surg 1993;7:146–52.[Abstract]
- Bachet JE, Termignon JL, Dreyfus G, et al. Aortic dissection: prevalence, cause, and results of late reoperation. J Thorac Cardiovasc Surg 1994;108:199–206.[Abstract/Free Full Text]
- Crawford ES, Kirklin JW, Naftel DC, et al. Surgery for acute dissection of the ascending aorta—should the arch be included? J Thorac Cardiovasc Surg 1992;104:46–59.[Abstract]
- Miller DC. Concomitant arch repair in acute type A aortic dissection [invited letter]. J Thorac Cardiovasc Surg 1992;104:206.[Medline]
- Von Segesser LK, Killer I, Ziswiler M, et al. Dissection of the descending thoracic aorta extending into the ascending aorta—a therapeutic challenge. J Thorac Cardiovasc Surg 1994;108:755–61.[Abstract/Free Full Text]
- Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery: Clinical observations, experimental investigations, and statistical analyses, Part II. Curr Probl Surg 1992;29:913–1057.[Medline]
- Kazui T, Kimura N, Yamada O, et al. Total arch graft replacement in patients with acute type A aortic dissection. Ann Thorac Surg 1994;58:1462–8.[Abstract]
- Miller DC, Mitchell RS, Oyer PE, et al. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153–64.[Free Full Text]
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