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Ann Thorac Surg 2002;74:S1836-S1839
© 2002 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
* Address reprint requests to Dr Hanafusa, Department of Cardiovascular Surgery National Cardiovasular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
e-mail: nakai{at}hsp.ncvc.go.jp
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: The surgical management of type A dissection with the intimal tear in the descending aorta—retrograde dissection—has some challenging aspects because the standard approach through a median sternotomy for ascending aortic dissection is difficult in these cases in which the intimal tear is located in the descending aorta.
METHODS: From January 1995 to December 2001, 12 (8.6%) consecutive patients aged 40 to 71 years underwent total arch replacement with an elephant trunk procedure through a median sternotomy for retrograde dissection of the ascending aorta (acute: 10, chronic: 2) among 139 patients with type A dissection. The intimal tear was located in the descending aorta in all patients. Dissection extended proximally to the aortic root in 7 patients and to the ascending aorta in 5, and extended distally to the abdominal aorta in 4 and to the common iliac artery in 8.
RESULTS: Hospital mortality occurred in 1 patient (8%) owing to multiple organ failure after malperfusion of the renal arteries. Postoperatively the false lumen in the descending aorta was closed in all patients who survived but the false lumen in the abdominal aorta was patent in 9. The thoracic and abdominal aorta had slight dilatation in 2 patients.
CONCLUSIONS: These data suggest that total arch replacement with an elephant trunk procedure through a median sternomy should be recommended in patients with type A dissection and the intimal tear in the descending aorta. This procedure induces thrombosis of the remaining false lumen in the distal aorta postoperatively.
The prognosis of type A dissection with the intimal tear in the descending aorta—so called retrograde dissection—is considered to be extremely poor [1, 2] and the choice of therapeutic approaches and surgical procedures has been controversial. We now have a policy that total arch replacement with an elephant trunk procedure is performed through a median sternotomy in these patients. The elephant trunk procedure in aortic dissection prevents blood flow leakage into the false channel at the anastomosis site, reinforces this area, and induces thrombotic closure of the distal false channel postoperatively. We reviewed our experience with this approach to the treatment of retrograde dissection.
Patients and methods
Between January 1995 and December 2001, 12 patients (9 men and 3 women) underwent total arch replacement with an elephant trunk procedure through a median sternotomy for type A dissection with the intimal tear in the descending aorta at the National Cardiovascular Center in Osaka, Japan; these were among a total of 139 patients with type A dissection (acute: 97, chronic: 42). The preoperative and operative data are summarized in Tables 1 and 2. Acute dissection was observed in 10 patients and chronic dissection in 2. The mean age of the patients was 59 ± 9 years (range: 40 to 71). Five patients had aortic regurgitation (AR), 2 had acute myocardial infarction, and 2 had cardiac tamponade preoperatively. One patient (patient 4) had annuloaortic ectasia and grade 3 AR associated with Marfan’s syndrome. Preoperatively, malperfusion of the renal arteries bilaterally occurred in 1 patient (patient 1) and of the brachiocephalic and superior mesenteric arteries in another (patient 11). The exact locations of the intimal tears were found by intraoperative transesophageal echocardiography in 6 patients and by direct intraoperative observation in 4. Only 2 patients with chronic dissection (patients 7 and 8) underwent elective digital subtraction angiography (DSA), which demonstrated the location of the intimal tear in the descending aorta. Dissection extended proximally to the aortic root in 7 patients and to the ascending aorta in 5 and extended distally to the abdominal aorta in 4 and to the common iliac artery in 8.
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All 12 patients underwent total arch replacement accompanied by reconstruction of the cervical vessels. The concomitant procedures were coronary bypass grafting in 2 patients, aortic valve resuspension in 4, and Bentall operation in 1 patient (patient 4) who had annuloaortic ectasia associated with Marfan’s syndrome. The average durations of cardiopulmonary bypass, aortic crossclamping, RCP, and SCP were 236 ± 44, 129 ± 23, 68 ± 15, and 158 ± 23 minutes, respectively (Table 2).
Results
There was 1 hospital death and the overall hospital mortality rate was 8%. The single death resulted from multiple organ failure 79 days after operation due to preoperative malperfusion of the renal arteries.
Two patients required reoperation. One (patient 2) had a pseudoaneurysm of the proximal anastomosis site. It became larger gradually, therefore 77 months later resection of the pseudoaneurysm and replacement of the ascending aorta were carried out. The other (patient 10) had aortic stenosis due to the felt strip used for closure of the false channel at the site of the proximal anastomosis. Two months after the first operation a second procedure involving resection of the felt strip was carried out.
There were no late deaths. The remaining 9 patients had no complications and are doing well. None of the patients who survived underwent a second-stage operation for a distal aortic lesion. DSA and CT were performed after operation in 11 patients to evaluate the state of the false channel in the distal descending and abdominal aorta. The preoperative and postoperative findings of these examinations are shown in Table 3. The false channel just below the distal anastomosis in the descending aorta was closed with thrombi in all eleven patients, while the false channel in the abdominal aorta was partially patent in 9 patients. Two patients (patients 2 and 7) had aneurysmal changes in the descending aorta and abdominal aorta but surgical intervention for persistent aortic dissection with dilatation was not carried out because the lesion did not become larger during follow-up.
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Type A dissection usually involves an intimal tear adjacent to the coronary arteries and commonly extends to the aortic arch or more distally. Dissection of the descending aorta usually presents with a tear near the origin of the left subclavian artery. In the presence of antegrade extension only, the prognosis is much better and the results of medical treatment are very satisfactory in the absence of malperfusion, enlargement of the aorta to form an aneurysm, or ischemia of the lower extremities. However, surgical intervention for type A dissection with the intimal tear in the descending aorta with retrograde extension toward the ascending aorta is now controversial. Lansman and associates [3] reported that 5 (7%) of 69 cases of acute type A dissection treated surgically were of this type. Von Segesser [4] reported that 9 (10%) of 89 consecutive patients with type A dissection who received surgical treatment had a tear in the descending aorta. In our series, among 12 (8%) of 139 consecutive patients with type A dissection, total arch replacement with an elephant trunk procedure was performed.
Basically, treatment of type A dissection consists of replacement of the ascending aorta or the aortic arch or both, and resection of the intimal tear with additional surgical treatment of complications if necessary. Miller and associates [5] demonstrated that resection of the intimal tear was not necessary for patients with acute type A dissection because of lack of statistical difference between patients with and without intimal tear resection. If the intimal tear is not resected, however, development of a progressively enlarging aneurysm and rupture seem more likely to occur because of the residual false channel proximal or distal to the intimal tear, and the incidence of reoperation and death will be higher. As it is difficult to resect the intimal tear in the descending aorta through a median sternotomy in patients with type A dissection, the surgical treatment of this condition is controversial.
There are few reports concerning the surgical treatment of this type of acute retrograde type A dissection [4, 6–8]. Erbel and colleagues [6] reported that replacement of only the ascending aorta in such cases did not result in progression of thrombus formation because this technique could not eliminate flow in the false channel. Von Segesser and associates [4] recommended that replacement of the aortic arch with a variable portion of the ascending aorta through a median sternotomy be performed in patients with an enlarged aortic diameter, pericardial effusion, or aortic regurgitation in this situation. In cases in which dissection predominated distal to the tear, with a dilated descending aorta or distal complications or both, they suggested that the best approach was through a lateral thoracotomy. Kazui and colleagues [7] reported that extended aortic reconstruction by resection of the intimal tear in the descending aorta and total arch replacement was a reasonable surgical technique for retrograde dissection complicated by pericardial effusion, aortic regurgitation, cerebral ischemia, and dilatation of the ascending aorta.
In conclusion we recommend total arch replacement with an elephant trunk procedure through a median sternotomy for type A dissection with the intimal tear in the descending aorta. This is a feasible technique and provides good results.
References
This article has been cited by other articles:
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  L. Sun, R. Qi, Q. Chang, J. Zhu, Y. Liu, C. Yu, H. Zhang, B. Lv, J. Zheng, L. Tian, et al. Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure Ann. Thorac. Surg., April 1, 2009; 87(4): 1177 - 1180. [Abstract] [Full Text] [PDF]
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 M. Karck and H. Kamiya Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch? Eur. J. Cardiothorac. Surg., June 1, 2008; 33(6): 1007 - 1013. [Abstract] [Full Text] [PDF]
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