Ann Thorac Surg 2005;79:1761-1763
© 2005 The Society of Thoracic Surgeons
Case report
Surgical Repair and Stent Positioning for Type A Acute Aortic Dissection: A Step Forward?
Stefano Saccani, MDa,
Marzio Busi, MDa,
Claudio Fragnito, MDa,
Andrea Agostinelli, MDa,*,
Bruno Borrello, MDa,
Francesco Nicolini, MDa,
Tiziano Gherli, MDa
a Cardiac Surgery Department, University of Parma, Parma, Italy
Accepted for publication October 16, 2003.
* Address reprint requests to Dr Agostinelli, c/o Cardiochirurgia Ospedale Maggiore Via A. Gramsci 14, 43100 Parma, Italy
andrea.agostinelli{at}tiscalinet.it
 |
Abstract
|
|---|
We report two cases of type A acute aortic dissection in which the traditional ascending aorta replacement was completed by aortic arch stenting to achieve a complete treatment and to avoid the risks that are connected to aortic arch replacement. Correct deployment of the stent was evaluated through an endoscope inserted in the transverse arch, which avoided fluoroangiography and the involvement of a radiologic team.
|
Introduction
|
|---|
Type A acute aortic dissection is a dramatic event that requires emergent surgical repair. Ascending aorta replacement has been the treatment of choice for years, but recent improvements in cerebral protection and surgical technique could justify total arch replacement in an emergency setting without the risk of later complications and death. This strategy is, however, technically demanding and still affected by high mortality and morbidity. We report two cases of ascending aorta replacement with a stent-graft deployment in the aortic arch.
|
Case Reports
|
|---|
Patient 1
A 74-year-old man with a history of arterial hypertension presented at the emergency department with chest pain. His blood pressure was 200/100 mm Hg. An electrocardiogram and myocardial enzyme levels were normal. Contrast-enhanced chest computed tomography (CT) showed an aortic type A dissection (Fig 1A) arising in the ascending aorta and extending to the diaphragmatic aorta. The patient gave informed consent for an operation.
View larger version (93K):
[in this window]
[in a new window]
|
Fig 1. Computed tomographic scans of the transverse aortic arch in patient 1: (A) preoperative and (B) before discharge from the hospital.
|
|
Transesophageal echocardiography (TEE) performed in the operating room confirmed the diagnosis, and the primary entry tear was located in the ascending aorta. Cardiopulmonary bypass was established between the right subclavian artery and the right atrium. Moderate hypothermia was induced.
The proximal aortic stump was reconstructed with continuous a mattress suture and circular Teflon (DuPont, Wilmington, DE) collars after gelatin-resorcin-formol (GRF) glue was applied to the false channel during cooling. Extracorporeal circulation was arrested at 25°C of the nasopharyngeal temperature; the right carotid was perfused at a rate of 10 mL · kg–1 · min–1 through the arterial cannula. The distal aortic stump was reconstructed with the same technique as the proximal one.
A 9-cm-long balloon-expandable uncovered stent (Djumbodis Dissection Systeme, Saint Come-Chirurgie, Marseille, France) made of 316 L stainless steel was inserted in the aortic arch. The compliant balloon was then inflated until the stent adapted to the shape of the aortic arch and until the external and internal layer of the aorta coapted properly. TEE verified the correct opening of the stent and, after a brief suspension of cerebral perfusion, a 7-mm endoscope was inserted through the stent and into the aortic arch to verify the correct deployment and adaptation of the stent to the aortic wall (Fig 2). The distal end of a Dacron (DuPont, Wilmington, DE) graft was then anastomosed. Extracorporeal circulation was restored, and the proximal anastomosis of the Dacron graft was completed while the patient was rewarming. The circulatory arrest and cerebral perfusion lasted 34 minutes.
View larger version (151K):
[in this window]
[in a new window]
|
Fig 2. Endoscopic view of the transverse arch in patient 1 after the Djumbodis dissection system was positioned. (* = supraortic trunks.)
|
|
The patient was asymptomatic upon discharge 7 days after the operation. A predischarge CT scan showed no patent false lumen in the aortic arch (Fig 1B), although a patent false lumen was still present in descending aorta because of a tear 2 cm below the distal end of the stent. A follow-up CT scan was planned.
Patient 2
A 37-year-old man with acute right leg ischemia was referred to the Cardiac Surgery Department with a CT scan diagnosis of a type A acute aortic dissection that extended to the right common iliac artery. TEE confirmed the diagnosis and detected the entry tear in the ascending aorta. The patient's informed consent was obtained. The patient was then operated on with the same procedure used in the first patient. Total circulatory arrest time was 31 minutes. The patient was asymptomatic when he was discharged on postoperative day 5. A predischarge CT scan revealed an occlusion of the false lumen in the transverse arch and a severe reduction in the descending and abdominal aorta. A serial CT scan follow-up was planned.
|
Comment
|
|---|
The appropriate treatment of an acute type A aortic dissection is still an open issue. The traditional goal of emergency surgical treatment has always been to save the patient, but considering the high mortality and morbidity associated with emergency repair of the aortic arch, many authors have advocated the limited replacement of the ascending aorta as the standard treatment.
In his study of 143 patients, Bachet and colleagues concluded, "when (and only when) the intimal tear is located in or extends to the transverse arch, this segment should be partially or totally replaced."[1] This treatment is far from being resolutive. Ergin and colleagues evaluated the destiny of the false lumen in patients operated for type A acute aortic dissection and found that it was patent in 60% of the patients in which only the ascending aorta was replaced, but was found to be patent in only 23% of the patients in which partial or total arch resection was required for the location of the primary tear [2]. Again, Bachet, after revising 212 patients who underwent emergent surgical repair for type A acute aortic dissection, found that not replacing the aortic arch was a determinant risk for reoperation [3].
More recent reports, however, conclude that extended total arch replacement can also be done with acceptable mortality and morbidity, and with better long term results, when the primary tear is found to be in the ascending aorta [4, 5]. According to Hirotani, "because both skillful management and techniques will be needed to replace the transverse arch, in less experienced centers the more limited standard repair... remains the most appropriate" [4].
The ascending aorta in both of our patients was replaced with a standard technique because of the presence of the entry tear. The dissected transverse arch was reconstructed with GRF glue, and the stent was inserted under direct vision. Total circulatory arrest time was safe, given the selective perfusion of the right carotid artery. Thus, the insertion of the Djumbodis System, together with the use of GRF glue, allowed the restoration of the true lumen and the definitive exclusion of the false lumen in the aortic arch with an easy and reproducible technique. The insertion of the 7-mm endoscope within the transverse arch was fundamental to verify the correct deployment and adaptation of the stent to the aortic wall; moreover, this procedure made it possible to avoid the use of fluoroangiography and the involvement of a radiologic team, which would be difficult in an emergency setting. The high risks associated with such a demanding procedure as total arch replacement were avoided.
Roux and colleagues reported their use of surgical technique plus stent positioning to treat 2 patients affected by type A aortic dissection [6]. In both these patients, the entry tear was located in the distal arch and the stent was positioned after the biological glue was inserted through the tear itself. The procedure was performed under fluoroangiography with a portable apparatus.
We believe that the best treatment of a dissection in order to obtain better long-term results is the replacement of the segment of aorta that contains the port of entry and the reinforcement of the dissected segments. The insertion of the Djumbodis stent in aortic arch and the confirmation by endoscopy, together with the traditional replacement of the ascending aorta, allows these important goals to be reached with a relatively easy and reproducible technique. If the false lumen remains patent in the descending aorta, it can be treated later on with an endovascular repair, if necessary.
|
References
|
|---|
- 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]
- Ergin MA, Phillips RA, Galla JD, et al. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg. 1994;57:820–825[Abstract]
- Bachet J, Goudot B, Dreyfus G, Brodaty D, et al. Surgery of acute type A dissection: what have we learned during the past 25 years? Z Kardiol. 2000;89(Suppl 7):47–54
- Hirotani T, Kameda T, Kumamoto T, et al. Results of a total aortic arch replacement for an acute aortic arch dissection. J Thorac Cardiovasc Surg. 2000;120:686–691[Abstract/Free Full Text]
- Kazui T, Washiyama N, Muhammad BA, et al. Extended total arch replacement for acute type A aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg. 2000;119:558–565[Abstract/Free Full Text]
- Roux D, Brouchet L, Concina P, et al. Type-A acute aortic dissection. Combined operation plus stent management. Ann Thorac Surg. 2002;73:1616–1618[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
B. Leobon, D. Roux, S. Saccani, A. Mugniot, F. Muscari, Y. Glock, and G. Fournial
Type A aortic dissection: New surgical strategy using intra-operative stenting
J. Thorac. Cardiovasc. Surg.,
February 1, 2006;
131(2):
482 - 483.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
