Ann Thorac Surg 2005;80:1302
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Walter J. Gomes, MD, PhD
Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Botucatu 740, São Paulo, SP 04023-900 Brazil
(Email: wjgomes.dcir{at}epm.br).
Despite advances in operative techniques and postoperative care, repair of aortic dissection involving the arch remains a challenging and high-risk procedure. Moreover, extended aortic arch replacement still carries a considerable operative risk. However, this is a timely subject, as it addresses integral treatment of a lethal condition.
In this issue, Ochiai and colleagues [1] report results of an operative strategy of total aortic arch replacement using a branched graft in cases of type A aortic dissection with arch involvement. This is a large experience and presents one of the largest casuistic so far on this subject, comparing favorably with previous studies. The rationale is the operative treatment of wider segments of the diseased aorta and more complete resection of intimal tears, which reduces the long-term complication rate.
The value of the study is the extended follow-up; for this reason this report is quite interesting. Few studies report long-term follow-up of patients who had total aortic arch replacement. Importantly, the procedure was accomplished with low mortality; the distal false lumen in the aorta was thrombosed in more than 70% of patients at latest follow-up; and no patient required aortic arch reoperation. Freedom from reoperation was 98.0% at 5 years and 94.4% at 10 years. Frequent complications usually related to acute type A aortic dissections and a poorer postoperative prognosis (eg, renal and mesenteric ischemia, paraplegia, limb ischemia, Marfan syndrome) were not found in the present study. Surely, absence of these complications contributed to the excellent outcome and may justify greater perioperative morbidity and mortality in higher risk patients.
This article endorses the fact that contemporary cerebral protection methods, proper indications, and total arch replacement can produce acceptable mortality in patients with type A aortic dissection and provide more satisfactory long-term outcomes. The information provided by this study supports and encourages aggressive treatment of this disease.
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References
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- Ochiai Y, Imoto Y, Sakamoto M, et al. Long-term effectiveness of total arch replacement for type A aortic dissection Ann Thorac Surg 2005;80:1297-1302.[Abstract/Free Full Text]
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