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Original Articles: Cardiovascular

Invited commentary

Department of Cardiovascular Surgery, Hospital Clinico, Villarroel 170, Barcelona 08036, Spain

(Email: cmestres{at}clinic.ub.es).

Primary or reoperative surgery of the thoracic aorta continues to be a challenge. In aortic dissection, the fate of the false lumen is still a matter of concern and it will remain patent in a substantial proportion of patients with the potential for a growing aorta and need for reoperation. Atherosclerotic aneurysms with arch involvement seem to be challenging when regarding the appropriateness of a given technique for repair.

The article by Gorlitzer and colleagues [1] has to seriously be taken into account. The authors have to be commended for their early series study of 7 patients with complex aortic lesions who were radically treated with a novel device with substantial success. They used a recently developed device (E-Vita Open; Jotec Inc, Hechingen, Germany) that consists of a nitinol stent-graft with an integrated Dacron vascular graft. The attractive design of this new device allows for a one-step radical treatment of complex primary or iterative lesions of the intrathoracic aorta. In contrast to the Borst "elephant trunk" technique [2], the use of integrated hybrid prosthesis may potentially offer some advantages. The first advantage, as pointed out by Gorlitzer and colleagues [1], is the possibility of treating all intrathoracic lesions in one operation. The second advantage, is a fully thrombosed false lumen shortly after surgery. This may lead to cure of aortic disease avoiding the consequences of persistent false lumen in dissection. The potential to reduce the chances for repeated operations are not to be neglected.

There are a handful of reports referring to potential advantages of this new device [3–5]. The early thrombosis of a false lumen in the case of dissections is common. The comments of Dobrilovic and Elefteriades [6] are strong regarding the fate of the false lumen, provided the arch tear is resected, but they also provide a word of caution regarding this hybrid technique. This may eventually be the impact of the new device in the late results of surgery of the thoracic aorta, if more experience is accumulated. Atherosclerotic aneurysms can be similarly treated by avoiding or facilitating eventual reoperations. There are a few devices on the market with a similar design aiming to allow single-stage treatment of complex lesions [7, 8]. The device used by Gorlitzer and colleagues [1] sounds very promising, especially if documented experience and follow-up confirm the benefit of an early thrombosis of the false lumen. Thorough analysis of data, avoidance of skewed indications together with appropriate judgment in the decision-making process will be of extreme help in defining the role of these newer devices.

	References

Top References

 

1. Gorlitzer M, Weiss G, Thalmann M. Combined surgical and endovascular repair of complex aortic pathologies with new hybrid prosthesis Ann Thorac Surg 2007;84:1971-1977.[Abstract/Free Full Text]
2. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using elephant trunk prosthesis Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
3. Herold U, Tsagakis K, Kamler M, et al. Change of paradigms in the surgical treatment of complex thoracic aortic disease Herz 2006;31:434-442.[Medline]
4. Mestres CA, Fernández C, Josa M, Mulet J. Hybrid antegrade repair of the arch and descending thoracic aorta with a new integrated stent-Dacron graft in acute type A aortic dissection: a look into the future with new devices Interact Cardiovasc Thorac Surg 2007;6:257-259.[Abstract/Free Full Text]
5. Schoenhoff FS, Schmidli J, Eckstein FS, Berdat PA, Immer FF, Carrel TP. The frozen elephant trunk: an interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta J Vasc Surg 2007;45:597-599.[Medline]
6. Dobrilovic N, Elefteriades J. Stenting the descending thoracic aorta during repair of type A dissection: technology looking for an application? J Thorac Cardiovasc Surg 2006;131:777-778.[Free Full Text]
7. Chavan A, Karck M, Hagl C, et al. Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta J Vasc Interv Radiol 2005;16:823-829.[Medline]
8. Uchida N, Ishihara H, Shibamura H, Kyo H, Ozawa M. Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type A aortic dissection J Thorac Cardiovasc Surg 2006;131:862-867.[Abstract/Free Full Text]

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