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Department of Surgery, Division of Cardiovascular Surgery, Hospital of The University of Pennsylvania, 3400 Spruce St, 6th Floor, Silverstein, Philadelphia, PA 19104
(Email: szetow{at}uphs.upenn.edu).
Advances in the surgical management of acute aortic dissection involving the ascending aorta have resulted in significant improvement in morbidity and mortality. However, conventional surgical technique designed to address the ascending aortic pathology often results in leaving residual dissection in the descending thoracoabdominal aorta. The management of late aneurysmal formation in the remaining distal aorta remains a clinical challenge. Even in a contemporary series, distal reoperation of thoracoabdominal aortic aneurysms in the setting of chronic dissections has been associated with perioperative mortality up to 30% [1].
Jakob and coauthors [2] propose a novel modification of the conventional open repair in an attempt to alter the fate of distal residual aortic dissection and possibly improve long-term outcome. The fundamental question is: "Does obliteration of the false lumen in the distal aorta (with the use of stent graft therapy) positively affect aortic remodeling and prevent aneurysmal formation?" In this series, 45 patients with acute DeBakey type I aortic dissection underwent either conventional surgery (n = 23) or hybrid repair (n = 22). The hybrid repair consists of conventional surgical repair of the ascending aortic dissection with concomitant stent graft therapy of the descending thoracic aorta. The hypothesis is that stent graft therapy of the descending thoracic aorta results in the obliteration and thrombosis of the false lumen, thus preventing aneurysmal formation of the distal thoracoabdominal aorta.
The authors should be congratulated for their remarkable results on such a difficult group of patients. Their overall operative mortality was 16% (conventional surgery, 22%; hybrid, 9%; p = 0.22). Despite higher incidences of cerebral malperfusion and hemodynamic compromise in the hybrid group, there was no difference in mortality. In terms of the conduct of the operations, there was no difference in the duration of CPB, selective antegrade cerebral perfusion and deep hypothermia and circulatory arrest. Interestingly, the duration of the aortic cross clamp was shorter in the hybrid group. Postoperative results were also similar between the two groups. There was no difference in operative mortality, renal failure, stroke, and intubation time.
By demonstrating no differences in the perioperative and short-term outcome between the two groups, the authors reassure us that the advances made in the proximal reconstruction and surgical outcome of ascending aortic dissection have not been compromised with this new technique. I believe this is an important point that the authors have appropriately emphasized. However, the main question of the study lies in the fate of the distal aorta (ie, aortic remodeling) after proximal reconstruction of the aortic dissection. Although early results from this study is encouraging, the study is simply too small and the follow-up too short (23 months in the hybrid group) to make definitive conclusions.
Nevertheless, the fundamental concept of distal aortic remodeling in aortic dissection is an important question that should be pursued. Larger studies with long-term follow-up are needed before definitive conclusions can be made. Other issues need to be addressed and answered. Will this technique have any impact on neurologic events, such as stroke or spinal cord ischemia? What is the optimal length of coverage of the descending thoracic aorta with the endograft, as this decision must be made in considering between the effectiveness of the therapy versus the risk of spinal cord ischemia and perhaps distal malperfusion? If false lumen patency persists in the thoracic aorta despite stent graft therapy (seen in 10% patients in this study), how does that affect aortic remodeling? Also, how does the presence of a stent graft in the descending thoracic aorta affect distal reoperations? The authors demonstrated that the hybrid operation can be performed safely with no difference in mortality from the conventional surgical approach. I believe this study serves an important role in defining the concept and setting the stage for future studies.
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