Ann Thorac Surg 2009;87:108. doi:10.1016/j.athoracsur.2008.10.035
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Shinji Miyamoto, MD
Department of Cardiovascular Surgery, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu-shi, Oita, 879-5593 Japan
(Email: smiyamot{at}med.oita-u.ac.jp).
The less than 10% survival rate after repair of an acute type A dissection inspires interest in the fate of the survivors. Aneurysmal change of the residual false lumen brings on an unwelcome second or even third operation with no proper proximal clamp site. Recognition of aortic metamorphosis from its initial condition is essential to determine what the first procedure should be, so as to avoid falling into this morass afterward. The authors demonstrate here [1] that postoperative dilatation occurred more frequently in the thoracic aorta, in the young, and in the cases of patent or wide false lumen, larger aortic diameter, and Marfan syndrome. This result supports previous reports [2, 3]. Among these knotty conditions, surgeons can merely work out how to avoid leaving the false lumen patent in the thoracic aorta. Endoleak at the distal anastomosis or remaining entry (re-entry) in the descending thoracic aorta provides more opportunities for the false lumen to be patent. Therefore, it is consequential that application of the elephant trunk procedure, which reduces endoleak and increases the possibility of shielding an entry that may exist in the downstream aorta [4], improves long-term survival. In the past, one might have intervened in an acute dissection with ascending replacement of the aorta, thinking only of saving the patient's life immediately, not the mid-term outcome. Now the trend is toward total arch replacement, which offers excellent early outcomes and helps avoid future distal interventions or at least provides greater convenience if one is necessary. Furthermore, an ascending or partial arch replacement can not carry the elephant trunk, which prevents endoleak and reduces the likelihood of additional interventions in the descending aorta. Currently, the "frozen elephant trunk," which has a stent graft distally as a trunk, is expected to enhance the value of the elephant trunk technique for dissections [5, 6].
Morphology after the repair of an acute type A dissection mirrors a type B aortic dissection. Tsai and colleagues [7] interestingly reported that partial thrombosis of the false lumen in an acute type B dissection has a worse prognosis than complete patency. In the present article, "patent false lumen" includes partial thrombosis. Subdivisions of patency (or thrombosis) may afford more significant and informative data for decision-making regarding the second intervention. Lately, thoracic endovascular aortic repair, like the proverbial little Dutch boy, has put its finger in the dike for us regarding complicated type B dissections [8]. Thoracic endovascular aortic repair can be the first approach for potentially troublesome distal lesions after repair of a type A dissection, followed by open graft replacement as the second approach, if necessary [9]. The elephant trunk provides a good proximal neck for both thoracic endovascular aortic repair and graft replacement. In short, no elephant trunk? No way.
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References
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- Park K-H, Lim C, Choi JH, et al. Midterm change of descending aortic false lumen after repair of acute type I dissection Ann Thorac Surg 2009;87:103-108.[Abstract/Free Full Text]
- Zierer A, Voeller RK, Hill KE, et al. Aortic enlargement and late reoperation after repair of acute type A aortic dissection Ann Thorac Surg 2007;84:479-487.[Abstract/Free Full Text]
- Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection Am J Coldiol 2001;87:1378-1382.
- Miyamoto S, Hadama T, Anai H, et al. Simplified elephant trunk technique promotes thrombo-occlusion of the false lumen in acute type A aortic dissection Ann Thorac Cardiovasc Surg 2006;12:412-416.[Medline]
- Jakob H, Tsagakis K, Tossios P, et al. Combining classic surgery with discending stent grafting for acute DeBakey type I dissection Ann Thorac Surg 2008;86:95-102.[Abstract/Free Full Text]
- Mizuno T, Toyama M, Tabuchi N, et al. Stented elephant trunk procedure combined with ascending aorta and arch replacement for acute type A aortic dissection Eur J Cardio-Thorac 2002;22:504-509.
- Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosisi of the false lumen in patients with acute type B aortic dissection N Engl J Med 2007;357:349-359.[Medline]
- Verhoye JP, Miller DC, Sze D, et al. Complicated acute type B aortic dissection: Midterm results of emergency endovascular stent-grafting J Thorac Cardiovasc Surg 2008;136:424-430.[Abstract/Free Full Text]
- Chen IM, Shin CC. Extending hybrid approach to residual Stanford type A dissecting aortic aneurysm Interact CardioVasc Thorac Surg 2007;6:204-207.[Abstract/Free Full Text]
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Midterm Change of Descending Aortic False Lumen After Repair of Acute Type I Dissection
- Kay-Hyun Park, Cheong Lim, Jin Ho Choi, Euisuk Chung, Sang Il Choi, Eun Ju Chun, and Kiick Sung
Ann. Thorac. Surg. 2009 87: 103-108.
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