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Original Articles: Adult Cardiac

Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure

^a Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
^b Department of Radiology, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
^c Department of Cardiovascular Surgery, Tianjin Cardiovascular Institute and Tianjin Chest Hospital, Tianjin, China

Accepted for publication January 16, 2009.

^_* Address correspondence to Dr Sun, Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, 167 Beilishi Rd, Beijing, 100037, China (Email: slzh_2005{at}yahoo.com.cn).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
Background: Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure.

Methods: Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography.

Results: Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 ± 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up.

Conclusions: Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Appropriate management of acute type A dissection with retrograde extension of the dissection into the ascending aorta and an intimal tear located in the descending aorta (retrograde dissection) is controversial. Patients with retrograde dissection have an extremely poor prognosis [1]. Several therapeutic approaches have been used in patients with retrograde dissection [1–5], but the effectiveness of these approaches and surgical procedures is uncertain. We report our experience of total replacement of the arch combined with implantation of the stented elephant trunk in patients with acute type A dissection with the tear in the descending aorta with retrograde extension to the ascending aorta.

	Material and Methods

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Patients
Two-hundred fourteen patients with acute type A dissection underwent surgical treatment in Fuwai Hospital, Beijing, China, from April 2003 to June 2007. Thirty-three patients (15.4%) had acute type A dissection with the tear in the descending aorta with retrograde extension to the ascending aorta. Patients with retrograde dissection underwent total replacement of the arch combined with stented elephant trunk implantation through a median sternotomy under hypothermic cardiopulmonary bypass (CPB) with selective cerebral perfusion (SCP). This technique was approved by the institutional review board of the Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.

Surgery was performed during the acute stage (within 2 weeks of the onset of acute aortic dissection). There were 31 males and 2 females (mean age, 45 ± 11 years; range, 24 to 78 years). Only 1 patient had Marfan's syndrome. A history of hypertension was the most common preoperative finding (Table 1). All patients had precordial, back, or abdominal pain at symptom onset. Among 33 patients with acute type A dissection with the tear in the descending aorta in this study, involvement of the supraaortic branches was observed in 24 patients (24 of 33 patients, 72.7%); aortic rupture in 8 patients; sign of aortic rupture (hemorrhagic effusion in the pericardial space) in 6 patients; acute cardiac tamponade in 1 patient; aortic insufficiency in 9 patients (surgical intervention in 5); and involvement of the right coronary artery in 10 (surgical intervention in 4). Preoperative complications were common (Table 1).

Surgical Technique
Total arch replacement combined with stented elephant trunk implantation was performed through a median sternotomy under hypothermic CPB with SCP: these techniques have been described in detail by our research group [6, 7]. Cannulation for CPB was carried out through the right axillary artery and the right atrium. Under hypothermic CPB with SCP and cardiac protection with cold-blood cardioplegia, the ascending aorta and the transverse aortic arch was opened and inspected closely after the aortic root procedures were carried out (if necessary). The primary intimal tear in the descending aorta was identified by direct intraoperative observation. The stented elephant trunk could seal off the intimal tear in the descending aorta where the stented elephant trunk could reach. With this in mind, the distal aorta was transected circumferentially close to the proximal margin of the origin of the left subclavian artery. A catheter sheath containing a 10-cm-long stent graft (MicroPort Medical Co, Ltd, Shanghai, China) was inserted into the true lumen of the descending aorta in a bound, compressed state as the stented elephant trunk. The choice of appropriate sizing of the stented elephant trunk in patients with acute type A dissection has been previously described in detail by our research group [6]. The distal end of a four-branched prosthetic graft was anastomosed to the descending thoracic aorta containing the intraluminal stented elephant trunk. Air was eliminated from the descending aorta when the anastomoses were completed. Antegrade systemic reperfusion was started through the perfusion limb of the four-branched prosthetic graft. Anastomosis to the left common carotid artery was done in an end-to-end fashion. After anastomosis, SCP was discontinued, CPB was gradually resumed to normal flow, and rewarming was started. Anastomosis to the left subclavian artery and the innominate artery was done in the same fashion. After reconstruction of all arch vessels, the proximal anastomosis was carried out during rewarming.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Surgical Data
Patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation under hypothermic CPB with SCP. The CPB time was 135 to 379 minutes (mean, 202 ± 53 minutes); aortic cross-clamp time was 70 to 198 minutes (mean, 112 ± 31 minutes); and SCP time was 15 to 52 minutes (mean, 25 ± 9 minutes). Concomitant procedures are summarized in Table 2.

Paraparesis in the left lower extremity was observed in 1 patient. The patient with preoperative lower extremity ischemia had a subdural hematoma as evaluated by computed tomography. Paraparesis in the lower extremity may be related to preoperative ischemia or postoperative subdural hematoma. One patient had transient neurologic dysfunction and recovered before hospital discharge. One patient with preoperative chronic renal dysfunction received hemodialysis.

Imaging
Surviving patients underwent computed tomography during follow-up. Thrombus obliteration of the false lumen at the distal edge of the stented graft was observed in 29 patients (97%) and at the diaphragmatic level in 20 patients (67%) (Fig 1). Mean diameter of the descending aorta decreased from 34.10 ± 6.56 mm to 29.13 ± 2.34 mm during follow-up. Preoperative diameter of the false lumen in the descending aorta was 21.85 ± 3.62 mm. After remodeling of the aortic wall, complete or nearly complete reabsorption of the thrombus in the false lumen was observed, and the descending aorta returned to normal in 19 patients (63%) during follow-up. Obvious enlargement of the abdominal aorta was not observed at the level of the superior mesenteric artery compared with preoperative imaging. Thrombosis of the false lumen, enlargement of the true lumen, and reabsorption of the false lumen thrombosis was a dynamic process after implantation of the stented elephant trunk in the true lumen of the descending aorta.

View larger version (110K): [in this window] [in a new window]   Fig 1. Computed tomographic scans of a patient with acute type A dissection with the tear in the descending aorta 2 weeks (A and B) and 15 months (C and D) after surgery. Thrombosis of the false lumen was observed at the distal edge of the stented graft (A) and at the diaphragmatic level (B) 2 weeks after surgery. Absorption of false-channel thrombosis was observed at the distal edge of the stented graft (C) and at the diaphragmatic level (D) 15 months after surgery. The true lumen resumed completely, and the descending aorta returned to normal size after remodeling of the aortic wall during follow-up (C and D).

	Comment

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Stanford type A aortic dissection usually involves an intimal tear that is on the ascending aorta and extends to the aortic arch or more distally in an antegrade fashion. Aortic dissection may develop in an antegrade or retrograde direction. Type A dissection with an intimal tear in the descending aorta may extend retrograde to involve the ascending aorta or even the aortic root. The prognosis of acute retrograde dissection is considered to be extremely poor because blood flow in the false lumen cannot be eliminated using a conventional surgical technique [1].

Appropriate management of acute type A dissection with the tear in the descending aorta with retrograde extension to the ascending aorta is controversial. Primary medical therapy was recommended in patients with a small ascending aorta, thrombosed proximal false lumen and absence of pericardial effusion, aortic regurgitation, or the complications caused by descending aortic dissection. Otherwise, early surgical treatment was recommended in these cases [4]. Kaji and associates [5] recommended that retrograde aortic dissection with a thrombosed false lumen in the ascending aorta should be initially treated medically followed by timed surgical repair.

Several surgical procedures were used in patients with acute type A dissection with the tear in the descending aorta with retrograde extension to the ascending aorta. Erbel and colleagues [1] stated that replacement of the ascending aorta was unsuitable for this group because it would not eliminate blood flow in the false lumen, which closely correlated with late complications. von Segesser and coworkers [4] recommended retrograde dissection should be managed according to the site of the predominant lesion. Arch replacement with a varying portion of the ascending aorta should be done in patients with predominant proximal aortic lesions through a median sternotomy. Replacement of the descending thoracic aorta with resection of the intimal tear was carried out in patients with predominant distal aortic lesions through a lateral thoracotomy, but the minimally affected aortic segment is left untreated. The intimal tear, which correlated closely with a higher rate of reoperation and mortality according to Erbel and colleagues [1], was untreated in some patients. Total replacement of the ascending aorta and aortic arch accompanied by resection of an intimal tear was recommended by Kazui and associates [3] in patients with acute type A dissection with the tear in the descending aorta, but the descending aortic dissection remained untreated. Considering the technical difficulty of dealing with proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy, total arch replacement with elephant trunk implantation was done to repair proximal aortic lesions and induce thrombotic closure of the distal false channel through a median sternotomy in patients with acute type A dissection with the tear in the descending aorta [2].

Complications (eg, kinking and obstruction of the graft, embolization, paraplegia) were observed using the conventional elephant trunk technique [8]. Some modifications of the elephant trunk technique were made by our research group, and encouraging preliminary results were achieved in patients with type A dissection using total arch replacement combined with stented elephant trunk implantation [7]. We therefore applied this technique to patients with type A dissection with the intimal tear in the descending aorta with retrograde extension to the ascending aorta. The biggest advantage of this technique was that the distal anastomosis could be carried out close to the proximal margin of the origin of the left subclavian artery because the intimal tear in the descending aorta, where the stented elephant trunk reached, could be sealed off by the stented elephant trunk. This avoided the difficulty in carrying out the distal anastomosis in the descending aorta as described by Kazui and coworkers [3]. Phrenic nerve plasty therefore decreased significantly, and phrenic nerve injury did not occur in this group. Second, repair of aortic root lesions, retrograde dissection of the ascending aorta and the aortic arch, and sealing of the primary tear in the descending aorta could be obtained simultaneously using this technique through a median sternotomy. Thrombosis of the false lumen in the descending aorta was achieved concomitantly with this technique. Thrombus obliteration of the false lumen at the distal edge of the stented graft was observed in most patients (29 of 30, 97%). Thrombosis of the false lumen at the diaphragmatic level was seen in 20 patients (20 of 30, 67%). Third, this technique could prolong the reoperation interval or reduce the number of late thoracoabdominal aortic replacements. Reoperation related to residual dissected aorta was not done during follow-up. Finally, the anastomosis between the distal end of the stent elephant trunk and the Dacron graft was made safer and easier as a result of 1 cm of extra vascular graft of the distal end of the surgical stent graft for sewing if late thoracoabdominal aortic replacement was required.

Acceptable morbidity and mortality was obtained in patients with the intimal tear in the descending aorta with retrograde extension to the ascending aorta using this technique. The overall prevalence of in-hospital death was 6.06% (2 of 33 patients). The 2 deaths were attributable to preoperative acute renal failure and mesenteric ischemia. The technique was associated with higher surgical mortality for patients with compromised renal and mesenteric perfusion than for those without compromised renal and mesenteric perfusion. We thought that concomitant renal failure or mesenteric ischemia was responsible for in-hospital mortality in this group [9, 10]. Encouraging outcomes were obtained with regard to morbidity using this technique. Paraparesis in the left lower extremity was observed in 1 patient. Paraparesis may be related to preoperative ischemia of the lower extremity or postoperative subdural hematoma. Although transient neurologic dysfunction occurred in 1 patient, no patient suffered persistent neurologic dysfunction in this group.

Total replacement of the arch combined with stented elephant trunk implantation was a feasible technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained. Satisfactory results were achieved in this study.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Erbel R, Oelert H, Meyer J, et al. The European Cooperative Study Group on Echocardiography Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. Circulation 1993;87:1604-1615.[Abstract/Free Full Text]
2. Hanafusa Y, Ogino H, Sasaki H, et al. Total arch replacement with elephant trunk procedure for retrograde dissection Ann Thorac Surg 2002;74(Suppl):S1836-S1839discussion S1857–63.[Abstract/Free Full Text]
3. Kazui T, Tamiya Y, Tanaka T, Komatsu S. Extended aortic replacement for acute type A dissection with the tear in the descending aorta J Thorac Cardiovasc Surg 1996;112:973-978.[Abstract/Free Full Text]
4. von Segesser LK, Killer I, Ziswiler M, et al. Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge. J Thorac Cardiovasc Surg 1994;108:755-761.[Abstract/Free Full Text]
5. Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to the ascending aorta Circulation 2003;108(Suppl 1):II-300-II-306.[Abstract/Free Full Text]
6. Sun LZ, Qi RD, Chang Q, et al. Surgery for Marfan patients with acute type A dissection using a stented elephant trunk procedure Ann Thorac Surg 2008;86:1821-1825.[Abstract/Free Full Text]
7. Liu ZG, Sun LZ, Chang Q, et al. Should the "elephant trunk" be skeletonized?. Total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection. J Thorac Cardiovasc Surg 2006;131:107-113.[Abstract/Free Full Text]
8. Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR. Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537.[Medline]
9. Fann JI, Sarris GE, Mitchell RS, et al. Treatment of patients with aortic dissection presenting with peripheral vascular complications Ann Surg 1990;212:705-713.[Medline]
10. Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinants of operative mortality for patients with aortic dissections Circulation 1984;70(3 Pt 2):I-153-64.

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