Ann Thorac Surg 2009;87:1181. doi:10.1016/j.athoracsur.2009.02.009
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Martin Czerny, MD,
Michael Grimm, MD
Department of Cardiothoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Leistelle 20 West, Gruner Bettenturm, A-1090 Vienna, Austria
(Email: michael.grimm{at}meduniwien.ac.at).
The authors report their results with a stented elephant trunk being added to conventional total arch replacement in patients undergoing surgery for acute retrograde type A dissection [1]. We would like to discuss some issues regarding this elegant and effective approach, which the authors have provided.
It is important to realize the difference between a classic type A dissection and a retrograde type A dissection, because treatments differ. In contrast to the classic type A dissection, a primary entry tear is not detectable during ascending aortic replacement for retrograde type A dissection. Thus, it is not certain that the pathogenesis has been treated properly. These patients therefore remain at risk for adverse events related to unidentified and untreated lesions in distal aortic segments. By combining open and endovascular technology, a better treatment may be provided to prevent subsequent enlargement of the distal arch and the proximal descending aorta. Nevertheless, the insertion of a prosthesis into as freshly dissected descending aorta may be hazardous and has to be done carefully. Placement of a superstiff guidewire into the true lumen before starting the procedure often is helpful.
The combined approach will not eliminate late surgical reintervention in downstream aortic segments in all patients, but it will shift critical disease more distally to enable late thoracoabdominal management with left heart bypass. This avoids circulatory arrest and associated bleeding. Finally, routine combined total arch replacement may not be required because combination open and endovascular therapy may be used without arch replacement.
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References
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- Sun L, Qi R, Chang Q, et al. Surgery for acute type A dissection with the tear in the descending aorta using a stented elephant trunk procedure Ann Thorac Surg 2009;87:1177-1181.[Abstract/Free Full Text]
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