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Correspondence

Should an Endovascular Procedure Be Combined With Resection for Type A Aortic Dissection?

Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Fondazione CNR-G Monasterio, Via Aurelia Sud, Massa, 54100 Italy

(Email: michelem{at}ifc.cnr.it).

To the Editor:

We read with great interest the article of Jakob and coworkers [1]. In their report, the authors successfully demonstrated the technical feasibility of a combined surgical and endovascular procedure for acute DeBakey type I dissection. The authors' rationale for using this hybrid approach is based on the hypothesis that adding a stent graft in the descending aorta during open surgical repair will result in thrombosis of the residual false lumen and prevent development of aneurysmal dilatation of the distal thoracoabdominal aorta.

Although the idea is extremely attractive, we have doubts about the benefit. Many published studies show that the residual dissected aorta tends to enlarge, but that a long time is required for the development of a large aneurysm that requires surgical intervention. Halstead and colleagues [2] reported a series of 179 patients operated on for type A aortic dissection and demonstrated that the median growth rate of the diameter of the descending aorta was 1.0 mm/y. The authors concluded that aortic expansion after type A dissection is typically slow and linear, which renders distal reoperation relatively uncommon. Similar conclusions have been reported by Sabik and colleagues [3] and by Dobrilovic and Elefteriades [4].

In a recently published paper, Kimura and coworkers [5] assessed the influence of a residual patent lumen on long-term outcome in a series of 193 surviving patients who underwent standard surgical repair of type A aortic dissection. Their results showed that the presence of a residual patent lumen does not affect long-term outcome and it is not necessarily associated with a faster aortic growth rate. For these reasons, we believe that adjunctive descending aortic endovascular stent grafting may be viewed as a procedure to stabilize something that is not likely to cause a surgical problem, but adds additional risk to an already complex procedure with a high mortality rate. In our opinion, the authors deserve praise for their excellent results, which demonstrate that a combined procedure for type A aortic dissection can be safely performed; however, the question is: Should it be performed?

	References

Top References

 

1. Jakob H, Tsagakis K, Tossios P, et al. Combining classic surgery with descending stent grafting for acute DeBakey type I dissection Ann Thorac Surg 2008;86:95-101.[Abstract/Free Full Text]
2. Halstead JC, Meier M, Etz C, et al. The fate of the distal aorta after repaior of acute type A aortic dissection J Thorac Cardiovasc Surg 2007;133:127-135.[Abstract/Free Full Text]
3. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections J Thorac Cardiovasc Surg 2000;104:46-59.
4. Dobrilovic N, Elefteriades JA. Stenting the descending aorta during repair of type A dissections: technology looking for an application? J Thorac Cardiovasc Surg 2006;131:777-778.[Free Full Text]
5. Kimura N, Tanaka M, Kawahito K, Yamaguchi A, Ino T, Adachi H. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection J Thorac Cardiovasc Surg 2008;136:1160-1166.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. Tsagakis, P. Tossios, M. Kamler, J. Benedik, D. Natour, H. Eggebrecht, J. Piotrowski, and H. Jakob The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition Eur J Cardiothorac Surg, November 1, 2011; 40(5): 1078 - 1084. [Abstract] [Full Text] [PDF]

				H. Jakob and K. Tsagakis Reply. Ann. Thorac. Surg., October 1, 2009; 88(4): 1388 - 1389. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michele Murzi Mattia Glauber Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Murzi, M. Articles by Glauber, M. Search for Related Content PubMed PubMed Citation Articles by Murzi, M. Articles by Glauber, M. Related Collections Great vessels Related Article