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Correspondence

Reply

Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital of Essen, Hufelandstr. 55, Essen, D-45122 Germany

(Email: heinz.jakob{at}uk-essen.de).

To the Editor:

Dr Jakob discloses that he has a financial relationship with JOTEC GmbH.

 

We appreciate the interest and comments by Drs Murzi and Glauber [1] regarding our article [2]. We respect their concern and would like to clarify our position.

The fate of a patent distal false lumen and its impact on long-term outcome is controversial. Uchida and colleagues [3] report a significant increase of adverse events affecting the thoracic aorta in hemi-arch procedures in contrast with frozen elephant trunk operations. Yeh and colleagues [4] confirmed these findings by multivariate analysis; a patent false lumen significantly enhances the chance of aneurysm formation in the descending aorta. Thus, the literature does not provide evidence for the best method.

Our personal experience with 26 patients presenting with life-threatening complications such as a rupture, aneurysm formation, and persisting true lumen collapse downstream within 8 months to 7 years after proximal aortic replacement for type I aortic dissection, stimulated change in our surgical concepts described in our article [2]. The following steps have been taken toward these changes:

1 Removal of all entry or re-entry tears accessible in the ascending aorta or aortic arch during deep hypothermic circulatory arrest and selective antegrade cerebral perfusion.

2 In the case of full circular arch dissections, or re-entry or entry sites at or around the subclavian artery, we replace the total arch.

3 In the case of required total arch replacements, the indication for downstream placement of the E-vita open hybrid graft is to simultaneously cover additional proximal re-entry sites in the descending aorta demonstrated by transesophageal echocardiography prior to surgery and more recently by direct angioscopy. An immediate positive side effect is the quick thrombosing process of the false lumen after protamine administration leading to fast stabilization of the descending stump anastomosis with the E-vita open graft. The deployment maneuver takes an additional 2 to 3 minutes beyond the time needed for total arch replacement. At follow-up, after a mean of 17 months, complete thrombosis of the false lumen was observed in 91% of our cases down to the level of the stent-graft end [5].

Twenty-six of 42 patients, operated on for acute type I aortic dissection within the last 4 years, had an E-vita open hybrid graft implanted. Sixteen patients had either an ascending aorta (2 patients), hemi-arch (10 patients), or total arch replacement (4 patients) alone. This illustrates the selective indication for placement of the E-vita open stent-graft in the most difficult patient subgroup. We certainly do not recommend total arch replacement with descending stent-grafts in cases other than those previously listed. Our common line with Murzi and Glauber [1] is the intention to get the best possible result for our patients, not only in regard to hospital survival, but hopefully also for long-term freedom from events related to the thoracic aorta. Whether or not this aim will be reached is a matter of a retrospective and prospective investigation by a European multicenter study group established in 2008 to collect a large data pool within the years to come.

	References

Top References

 

1. Murzi M, Glauber M. Should an endovascular procedure be combined with resection for type A aortic dissection? (letter) Ann Thorac Surg 2009;88:1387-1388.[Free Full Text]
2. 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]
3. Uchida N, Shibamura H, Katayama A, Shimada N, Sutoh M, Ishihara H. Operative strategy for acute type a aortic dissection: ascending aortic or hemi-arch versus total arch replacement with frozen elephant trunk Ann Thorac Surg 2009;87:773-777.[Abstract/Free Full Text]
4. Yeh CH, Chen MC, Wu YC, Wang YC, Chu JJ, Lin PJ. Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection Chest 2003;124:989-995.[Medline]
5. Tsagakis K, Kamler M, Kuehl H, et al. Avoidance of proximal endoleakage using a hybrid stent graft in arch replacement and descending aorta stenting Ann Thorac Surg 2009;88:773-780.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Heinz Jakob Konstantinos Tsagakis Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jakob, H. Articles by Tsagakis, K. Search for Related Content PubMed Articles by Jakob, H. Articles by Tsagakis, K. Related Collections Related Article