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Ann Thorac Surg 1997;63:1084
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Widenmayerstr 7, 80538 Munich, Germany

See also page 1081.

Palma and associates present a potentially useful alternative surgical approach to acute type B aortic dissection by inserting a tube graft (more recently stented proximally) into the true lumen of the descending aorta during hypothermic circulatory arrest. Why do I stress "potentially"?

First, the indications for this procedure remain somewhat obscure. Palma and associates cite several references dating from the 1970s and early 1980s attesting to the dismal short-term and long-term prognosis of medically treated acute type B dissection. The question arises whether this is still tenable today, when such patients undergo systematic antihypertensive therapy in the acute phase. Additionally, patients properly followed up will have their descending aorta replaced electively in the interim at a very low risk when aneurysmal enlargement occurs. On the other hand, patients with certain well-defined complications of type B dissection, including persisting back pain despite maximal antihypertensive therapy, penetration of neighboring structures, and threatened or manifest rupture, presently are operated on emergently by most experienced surgeons, although at a relatively high risk.

Palma and associates state that theirs is a consecutive series of 70 patients with complicated acute type B dissection. If one examines these complications it turns out that at least 12 of the 36 listed are not typical for acute type B dissection, including aortic insufficiency (8), hemopericardium (2), and cerebral ischemia (2). Others occur commonly in dissections (renal and limb ischemia) and generally do not require replacement of the descending aorta. Surprisingly, 10 patients did not have classic type B dissection but proximal extension of the process into the arch or even the ascending aorta. One wonders therefore about both the diagnostic expertise of the group and the selection of patients for this new procedure. Clearly, most experts in this field would first approach the proximally dissected aorta rather than the distal vessel except in the rare cases where both aortic portions need to be dealt with.

Second, the considerable early mortality and complication rates of this procedure do not appear to recommend its general use. Twenty percent of the patients succumbed perioperatively, a percentage that exceeds the present early mortality obtained by others in this condition. Palma and associates explain this fact by their initial inexperience in patient selection and by the "complicated presentations" of their patients. Although the former may be eliminated in the future, complications expressively had triggered operation in this series, and deaths therefrom likely will remain unavoidable.

In summary, I believe that Palma and associates have failed to prove their point regarding the superiority of their approach over either medical therapy or conventional replacement of the acutely dissected distal aorta. I rather see the merit of this contribution in documenting the potential of an approach that, if cautiously applied to highly selected patients rather than a "consecutive" series, might indeed simplify the surgical therapy of acute type B dissection. The use of stented elephant trunk grafts, as employed in more recent patients of this series, is an elegant improvement over the original method, which required reoperation for proximal anastomotic leakage in two instances. It remains to be seen, however, whether the transfemoral mode of aortic stent insertion will offer the ultimate solution of this complex problem.

Related Article

Surgical Treatment of Acute Type B Aortic Dissection Using an Endoprosthesis (Elephant Trunk)

J. Honório Palma, Dirceu R. Almeida, Antonio C. Carvalho, José Carlos S. Andrade, and Enio Buffolo
Ann. Thorac. Surg. 1997 63: 1081-1084. [Abstract] [Full Text]

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