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Ann Thorac Surg 2004;78:1266-1267
© 2004 The Society of Thoracic Surgeons
Methodist DeBakey Heart Center, 6560 Fannin St, No 1002, Houston, TX 77030–2761, USA
mreardon{at}tmh.tmc.edu
During the second half of the last century, all areas of thoracic aorta became accessible to the thoracic surgeon for repair. Despite tremendous advances in surgical techniques and care, surgical repair of an acute aortic dissection remains a high-risk procedure. Acute aortic dissection is a complicated manifestation of aortic wall pathology. The prognosis of acute aortic dissection rests mainly on the anatomic location of the dissection and patient specific characteristics. At the Methodist DeBakey Heart Center, we continue to follow the teachings of Drs Michael E. DeBakey and E. Stanley Crawford, who developed our thoracic aortic program, operating acutely on DeBakey type I and II (Stanford type A) aortic dissections, and treating DeBakey type III (Stanford type B) acute dissections medically unless they are complicated. Our definition of complicated descending thoracic aortic dissection matches that of the author, including contained rupture, hemothorax, life-threatening malperfusion, and refractory pain. We agree with the Stanford group that the prognosis in uncomplicated descending thoracic aortic dissection is similar for medically and successfully surgically treated patients [1]. The problematic point is the difficulty in achieving a successful surgical outcome in cases of acute descending thoracic aortic dissection.
The current paper by Duebener and colleagues describes their experience with 10 patients undergoing emergency stent graft placement for complicated descending thoracic aortic dissection within 24 hours of diagnosis. This represents an extremely high-risk group and a very rapid turnaround time for stent placement. They have an early mortality rate of 2 of 10 patients (20%) compared with 7 of 13 patients (54%) treated with open surgical repair at their institution during the same time frame.
Although the mortality rate associated with open surgical repair of complicated acute dissection continues to decline, and there is even a series reporting zero mortality [2], it remains a substantial surgical challenge, and a 50% mortality is closer to what most surgical groups are likely to achieve with open repair. Three patients did require consecutive surgical repair for complications of the stent or stent placement.
There are currently three thoracic stent graft clinical trials in the United States, and no commercially available thoracic stent grafts. At the Methodist DeBakey Heart Center, we are participating in one of these trials. All surgeons who have operated on patients with a complicated acute descending thoracic aortic dissection knowthat is an extremely difficult situation, and any improvement in the care of these patients would be a welcome addition.
I congratulate Duebener and colleagues for their outstanding care in this very difficult group of patients. The technique, indications, and effect on the natural history of the disease remain to be worked out for stent placement in acute descending thoracic aortic dissection, but these early results help set the stage and place the bar. I have no doubt that the use of stent grafts to treat all our patients with thoracic aortic pathology will continue to progress, and I look forward to future advances from this pioneering group.
References
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