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Ann Thorac Surg 2002;74:761-765
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Combined Surgical and Endovascular Treatment of Acute Aortic Dissection Type A

Preliminary Results

^a Department of Cardiothoracic Surgery, Vienna, Austria
^b Department of Interventional Radiology and Angiography, University of Vienna, Austria

Accepted for publication April 30, 2002.

* Address reprint requests to Dr Grabenwoger, Department of Cardio-thoracic Surgery, University of Vienna, Waehringer Gürtel 18-20, 1090 Vienna, Austria
e-mail: martin.grabenwoeger{at}univie.ac.at

	Abstract

Top Abstract Introduction Patients and methods Comment References

 
Background. The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta.

Methods. From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery.

Results. Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months).

Conclusions. This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.

	Introduction

Top Abstract Introduction Patients and methods Comment References

 
Acute aortic dissection type A is a fatal event affecting 10 to 20 people per million per year [1]. Mortality, when left untreated, ranges from 36% to 72% in the first 48 hours after diagnosis [2]. Patients with a Stanford type A dissection are treated with emergency surgical repair of the ascending aorta and various portions of the aortic arch to prevent lethal complications such as aortic rupture, cardiac tamponade, aortic regurgitation, and myocardial infarction [3, 4]. However, operative repair is limited to the ascending thoracic aorta, whereas the descending aorta is left untreated. Concerns have been raised that patients with replaced ascending aortas experience chronic type B dissection with increasing aortic diameter. Recent publications investigating the natural history of chronic type B dissection showed that 20% to 28% of patients had to undergo operation on the descending thoracic aorta because of aneurysm formation in a follow-up period of 40 to 50 months. Fatal rupture of the aorta occurred in 18% of the study cohort, stressing the importance of a more aggressive surgical management [4, 5].

We report a combined approach of open repair of the ascending thoracic aorta with simultaneous endoluminal stent graft placement in the descending thoracic aorta to prevent late complications of chronic type B dissection.

	Patients and methods

Top Abstract Introduction Patients and methods Comment References

 
Patients
From April 2001 to February 2002, 8 consecutive patients with acute aortic dissection type A were treated with the intention to perform a combined approach of open repair and stent graft placement. Emergency operations were performed within 10 hours after onset of symptoms. There were 3 women (37.5%) and 5 men (62.5%), with a mean age of 55.7 years (range, 45 to 70 years). The most common underlying medical disorder was hypertension, present in all 8 patients. One patient was already scheduled for elective ascending aortic repair. No patient had previously undergone a cardiothoracic operation. Preoperative complications were seen in 4 of 8 patients (50%). Two patients (25%) had an aortic regurgitation grade II to III, 1 patient (12.5%) had a malperfusion of the left kidney, and 1 patient (12.5%) had a stroke owing to dissection of the left carotid artery.

Preoperative evaluation included multislice computed tomographic (CT) scans and echocardiography. Multislice CT revealed in all patients an aortic dissection type A with a perfused false lumen. In 1 patient, dissection of the left carotid artery was seen, resulting in a preoperative stroke.

Endovascular prothesis
Specially designed Talent stent grafts were used in all patients (Medtronic Talent CPS Coil Trac Delivery System; Medtronic Inc, Minneapolis, MN; Fig 1). It is composed of a skeleton of self-expanding nitinol stents very similar to Z stents. The stents are connected by a stabilizing bar to which thin-walled polyethylene terephthalate fiber (Dacron) graft material is annealed. The model we use is prebuilt in three different diameters (32, 36, and 40 mm) and designed after our own suggestions to optimize performance for this specific indication. The whole device is shorter as compared with the standard model, and the sheath catheter is made of transparent material so that the proximal end of the stent can be seen when it is inserted under direct vision. The stent graft is deployed within the aorta by withdrawing the sheath, allowing the self-expanding stent skeleton to oppose itself against the vessel wall, and is tamped into place by a balloon, which is part of the delivery catheter.

View larger version (72K): [in this window] [in a new window]   Fig 1. Macroscopic aspect of the specially designed stent graft. The stent graft is loaded into a transparent sheath with an integrated balloon. Note that the whole system is very short to facilitate antegrade access. Furthermore, the pigtail catheter as well as the extra stiff guidewire, necessary for stent insertion, are depicted.

During the period of circulatory arrest a pigtail catheter (Pigtail Aortic Flush Super Torque 6F, 65 cm; Cordis Inc, The Netherlands) was inserted into the descending aorta under direct vision. A stiff guidewire (Steerable Guidewire Back-Up Meier, 0.035 inches, 185 cm; Boston Scientific Scimed Inc) was delivered through the pigtail catheter into the descending aorta. After removing the pigtail catheter, the Talent stent graft was inserted through the guidewire into the proximal descending aorta. Diameter of the stent graft was 40 mm in 2 (28.6%), 32 mm in 2 (28.6%) and 36 mm in 3 (42.9%) patients. Stent length was 13 cm in all patients. Positioning and deployment of the stent graft was performed under direct vision to ensure that the proximal end of the stent was placed exactly just distal to the left subclavian artery. Then the ascending aorta was replaced using a gelatin-impregnated Dacron graft (Gelweave, Vaskutek; Renfrewshire, Scotland) after reinforcing the distal and proximal anastomoses with polytetrafluoroethylene (Teflon) felt strips. Diameter of the Dacron grafts were 28 mm in 3 (36.5%), 30 mm in 2 (25%), 32 mm in 2 (25%) and 34 mm in 1 (12.5%) patients, respectively.

Follow-up examination consisted of multislice CT scans, which were performed at discharge and after approximately 6 months.

Results
There was no intraoperative death: hospital mortality was 12.5% (1 of 8). One patient with a history of preoperative stroke had a lethal cerebral hemorrhage 2 days after operation. The remaining 7 patients experienced an uneventful postoperative course. One patient had postoperative delirium, which resolved after 3 days. No permanent neurologic deficit was observed. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days), and overall hospital stay was 18.2 days (range, 7 to 33 days).

Operative time ranged from 270 minutes to 540 minutes (mean, 390 minutes), and mean extracorporal circulation time was 196 minutes (range, 150 to 253 minutes). Circulatory arrest time varied between 30 and 67 minutes (mean, 38.8 minutes). Stent graft placement was successful in 7 of 8 patients (87.5%). The procedure of stent graft insertion and deployment during the period of hypothermic circulatory arrest ranged from 6 to 13 minutes (mean, 8 minutes). In the first patient we were not able to insert the stent graft into the descending aorta owing to severe kinking as well as to use of a soft guidewire. After switch to an extra stiff guidewire (Back-Up Meier), we were able to guide the stent graft around the curvature of the distal aortic arch into the descending aorta. In all patients the ascending aorta and the hemiarch was replaced by the use of a Vascutek prosthesis. Aortic valve could be preserved in all cases by remodeling of the sinotubular junction. Postoperative echocardiography showed only mild aortic regurgitation. Other concomitant procedures were one coronary bypass graft owing to a dissected right coronary artery.

Follow-up period ranged from 1 to 9 months (mean, 5.4 months). Multislice CT scans performed before discharge revealed complete thrombosis of the false lumen in 2 (28.6%) patients. Interestingly, we observed an increase in maximum stent diameter within the follow-up period, leading to a significant decrease of thrombotic material within the false lumen (Fig 2). Partial thrombosis of the false lumen was seen in the remaining 4 (57.2%) patients (Fig 3). In case of complete thrombosis of the false lumen, a 40% progression in stent diameter was noted, whereas in patients with a partially thrombosed false lumen, an increase in stent diameter of 10% was present.

View larger version (104K): [in this window] [in a new window]   Fig 2. (A) Complete thrombosis of the false lumen at discharge, with the stent graft in regular position, but not fully expanded. (B) Impressive increase in stent diameter as well as a decrease of surrounding thrombotic material.

View larger version (146K): [in this window] [in a new window]   Fig 3. Computed tomographic scans at discharge (A, C) exhibit still-perfused false lumen and a partially expanded stent graft. Follow-up computed tomographic scans (B, D) reveal a marked decrease in perigraft perfusion and an increase of stent diameter.

	Comment

Top Abstract Introduction Patients and methods Comment References

The standard treatment for acute aortic dissections is either surgical or medical therapy depending on the localization as well as the morphology of the lesion. For patients with acute Stanford type A dissection, surgical treatment is the method of choice because of the possibility of fatal complications such as cardiac tamponade, myocardial infarction, and aortic regurgitation. In contrast, type B dissections are treated pharmacologically mainly, including use of beta-blockers. Surgical repair is reserved for patients with impending rupture or to prevent irreversible end-organ ischemia. However, significant morbidity and mortality rates are reported for surgical therapy as well as for medical treatment [6, 7].

Endovascular stent graft placement is emerging as a new treatment modality with excellent outcomes related to its high efficacy and its low complication rate [8–12]. In our study we combined mandatory open repair of the ascending aorta and various portions of the aortic arch with transluminal stent graft placement during the period of circulatory arrest intending to prevent the associated late complications related to chronic dissection of the descending aorta. Most importantly, consecutive dilatation of the descending aorta, needing further intervention, may occur. Additionally, compression of the true lumen by the dissection membrane may lead to impaired distal perfusion resulting in visceral and lower limb ischemia (Fig 4).

View larger version (144K): [in this window] [in a new window]   Fig 4. Computed tomographic scan of a conventionally treated type A dissection without stent graft insertion. Note the remaining chronic type B dissection with the sickle-shaped compression of the true lumen, causing distal malperfusion (arrow).

Stent graft insertion and deployment was performed in the period of deep hypothermic circulatory arrest. This procedure, which lasted in average 35.6 minutes, did not markedly prolong circulatory arrest time. In 7 of 8 patients circulatory arrest time did not exceed 40 minutes (90%), which is considered to be the "safe period" with regard to cerebral protection [13]. Therefore, we suggest that the risk of cerebral complications is not increased using this combined approach. In contrast to the elephant trunk technique described by Borst and colleagues in 1983 [14], which was primarily developed to facilitate consecutive operations at the descending aorta, our combined approach intended to minimize the necessity of further aortic surgical procedures. Although promising results using the elephant trunk technique in acute aortic dissection have been reported [15], the complexity of this procedure in the acute setting is still a matter of discussion [16]. If operation on the descending thoracic aorta becomes necessary, the elephant trunk technique helps to avoid deep hypothermic circulatory arrest. Addressing this issue with regard to our combined approach, operation of the descending thoracic aorta has to be performed in deep hypothermic circulatory arrest. However, this technique is also mandatory in conventionally operated type A dissections with late distal arch as well as descending thoracic aortic complications.

Concerning the technical aspect of stent insertion, we failed to guide the stent graft around the curvature of the distal aortic arch into the descending aorta in 1 patient. This unsuccessful placement was based on the use of a soft guidewire. After switching to an extra stiff guidewire (Back-Up Meier), no further difficulties were experienced. To avoid injury of the aortic wall, this extra stiff guidewire should be inserted through a pigtail catheter into the descending aorta.

In conclusion, our preliminary results suggest that a combined surgical and endovascular approach in the treatment of acute type A dissection is feasible, and complete or at least partial thrombosis of the false lumen can be achieved. Thus, late complications of chronic type B dissection such as increasing aortic diameter and rupture may be reduced. However, further investigations are mandatory to evaluate long-term effectiveness of this new combined treatment modality.[3]

	References

Top Abstract Introduction Patients and methods Comment References

 

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