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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): Thoralf M. Sundt Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sundt, T. M. Search for Related Content PubMed Articles by Sundt, T. M.

Ann Thorac Surg 2003;75:1790-1791
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Invited commentary

^a Division of Cardiovascular Surgery, Mayo Clinic, 200 First Street, SWRochester, MN 55905, USA

e-mail: sundt.thoralf{at}mayo.edu

Ours is a field in which aggressiveness is applauded and bold action rewarded. Accordingly, one is more likely to see articles in our literature advocating radical approaches to problems than "conservative" ones. This manuscript is an exception to that rule.

Dr Park and his associates have revisited a reparative technique generally thought inadequate because of perceived poor durability. In my training I was taught to resect and replace the region of the tear in cases of acute dissection. This is easily said and generally not too complex to perform if the tear is on the underside of the arch, or even in the front or back wall. But what about tears between the brachiocephalic vessels or on the far side of the subclavian artery? Total arch replacement would likely be the safe answer for the board examinations, and there is certainly a growing literature supporting the safety of this approach. But as Dr Park has implied, these reports come from large centers with enormous experience in arch surgery. What about the surgeon in a smaller center who sees perhaps only a handful of dissections in a year?

There is no doubt that total arch replacement will be a more durable repair than local repair. If the patient survives hospitalization, the likelihood of reoperation for arch disease will be less if the arch is made of dacron. However, if we accept Dr Park’s data, the notion that the late results of local repair are poor appears to be in error. Although the number of patients undergoing local repair was small, the authors have provided just the data we require—serial imaging studies demonstrating satisfactory results at least in the intermediate term. This is particularly true of the patients having a "full thickness" repair.

I am not sure that I agree with their stated indications. I would be more inclined to replace than repair an "extremely thin aortic wall in the distal arch" or one with "muddy atheroma. Furthermore, despite the results presented here, the authors have not convinced me that local repair is a better option than arch replacement—or that it is even equivalent. Indeed, they themselves are tending to do more full arch replacements and fewer local repairs. But they have provided us with some intriguing observations and they have convinced me, at least, that this sort of repair is an option.

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): Thoralf M. Sundt Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sundt, T. M. Search for Related Content PubMed Articles by Sundt, T. M.