A new paradigm in the management of acute type A aortic dissection: Total aortic repair

Abstract

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and ''hemi-arch'' with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of ''branch first'' total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.

Total aortic repair for acute type A dissection: Not every patient; not every surgeon

“…Those with evolving malperfusion, rapidly enlarging false lumen, or collapsed true lumen would proceed to stenting of the entire thoracoabdominal aorta, with a proximal covered stent, distal bare metal stents, and balloon rupture of the septum. Of the 72 patients who underwent surgery for ATAD in the report of Matalanis and Ip, 1 12 patients (16.7%) underwent total aortic repair with the described technique in the acute setting; an additional 3 patients had endovascular completion in the chronic phase. The results reported are outstanding, with no early deaths and a low rate of neurologic and other complications.…”

Invited Commentary

“…9 The patients in the current report were unable to be risk-adjusted; therefore, the observed differences in morbidity and mortality rates between hemiarch and total arch replacement (1.7-fold higher mortality rate and higher stroke rate after total arch versus hemiarch) could reflect differences in patient risk, rather than just resulting from the extent of operation performed. Although routine total arch replacement for ATAD has been suggested by some, 12 the current data should give the aortic community pause in this regard and highlights the need for additional study to elucidate those ATAD patients who might benefit from more extensive arch replacement at the index repair. The most recent upgrade to the aortic surgery component of the STS-ACSD (v2.9) will likely provide further insights on this topic given the more comprehensive physiologic and anatomic data being captured, 8 and we should look forward to future reports from the STS-ACSD around ATAD repair.…”

Current and Future Management Strategies of Type A Aortic Dissection

“…Matalanis [49] has introduced the concept of total aortic repair to prevent the above mentioned complication. Patients presenting with TAAD and a descending thoracic aorta diameter of more than 40 mm can benefited from this approach.…”