Acute type A aortic dissection extending beyond ascending aorta: Limited or extensive distal repair

Rylski, Bartosz; Beyersdorf, Friedhelm; Kari, Fabian A.; Schlosser, Julia; Blanke, Philipp; Siepe, Matthias

doi:10.1016/j.jtcvs.2014.05.051

Cited by 108 publications

(99 citation statements)

References 18 publications

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“…There are encouraging reports for this technique but the complicated procedure of total arch replacement still posed a great challenge and steep learning curve to many cardiac surgeons. When a long-term stent graft is inserted, the risk of paraplegia and spinal cord injury must be considered due to extensive sacrifice of spinal arteries impairing collateral blood flow to the spinal cord, combined with inadequate protection during the operation (14). The longer cardiopulmonary bypass and cardiac arrest time, aortic cross-clamping time and cerebral perfusion time might inevitably be associated with post-operative cardiac and cerebral injury and organ dysfunction (25,(29)(30)(31)(32).…”

Section: Discussionmentioning

confidence: 99%

“…The longer cardiopulmonary bypass and cardiac arrest time, aortic cross-clamping time and cerebral perfusion time might inevitably be associated with post-operative cardiac and cerebral injury and organ dysfunction (25,(29)(30)(31)(32). In some cases, extending the initial surgery to total arch replacement might not be able to eliminate the entire dissection in the downstream aorta, e.g., at the level of coeliac trunk and iliac arteries (14).…”

Section: Discussionmentioning

confidence: 99%

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Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

Poon

Theologou

Harrington

et al. 2016

Ann. Cardiothorac. Surg.

118

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Background: Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection.Methods: A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65-1.09; P=0.20; I 2 =0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation.Conclusions: Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

Poon

Theologou

Harrington

et al. 2016

Ann. Cardiothorac. Surg.

118

View full text Add to dashboard Cite

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“…Moreover, incomplete resection of the dissected aortic arch did not correlate with the need for distal aortic reintervention: instead, Marfan syndrome and dissection of all aortic segments were the only predictors of distal aortic reintervention. 19 Kim and colleagues 20 reported a reduced survival rate and fewer neurologic sequelae for patients who underwent total arch replacement, with a rate of reoperation that was unaffected by the type of surgery for AAD, and without significant reoperative morbidity or death. Conversely, Uchida and co-authors, 6 in comparing hemiarch and total arch replacement in AAD, found similar operative mortality rates (4.5% vs 3.5%, respectively) but a 5-year survival rate that was significantly lower in the hemiarch group (69% vs 95.3%).…”

Section: Discussionmentioning

confidence: 99%

“…Our mortality rate of 22% is in accord with other series. [1][2][3]11,18,19 Total arch replacement is a more complex type of surgery that requires longer CPB, cardiac ischemic, and circulatory arrest times, in comparision with a more conservative approach, such as hemiarch repair. In our experience, patients who underwent total arch replacement had a higher operative mortality rate than did those who underwent hemiarch repair (P=0.044); however, patients in the total arch group had a higher risk profile, with a 10% rate of repeat cardiac interventions.…”

Section: Discussionmentioning

confidence: 99%

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

Lio¹,

Nicolò²,

Bovio³

et al. 2016

Texas Heart Institute Journal

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T he surgical mortality rate for type A acute aortic dissection (AAD) still remains high (8%-34%), despite improvements in perioperative and postoperative management during the last decade.1-3 Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are still considered the standard of care for type A dissection surgery. Because the residual dissection flap in the aortic arch and descending aorta carries risks of progressive aortic dilation and rupture and the need for secondary intervention, several groups have suggested immediate extensive surgery that involves the aortic arch, although concomitant distal aortic manipulation has been associated with an increased risk of morbidity and death. [4][5][6][7][8][9][10][11][12][13] In this situation, 2 different surgical strategies have been proposed: total arch replacement or hemiarch replacement (a more conservative repair limited to the ascending aorta and proximal arch). 4,[9][10][11][12] We evaluated the early and intermediate outcomes of aortic arch surgery in patients with type A AAD, investigating the effect, upon postoperative results, of aortic arch extension. Patients and MethodsWe undertook a retrospective, observational study of prospectively collected data on consecutive patients who had presented with type A AAD at our institution. This cohort study was approved by our local ethics committee, and individual consent was obtained by each patient's physician. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent surgery at our institution. For the purposes of this study, we did not consider 109 AAD patients who underwent isolated replacement of the ascending aorta. We included only the 92 patients who underwent

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“…Arch surgery in type A dissection is extremely difficult as was stressed by de group of Freiburg, having seen a 30%-mortality, thereby suggesting to limit the initial operation to hemiarch only and to be liberal with early reoperation in elective setting as the results of this sequential approach were excellent (4).…”

mentioning

confidence: 99%

Why to be cautious with the use of the frozen elephant trunk in acute type A aortic dissection

Morshuis

2018

J. Vis. Surg.

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Figure 2 By closing of the entry tear we may achieve the same results as in stenting a type B dissection with opening the true lumen and improvement of mesenteric and distal perfusion, as well as a trombosing false lumen and reducing diameter at follow up. Journal of Visualized Surgery, 2018© Journal of Visualized Surgery. All rights reserved.J Vis Surg 2018;4:73 jovs.amegroups.com Page 4 of 5 group of Sultan and Bavaria (16) in addition to ascending and hemi-arch replacement. However, this relatively easy extension of surgery, almost doubles circulatory arrest time and increases the operation time by one hour, up to 7 hours average. Yes, false lumen trombosis does occur, but not complete in even half of the patients. And yes, there is a significant increase of true lumen diameter but the total lumen diameter does not change.Techniques like this have to be used overseas as the FET is still not FDA approved, leaving the European and Asian patients being exposed to the inevitable risks of innovation. For me, in acute type A dissection, the only indication would be an entry far in the arch, especially those with distal malperfusion, although a complete arch operation is also possible (Figure 4). For all other cases, especially in setting of limited aortic surgery exposure, I think experts should advise on life saving surgery and on focus more on aortic root problems. For the audience, I think it is wise not to go along with all innovations as in the old days of Bologna with people showing off their wealth by building towers and to carefully study the reports of the expert-centers, who do have to be honored for their efforts and to be cautious to implement new techniques, as in the end only one or two techniques will remain, and even these bending over in time. AcknowledgementsNone. Footnote Conflicts of Interest:The author is consultant with Vascutek Inc.

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Acute type A aortic dissection extending beyond ascending aorta: Limited or extensive distal repair

Abstract: Limiting the extent of surgery for type A aortic dissection to ascending aortic replacement was associated with low perioperative mortality. Thus, aortic arch repair can be deferred, because it can be performed electively with a lower mortality risk.

Cited by 108 publications

References 18 publications

Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

Why to be cautious with the use of the frozen elephant trunk in acute type A aortic dissection

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