Aortic arch debranching and thoracic endovascular repair

Abstract

Despite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than one-third of the aneurysms' diameters decrease over 5 years as a measure of the long-term efficacy of treatment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required.

Delayed Type A Aortic Dissection Following Complete Debranching of the Aortic Arch and Stent Graft Placement

“…In almost all the published reports, acute type A aortic dissections after the hybrid approach occur as an extension of a previously treated dissection (retrograde fashion). Retrograde aortic dissection (RAD) has an estimated incidence of 1.33% to 3.5% [1][2][3] and predominately occurs in the first month after surgery (70% of cases). Twenty nine percent of RADs occur after the 30-day [4][5] The fragility of the ascending aortic wall and stent graftrelated factors including an oversized stent, aggressive balloon, and the use of proximal bare stent grafts all may contribute to the incidence of RAD.…”

“…1 Open surgical approach is the standard method of treatment, which makes use of cardiopulmonary bypass (CPB), hypothermic circulatory arrest, and cerebral perfusion. [1][2][3] Despite the significant improvement in outcomes, the standard approach continues to be associated with a 15% to 20% mortality rate, according to the U.S. National (Nationwide) Inpatient Sample database. Thus, it is not a suitable option for high-risk surgical patients.…”

“…Thus, it is not a suitable option for high-risk surgical patients. 1,2 Hybrid aortic arch repair has become widely adopted in clinical practice because it is a less invasive technique that combines aortic debranching and thoracic aortic endovascular repair (TEVAR). This approach limits the need to perform a median sternotomy, single-lung ventilation, CBP, and aortic cross-clamp.…”

“…Moreover, the debranching method provides a healthy and adequate landing zone for the stent graft. 1,2 This technique, however, is associated with its own complications and risks, such as endoleak, paraplegia, stroke, and risk of acute ascending aortic dissection. [1][2][3] In particular, it is commonly reported that acute aortic dissection can occur in a retrograde fashion shortly after surgery.…”

Open repair techniques in the aortic arch are still superior

“…In 2013, De Rango et al published a series of 104 consecutive patients with elective debranching and TEVAR including 19 patients with zone 0 disease requiring total debranching (61).…”