Distal Aortic Remodeling after Type A Dissection Repair: An Ongoing Mirage

Abstract

Remodeling is a commonly encountered term in the field of cardiothoracic surgery that is often used to describe various pathophysiological changes in the dimension, structure, and function of various cardiac chambers, including the aorta. Stanford type A or DeBakey type 1 aortic dissection (TAAD) is a perplexing pathologic condition that can present surgical teams with the need to navigate a maze of complex decision-making. Ascending or hemi-arch replacement leaves behind a significant amount of distal diseased aortic tissue, which might have a persistent false lumen or primary or secondary intimal tears (or communications between lumina), which can lead to dilatation of the aortic arch. Unfavorable aortic remodeling is a major cause of distal aortic deterioration after the index surgery. Cardiac surgeons are aware of post-surgical cardiac chamber remodeling, but the concept of distal aortic remodeling is still idealized. The contemporary literature from established aortic centers supports aggressive management of the residual aortic pathology during the index surgery, and with continuing technical advancements, endovascular stenting options are readily available for patients with TAAD or for complicated type B aortic dissection cases. This review discusses the pathophysiology and treatment options for favorable distal aortic remodeling, as well as its impact on mid-to long-term outcomes following TAAD repair.

Baseline 4D Flow-Derived in vivo Hemodynamic Parameters Stratify Descending Aortic Dissection Patients With Enlarging Aortas

“…AD can be isolated to the descending aorta (Stanford type B aortic dissection/TBAD) or associated with dissections originating in the ascending aorta (Stanford type A aortic dissection/TAAD), while repaired TAAD with unresolved dissection extending into the descending aorta is classified as residual TBAD (rTAAD) ( 2 , 3 ). If not fatal, all types of TBAD transition from an acute to chronic state as the aorta remodels ( 4 ). This natural history has important implications for selection and timing of treatments, with 20–50% of patients eventually requiring intervention for aneurysmal degeneration, rapid expansion, rupture, or end organ malperfusion ( 5 – 8 ).…”

Is TEVAR an Effective Approach to Prevent Complications after Surgery for Aortic Dissection Type A? A Systematic Review

“…The indications vary a lot, but several predictors of negative aortic remodeling are commonly acceptable. Among these predictors, an aortic diameter > 35 mm, a false lumen diameter > 22 mm and an entry tear >1 mm were reported by the eligible studies [14]. Undoubtfully, the development of certain criteria for TEVAR usage after aortic dissection may offer the better management of such cases and improved documentation of the outcomes.…”

Volume Changes in the Descending Aorta after Frozen Elephant Trunk and Conventional Hemi-Arch Repair after Acute Type A Aortic Dissection

“…The usual surgical approach for complex tears in the aorta with (several) re-entries consists of FET as the stent graft in the descending thoracic aorta and may open the true lumen, obliterate secondary entry tears, and induce FL thrombosis, resulting in a better remodeling [ 15 , 16 ]. In the existing literature, several studies investigated the utility of the FET procedure in promoting FL thrombosis and aortic remodeling [ 15 , 16 , 17 ]. However, volumetric changes of the thoraco-abdominal aorta after the surgical treatment of the aortic arch are not yet part of the surveillance routine, and the majority of data evaluating lumen modifications refer to two-dimensional surface records at different aortic levels in CTA- based studies.…”