Early Results of a Novel Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With Distal Anastomosis Line Beyond Aortic Arch Zone Zero

Abstract

IntroductionAcute aortic dissection type A (AADA) is associated with high perioperative morbidity and mortality. A novel non-covered hybrid prosthesis (Ascyrus Medical Dissection Stent (AMDS) Hybrid Prosthesis, Cryolife/Jotec, Hechingen, Germany) can be easily implanted to stabilize the true lumen (TL), improve remodeling, and preserve organ perfusion. Although developed for implantation in aortic zone 0, occasionally, partial replacement of the aortic arch and further distal implantation of AMDS may appear favorable. Implantation of AMDS with anastomosis line beyond zone 0 has not been described yet.Materials and MethodsBetween 08/2019 and 12/2020, a total of n = 97 patients were treated due to AADA at a single University hospital. Of those, n = 28 received an AMDS hybrid prosthesis, of whom in eight patients, due to intraoperative finding the distal anastomosis line was placed distal to the brachiocephalic trunk. Three patients had AMDS implantation in zone I and four were treated by implantation of the prostheses in zone II, and one patient had the implantation performed in zone III. Clinical outcome and the development of a proportional area of TL and false lumen (FL) at defined levels of the thoracic aorta were analyzed.ResultsNone of the surviving patients (87.5%) showed signs of clinical malperfusion (i.e., stroke, spinal cord injury, and need for dialysis). A postoperative CT scan showed an open TL in all patients. The proportion of TL with respect to total aortic diameter (TL+FL) was postoperatively significantly higher in zone III (p = 0.016) and at the level of T11 (p = 0.009). The mean area of TL+FL was comparable between pre- and postoperative CT-scan (p = n.s.). One patient with preoperative resuscitation died of multiple organ failure on extracorporeal life support on postoperative day 3.ConclusionImplantation of AMDS can be safely performed in patients who need partial replacement of the aortic arch beyond zone 0. The advantages of the AMDS can be combined with those of the total arch repair (remodeling of the arch and prevention of TL collapse) without the possible disadvantages (risk of spinal cord injury).

Early Outcomes of Using Skeletonized Left Internal Mammary Artery (LIMA) for Sequential Grafting of Multiple Left Anterior Descending Artery Lesions

“…This caused a great volume of suture material being lodged in anastomosis area and leads to accelerated vessel occlusion. Moreover, plaque fracture may lead to imminent dissection in the anastomosis area and further occlusion [31] . Also, Kaya et al [32] found that in the second method diffuse lesions are managed by using small arteriotomies in seemingly normal LAD artery areas or anterolateral wall with fewer plaque densities and then side to side LIMA anastomosis and multi-segment jump anastomosis are performed.…”

Ascyrus Medical Dissection Stent In the treatment of acute type A Aortic dissection. A First-Hand Experience

“…It may be more useful in particular situations in the setting of aortic dissection like when there is arch aneurysm, or there is an entry tear within the arch or in the proximal descending thoracic aorta associated with the dissection 13 . Between these two approaches, the AMDS represents a novel hybrid solution providing long thoracic coverage alleviating malperfusion and excluding entry tears without significantly increasing the complexity of surgery [4][5][6] .…”

Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection?

“…AMDS in clinical practice: Overview of clinical outcomes. Bozso et al 26 Montagner et al 28 Mehdiani et al 29 Cohort 10.3% had partially thrombosed arch FL at one-year follow-up. At the DTA level, FL obliteration or complete thrombosis occurred in as little as 52.6% after the first year.…”

“…Further, total occlusions in the supra-aortic vessels were relieved completely after the surgery. 8,28 Another recent study by Mehdiani and colleagues 29 performed the analysis of eight patients in whom the AMDS device was implanted with distal anastomosis beyond Zone 0. Table 1 highlights some of the baseline characteristics, operative data and clinical outcomes of their recruited patients.…”

“…A significant change was also observed at the level of T11 (0.34 + 0.24 pre-op vs. 0.64 + 0.07 post-op; p = 0.02). 29 Future of ATAAD repair: To replace or to stent the arch?…”