Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic Dissection

Eusanio, Marco Di; Berretta, Paolo; Cefarelli, Mariano; Alfonsi, Jacopo; Murana, Giacomo; Castrovinci, Sebastiano; Bartolomeo, Roberto Di

doi:10.1016/j.athoracsur.2015.02.041

Cited by 78 publications

(69 citation statements)

References 25 publications

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“…We have excluded studies with an NOS score of less than seven due to risk of substantial bias. Our up to date search strategy resulted in six more key and balanced studies (12,(18)(19)(20)(21)(22) comparing conservative versus extensive arch replacement, resulting in comparison of 1,435 conservative hemiarch replacement and 786 extensive total arch replacement as opposed to 1,236 proximal and 646 extensive replacement in the earlier published review. The estimates provided by our review for long-term follow-up data are more robust due to inclusion of more follow-up studies and time-to-event analysis of freedom from aortic re-operation, in addition to initial published studies.…”

Section: Discussionmentioning

confidence: 99%

“…In patients with an intimal tear localized along the greater curvature close to the supra-aortic vessels, total arch replacement was performed. Concomitant stent graft was deployed in eight studies (4,10,13,17,18,(20)(21)(22). In total arch replacement with frozen elephant trunk, the deployment of stent graft was described differently between studies.…”

Section: Surgical Techniquementioning

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: Surgical Techniquementioning

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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“…The Cleveland Clinic and more recently Gleason's team at the University of Pittsburgh have reported that a more extensive operation, i.e., total arch replacement, was associated with a trend towards lower early and late survival, though the differences were not statistically significant (81,147). Finally, total arch replacement has not been shown to improve the freedom from late distal aortic reintervention compared with more conservative arch management in propensity score analyses from South Korea and Italy (148,149).…”

Section: The Fate Of the Dissected Arch And Thoracoabdominal Aorta: Hmentioning

confidence: 99%

Evolution of surgical therapy for Stanford acute type A aortic dissection

Chiu¹,

Miller²

2016

ASVIDE

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Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small?The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

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“…The advantages of this approach, for a number of reasons, are not widely accepted (9)(10)(11)(12). These include: a higher surgical risk, the availability, in the acute phase, of surgeons specialized in arch surgery, the real clinical advantage of an immediate radical correction compared to an elective re-operation of selected patients requiring a treatment of the residual thoracic aorta (13)(14)(15).…”

Section: Introductionmentioning

confidence: 99%

“…However after initial operation these patients have an advantage from arch replacement with better evolution and remodeling of the false channel (6)(7)(8)(9).…”

Section: Introductionmentioning

confidence: 99%

Intimal re-layering technique for type A acute aortic dissection—reconstructing the intimal layer continuity to induce remodeling of the false channel

et al. 2018

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Background: Residual false channel is common after repair of type A acute aortic dissection (TAAAD).Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions.Methods: Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 ℃) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation.Results: No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions:This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

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Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic Dissection

Cited by 78 publications

References 25 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

Evolution of surgical therapy for Stanford acute type A aortic dissection

Intimal re-layering technique for type A acute aortic dissection—reconstructing the intimal layer continuity to induce remodeling of the false channel

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