True Lumen Stabilization to Overcome Malperfusion in Acute Type I Aortic Dissection

Abstract

Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean § standard deviation 3.44 § 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen.

Revascularization‐first strategy in acute aortic dissection with mesenteric malperfusion

“…In accordance with Tsagakis et al, 6,7 even in patients with initial circulatory instability due to tamponade, invasive diagnostics and treatment for organ malperfusion is possible in hybrid OR after cautious tamponade release and pericardial drainage under blood pressure control. Tsagakis et al 6,7 have proposed that revascularization of malperfusion should be considered after cardiac drainage in hybrid OR even after full sternotomy. In the present study, after attaining hemodynamic stability, IVR should have been prioritized, followed by central repair.…”

“…1 Specific mesenteric malperfusion rates were T A B L E 1 Characteristics of patients undergoing surgical intervention for acute aortic dissection with mesenteric malperfusion The classic treatment algorithm in AAD was to close the proximal entry tear and to reestablish peripheral true lumen perfusion. 4,6,7 However, primary surgical repair of the entry site can add trauma to the already-ischemic organs, and the ensuing uncontrolled In accordance with Tsagakis et al, 6,7 performed first. Therefore, the strategy for these severely complicated cases is still controversial.…”

“…Hybrid ORs are currently gaining popularity worldwide due to the exponential growth of transcatheter aortic valve implantation procedures. Tsagakis et al 6,7 recommended that all patients with established or suspected diagnosis of acute aortic syndrome be admitted directly from helicopter or ambulance transport to the hybrid OR in the presence of aortic team. The potential of this hybrid OR concept is that it enables fast online diagnostics, followed by immediate intervention and/or open surgery, particularly for hemodynamically unstable patients 6,7 .…”

“…Deeb et al 5 also recommended delaying surgery for primary distal reperfusion and stabilization. Tsagakis et al6,7 proposed the hybrid OR concept prioritizing revascularization of malperfusion. Thus, the authors emphasized the controversial paradigm of mesenteric revascularizationfirst approach using IVR before the central repair to alleviate metabolic crisis.Basically, in our institute, revascularization-first strategy is chosen for any type of mesenteric malperfusion because whether it is a dynamic or static malperfusion is usually unclear preoperatively, a combination of a static and a dynamic component is present,3 and malperfusion may worsen because the dissection flap extending into the branch changes after the central repair 8.…”

Revascularization-first strategy in acute aortic dissection with mesenteric malperfusion

“…Tsagakis et al advocated the Hybrid OR concept to prioritize revascularization for ischemic organs even after cardiac drainage. 6,7 Because the infinite possibilities of the hybrid OR have been described, 6,7 we also conducted this study to investigate the utility of the hybrid OR.…”