When and how to replace the aortic arch for type A dissection

Abstract

Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high.The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.

Results of frozen elephant trunk from the international E-vita Open registry

“…Although the advantages of FET for the treatment of multisegmental thoracic aortic disease are well known, the use of FET as standard treatment for such patients remains controversial (20,21). FET is a major invasive operation and is associated with substantial morbidity and mortality.…”

Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection

“…(Ann Thorac Surg 2018;105:505-12) Ó 2018 by The Society of Thoracic Surgeons A cute type A aortic dissection remains a surgical emergency, with contemporary perioperative morality rates of 13% to 17% [1]. Despite these excellent results, controversy remains regarding the extent of aortic resection needed to optimize outcomes [2,3].…”

Noteworthy Literature Published in 2016 for Cardiac Surgery

“…In the last year, the adoption of full arch or elephant trunk repairs of type A dissection has become exceedingly common, as represented by 2 recent publications. 20,21 In the first recent publication, Dr Sun's group from China published a series of over 500 full arches with stented elephant trunk for acute dissection with an incredible mortality rate of 3.6%. 21 The group from Bologna led by Dr Di Bartolomeo published an excellent treatise on various arch replacement techniques in aortic dissection and their indications.…”