Is distal anastomosis only to the true channel in chronic type B aortic dissection justified?

Mid-term results of distal anastomosis to the true lumen for chronic type B aortic dissection

We investigated whether distal anastomosis to the true lumen in open surgical repair of descending aorta for chronic type B aortic dissection improved the long-term outcomes with aortic remodeling. We retrospectively reviewed 71 patients with chronic type B aortic dissection, excluding those with connective tissue disorder, from October 2001 to June 2021. The patients who underwent distal true lumen anastomosis (group T, n = 36) were compared to those with both lumens' anastomosis (group B, n = 35), regarding survival, overall and distal aortic events. The growth rates of the distal aorta (maximum diameter in descending thoracic, suprarenal and infrarenal abdominal aorta) were also investigated. Median age was significantly higher in group T (T; 66 vs B; 60, P = .001). Group T had significantly higher rates of complete and partial thrombosis formation in the false lumen than group B postoperatively (26.9 vs 0%, P = .01 for complete, 65.4 vs 3.9%, P < .0001 for partial, respectively). At median follow-up for 6.8 years of 63 patients (88.7%), survival, overall and distal aortic event-free rates, and the growth rates of the distal aorta were not significantly different between the groups. Distal anastomosis to the true lumen did not improve mid-term survival, aortic event-free rates and the growth rates of the distal aorta compared with that of both lumens for chronic type B aortic dissection.

A 10-year study of surgical results of descending aorta aneurysm repair following chronic aortic dissection

BACKGROUND

Patients presenting with descending aortic aneurysms developing after aortic dissection often undergo continued aortic expansion which may require operative interventions to address the risk of aortic rupture. In light of the current advances in various treatment options, including endovascular approaches, we analyzed our experience with open surgical repair (OSR) of aneurysms of the descending aorta following aortic dissection.

METHODS

Patients who underwent open repair for aneurysmal changes of the descending aorta after chronic dissection were retrospectively studied. The 30-day operative mortality rate, midterm survival, and major complications were analyzed. Patients were divided into two categories; primary chronic type B aortic dissection and remnant repaired type A aortic dissection (RTAAD).

RESULTS

There were 149 patients with enlargement of the descending thoracic aorta developing after aortic dissection. Of these, 49 patients had medical management, while the remaining 100 patients received OSR. These patients were included in the present analysis. The 30-day mortality and permanent paraplegia rates were 9% and 4%, respectively. The 1-, 3-, and 5-year survival rates were 83%, 80.9%, and 76.1%, respectively. The 1- and 5-year survival rates between the primary chronic type B aortic dissection and remnant RTAAD groups showed no significant between-group differences at 86.7% and 84.3%, and 80% and 71.3%, respectively (P = .289). The overall outcomes of other complications such as renal injury, bleeding reoperation, and extracorporeal membrane oxygenation support showed no significant between-group differences, including an insignificantly higher neurologic complication rate in the remnant RTAAD group. The survival rate in patients with Marfan syndrome was significantly higher than in the patients without Marfan syndrome (P = .033).

CONCLUSIONS

OSR for descending aortic aneurysms developing after chronic aortic dissection showed good early and mid- to long-term outcomes, with acceptably low complication rates. OSR for descending aortic aneurysm after chronic aortic dissection associated with Marfan syndrome also showed good early and mid- to long-term outcomes.

Open surgical repair for chronic type B aortic dissection: a systematic review

BACKGROUND

The treatment of chronic type B aortic dissection (CBAD) remains complicated. Thoracic endovascular aortic repair (TEVAR) has supplanted open surgical repair (OSR) as the preferred surgical treatment for CBAD. Despite TEVAR's superior short-term results, much less is understood about its long-term outcomes. As much of the understanding of OSR originates from historical report, contemporary series, with modern surgical techniques and technologies, may present an alternative to TEVAR. The present systematic review will assess the short- and long-term outcomes of historic and contemporary series of OSR for CBAD.

METHODS

Electronic searches were performed using six databases from their inception to March 2014. Relevant studies with OSRs for chronic type B dissection were identified. Data were extracted by two independent reviewers and analyzed according to predefined clinical endpoints. Studies were sub-classified into the pre-endovascular (historic series) and endovascular era (contemporary series) depending on whether the majority of cases were performed after 1999.

RESULTS

Nineteen studies were identified for inclusion for quantitative analysis. Pooled short-term mortality was 11.1% overall, and 7.5% in the nine contemporary studies. Stroke, spinal cord ischemia, renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively.

CONCLUSIONS

OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.

Modified elephant trunk technique for chronic aortic dissection: the "double elephant trunk"

The most widely used technique for chronic dissection of the aortic arch and thoracoabdominal aorta is the "elephant trunk" (ET). A technique, in which an original modification of the ET technique was necessary to avoid visceral malperfusion due to the obliteration of the patent false lumen from where splanchnic arteries arose, is presented.

Recent outcomes of surgery for chronic type B aortic dissection

OBJECTIVE

Chronic type B dissection though optimal is still considered to be a controversial procedure, even in the advent of stent grafts. Recently, we used a novel surgical technique involving left axillary perfusion to analyze the results of our surgical strategy and compare them with those reported in the literature.

MATERIALS AND METHODS

Between August 2004 and July 2009, 39 patients underwent graft replacement for chronic type B aortic dissection. The left axillary artery was used for perfusion inflow. Perfusion was maintained at approximately 23˚C during open proximal anastomosis. The graft was anastomosed to the distal true lumen whenever possible.

RESULTS

Open proximal anastomosis was performed in 22 patients (56%). In 24 cases (62%), grafts were anastomosed to the true lumen of the peripheral aorta. The early overall mortality rate was 3% (1 patient). Permanent cerebral infarction occurred in 2 patients (5%); and paraparesis, in 1 patient (3%). The Kaplan-Meier survival estimates were 91% at 2 years and 88% at 5 years.

CONCLUSION

Our surgical strategy is associated with excellent short-term and midterm outcomes. Although further investigation is needed, this strategy may be useful for patients with chronic type B dissection.

Should the transverse aortic arch be replaced simultaneously with aortic root replacement for annuloaortic ectasia in marfan syndrome?

OBJECTIVE

The purpose of this study was to determine, on the basis of the late fate of the intact aortic arch with abnormal tissue after aortic root replacement, whether the intact aortic arch should be replaced prophylactically at the time of aortic root replacement for annuloaortic ectasia in Marfan syndrome.

METHODS

A retrospective review was performed in 85 patients with Marfan syndrome who underwent aortic root replacement for annuloaortic ectasia with or without aortic dissection (mean age 37 years, range 19-61 years). These 85 patients were divided into four groups according to the postoperative condition of the residual aorta. In group I (n = 47), the patients underwent aortic root replacement for annuloaortic ectasia with or without localized dissection in the ascending aorta. In these patients the residual aorta, including the aortic arch, was therefore intact. In group II (n = 10), the aortic arch was intact, although the descending thoracic aorta was dissected because of the preoperative type B dissection. In groups III and IV, the patients had type A dissection involving the transverse arch associated with annuloaortic ectasia. In group III (n = 13), residual dissection existed in the descending thoracic aorta after concomitant total arch replacement. In group IV (n = 15), the aortic arch and the descending thoracic aorta were dissected.

RESULTS

There were 5 early deaths (3 in group I, 1 in group II, and 1 in group III). Subsequent operations were required in 10, 5, 6, and 7 cases in groups I, II, III, and IV, respectively. Regarding the aortic arch, only 2 of 53 survivors of the initial hospitalization with an intact aortic arch (groups I and II) underwent subsequent total arch replacement for the onset of dissection in the aortic arch, and 4 of 14 survivors of the initial hospitalization with a residual dissecting arch (group III) needed subsequent total arch replacement. Actuarial freedom from arch repair among patients with an intact aortic arch (91% at 15 years) was significantly higher than that among patients with a residual dissecting arch (49% at 15 years, P =.0078).

CONCLUSIONS

The incidence of new dissection in the residual intact arch after aortic root replacement was extremely low. Therefore prophylactic replacement of the intact arch does not appear to be necessary at aortic root replacement for annuloaortic ectasia in Marfan syndrome.

Treatment of descending thoracic aneurysms by endovascular stent grafting

PURPOSE

Endovascular stent-graft treatment for true aneurysms of the descending thoracic aorta is a valid and effective alternative to conventional surgery. A review of our experience with 21 consecutive patients is reported and technical considerations are discussed.

METHODS

Twenty-one patients (mean age 73 years) with true aneurysms of the descending thoracic aorta (n = 14) or contained rupture (n = 7) were treated between October 1999 and July 2001. Seven patients (33%) underwent emergency endovascular procedure. Postoperatively, the patients were followed with CT scans at 1, 3, 6, and 12 months. Follow-up, which averaged 17 months, was 100% complete. THIRTY-DAY RESULTS: No conversions to open repair were necessary. Two patients died (10%), one of acute intestinal ischemia and the other because of multiorgan failure. Four patients showed endoleaks immediately after stenting. Two patients required new endovascular stentgrafts, while the remaining two were treated conservatively. Besides endoleaks, eight major complications occurred in six patients (two stroke, two paraplegia, two respiratory insufficiency, and one renal failure). MID-TERM RESULTS: Three more patients died during the follow-up period. One patient died of heart failure after a complicated postoperative course, 91 days after stenting. The second patient died because of aortic rupture, 139 days after stenting. The third patient died of heart failure, 15 months after the endovascular procedure. The remaining 16 patients are alive and have been regularly controlled by CT scans. No late migration or endoleaks have been detected. In all the survivors, the size of the aneurysm was unchanged or diminished.

CONCLUSIONS

Treatment of descending thoracic aortic aneurysms by endovascular stentgraft devices has good early and mid-term results. More accurate selection of patients may further reduce mortality and morbidity.

Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients

PURPOSE

To report an initial experience with endovascular stent-graft implantation for diseases of the descending thoracic aorta in high-risk patients.

METHODS

Forty-three patients (28 men; mean age 67 years, range 17-82) with 16 descending thoracic aortic dissections, 14 aneurysms, 7 contained ruptures, 3 mycotic aneurysms, 2 posttraumatic pseudoaneurysms, and an aneurysm of an anomalous right subclavian artery were treated between June 1999 and July 2001. Twenty-three (53%) patients were treated emergently.

RESULTS

There were no conversions to open repair, but 3 (7%) patients died during the first 30 days (pneumonia, multiorgan failure, and acute bowel ischemia). Thirteen (30%) patients suffered 18 major complications (8 strokes, paraplegia in 3, respiratory insufficiency in 6, and 1 renal failure). Of 7 (16%) endoleaks detected in the early postoperative period, 3 required additional stents, while the other 4 were treated conservatively. Follow-up, which averaged 19 +/- 6 months (median: 13; range 0-34), was 100% complete. Five (12%) patients died: 3 of aortic rupture at 34, 47, and 139 days, respectively, and 2 from heart failure at 3 and 15 months, respectively. No late migration or endoleaks have been detected in the remaining 35 patients; however, 1 (2%) patient showed progressive aortic dissection proximal to the stent-graft. In all other cases, the size of the aneurysm or the false lumen was unchanged or diminished.

CONCLUSIONS

Treatment of descending thoracic aortic diseases with an endovascular approach has acceptable early mortality and morbidity in high-risk patients. In selected cases, stent-grafts may afford the best therapy.

The effect of aortic dissection on outcome in descending thoracic and thoracoabdominal aortic aneurysm repair

It is estimated that 20% to 40% of the patients who survive the acute phase of aortic dissection will develop significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta. Aortic dissection has long been considered a risk factor for mortality and neurologic deficit following surgical repair of the descending thoracic and/or thoracoabdominal aorta. In this article we review the surgical approach to patients with aortic dissection and thoracoabdominal aortic aneurysms and discuss the impact of adjuncts on survival and neurologic outcome.