Total Arch Replacement Combined With Stented Elephant Trunk Implantation: A New “Standard” Therapy for Type A Dissection Involving Repair of the Aortic Arch?

Feb 28, 2011
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Authors:
Sun L, Qi R, Zhu J, et al.
Citation:
Circulation 2011;123:971-978.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is the appropriate approach for patients with type A dissection involving the aortic arch?

Methods:

Between January 2003 and September 2008, 544 patients with type A dissection underwent surgical treatment at Fuwai Hospital (Beijing, China). A total of 291 patients (acute 148, chronic 143) with type A dissection underwent total arch replacement combined with stented elephant trunk (SET) implantation during this time period, and 120 patients underwent conventional surgical repair. The difference in survival function between the two groups was tested by the log-rank test.

Results:

In-hospital mortality was 3.09% (9 of 291) for stented (acute = 4.73%, 7 of 148; chronic = 1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acute = 6.06%, 4 of 66; chronic = 3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stented = 2.41%, 7 of 291; conventional = 0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stented = 1 and conventional = 4; p = 0.031) and 3.05% (6 of 197) for chronic dissection (stented = 4 and conventional = 2; p = 0.661) during follow-up. Obliteration of the false lumen around the SET occurred in 94.2% (130 of 138) of patients with acute dissection and in 92.0% (126 of 137) of patients with chronic dissection.

Conclusions:

The authors concluded that total arch replacement combined with SET implantation demonstrated the superiority of the combination of the surgical and interventional approaches.

Perspective:

In this study, total arch replacement combined with SET implantation demonstrated the superiority of the combination of surgical and interventional approaches while avoiding the weaknesses associated with the individual methods. A low prevalence of morbidity and mortality was obtained in this study population. Limited conclusions may be drawn from the present study because it was observational and retrospective. The optimal method to compare conventional surgical repair and SET (frozen elephant trunk procedure) for type A dissection would be a prospective randomized trial.

Keywords: Stroke, China, Follow-Up Studies, Stents


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