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Acute Type I Aortic Dissection: Traditional Versus Hybrid Repair With Antegrade Stent Delivery to the Descending Thoracic Aorta
Study Questions:
What are the short-term outcomes between patients who had undergone classic repair for type I aortic dissection and those who had undergone concomitant antegrade stenting in the descending thoracic aorta?
Methods:
From January 2005 to December 2012, 112 patients were treated for acute type I aortic dissection. Of these, 87 patients (group A) underwent traditional operations on the ascending and proximal arch (n = 79, 90.8%), total arch (n = 7, 8.1%), or ascending aorta (n = 1, 1.2%); and 25 patients (group B) underwent ascending and proximal arch repair and antegrade stent grafting in the descending thoracic aorta.
Results:
Various concomitant procedures were performed in both groups. The circulatory arrest times were similar between the two groups. The 30-day mortality was 13.8% (n = 12) in group A and 12% (n = 3) in group B. Postoperative stroke occurred in nine patients in group A (10.3%) and three in group B (12%). In group A, one patient (1.5%) developed transient spinal cord ischemia, and in group B, two patients had transient paraparesis (8.0%). Preoperatively, 24 group A patients and 19 group B patients had malperfusion; this condition resolved postoperatively in 13 group A patients (54.2%) and 16 group B patients (84.2%; p < 0.037). Eight group A patients (10.8%) and one group B patient (4.5%) underwent additional postoperative procedures on the thoracoabdominal aorta a median of 776.5 days (range 168.5-1,102.0) and 54 days postoperatively, respectively.
Conclusions:
Antegrade endovascular grafting of the descending thoracic aorta during repair of acute type I aortic dissection is technically safe, does not increase circulatory arrest time, and could help patients with preoperative malperfusion. Long-term follow-up data are needed.
Perspective:
Acute type I aortic dissection traditionally is treated with emergent ascending aortic replacement with or without aortic valve or aortic root repair or replacement. The distal anastomosis is open, and the remaining dissection in the thoracoabdominal aorta is managed medically. However, some patients develop progressive aneurysmal dilatation of the descending aorta with risk of fatal rupture, potentially mandating reoperation. Emerging endovascular technology offers new options for therapy, including extending the traditional primary open repair of acute type I aortic dissection to include the proximal descending aorta. This report of a hybrid procedure that involves open repair of the ascending aorta plus endovascular graft repair of the descending thoracic aorta with open repair alone suggests feasibility and good short-term outcomes, without added circulatory arrest times.
Keywords: Spinal Cord Ischemia, Stroke, Follow-Up Studies, Reoperation, Aortic Aneurysm, Thoracic, Dilatation, Postoperative Care, Stents
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