- Email: [email protected]
Ascending, Total Arch, and Descending Thoracic Aortic Repair for Acute DeBakey Type I Aortic Dissection Without Circulatory Arrest
Ascending, Total Arch, and Descending Thoracic Aortic Repair for Acute DeBakey Type I Aortic Dissection Without Circulatory Arrest William D. T. Kent, MD, MS, Eric J. Herget, MD, Jason K. Wong, MD, and Jehangir J. Appoo, MDCM Libin Cardiovascular Institute of Alberta, Division of Cardiac Surgery; and Department of Diagnostic Imaging, Division of Interventional Radiology, University of Calgary, Calgary, Alberta, Canada
Complications may arise from the residual dissected arch and descending thoracic aorta after conventional ascending and hemiarch repair of acute DeBakey type I aortic dissection. To mitigate these complications, a total arch and elephant trunk procedure has been advocated. This case demonstrates a less invasive hybrid technique, performed in a single-stage fashion through a sternotomy without circulatory arrest or deep hypothermia, to achieve the benefits of the total arch and elephant trunk operation. (Ann Thorac Surg 2012;94:e59 – 61) © 2012 by The Society of Thoracic Surgeons
L
ate postoperative mortality after acute DeBakey type I aortic dissection repair can be associated with aneurysm formation, distal malperfusion or rupture of the residual dissected arch, and descending thoracic aorta. To diminish the occurrence of these outcomes, total arch replacement with elephant trunk creation or simultaneous stent grafting of the proximal descending thoracic aorta at the time of acute dissection repair has been advocated [1– 6]. However, replacing the entire arch adds complexity to an operation that already has a 24% rate of mortality in contemporary series [7]. This case presents a single-stage technique using a prefabricated Dacron branched graft to replace the ascending aorta and debranch the arch without deep hypothermia or circulatory arrest in the setting of an acute DeBakey type I aortic dissection. Total arch and proximal descending thoracic aortic repair is simultaneously achieved with antegrade zone 0 endovascular stent graft deployment without peripheral access. A 68-year-old man presented with neck pain and hypotension. A computed tomographic angiogram identified an acute DeBakey type 1 aortic dissection with a 4.8-cm aneurysm of the ascending aorta, an effaced 5-mm true lumen in the descending thoracic aorta and a malperfused left kidney (Fig 1). Emergency surgical intervention was performed. After heparinization, cardiopulmonary bypass was initiated with right axillary and right atrial cannulation and the patient was cooled to 30°C. After cross clamping, the dissected ascending aorta was resected, the aortic root was reconstructed, and the trileaflet aortic valve was resuspended. The ascending aorta was replaced in an end-to-end fashion using a Bavaria
Fig 1. Preoperative computed tomographic angiogram showing acute type A dissection with effaced true lumen in the descending thoracic aorta.
graft (Vascutek; Terumo Cardiovascular Systems, Ann Arbor, MI); a 28-mm prefabricated Dacron tube graft with four side-limbs designed for arch debranching (Fig 2). Following completion of the distal anastomosis, the cross clamp was removed. Arch debranching was performed sequentially with one limb anastomosed to the left carotid artery and a second to the innominate artery. The subclavian artery was very posterior and difficult to expose; therefore, it was ligated and the third limb was anastomosed directly to the left axillary artery (Fig 2). With the patient weaned from cardiopulmonary bypass, the fourth limb was used for antegrade stent graft delivery. A Cook Zenith TX2 37 ⫻ 202-mm (Cook Medical, Bloomington, IN) thoracic endovascular stent graft was deployed in an antegrade fashion from the ascending aorta, across the arch, and to the middle descending thoracic aorta with the proximal landing zone in the Dacron Bavaria graft (Fig 3A). The patient had an uneventful postoperative recovery, and the acute renal malperfusion resolved. Follow-up imaging at 5 months showed a well-positioned stent graft with no evidence of endoleak, a thrombosed false lumen in the arch and proximal descending thoracic aorta, and a comparatively enlarged 12-mm true lumen in the descending thoracic aorta (Fig 3B). The limb to the left axillary artery had occluded where it was tunneled under the clavicle.
Accepted for publication Feb 13, 2012. Address correspondence to Dr. Appoo, Foothills Hospital, C828, 1403 29th St NW, Calgary, AB T2N 2T9; e-mail: jehangir.appoo@ albertahealthservices.ca.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Appoo discloses financial relationships with Edwards Lifesciences, Cook Medical, and Gore Medical.
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.080
e60
CASE REPORT KENT ET AL HYBRID ARCH REPAIR FOR ACUTE DISSECTION
Fig 2. Completed single-stage repair with a prefabricated fourbranch Bavaria graft used for replacement of the ascending aorta, arch debranching, and antegrade endovascular zone 0 stent graft deployment.
Comment Conventional repair of acute DeBakey type I aortic dissection involves replacement of the ascending aorta and proximal arch under hypothermic circulatory arrest. This repair commonly leaves a persistent patent false lumen through the remaining arch and descending thoracic aorta. Recently, there has been significant attention to the fate of this false lumen. Consequently, hybrid techniques have been developed involving repair of the ascending Fig 3. (A) Intraoperative angiogram showing stent graft positioned across the arch after completed arch debranching and (B) postoperative volume averaged computed tomographic reconstruction of the completed hybrid arch repair.
Ann Thorac Surg 2012;94:e59 – 61
and total arch with a Dacron graft under hypothermic circulatory arrest followed by endovascular stent graft deployment in the descending aorta to re-expand the true lumen and obliterate the residual false lumen [1–3, 5, 6]. Although replacement of the entire arch with Dacron provides a robust repair, it is achieved at the expense of a more complex operation. Risks include an inability to reconstruct the friable dissected arch, stroke and visceral ischemia from prolonged circulatory arrest, bleeding from the distal anastomosis and coagulopathy associated with deep hypothermia. Alternatively, an arch debranching strategy may be a better option in the setting of acute dissection. Recently, there have been two reports of arch debranching and zone 0 stent graft deployment for acute aortic dissection. Diethrich and colleagues [4] constructed their own Dacron graft with two side limbs to debranch the innominate and left carotid arteries without circulatory arrest before using peripheral access to deploy the stent graft. Using circulatory arrest, Marullo and colleagues [3] replaced the ascending aorta and performed arch debranching; they chose to deploy the stent graft at a later date if required. We report an alternative single stage approach without circulatory arrest or deep hypothermia to repair the ascending, total arch and proximal descending thoracic aorta in the setting of acute DeBakey type I dissection. To manage complex thoracic aortomegaly, we have recently implemented this hybrid arch strategy in the elective setting [8]. Our simplified procedure eliminates the need for circulatory arrest and peripheral arterial access. By landing the stent graft in Dacron rather than native aorta we hope to eliminate the risk of retrograde type A dissection, which is one of the most serious complications of endograft deployment in the arch. This case report represents the first time we have used this technique to manage an acute dissection. By repairing the entire arch and proximal descending thoracic aorta, this disease-specific approach has advan-
Ann Thorac Surg 2012;94:e59 – 61
tages over the conventional tear-specific approach. We hypothesize that this technique represents a significantly less invasive strategy than formal total arch replacement and elephant trunk creation, and it may provide both short and long term benefits. Acutely, it may have the potential to decrease bleeding associated with arch reconstruction under deep hypothermia, to decrease the risk of stroke by eliminating circulatory arrest, and to treat visceral malperfusion by opening up the true lumen in the descending aorta. In the long term, this strategy may decrease complications by promoting thrombosis of the false lumen in the arch and descending thoracic aorta. The authors wish to recognize Mark Cromwell, who is responsible for the illustrations.
References 1. Uchida N, Shibamura H, Katayama A, et al. Operative strategy for acute type A aortic dissection: ascending aortic or hemiarch vesus total arch replacement with frozen elephant trunk. Ann Thorac Surg 2009;87:773–7.
CASE REPORT KENT ET AL HYBRID ARCH REPAIR FOR ACUTE DISSECTION
e61
2. Jakob H, Tsagakis K. DeBakey type I dissection: when hybrid stent-grafting is indicated? J Cardiovasc Surg 2010; 51:633– 40. 3. Marullo GM, Bichi S, Pennetta R, et al. Hybrid aortic arch debranching with staged endovascular completion in DeBakey type I aortic dissection. Ann Thorac Surg 2010;90: 1847–53. 4. Diethrich EB, Ghazoul M, Wheatley III GH, et al. Surgical correction of ascending type A thoracic aortic dissection: simultaneous endoluminal exclusion of the arch and distal aorta. J Endovasc Ther 2005;12:660 – 6. 5. Desai ND, Pochettino A. Distal aortic remodeling using endovascular repair in acute DeBakey I aortic dissection. Semin Thorac Cardiovasc Surg 2009;21:387–92. 6. Chen L-W, Wu X-J, Lu L, et al. Total arch repair for acute type A aortic dissection with 2 modified techniques: open singlebranched stent graft placement and reinforcement of the dissected arch vessel stump with stent graft. Circulation 2011;123:2536 – 41. 7. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the international registry of acute aortic dissection score. Ann Thorac Surg 2007;83:55– 61. 8. Kent WDT, Wong JK, Herget EJ, et al. An alternative approach to diffuse thoracic aortomegaly: on-pump total arch repair without circulatory arrest. Ann Thorac Surg 2012;93: 326 – 8.
Complications may arise from the residual dissected arch and descending thoracic aorta after conventional ascending and hemiarch repair of acute DeBakey type I aortic dissection. To mitigate these complications, a total arch and elephant trunk procedure has been advocated. This case demonstrates a less invasive hybrid technique, performed in a single-stage fashion through a sternotomy without circulatory arrest or deep hypothermia, to achieve the benefits of the total arch and elephant trunk operation. (Ann Thorac Surg 2012;94:e59 – 61) © 2012 by The Society of Thoracic Surgeons
L
ate postoperative mortality after acute DeBakey type I aortic dissection repair can be associated with aneurysm formation, distal malperfusion or rupture of the residual dissected arch, and descending thoracic aorta. To diminish the occurrence of these outcomes, total arch replacement with elephant trunk creation or simultaneous stent grafting of the proximal descending thoracic aorta at the time of acute dissection repair has been advocated [1– 6]. However, replacing the entire arch adds complexity to an operation that already has a 24% rate of mortality in contemporary series [7]. This case presents a single-stage technique using a prefabricated Dacron branched graft to replace the ascending aorta and debranch the arch without deep hypothermia or circulatory arrest in the setting of an acute DeBakey type I aortic dissection. Total arch and proximal descending thoracic aortic repair is simultaneously achieved with antegrade zone 0 endovascular stent graft deployment without peripheral access. A 68-year-old man presented with neck pain and hypotension. A computed tomographic angiogram identified an acute DeBakey type 1 aortic dissection with a 4.8-cm aneurysm of the ascending aorta, an effaced 5-mm true lumen in the descending thoracic aorta and a malperfused left kidney (Fig 1). Emergency surgical intervention was performed. After heparinization, cardiopulmonary bypass was initiated with right axillary and right atrial cannulation and the patient was cooled to 30°C. After cross clamping, the dissected ascending aorta was resected, the aortic root was reconstructed, and the trileaflet aortic valve was resuspended. The ascending aorta was replaced in an end-to-end fashion using a Bavaria
Fig 1. Preoperative computed tomographic angiogram showing acute type A dissection with effaced true lumen in the descending thoracic aorta.
graft (Vascutek; Terumo Cardiovascular Systems, Ann Arbor, MI); a 28-mm prefabricated Dacron tube graft with four side-limbs designed for arch debranching (Fig 2). Following completion of the distal anastomosis, the cross clamp was removed. Arch debranching was performed sequentially with one limb anastomosed to the left carotid artery and a second to the innominate artery. The subclavian artery was very posterior and difficult to expose; therefore, it was ligated and the third limb was anastomosed directly to the left axillary artery (Fig 2). With the patient weaned from cardiopulmonary bypass, the fourth limb was used for antegrade stent graft delivery. A Cook Zenith TX2 37 ⫻ 202-mm (Cook Medical, Bloomington, IN) thoracic endovascular stent graft was deployed in an antegrade fashion from the ascending aorta, across the arch, and to the middle descending thoracic aorta with the proximal landing zone in the Dacron Bavaria graft (Fig 3A). The patient had an uneventful postoperative recovery, and the acute renal malperfusion resolved. Follow-up imaging at 5 months showed a well-positioned stent graft with no evidence of endoleak, a thrombosed false lumen in the arch and proximal descending thoracic aorta, and a comparatively enlarged 12-mm true lumen in the descending thoracic aorta (Fig 3B). The limb to the left axillary artery had occluded where it was tunneled under the clavicle.
Accepted for publication Feb 13, 2012. Address correspondence to Dr. Appoo, Foothills Hospital, C828, 1403 29th St NW, Calgary, AB T2N 2T9; e-mail: jehangir.appoo@ albertahealthservices.ca.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Appoo discloses financial relationships with Edwards Lifesciences, Cook Medical, and Gore Medical.
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.080
e60
CASE REPORT KENT ET AL HYBRID ARCH REPAIR FOR ACUTE DISSECTION
Fig 2. Completed single-stage repair with a prefabricated fourbranch Bavaria graft used for replacement of the ascending aorta, arch debranching, and antegrade endovascular zone 0 stent graft deployment.
Comment Conventional repair of acute DeBakey type I aortic dissection involves replacement of the ascending aorta and proximal arch under hypothermic circulatory arrest. This repair commonly leaves a persistent patent false lumen through the remaining arch and descending thoracic aorta. Recently, there has been significant attention to the fate of this false lumen. Consequently, hybrid techniques have been developed involving repair of the ascending Fig 3. (A) Intraoperative angiogram showing stent graft positioned across the arch after completed arch debranching and (B) postoperative volume averaged computed tomographic reconstruction of the completed hybrid arch repair.
Ann Thorac Surg 2012;94:e59 – 61
and total arch with a Dacron graft under hypothermic circulatory arrest followed by endovascular stent graft deployment in the descending aorta to re-expand the true lumen and obliterate the residual false lumen [1–3, 5, 6]. Although replacement of the entire arch with Dacron provides a robust repair, it is achieved at the expense of a more complex operation. Risks include an inability to reconstruct the friable dissected arch, stroke and visceral ischemia from prolonged circulatory arrest, bleeding from the distal anastomosis and coagulopathy associated with deep hypothermia. Alternatively, an arch debranching strategy may be a better option in the setting of acute dissection. Recently, there have been two reports of arch debranching and zone 0 stent graft deployment for acute aortic dissection. Diethrich and colleagues [4] constructed their own Dacron graft with two side limbs to debranch the innominate and left carotid arteries without circulatory arrest before using peripheral access to deploy the stent graft. Using circulatory arrest, Marullo and colleagues [3] replaced the ascending aorta and performed arch debranching; they chose to deploy the stent graft at a later date if required. We report an alternative single stage approach without circulatory arrest or deep hypothermia to repair the ascending, total arch and proximal descending thoracic aorta in the setting of acute DeBakey type I dissection. To manage complex thoracic aortomegaly, we have recently implemented this hybrid arch strategy in the elective setting [8]. Our simplified procedure eliminates the need for circulatory arrest and peripheral arterial access. By landing the stent graft in Dacron rather than native aorta we hope to eliminate the risk of retrograde type A dissection, which is one of the most serious complications of endograft deployment in the arch. This case report represents the first time we have used this technique to manage an acute dissection. By repairing the entire arch and proximal descending thoracic aorta, this disease-specific approach has advan-
Ann Thorac Surg 2012;94:e59 – 61
tages over the conventional tear-specific approach. We hypothesize that this technique represents a significantly less invasive strategy than formal total arch replacement and elephant trunk creation, and it may provide both short and long term benefits. Acutely, it may have the potential to decrease bleeding associated with arch reconstruction under deep hypothermia, to decrease the risk of stroke by eliminating circulatory arrest, and to treat visceral malperfusion by opening up the true lumen in the descending aorta. In the long term, this strategy may decrease complications by promoting thrombosis of the false lumen in the arch and descending thoracic aorta. The authors wish to recognize Mark Cromwell, who is responsible for the illustrations.
References 1. Uchida N, Shibamura H, Katayama A, et al. Operative strategy for acute type A aortic dissection: ascending aortic or hemiarch vesus total arch replacement with frozen elephant trunk. Ann Thorac Surg 2009;87:773–7.
CASE REPORT KENT ET AL HYBRID ARCH REPAIR FOR ACUTE DISSECTION
e61
2. Jakob H, Tsagakis K. DeBakey type I dissection: when hybrid stent-grafting is indicated? J Cardiovasc Surg 2010; 51:633– 40. 3. Marullo GM, Bichi S, Pennetta R, et al. Hybrid aortic arch debranching with staged endovascular completion in DeBakey type I aortic dissection. Ann Thorac Surg 2010;90: 1847–53. 4. Diethrich EB, Ghazoul M, Wheatley III GH, et al. Surgical correction of ascending type A thoracic aortic dissection: simultaneous endoluminal exclusion of the arch and distal aorta. J Endovasc Ther 2005;12:660 – 6. 5. Desai ND, Pochettino A. Distal aortic remodeling using endovascular repair in acute DeBakey I aortic dissection. Semin Thorac Cardiovasc Surg 2009;21:387–92. 6. Chen L-W, Wu X-J, Lu L, et al. Total arch repair for acute type A aortic dissection with 2 modified techniques: open singlebranched stent graft placement and reinforcement of the dissected arch vessel stump with stent graft. Circulation 2011;123:2536 – 41. 7. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the international registry of acute aortic dissection score. Ann Thorac Surg 2007;83:55– 61. 8. Kent WDT, Wong JK, Herget EJ, et al. An alternative approach to diffuse thoracic aortomegaly: on-pump total arch repair without circulatory arrest. Ann Thorac Surg 2012;93: 326 – 8.