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Editorial Comment: Extended Resection in Acute Type A Aortic Dissection
Editorial Comment: Ex te nded Resecti o n i n Ac ut e Typ e A Aor ti c Dissection John A. Elefteriades, MD In their article in this issue of Cardiology Clinics, Dr Paul P. Urbanski and colleagues analyze the entire spectrum of surgical options in the care of acute type A aortic dissection, from imaging to categorization, cannulation, brain protection, use of glues, aortic resection, and extent of repair. They make excellent points regarding all of these variables (Fig. 1). Regarding the specific topic of the debate, the authors make a reasonable case, based on their excellent recent experience, for
extending resection to include the aortic arch. Their point is that extended resection permits removal of all dissected tissue and that anastomosis to nondissected branches are quite cogent. There are, however, several weak points in their argument. First, most of their discussion refers to dissections that are confined to the ascending aorta or that extend only to the ligamentum arteriosum. Complete resection, encompassing all the dissected tissue, makes most sense for these
Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, Yale-New Haven Hospital, PO Box 208039, New Haven, CT 06520-8039, USA E-mail address: [email protected] Cardiol Clin 28 (2010) 349–350 doi:10.1016/j.ccl.2010.02.008 0733-8651/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
cardiology.theclinics.com
Fig. 1. Although extended resection may soon be proved superior, confirmative evidence at this point is not yet available.
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Elefteriades unusual and more limited forms of type A dissection. The authors are less sanguine, and their arguments less persuasive, regarding more common and more extensive dissections that extend all the way to the abdomen. Secondly, although their experience and results are exceptionally good, there is no control group of more limited resection, even within their single center. The article by Dr Arnar Geirsson makes excellent points regarding the actual findings in comparative studies on extent of resection, arguing that (1) there is no evidence of survival benefit from more extensive resection, (2) surgical mortality is generally higher with more extensive resection, (3) there is no evidence that more extensive resection actually decreases the need for late reoperation, and (4) it is unproven that resection of the inciting tear is really required. The Editor takes an intermediate approach between limited ascending resection and routine full aortic arch replacement. In a large experience at the Editor’s center, traditional ascending and hemiarch replacement for acute aortic dissection has yielded excellent clinical results, with excellent early survival, good late survival, and low need for late reoperation.1 Furthermore, reoperations that were required were well tolerated. However, the theoretical points made by Dr Urbanski are cogent, even though, as Dr Geirsson points out,
it is hard to prove benefit from the literature at this point. So, in selected cases, a tailored arch resection is performed with a specific technique: the aorta is resected to a level between the left carotid and left subclavian arteries. This resection permits a distal anastomosis that is fully and easily accessible. The distal anastomosis is done with an elephant trunk, so it is a simple circular suture line. The aorta is smaller at this site than at the hemiarch level, so the wall tension is low. Then, the head vessels (innominate and left carotid) are reimplanted as a single patch, with the anastomosis again easily accessible. Both anastomoses are done with a single period of straight hypothermic arrest, usually of about 40 minutes. This specific technique permits the ‘‘best of both worlds,’’ namely, a straightforward, efficient operation, with more complete resection. Furthermore, this procedure leaves an elephant trunk dangling, thus facilitating a late reoperation for the descending aorta, for the few patients in whom this becomes necessary in the very long term.
REFERENCE 1. Elefteriades JA. What operation for acute type A dissection? J Thorac Cardiovasc Surg 2002;123: 201–3.
extending resection to include the aortic arch. Their point is that extended resection permits removal of all dissected tissue and that anastomosis to nondissected branches are quite cogent. There are, however, several weak points in their argument. First, most of their discussion refers to dissections that are confined to the ascending aorta or that extend only to the ligamentum arteriosum. Complete resection, encompassing all the dissected tissue, makes most sense for these
Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, Yale-New Haven Hospital, PO Box 208039, New Haven, CT 06520-8039, USA E-mail address: [email protected] Cardiol Clin 28 (2010) 349–350 doi:10.1016/j.ccl.2010.02.008 0733-8651/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
cardiology.theclinics.com
Fig. 1. Although extended resection may soon be proved superior, confirmative evidence at this point is not yet available.
350
Elefteriades unusual and more limited forms of type A dissection. The authors are less sanguine, and their arguments less persuasive, regarding more common and more extensive dissections that extend all the way to the abdomen. Secondly, although their experience and results are exceptionally good, there is no control group of more limited resection, even within their single center. The article by Dr Arnar Geirsson makes excellent points regarding the actual findings in comparative studies on extent of resection, arguing that (1) there is no evidence of survival benefit from more extensive resection, (2) surgical mortality is generally higher with more extensive resection, (3) there is no evidence that more extensive resection actually decreases the need for late reoperation, and (4) it is unproven that resection of the inciting tear is really required. The Editor takes an intermediate approach between limited ascending resection and routine full aortic arch replacement. In a large experience at the Editor’s center, traditional ascending and hemiarch replacement for acute aortic dissection has yielded excellent clinical results, with excellent early survival, good late survival, and low need for late reoperation.1 Furthermore, reoperations that were required were well tolerated. However, the theoretical points made by Dr Urbanski are cogent, even though, as Dr Geirsson points out,
it is hard to prove benefit from the literature at this point. So, in selected cases, a tailored arch resection is performed with a specific technique: the aorta is resected to a level between the left carotid and left subclavian arteries. This resection permits a distal anastomosis that is fully and easily accessible. The distal anastomosis is done with an elephant trunk, so it is a simple circular suture line. The aorta is smaller at this site than at the hemiarch level, so the wall tension is low. Then, the head vessels (innominate and left carotid) are reimplanted as a single patch, with the anastomosis again easily accessible. Both anastomoses are done with a single period of straight hypothermic arrest, usually of about 40 minutes. This specific technique permits the ‘‘best of both worlds,’’ namely, a straightforward, efficient operation, with more complete resection. Furthermore, this procedure leaves an elephant trunk dangling, thus facilitating a late reoperation for the descending aorta, for the few patients in whom this becomes necessary in the very long term.
REFERENCE 1. Elefteriades JA. What operation for acute type A dissection? J Thorac Cardiovasc Surg 2002;123: 201–3.