Is An Off-Pump Wrapping Procedure for Stanford Type A Acute Aortic Dissection Low Invasive Surgery?

Aortic Remodeling After Stepwise External Wrapping for Type A Acute Aortic Dissection

BACKGROUND

The optimal repair technique for type A acute aortic dissection is graft replacement; however, the treatment approach in high-risk patients remains controversial or suboptimal.

METHODS

We have retrospectively analyzed a cohort of high-risk patients who were admitted to our center for type A acute aortic dissection and who were treated by a new surgical approach using artificial grafts (stepwise external wrapping) between January 2016 and January 2020. The primary endpoints included inhospital mortality and survival during follow-up. Secondary endpoints included the assessment of aortic remodeling after ascending aorta wrapping.

RESULTS

Among the 134 patients admitted for type A acute aortic dissection, 43 patients underwent stepwise external wrapping. The mean patient age was 79.1 ± 6.8 years. The new standard European System for Cardiac Operative Risk Evaluation score was 64% ± 12%. There was one hospital death (2.3%). There were two major complications of persistent cerebral disorder (4.6%). Minor complications included temporary neurologic disorder (2.3%) and renal failure (2.3%). The intensive care unit and hospital stays were 2.8 ± 1.0 days and 11.7 ± 2.5 days, respectively. The follow-up survival rate was 95.3% ± 6.2% and 91% ± 10.2% at 1 and 3 years, respectively, after surgery. There was no aortic-related death during follow-up. At 1 year after surgery, complete remodeling of the ascending aorta was obtained in 30 patients (85.7%), and 5 patients (14.3%) showed partial remodeling.

CONCLUSIONS

Our stepwise external wrapping technique was associated with excellent outcomes for high-risk patients with type A acute aortic dissection.

Hybrid stepwise external wrapping for type a acute aortic dissection with cerebral Malperfusion

Background

Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion.

Case presentation

The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications.

Conclusions

Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.

The ascending aorta and arch in the sights of transcatheter therapy: A time for reappraisal

The ascending aorta and arch have until recently been one of the last bastions of cardiovascular surgery, where life-threatening diseases impose the need for prompt correction and reversal of the impending adverse prognosis. Though a disease where dogmatic recommendations prevail, with upfront surgical intervention in the mind of every physician, type A acute aortic dissection (AAD) is a subject still blurred with many uncertainties. Endovascular intervention for the treatment of type A AAD is rapidly progressing and utilization of transcatheter therapies in the ascending aorta for treating type A AAD has demonstrated technical success in small studies, low early mortality rates, and relatively acceptable aorta-related mortality rates in the long term. These findings strengthen the preponderant role of the endovascular heart surgeon in the management of these procedures, where a combination of wire skill training and surgical proficiency encompassing all technical options available makes it distinctive and resourceful, which provides complete resolution to each multicomponent of this disease in one setting, besides the promptness to repair the inherent complications that will accompany these interventions. Transcatheter procedures and open surgery will coexist side by side and be regarded as complementary rather than competing. Substantial more refinement and technological innovation will be necessary before endovascular repair of type A AAD comes to widespread use, the ideal timespan for cardiovascular surgeons to be involved, and prepared to take on the challenges of leading this new enterprise.