ADULT CARDIAC
Stented Elephant Trunk Technique for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Repair Bin Li, MD,* Xu-Dong Pan, MD,* Wei-Guo Ma, MD, Jun Zheng, MD, Ying-Long Liu, MD, Jun-Ming Zhu, MD, Yong-Min Liu, MD, and Li-Zhong Sun, MD Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing, China
Background. Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique. Methods. Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1 ± 8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results.
Results. Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2 ± 13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival. Conclusions. The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.
S
angiography (CTA) was performed, allowing for evaluation of the extent of the dissection. Marfan patients were excluded from consideration as candidates for TEVAR. Acute B-AD denoted dissection confined to the descending aorta presenting within 14 days from the onset of symptoms. There were 6 patients (0.9%, 6 of 669) who suffered RTAD after TEVAR in our center. Another 18 patients were transferred to our center from outside hospitals for the same reason. The RTAD was diagnosed within 14 days after TEVAR in 14 (58.3%) patients. For the other 10 patients, the time from TEVAR to RTAD ranged from 20 days to 9 months. The mean age of the group was 41.2 8.1 years. In these 24 patients, there were 4 women (16.7%), 4 Marfan syndrome (16.7%), 5 smokers (20.5%), 18 hypertensive (75%), and 1 diabetic (4.1%). Table 1 describes the detailed aortic pathology and patient profile. In 15 patients (62.5%), initial TEVAR was performed in the acute phase of B-AD (< 14 days). Patients usually complained of a new onset chest or back pain after TEVAR. The RTAD may occur during the procedure or in the days or weeks after TEVAR. Preoperative investigation included chest-X ray, CTA, and echocardiography to select the appropriate surgical management strategies. Informed consent was obtained from all patients. The study was approved by the Institutional Review Board of Beijing Anzhen Hospital.
ince the introduction of thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease by Dake and colleagues [1] in 1994, it has become a valid and safe alternative to surgical treatment for type B aortic dissection (B-AD) until now. However, some potential fatal complications may arise, including acute or delayed retrograde type A aortic dissection (RTAD) as described in some reports [2–6]. This complication represents a lifethreatening pathology with a high mortality rate [3–7]. In this paper, we report a modified stented elephant trunk procedure (SET) for RTAD and analyze the clinical outcomes of this surgical technique for these serious complications.
Material and Methods Patients Between April 2005 and September 2012, 669 patients with type B dissection underwent TEVAR in our center. For the preoperative diagnosis, computed tomography Accepted for publication Sept 10, 2013. *Dr Bin Li and Dr Xu-Dong Pan contributed equally to this work. Address correspondence to Dr Y-L Liu, Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, 2 Anzhen Rd, Beijing 100029, China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:596–602) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.033
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
Table 1. Patients’ Characteristics All Patients (n ¼ 24)
Characteristic Age (years) Female Hypertension Ischemic heart disease Diabetes mellitus Smoking Marfan syndrome Renal insufficiency Aortic insufficiency Pericardial effusion Rupture Initial details of TEVAR Initial TEVAR in acute status (< 14 days) Emergent procedure LSA involved by dissection before TEVAR Proximal landing zone Zone 2 Zone 3 Uncontrolled hypertension after TEVAR Onset of retrograde dissection within 14 days after TEVAR Chest pain Asymptomatic
41.2 8.1(29-65) 4 (16.7%) 18 (75%) 1 (4.1%) 1 (4.1%) 5 (20.8%) 4 (16.7) 1 (4.1%) 2 (8.3%) 4 (16.7%) 3 (12.5%) 15 (62.5%) 15 (62.5%) 8 (33.3%) 13 11 14 14
(54.2%) (45.8%) (58.3%) (58.3%)
16 (66.2%) 8 (33.3%)
Data are presented as n (%) or mean (range). LSA ¼ left subclavian artery; repair.
TEVAR ¼ thoracic endovascular aortic
Open Stent Graft The open stent graft, Cronus (MicroPort Medical Company, Ltd, Shanghai China) consists of 3 parts (Fig 1): a self-expandable metal stent made of medical elastic alloy; a woven polyester vascular graft sewn and attached outside the stent; and a delivery system comprised of a handle with shaft, a pulling wire, and surgical thread.
Fig 1. The stent graft, Cronus. (1 ¼ pull wire; 2 ¼ handle; 3 ¼ compressed state by a surgical thread; 4 ¼ tip; 5 ¼ released state.)
597
Before release, the stent is compressed by a surgical thread. Upon release, the system is deployed by inserting the compressed stent graft system into the aorta. The pulling wire was drawn to steadily release the stent graft while holding the handle. The open stent graft (24 to 32 mm in diameter and 100 mm long each) contains an extra centimeter of attached regular vascular graft, proximally and distally, to which a conventional hand-sewn anastomosis can be performed.
Surgical Technique After induction of general anesthesia, the right axillary artery is exposed through a right subclavian incision as routinely used for cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion (SCP). Aortic arch vessels can be involved by RTAD. Therefore, patients who present with an innominate artery malperfusion may not have enough perfusion for CPB. In this case, the femoral artery was cannulated in addition to the axillary artery cannulation. An arterial cannula is inserted into the right axillary artery, and a dual-stage caval cannula is inserted into the right atrium. The CPB flow is maintained between 2.2 and 2.4 L/min1/m2, and patients are cooled to a rectal temperature of 22 to 25 C. During the cooling period, the ascending aorta is cross-clamped and the heart is arrested with cold blood cardioplegia. The ascending aorta just distal to the sinotubular junction is transected. Additional procedures are performed during cooling if indicated. The brain is perfused through the right axillary artery at a flow rate of 5 to 10 mL/kg1/ min1 as soon as CPB was discontinued at a rectal temperature of 22 to 25 C. The aortic arch was opened longitudinally. Partial transaction of the arch of the aorta was made between the left common carotid and left subclavian arteries. Only in these acute RTAD with an interval from primary TEVAR to redo surgery less than 14 days, previous endovascular stent grafts could be removed. However, great care should be taken to prevent a new initial tear in the fragile aortic wall while removing the implanted stent. In the other 10 cases with an interval from primary TEVAR to redo surgery greater than 14 days, the previous endovascular stent grafts were left in place. In addition, the bare waved wire of the endovascular graft proximal edge was cut off to facilitate suturing and to prevent further injuries. The delivery system of open stent graft we used was different with frozen elephant trunk described by some reports. A catheter sheath containing a 10-cm long stent graft (MicroPort Medical Co) was inserted into the true lumen of the descending aorta in a compressed state through the opened aortic arch under direct vision during hypothermic circulatory arrest. The diameter of the proximal end of the open stent graft was chosen to match the size of the aorta just distally to the left subclavian artery. After the open stent graft is deployed into the descending aorta, the proximal ends of the stent graft and aneurysm wall are sewn together to a 4-branched prosthetic graft. When the anastomosis was completed, antegrade systemic perfusion resumed through the
ADULT CARDIAC
Ann Thorac Surg 2014;97:596–602
598
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC
10-mm branch of the graft connected to the CPB circuit. To minimize the time of cerebral and cardiac ischemia, the left common carotid artery is reconstructed first. Upon completion of anastomosis, rewarming begins and SCP is continued bilaterally through the right axillary and left common carotid arteries. Then, continuity between the tetrafurcate graft and the distal ascending aorta is established. The ascending aorta is de-clamped and heart beat returns. Finally, the left subclavian and innominate arteries are, in turn, anastomosed to the 4-branched graft end-to-end (Fig 2). Data of the surgical procedures are listed in Table 2.
Follow-Up Clinical data were obtained by personal and telephone interviews with patients, family members, and primary care physicians. Complications such as neurologic, renal, and respiratory morbidity were recorded. Contrastenhanced computed tomography was performed at 1, 6, and 12 postoperative months and annually thereafter.
Results Six patients suffered RTAD after TEVAR in our center, corresponding to a 0.9% institutional incidence of RTAD (6 of 669). All 6 patients underwent initial TEVAR in acute status and the rate of RTAD, in acute phase, was 1.9% (6 of 319). The RTAD seemed to occur more often in patients who underwent TEVAR for acute B-AD when compared with patients with chronic B-AD (1.9 % [6 of 319] vs 0% [0 of 350]; p < 0.005). The initial endovascular stent-graft device used and incidence of RTAD associated
Ann Thorac Surg 2014;97:596–602
with various types of stent grafts in our center are listed in Table 3. We explored the aortic arch in the operation and found RTAD originating from a new entry tear induced by the bare spring of the proximal part of the stent graft in 18 cases (Fig 3), 13 of which had proximal landing zones covering the left subclavian artery. In 3 cases, the new entry tear was located in the lesser curvature of the aortic arch, which excludes the stent graft as the cause. The entry tear was not completely excluded by the stent graft in 4 cases; refer to Table 3 for details. The mean time of cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest as measured by duration of SCP were 186.6 25.9, 93.1 15.2, and 25.3 9.1 minutes, respectively. Concomitant procedures are listed in Table 4. The Bentall procedure was performed in 2 cases; aortic valve repair and coronary artery bypass grafting, each in 1. The in-hospital mortality rate was 4.2% (1 of 24). One patient had preoperative chronic renal failure and required hemodialysis postoperatively and died from renal and cardiac failure on the third postoperative day. Reoperation for bleeding was required in 1 patient. One patient experienced coma and was awake with transient cerebral disorder postoperatively. It was transient and resolved completely before discharge. No spinal cord injury or stroke occurred. Mean time of staying in the intensive care unit was 3.64 1.93 days. Follow-up was completed with the 23 survivors. The mean follow-up period was 32.2 13.1 months (range, 12 to 49 months). No patient died during the follow-up period. Due to complete resection and graft replacement of the dissected aortic segments, no recurrent aneurysm formation or residual false lumen were
Fig 2. The stented elephant trunk (SET) procedure: total aortic arch replacement plus open SET.
Ann Thorac Surg 2014;97:596–602
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
599
Table 2. Exploration of the Arch in the Operation
Design of most proximal stent spring Free-flow bare spring Membrane-covered Over stenting of left subclavian artery Endoleak New entry tear Stent graft-induced perforation of the arch Underlying progression of aortic disease
18 6 13 4 20 17 3
ADULT CARDIAC
All Patients (n ¼ 24)
Variable
(75%) (25%) (54.2%) (16.7%) (83.3%) (70.8%) (10 %)
Data are presented as n (%).
observed in proximal aortic aorta during the follow-up period. Advanced or completed thrombus formation was noted around the stent graft after the mean follow-up of 32 months. Figure 4 shows the details of 1 patient who developed a RTAD 11 days after TEVAR and prognosis after SET operation. One patient with Marfan syndrome required reoperation for dilation of false lumen in the thoracoabdominal aorta, in which a reentry tear was detected in the distal descending aorta by CTA scan. The reentry tear caused persistent blood flow into the false lumen that may lead to an aneurismal dilatation of the distal thoracoabdominal aorta 5 months after the SET operation. This patient underwent thoracoabdominal aorta replacement successfully and enjoyed an uneventful recovery at the latest 5 years follow-up.
Comment In recent years, with the growing number of thoracic endovascular aortic repairs and expansion of indications, TEVAR has become an accepted alternative to traditional open surgery for treatment of uncomplicated type B dissections. Retrograde type A aortic dissection has been reported as a rare complication after TEVAR for type B dissection. However, the mortality rate of this
Fig 3. Intraoperative view of a perforated aortic arch by free-flow bare spring proximal end of endovascular stent graft.
post-TEVAR RTAD remains higher than that of spontaneous acute type A dissections [3, 8, 9]. Published literature has identified RTAD as a lethal complication of TEVAR for all indications with an estimate of 1.3% to 6.8% [3, 10–13]. Given the recent evidence, this complication may be associated with the procedure or device, or as a result of natural progression of disease. Possible risk factors for RTAD after TEVAR include the following: (1) using a free-flow bare spring proximal stent graft design [7, 14]; (2) endoleak at the proximal fixation Table 4. Data of Surgery Variable
Table 3. Initial Stent-Graft Device Used in Retrograde Type A Aortic Dissection Cases n ¼ 24 Stent Graft Device Used Cases Talent (Medtronic) Relay (Bolton) Zenith TX2 (Cook) Hercules (Microport) TAG (Gore) Valiant (Medtronic)
Our Center 6 3 1 1 1 0 0
(0.9%, 6/669) (1.1%a, 3/259) (1.2%a, 1/83) (1.2%a, 1/81) (1.3%a, 1/75) (0%a, 1/87) (0%a, 1/84)
Other Hospital 18 8 0 5 1 2 2
All Patients (n ¼ 24)
Emergency surgery 16 (66%) Cardiopulmonary bypass cannulation Isolated axillary artery cannulation 19 (79.2%) Axillary artery cannulationþ femoral 5 (20.8%) artery cannulation Ascending aorta þ SET 20 (83%) Bentall þ SET 2 (10%) Ascending aorta þ SET þ aortic 1 (4.1%) valve repair Ascending aorta þ SET þ coronary artery 1 (4.1%) bypass grafting Cardiopulmonary bypass time 186.6 25.9 minutes Aortic cross-clamp time 93.1 15.2 minutes Deep hypothermic circulatory arrest time 25.3 9.1 minutes
a
Incidence of retrograde type A aortic dissection for various type stent graft in our center.
Data are presented as n (%) or mean (range).
Data are presented as n (%).
SET ¼ stented elephant trunk.
600
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC Fig 4. Computed tomography angiography (CTA) of a patient with retrograde type A aortic dissection related to TEVAR. (A) Preoperative scan shows the aortic dissection located in descending aorta. (B) The CTA was performed 11 days post endovascular therapy due to newonset chest pain shows a dissection of the ascending aorta. (C) The true lumen of descending aorta return to normal and the false lumen were obliterated with thrombus 1 week after operation. (D) Thrombus absorption and shrinkage of false lumen make the shape of the descending aorta return to normal 3 months later.
site leading to retrograde enlargement of the false lumen; (3) passive bending of TEVAR at the arch with overstenting of the left subclavian artery leading to springback strength, which could yield stress on the greater curve of arch [3]; (4) wire and sheath handling or balloon dilatation during the endovascular procedure might trigger the intimal damage in the extremely fragile and easily injured aortic wall [15]; and (5) patients with connective tissue disorders such as Marfan, Ehlers-Danlos, and Loeys-Dietz syndromes [16].
Ann Thorac Surg 2014;97:596–602
Two other points are noteworthy. First, our data showed that patients in acute phase (within 14 days) had a higher incidence of RTAD undergoing TEVAR, which is consistent with previous reports. Duebener and colleagues [17] investigated the prognosis of 13 patients with acute type B dissection under TEVAR and new RTAD was observed in 3 cases. Neuhauser and colleagues [15] reported new RTAD developing in 5 of 28 candidates in a study of TEVAR of acute type B dissection. These reports stress the need for fixation stents to be flexible, less traumatic, and strong enough to create a blood seal in the friable tissue of an acutely dissected aorta. As a result, a new onset of chest or back pain in patients with successful initial treatment of acute aortic disease after TEVAR should raise the clinical suspicion for RTAD. Second, in reviewing the patients’ medical history, we found that 14 of 24 (58.3%) patients had uncontrolled hypertension after TEVAR. The detrimental influence of a high blood pressure in the acute phase of a type B aortic dissection has been recognized for a long time. According to the law of La Place, the parietal tension of a vessel is the product of intravascular pressure and diameter. With a higher systemic blood pressure, the stress of self-expandable stent graft increases and the risk of stress-related aorta injury would also increase. Four patients with Marfan syndrome were referred from other hospitals after TEVAR for rapidly emerging type A dissections. The aorta of Marfan patients cannot resist the high radial forces generated by the stent and are prone to new intimal injuries. Dong and colleagues [3] observed that post-stent grafting RTAD represented the most common complication among Marfan patients. Takahashi and colleagues [18] also reported serious complications after TEVAR, including RTAD caused by the proximal bare spring of the stent grafts, high rates of endoleaks, and late conversions to open surgery. In our center, presence of Marfan syndrome or a connective tissue disorder has been a strict exclusion criterion in all thoracic aortic stent-graft trials. When treating such diseases, it is always advisable to remember that “stent grafting in patients with Marfan syndrome or any other known connective tissue disorder is not recommended because of their thin, weak, and friable aortic wall that will predispose them to further developing false aneurysm or endoleaks,” as stated in a report by the Society of Thoracic Surgeons Endovascular Surgery Task Force [16]. Management of RTAD after TEVAR remains a challenge [10]. Despite improvements of intensive care and surgical technique, mortality remains as high as 16% to 20% [19, 20]. The RTAD usually presents with an entry tear adjacent to the proximal part of the stent graft and no outlet tear in the aorta. The dissection spreading retrogradely would involve the side branches and cause complications such as malperfusion syndrome by dynamic or static obstruction (resulting in cerebrovascular ischemia), tamponade, or aortic valve regurgitation. So far, the majority surgical experience of RTAD after TEVAR for type B dissection has been limited to sporadic case reports, or studies evaluating the general effects and complications of endovascular therapy. Totaro and
colleagues [21] reported replacement of only the ascending aorta with the graft reinforcing the proximal and distal anastomoses with resorcin-formolo glue and 2 Teflon felt strips. Lu and colleagues [22] reported total arch replacement or subtotal arch replacement, and the vascular graft anastomosed distally with the endovascular graft. Urbanski and colleagues [23] reported complete replacement of the ascending aorta and aortic arch using the elephant trunk technique. Estrera and colleagues [6] removed the endograft and placed a Dacron (DuPont, Wilmington, DE) graft in its place using the modified elephant trunk technique in order to expedite future distal repair if required. Because these complications have to be treated by a surgical procedure, extensive aortic replacement might allow reduction in recurrent aneurysm formation. The SET technique seems to be particularly useful in this type of dissection. Our experience has shown 2 advantages for the SET technique in the treatment of this serious complication. First, the open stent graft is easier to deploy into the descending aorta than conventional the elephant trunk. With close attachment to descending aorta, the open stent graft avoids the complications of kinking and graft occlusion. This stent graft has an extra centimeter of attached regular vascular graft, proximally and distally, to which a conventional hand-sewn anastomosis can be performed. However, previous endovascular stent grafts are hard to sew with vascular graft. The membrane of other endovascular stent grafts constructed of vulnerable polytetrafluoroethylene or thinner polyester does not tolerate suturing and increase the risk of bleeding. In contrast, the membrane of the open stent graft is Dacron, which is good for sewing and could be used as an inner layer to “sandwich” the suture. After deployment into the descending thoracic aorta, the open stent graft is easy to anastomose with a branched graft. This enables safe anchoring of its proximal vascular graft segment by a circumferential, hand-sewn anastomosis between the left carotid and subclavian arteries. Because of the unique design of this open stent graft, descending aortic repair has been simplified and circulatory arrest time has been shortened. Second, even if the second-stage repair of progressive thoracic aortic aneurysm is necessary, the extra centimeter of sewing edge at both ends facilitates distal anastomosis. The graft can also withstand the mechanical forces of clamps and other manipulations and regain its original shape spontaneously because of its memory alloy construction. Branch vessels are vulnerable to RTAD. This is very dangerous and should be treated as an emergency, especially in patients with no tear in the proximal aorta. Accordingly, brain protection should be taken with great care. Selective cerebral perfusion through cannulation of the right axillary artery has been used routinely in our institution. This simple technique provides better surgical exposure and avoids cluttering the operative field with cannula lines. It is considered an effective method of brain protection during aortic arch surgery [24, 25]. However, those patients who present with innominate artery malperfusion may not provide enough perfusion
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
601
for CPB. Under such circumstances, the femoral artery would also be cannulated. During the SCP period, the left common carotid artery is reconstructed first. Upon completion, rewarming begins, SCP is continued through the right axillary artery and left common carotid artery. Then, the distal ascending aorta is reconstructed, de-clamped, and the heart resumes perfusion. The left subclavian and innominate arteries are, in turn, reconstructed at the end. In doing so, the times of cerebral and cardiac ischemia are minimized. Awareness of the RTAD should be heightened after initial TEVAR of type B dissection. Our experience indicates that the SET is a feasible treatment option for RTAD after TEVAR. This strategy has demonstrated low morbidity and mortality in the early and mid-term stages. This study was supported by grants from project of International Scientific Cooperation and Exchange of Beijing Municipal Science and Technology Commission (2012DFA31110), Beijing Municipal Natural Science Foundation- Key Program of Science and Technology of Beijing Education Committee (KZ201010025017) and The Capital Health Research and Development of Special (2011-2006-05).
References 1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–34. 2. Fanelli F, Salvatori FM, Marcelli G, et al. Type A aortic dissection developing during endovascular repair of an acute type B dissection. J Endovasc Ther 2003;10:254–9. 3. Dong ZH, Fu WG, Wang YQ, et al. Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection. Circulation 2009;119:735–41. 4. Luehr M, Etz CD, Lehmkuhl L, Schmidt A, Misfeld M, Borger MA, Mohr FW. Surgical management of delayed retrograde type a aortic dissection following complete supraaortic de-branching and stent-grafting of the transverse arch. Eur J Cardiothorac Surg 2013 [Epub ahead of print]. 5. Gorlitzer M, Weiss G, Moidl R, et al. Repair of stent graftinduced retrograde type A aortic dissection using the Evita open prosthesis. Eur J Cardiothorac Surg 2012;42:566–70. 6. Estrera AL, Shah P, Lee TY, Irani AD, Safi HJ. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique. Vascular 2009;17:116–20. 7. Kische S, Ehrlich MP, Nienaber CA, et al. Endovascular treatment of acute and chronic aortic dissection: midterm results from the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg 2009;138:115–24. 8. Rubin S, Bayle A, Poncet A, Baehrel B. Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique. Interact Cardiovasc Thorac Surg 2006;5:746–8. 9. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry Of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. 10. Eggebrecht H, Thompson M, Rousseau H, et al. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European Registry on Endovascular Aortic Repair Complications. Circulation 2009;120(11 Suppl):S276–81. 11. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Heart J 1981;101:195–214.
ADULT CARDIAC
Ann Thorac Surg 2014;97:596–602
602
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC
12. Kpodonu J, Preventza O, Ramaiah VG, et al. Retrograde type a dissection after endovascular stenting of the descending thoracic aorta. Is the risk real? Eur J Cardiothorac Surg 2008;33:1014–8. 13. Tshomba Y, Bertoglio L, Marone EM, et al. Retrograde type A dissection after endovascular repair of a “zone 0” nondissecting aortic arch aneurysm. Ann Vasc Surg 2010;24: 952.e51–7. 14. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55: 1255–62. 15. Neuhauser B, Greiner A, Jaschke W, Chemelli A, Fraedrich G. Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection. Eur J Cardiothorac Surg 2008;33:58–63. 16. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85(1 Suppl):S1–41. 17. Duebener L, Hartmann F, Kurowski V, et al. Surgical interventions after emergency endovascular stent-grafting for acute type b aortic dissections. Interact Cardiovasc Thorac Surg 2007;6:288–92. 18. Takahashi Y, Tsutsumi Y, Shirakawa Y, Ohashi H. Total aortic repair in Marfan syndrome using stent grafting with hybrid techniques. J Vasc Surg 2010;52:1365–6.
Ann Thorac Surg 2014;97:596–602
19. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–52. 20. Misfeld M, Notzold A, Geist V, et al. Retrograde type A dissection after endovascular stent grafting of type B dissection. [Article in German] Z Kardiol 2002;91:274–7. 21. Totaro M, Miraldi F, Fanelli F, Mazzesi G. Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair. Eur J Cardiothorac Surg 2001;20:1057–8. 22. Lu S, Lai H, Wang C, et al. Surgical treatment for retrograde type A aortic dissection after endovascular stent graft placement for type B dissection. Interact Cardiovasc Thorac Surg 2012;14:538–42. 23. Urbanski PP. Retrograde extension of type B dissection after endovascular stent graft repair. Eur J Cardiothorac Surg 2002;21:767–9. 24. Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study. J Thorac Cardiovasc Surg 2003;125:849–54. 25. Khaladj N, Shrestha M, Meck S, et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg 2008;135:908–14.
Southern Thoracic Surgical Association: Sixty-First Annual Meeting The Sixty-First Annual Meeting of the Southern Thoracic Surgical Association (STSA) will be held November 5–8, 2014 at the JW Marriott Starr Pass Resort in Tucson, Arizona. Those wishing to participate in the Scientific Program should submit an abstract by April 7, 2014, 11:59 PM, Eastern Time. Abstracts must be submitted electronically. Instructions for the abstract submission process will be
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
posted on the STSA website at www.stsa.org as soon as they are available. Candidates for the Hawley Seiler Residents Competition must submit a manuscript to the STSA headquarters office no later than October 20, 2014. The Resident Award will be based on the quality of the candidate’s abstract, presentation, and manuscript.
Ann Thorac Surg 2014;97:602
0003-4975/$36.00
Stented Elephant Trunk Technique for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Repair Bin Li, MD,* Xu-Dong Pan, MD,* Wei-Guo Ma, MD, Jun Zheng, MD, Ying-Long Liu, MD, Jun-Ming Zhu, MD, Yong-Min Liu, MD, and Li-Zhong Sun, MD Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing, China
Background. Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique. Methods. Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1 ± 8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results.
Results. Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2 ± 13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival. Conclusions. The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.
S
angiography (CTA) was performed, allowing for evaluation of the extent of the dissection. Marfan patients were excluded from consideration as candidates for TEVAR. Acute B-AD denoted dissection confined to the descending aorta presenting within 14 days from the onset of symptoms. There were 6 patients (0.9%, 6 of 669) who suffered RTAD after TEVAR in our center. Another 18 patients were transferred to our center from outside hospitals for the same reason. The RTAD was diagnosed within 14 days after TEVAR in 14 (58.3%) patients. For the other 10 patients, the time from TEVAR to RTAD ranged from 20 days to 9 months. The mean age of the group was 41.2 8.1 years. In these 24 patients, there were 4 women (16.7%), 4 Marfan syndrome (16.7%), 5 smokers (20.5%), 18 hypertensive (75%), and 1 diabetic (4.1%). Table 1 describes the detailed aortic pathology and patient profile. In 15 patients (62.5%), initial TEVAR was performed in the acute phase of B-AD (< 14 days). Patients usually complained of a new onset chest or back pain after TEVAR. The RTAD may occur during the procedure or in the days or weeks after TEVAR. Preoperative investigation included chest-X ray, CTA, and echocardiography to select the appropriate surgical management strategies. Informed consent was obtained from all patients. The study was approved by the Institutional Review Board of Beijing Anzhen Hospital.
ince the introduction of thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease by Dake and colleagues [1] in 1994, it has become a valid and safe alternative to surgical treatment for type B aortic dissection (B-AD) until now. However, some potential fatal complications may arise, including acute or delayed retrograde type A aortic dissection (RTAD) as described in some reports [2–6]. This complication represents a lifethreatening pathology with a high mortality rate [3–7]. In this paper, we report a modified stented elephant trunk procedure (SET) for RTAD and analyze the clinical outcomes of this surgical technique for these serious complications.
Material and Methods Patients Between April 2005 and September 2012, 669 patients with type B dissection underwent TEVAR in our center. For the preoperative diagnosis, computed tomography Accepted for publication Sept 10, 2013. *Dr Bin Li and Dr Xu-Dong Pan contributed equally to this work. Address correspondence to Dr Y-L Liu, Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, 2 Anzhen Rd, Beijing 100029, China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:596–602) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.033
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
Table 1. Patients’ Characteristics All Patients (n ¼ 24)
Characteristic Age (years) Female Hypertension Ischemic heart disease Diabetes mellitus Smoking Marfan syndrome Renal insufficiency Aortic insufficiency Pericardial effusion Rupture Initial details of TEVAR Initial TEVAR in acute status (< 14 days) Emergent procedure LSA involved by dissection before TEVAR Proximal landing zone Zone 2 Zone 3 Uncontrolled hypertension after TEVAR Onset of retrograde dissection within 14 days after TEVAR Chest pain Asymptomatic
41.2 8.1(29-65) 4 (16.7%) 18 (75%) 1 (4.1%) 1 (4.1%) 5 (20.8%) 4 (16.7) 1 (4.1%) 2 (8.3%) 4 (16.7%) 3 (12.5%) 15 (62.5%) 15 (62.5%) 8 (33.3%) 13 11 14 14
(54.2%) (45.8%) (58.3%) (58.3%)
16 (66.2%) 8 (33.3%)
Data are presented as n (%) or mean (range). LSA ¼ left subclavian artery; repair.
TEVAR ¼ thoracic endovascular aortic
Open Stent Graft The open stent graft, Cronus (MicroPort Medical Company, Ltd, Shanghai China) consists of 3 parts (Fig 1): a self-expandable metal stent made of medical elastic alloy; a woven polyester vascular graft sewn and attached outside the stent; and a delivery system comprised of a handle with shaft, a pulling wire, and surgical thread.
Fig 1. The stent graft, Cronus. (1 ¼ pull wire; 2 ¼ handle; 3 ¼ compressed state by a surgical thread; 4 ¼ tip; 5 ¼ released state.)
597
Before release, the stent is compressed by a surgical thread. Upon release, the system is deployed by inserting the compressed stent graft system into the aorta. The pulling wire was drawn to steadily release the stent graft while holding the handle. The open stent graft (24 to 32 mm in diameter and 100 mm long each) contains an extra centimeter of attached regular vascular graft, proximally and distally, to which a conventional hand-sewn anastomosis can be performed.
Surgical Technique After induction of general anesthesia, the right axillary artery is exposed through a right subclavian incision as routinely used for cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion (SCP). Aortic arch vessels can be involved by RTAD. Therefore, patients who present with an innominate artery malperfusion may not have enough perfusion for CPB. In this case, the femoral artery was cannulated in addition to the axillary artery cannulation. An arterial cannula is inserted into the right axillary artery, and a dual-stage caval cannula is inserted into the right atrium. The CPB flow is maintained between 2.2 and 2.4 L/min1/m2, and patients are cooled to a rectal temperature of 22 to 25 C. During the cooling period, the ascending aorta is cross-clamped and the heart is arrested with cold blood cardioplegia. The ascending aorta just distal to the sinotubular junction is transected. Additional procedures are performed during cooling if indicated. The brain is perfused through the right axillary artery at a flow rate of 5 to 10 mL/kg1/ min1 as soon as CPB was discontinued at a rectal temperature of 22 to 25 C. The aortic arch was opened longitudinally. Partial transaction of the arch of the aorta was made between the left common carotid and left subclavian arteries. Only in these acute RTAD with an interval from primary TEVAR to redo surgery less than 14 days, previous endovascular stent grafts could be removed. However, great care should be taken to prevent a new initial tear in the fragile aortic wall while removing the implanted stent. In the other 10 cases with an interval from primary TEVAR to redo surgery greater than 14 days, the previous endovascular stent grafts were left in place. In addition, the bare waved wire of the endovascular graft proximal edge was cut off to facilitate suturing and to prevent further injuries. The delivery system of open stent graft we used was different with frozen elephant trunk described by some reports. A catheter sheath containing a 10-cm long stent graft (MicroPort Medical Co) was inserted into the true lumen of the descending aorta in a compressed state through the opened aortic arch under direct vision during hypothermic circulatory arrest. The diameter of the proximal end of the open stent graft was chosen to match the size of the aorta just distally to the left subclavian artery. After the open stent graft is deployed into the descending aorta, the proximal ends of the stent graft and aneurysm wall are sewn together to a 4-branched prosthetic graft. When the anastomosis was completed, antegrade systemic perfusion resumed through the
ADULT CARDIAC
Ann Thorac Surg 2014;97:596–602
598
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC
10-mm branch of the graft connected to the CPB circuit. To minimize the time of cerebral and cardiac ischemia, the left common carotid artery is reconstructed first. Upon completion of anastomosis, rewarming begins and SCP is continued bilaterally through the right axillary and left common carotid arteries. Then, continuity between the tetrafurcate graft and the distal ascending aorta is established. The ascending aorta is de-clamped and heart beat returns. Finally, the left subclavian and innominate arteries are, in turn, anastomosed to the 4-branched graft end-to-end (Fig 2). Data of the surgical procedures are listed in Table 2.
Follow-Up Clinical data were obtained by personal and telephone interviews with patients, family members, and primary care physicians. Complications such as neurologic, renal, and respiratory morbidity were recorded. Contrastenhanced computed tomography was performed at 1, 6, and 12 postoperative months and annually thereafter.
Results Six patients suffered RTAD after TEVAR in our center, corresponding to a 0.9% institutional incidence of RTAD (6 of 669). All 6 patients underwent initial TEVAR in acute status and the rate of RTAD, in acute phase, was 1.9% (6 of 319). The RTAD seemed to occur more often in patients who underwent TEVAR for acute B-AD when compared with patients with chronic B-AD (1.9 % [6 of 319] vs 0% [0 of 350]; p < 0.005). The initial endovascular stent-graft device used and incidence of RTAD associated
Ann Thorac Surg 2014;97:596–602
with various types of stent grafts in our center are listed in Table 3. We explored the aortic arch in the operation and found RTAD originating from a new entry tear induced by the bare spring of the proximal part of the stent graft in 18 cases (Fig 3), 13 of which had proximal landing zones covering the left subclavian artery. In 3 cases, the new entry tear was located in the lesser curvature of the aortic arch, which excludes the stent graft as the cause. The entry tear was not completely excluded by the stent graft in 4 cases; refer to Table 3 for details. The mean time of cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest as measured by duration of SCP were 186.6 25.9, 93.1 15.2, and 25.3 9.1 minutes, respectively. Concomitant procedures are listed in Table 4. The Bentall procedure was performed in 2 cases; aortic valve repair and coronary artery bypass grafting, each in 1. The in-hospital mortality rate was 4.2% (1 of 24). One patient had preoperative chronic renal failure and required hemodialysis postoperatively and died from renal and cardiac failure on the third postoperative day. Reoperation for bleeding was required in 1 patient. One patient experienced coma and was awake with transient cerebral disorder postoperatively. It was transient and resolved completely before discharge. No spinal cord injury or stroke occurred. Mean time of staying in the intensive care unit was 3.64 1.93 days. Follow-up was completed with the 23 survivors. The mean follow-up period was 32.2 13.1 months (range, 12 to 49 months). No patient died during the follow-up period. Due to complete resection and graft replacement of the dissected aortic segments, no recurrent aneurysm formation or residual false lumen were
Fig 2. The stented elephant trunk (SET) procedure: total aortic arch replacement plus open SET.
Ann Thorac Surg 2014;97:596–602
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
599
Table 2. Exploration of the Arch in the Operation
Design of most proximal stent spring Free-flow bare spring Membrane-covered Over stenting of left subclavian artery Endoleak New entry tear Stent graft-induced perforation of the arch Underlying progression of aortic disease
18 6 13 4 20 17 3
ADULT CARDIAC
All Patients (n ¼ 24)
Variable
(75%) (25%) (54.2%) (16.7%) (83.3%) (70.8%) (10 %)
Data are presented as n (%).
observed in proximal aortic aorta during the follow-up period. Advanced or completed thrombus formation was noted around the stent graft after the mean follow-up of 32 months. Figure 4 shows the details of 1 patient who developed a RTAD 11 days after TEVAR and prognosis after SET operation. One patient with Marfan syndrome required reoperation for dilation of false lumen in the thoracoabdominal aorta, in which a reentry tear was detected in the distal descending aorta by CTA scan. The reentry tear caused persistent blood flow into the false lumen that may lead to an aneurismal dilatation of the distal thoracoabdominal aorta 5 months after the SET operation. This patient underwent thoracoabdominal aorta replacement successfully and enjoyed an uneventful recovery at the latest 5 years follow-up.
Comment In recent years, with the growing number of thoracic endovascular aortic repairs and expansion of indications, TEVAR has become an accepted alternative to traditional open surgery for treatment of uncomplicated type B dissections. Retrograde type A aortic dissection has been reported as a rare complication after TEVAR for type B dissection. However, the mortality rate of this
Fig 3. Intraoperative view of a perforated aortic arch by free-flow bare spring proximal end of endovascular stent graft.
post-TEVAR RTAD remains higher than that of spontaneous acute type A dissections [3, 8, 9]. Published literature has identified RTAD as a lethal complication of TEVAR for all indications with an estimate of 1.3% to 6.8% [3, 10–13]. Given the recent evidence, this complication may be associated with the procedure or device, or as a result of natural progression of disease. Possible risk factors for RTAD after TEVAR include the following: (1) using a free-flow bare spring proximal stent graft design [7, 14]; (2) endoleak at the proximal fixation Table 4. Data of Surgery Variable
Table 3. Initial Stent-Graft Device Used in Retrograde Type A Aortic Dissection Cases n ¼ 24 Stent Graft Device Used Cases Talent (Medtronic) Relay (Bolton) Zenith TX2 (Cook) Hercules (Microport) TAG (Gore) Valiant (Medtronic)
Our Center 6 3 1 1 1 0 0
(0.9%, 6/669) (1.1%a, 3/259) (1.2%a, 1/83) (1.2%a, 1/81) (1.3%a, 1/75) (0%a, 1/87) (0%a, 1/84)
Other Hospital 18 8 0 5 1 2 2
All Patients (n ¼ 24)
Emergency surgery 16 (66%) Cardiopulmonary bypass cannulation Isolated axillary artery cannulation 19 (79.2%) Axillary artery cannulationþ femoral 5 (20.8%) artery cannulation Ascending aorta þ SET 20 (83%) Bentall þ SET 2 (10%) Ascending aorta þ SET þ aortic 1 (4.1%) valve repair Ascending aorta þ SET þ coronary artery 1 (4.1%) bypass grafting Cardiopulmonary bypass time 186.6 25.9 minutes Aortic cross-clamp time 93.1 15.2 minutes Deep hypothermic circulatory arrest time 25.3 9.1 minutes
a
Incidence of retrograde type A aortic dissection for various type stent graft in our center.
Data are presented as n (%) or mean (range).
Data are presented as n (%).
SET ¼ stented elephant trunk.
600
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC Fig 4. Computed tomography angiography (CTA) of a patient with retrograde type A aortic dissection related to TEVAR. (A) Preoperative scan shows the aortic dissection located in descending aorta. (B) The CTA was performed 11 days post endovascular therapy due to newonset chest pain shows a dissection of the ascending aorta. (C) The true lumen of descending aorta return to normal and the false lumen were obliterated with thrombus 1 week after operation. (D) Thrombus absorption and shrinkage of false lumen make the shape of the descending aorta return to normal 3 months later.
site leading to retrograde enlargement of the false lumen; (3) passive bending of TEVAR at the arch with overstenting of the left subclavian artery leading to springback strength, which could yield stress on the greater curve of arch [3]; (4) wire and sheath handling or balloon dilatation during the endovascular procedure might trigger the intimal damage in the extremely fragile and easily injured aortic wall [15]; and (5) patients with connective tissue disorders such as Marfan, Ehlers-Danlos, and Loeys-Dietz syndromes [16].
Ann Thorac Surg 2014;97:596–602
Two other points are noteworthy. First, our data showed that patients in acute phase (within 14 days) had a higher incidence of RTAD undergoing TEVAR, which is consistent with previous reports. Duebener and colleagues [17] investigated the prognosis of 13 patients with acute type B dissection under TEVAR and new RTAD was observed in 3 cases. Neuhauser and colleagues [15] reported new RTAD developing in 5 of 28 candidates in a study of TEVAR of acute type B dissection. These reports stress the need for fixation stents to be flexible, less traumatic, and strong enough to create a blood seal in the friable tissue of an acutely dissected aorta. As a result, a new onset of chest or back pain in patients with successful initial treatment of acute aortic disease after TEVAR should raise the clinical suspicion for RTAD. Second, in reviewing the patients’ medical history, we found that 14 of 24 (58.3%) patients had uncontrolled hypertension after TEVAR. The detrimental influence of a high blood pressure in the acute phase of a type B aortic dissection has been recognized for a long time. According to the law of La Place, the parietal tension of a vessel is the product of intravascular pressure and diameter. With a higher systemic blood pressure, the stress of self-expandable stent graft increases and the risk of stress-related aorta injury would also increase. Four patients with Marfan syndrome were referred from other hospitals after TEVAR for rapidly emerging type A dissections. The aorta of Marfan patients cannot resist the high radial forces generated by the stent and are prone to new intimal injuries. Dong and colleagues [3] observed that post-stent grafting RTAD represented the most common complication among Marfan patients. Takahashi and colleagues [18] also reported serious complications after TEVAR, including RTAD caused by the proximal bare spring of the stent grafts, high rates of endoleaks, and late conversions to open surgery. In our center, presence of Marfan syndrome or a connective tissue disorder has been a strict exclusion criterion in all thoracic aortic stent-graft trials. When treating such diseases, it is always advisable to remember that “stent grafting in patients with Marfan syndrome or any other known connective tissue disorder is not recommended because of their thin, weak, and friable aortic wall that will predispose them to further developing false aneurysm or endoleaks,” as stated in a report by the Society of Thoracic Surgeons Endovascular Surgery Task Force [16]. Management of RTAD after TEVAR remains a challenge [10]. Despite improvements of intensive care and surgical technique, mortality remains as high as 16% to 20% [19, 20]. The RTAD usually presents with an entry tear adjacent to the proximal part of the stent graft and no outlet tear in the aorta. The dissection spreading retrogradely would involve the side branches and cause complications such as malperfusion syndrome by dynamic or static obstruction (resulting in cerebrovascular ischemia), tamponade, or aortic valve regurgitation. So far, the majority surgical experience of RTAD after TEVAR for type B dissection has been limited to sporadic case reports, or studies evaluating the general effects and complications of endovascular therapy. Totaro and
colleagues [21] reported replacement of only the ascending aorta with the graft reinforcing the proximal and distal anastomoses with resorcin-formolo glue and 2 Teflon felt strips. Lu and colleagues [22] reported total arch replacement or subtotal arch replacement, and the vascular graft anastomosed distally with the endovascular graft. Urbanski and colleagues [23] reported complete replacement of the ascending aorta and aortic arch using the elephant trunk technique. Estrera and colleagues [6] removed the endograft and placed a Dacron (DuPont, Wilmington, DE) graft in its place using the modified elephant trunk technique in order to expedite future distal repair if required. Because these complications have to be treated by a surgical procedure, extensive aortic replacement might allow reduction in recurrent aneurysm formation. The SET technique seems to be particularly useful in this type of dissection. Our experience has shown 2 advantages for the SET technique in the treatment of this serious complication. First, the open stent graft is easier to deploy into the descending aorta than conventional the elephant trunk. With close attachment to descending aorta, the open stent graft avoids the complications of kinking and graft occlusion. This stent graft has an extra centimeter of attached regular vascular graft, proximally and distally, to which a conventional hand-sewn anastomosis can be performed. However, previous endovascular stent grafts are hard to sew with vascular graft. The membrane of other endovascular stent grafts constructed of vulnerable polytetrafluoroethylene or thinner polyester does not tolerate suturing and increase the risk of bleeding. In contrast, the membrane of the open stent graft is Dacron, which is good for sewing and could be used as an inner layer to “sandwich” the suture. After deployment into the descending thoracic aorta, the open stent graft is easy to anastomose with a branched graft. This enables safe anchoring of its proximal vascular graft segment by a circumferential, hand-sewn anastomosis between the left carotid and subclavian arteries. Because of the unique design of this open stent graft, descending aortic repair has been simplified and circulatory arrest time has been shortened. Second, even if the second-stage repair of progressive thoracic aortic aneurysm is necessary, the extra centimeter of sewing edge at both ends facilitates distal anastomosis. The graft can also withstand the mechanical forces of clamps and other manipulations and regain its original shape spontaneously because of its memory alloy construction. Branch vessels are vulnerable to RTAD. This is very dangerous and should be treated as an emergency, especially in patients with no tear in the proximal aorta. Accordingly, brain protection should be taken with great care. Selective cerebral perfusion through cannulation of the right axillary artery has been used routinely in our institution. This simple technique provides better surgical exposure and avoids cluttering the operative field with cannula lines. It is considered an effective method of brain protection during aortic arch surgery [24, 25]. However, those patients who present with innominate artery malperfusion may not provide enough perfusion
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
601
for CPB. Under such circumstances, the femoral artery would also be cannulated. During the SCP period, the left common carotid artery is reconstructed first. Upon completion, rewarming begins, SCP is continued through the right axillary artery and left common carotid artery. Then, the distal ascending aorta is reconstructed, de-clamped, and the heart resumes perfusion. The left subclavian and innominate arteries are, in turn, reconstructed at the end. In doing so, the times of cerebral and cardiac ischemia are minimized. Awareness of the RTAD should be heightened after initial TEVAR of type B dissection. Our experience indicates that the SET is a feasible treatment option for RTAD after TEVAR. This strategy has demonstrated low morbidity and mortality in the early and mid-term stages. This study was supported by grants from project of International Scientific Cooperation and Exchange of Beijing Municipal Science and Technology Commission (2012DFA31110), Beijing Municipal Natural Science Foundation- Key Program of Science and Technology of Beijing Education Committee (KZ201010025017) and The Capital Health Research and Development of Special (2011-2006-05).
References 1. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–34. 2. Fanelli F, Salvatori FM, Marcelli G, et al. Type A aortic dissection developing during endovascular repair of an acute type B dissection. J Endovasc Ther 2003;10:254–9. 3. Dong ZH, Fu WG, Wang YQ, et al. Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection. Circulation 2009;119:735–41. 4. Luehr M, Etz CD, Lehmkuhl L, Schmidt A, Misfeld M, Borger MA, Mohr FW. Surgical management of delayed retrograde type a aortic dissection following complete supraaortic de-branching and stent-grafting of the transverse arch. Eur J Cardiothorac Surg 2013 [Epub ahead of print]. 5. Gorlitzer M, Weiss G, Moidl R, et al. Repair of stent graftinduced retrograde type A aortic dissection using the Evita open prosthesis. Eur J Cardiothorac Surg 2012;42:566–70. 6. Estrera AL, Shah P, Lee TY, Irani AD, Safi HJ. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique. Vascular 2009;17:116–20. 7. Kische S, Ehrlich MP, Nienaber CA, et al. Endovascular treatment of acute and chronic aortic dissection: midterm results from the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg 2009;138:115–24. 8. Rubin S, Bayle A, Poncet A, Baehrel B. Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique. Interact Cardiovasc Thorac Surg 2006;5:746–8. 9. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry Of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. 10. Eggebrecht H, Thompson M, Rousseau H, et al. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European Registry on Endovascular Aortic Repair Complications. Circulation 2009;120(11 Suppl):S276–81. 11. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Heart J 1981;101:195–214.
ADULT CARDIAC
Ann Thorac Surg 2014;97:596–602
602
LI ET AL SET FOR RETROGRADE TYPE A AORTIC DISSECTION
ADULT CARDIAC
12. Kpodonu J, Preventza O, Ramaiah VG, et al. Retrograde type a dissection after endovascular stenting of the descending thoracic aorta. Is the risk real? Eur J Cardiothorac Surg 2008;33:1014–8. 13. Tshomba Y, Bertoglio L, Marone EM, et al. Retrograde type A dissection after endovascular repair of a “zone 0” nondissecting aortic arch aneurysm. Ann Vasc Surg 2010;24: 952.e51–7. 14. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55: 1255–62. 15. Neuhauser B, Greiner A, Jaschke W, Chemelli A, Fraedrich G. Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection. Eur J Cardiothorac Surg 2008;33:58–63. 16. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85(1 Suppl):S1–41. 17. Duebener L, Hartmann F, Kurowski V, et al. Surgical interventions after emergency endovascular stent-grafting for acute type b aortic dissections. Interact Cardiovasc Thorac Surg 2007;6:288–92. 18. Takahashi Y, Tsutsumi Y, Shirakawa Y, Ohashi H. Total aortic repair in Marfan syndrome using stent grafting with hybrid techniques. J Vasc Surg 2010;52:1365–6.
Ann Thorac Surg 2014;97:596–602
19. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–52. 20. Misfeld M, Notzold A, Geist V, et al. Retrograde type A dissection after endovascular stent grafting of type B dissection. [Article in German] Z Kardiol 2002;91:274–7. 21. Totaro M, Miraldi F, Fanelli F, Mazzesi G. Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair. Eur J Cardiothorac Surg 2001;20:1057–8. 22. Lu S, Lai H, Wang C, et al. Surgical treatment for retrograde type A aortic dissection after endovascular stent graft placement for type B dissection. Interact Cardiovasc Thorac Surg 2012;14:538–42. 23. Urbanski PP. Retrograde extension of type B dissection after endovascular stent graft repair. Eur J Cardiothorac Surg 2002;21:767–9. 24. Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study. J Thorac Cardiovasc Surg 2003;125:849–54. 25. Khaladj N, Shrestha M, Meck S, et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg 2008;135:908–14.
Southern Thoracic Surgical Association: Sixty-First Annual Meeting The Sixty-First Annual Meeting of the Southern Thoracic Surgical Association (STSA) will be held November 5–8, 2014 at the JW Marriott Starr Pass Resort in Tucson, Arizona. Those wishing to participate in the Scientific Program should submit an abstract by April 7, 2014, 11:59 PM, Eastern Time. Abstracts must be submitted electronically. Instructions for the abstract submission process will be
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
posted on the STSA website at www.stsa.org as soon as they are available. Candidates for the Hawley Seiler Residents Competition must submit a manuscript to the STSA headquarters office no later than October 20, 2014. The Resident Award will be based on the quality of the candidate’s abstract, presentation, and manuscript.
Ann Thorac Surg 2014;97:602
0003-4975/$36.00
