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istal Aortic Remodeling Using Endovascularepair in Acute DeBakey I Aortic Dissection

imesh D. Desai, MD, PhD, and Alberto Pochettino, MD

DeBakey type I aortic dissections pose significant challenges in operative and long-termmanagement of the arch and distal thoracic aorta. Concerns regarding management ofcomplex tears extending to the arch and descending thoracic aorta, malperfusion syn-dromes, and late aortic dilatation have provided an impetus to explore aortic repairs thatinvolve stent-graft placement into the descending thoracic aorta in combination withconventional hemi-arch or total arch repairs. Early results with these techniques arepromising but further study is warranted.Semin Thorac Cardiovasc Surg 21:387-392 © 2009 Elsevier Inc. All rights reserved.

KEYWORDS aortic aneurysm, aortic arch, aortic dissection, deep hypothermic circulatoryarrest, stent-graft

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cute dissection of the ascending aorta (Stanford type A)is a catastrophic condition with a 1%-2% mortality risk

er hour from the onset of symptoms. The overall incidences approximately 0.5-1 per 100,000 persons per year.1 Mo-alities of death from acute ascending aortic dissections in-lude rupture, congestive heart failure from severe aortic in-ufficiency, and coronary, cerebral, or visceral malperfusion.perative mortality ranges from 9% to 30% in the early pe-

iod and over the longer term less than half of these patientsurvive 10 years.2-5 While such patients often have significantomorbidities, many late deaths have been attributed to aor-ic events in the residual proximal or distal aorta. Amongatients with DeBakey type I aortic dissection, which in-olves the ascending arch and descending thoracic aorta, theistal dissected aorta is at risk for late aneurismal dilatationnd rupture. Aortic reinterventions in these patients are ex-remely morbid and typically require circulatory arrest andajor thoracoabdominal aortic resections. Concern regard-

ng the fate of the distal aorta has provided an impetus forxploring methods to address intimal tears extending deepern the aortic arch and improve compression or thrombosis ofhe false lumen in the distal arch and proximal descendinghoracic aorta using hybrid endovascular approaches withhoracic endovascular aortic repair (TEVAR).

ivision of Cardiovascular Surgery, Department of Surgery, University ofPennsylvania School of Medicine, Philadelphia, Pennsylvania.

ddress reprint requests to Nimesh D. Desai, MD, PhD, Division of Cardio-vascular Surgery, Hospital of the University of Pennsylvania, Sixth Floor,Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA 19104. E-mail:

pnimesh.desai@uphs.upenn.edu

043-0679/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1053/j.semtcvs.2009.12.003

ationale for IntroducingEVAR Technology to AcuteeBakey I Dissection Repairanagement of Distalalperfusion and Arch Tears

n contemporary series, up to 27% of patients with acute typedissection have concomitant malperfusion.6 Of these, over

0% of malperfusion cases involve arterial beds beyond theeft subclavian artery take-off.6 Virtually all studies examin-ng perioperative outcomes of acute type A dissection repairemonstrate a significant increase in early mortality in casesf limb or visceral malperfusion.6-8 In a study by Geirsson etl6 at the University of Pennsylvania, among 221 consecutiveatients operated for acute type A aortic dissection, mortalitymong patients with malperfusion was 30.5% vs only 6.2%mong those without malperfusion. This mortality burdenemains despite resection of the primary tear site in the as-ending aorta with the restoration of antegrade flow into therue lumen achieved with ascending aortic and hemi-archeplacement. Strategies, such as concomitant TEVAR, aimedt more fully re-expanding the true lumen and obliteratinghe false lumen in the descending thoracic aorta may providemproved restoration of distal visceral and limb perfusion.he scientific rationale for use of TEVAR in type A dissectionomplicated by malperfusion has been extrapolated from ex-eriences from management of acute type B dissections withisceral or limb malperfusion. In a recent review of the Uni-ersity of Pennsylvania experience, Szeto et al9 report on 17

atients treated with TEVAR � adjunctive peripheral stents

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or malperfusion in acute type B dissection. They were able tochieve 30-day mortality below 3% with 93% 1-year sur-ival. Our current practice for tears that extend into the distalrch malperfusion in DeBakey I dissections is to perform aybrid hemi-arch repair plus TEVAR as described later in theext as opposed to performing a total arch replacement.4 Thisimits the overall circulatory arrest time and mitigates con-erns about potential increased mortality or neurologic in-ury with total arch replacement vs hemi-arch replacement.n cases of distal malperfusion, we have increasingly used theybrid approach with encouraging results.Intimal tears that extend beyond the ascending aorta into the

rch or descending aorta pose a significant surgical challengend are present in as many as 30% of acute type A dissections.10

hile contemporary repair of type A dissections mandates re-ection of the primary tear site, this is not always possible with-ut conversion to either a total arch replacement or a thora-osternotomy approach, both of which substantially increaseorbidity. Sealing tears extending beyond the transverse archith a stent-graft provides an attractive alternative to this diffi-

ult problem. This technique may also provide improved falseumen obliteration in these patients thereby diminishing poten-ial malperfusion and late dilatation.

itigation of Dilatationf the Distal Thoracic Aortahe standard operation for DeBakey type I or II aortic dissection

s to perform an ascending aortic replacement with open distalemi-arch anastomosis. In patients with DeBakey type I dissec-ions, the residual dissected aorta in the arch and descendinghoracic aorta has a tendency to dilate over time. Studiesxamining aortic growth after proximal repair have shownighly variable growth rates and differing impact of patency

Figure 1 Kaplan-Meier freedomfromreoperation fordistal aorthan 45 years). (Reprinted with permission from Geirsson et a

f the false lumen on growth rate. Virtually all studies of r

ong-term changes in aortic dimensions are limited by signif-cant loss to follow-up, inconsistencies in measurement tech-iques, and limited data beyond 3-5 years. Park et al11 fol-

owed 122 patients with residual distal dissection afterroximal repair for DeBakey type I dissection and found that

n early postoperative computed tomographs (CTs), the tho-acic false lumen was patent in 85 patients (69.7%), andbdominal false lumen was patent in 111 patients (91.0%).n 3 year follow-up, the thoracic aortic false lumen remainedatent in over 80% of patients. In nearly half of all patients47.5%), the descending aorta dilated by more than 1 cm inhe follow-up period. Shrinkage of the thoracic false lumenccurred in 30% of patients, of whom, 96% had thrombosedhe false lumen. Kimura et al12 followed 218 patient’s un-ergo emergency surgery for a DeBakey type I or type IIIBcute ascending aortic dissections over a 10-year period.hey showed excellent perioperative results with a mortalityf only 7.3%. The surviving patients underwent CT angiog-aphy within the first month after operation to determinealse lumen patency. They found that 64% patients had aatent false lumen in the residual thoracic or abdominalorta. Of these approximately 30% were partially throm-osed. Although they had significant loss to follow-up, at aean follow-up of 3 years, annualized growth rate was 1.9 �

.0 mm/yr in the proximal descending aorta among patientsith patent false lumens. Among patients with thrombosed

alse lumens the aortic diameter shrunk by 0.7 � 2.8 mm/yr.our percent of patients required reoperation on the distalorta over the 3-year follow-up period. In a large study byeirrson et al13 at the University of Pennsylvania, among 221atients undergoing repair of type A dissections with a stan-ard hemi-arch technique, freedom from reoperation in theistal aortic segment was 86% and 75% at 5 and 10 years,

ionorcomplications stratifiedbyagegroup(oldervsyounger

ticdilat

espectively (Fig. 1). Importantly, need for reoperation was

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Distal aortic remodeling 389

ubstantially higher in younger patients. Freedom from re-peration among patients younger than 45 years was 67%nd 50% at 5 and 10 years, respectively. Mortality foristal reoperation was 31% in this series. Data from Fat-ouch et al14 in Palermo, Italy in 189 type A aortic dissec-ion patients showed significantly poorer 10-year survivalmong patients with patent false lumens after repair (oblit-rated false lumen 90% survival vs patent false lumen 60%urvival). Freedom from reintervention on the descendinghoracic aorta was 94% among patients with obliteratedalse lumens and 64% for those with patent false lumens.irsch et al15 from Créteil, France studied 160 patientsperated on for type A dissection over a 20-year periodnd found that over 20% of patients required distal aorticeoperation over 10 years. Kazui et al16 from Hamamatsu,apan also reported that over 20% of patients requiredistal reintervention over 10-year period.Other authors have suggested that late dilation of the aorta

s less common and predominantly benign.17,18 Halstead etl17 from Mount Sinai Hospital, New York, found that in 89atients with serial CTs, growth rate in the residual dissectedescending thoracic aorta was only 1 mm/yr with a cumula-ive probability of reoperation of 16% over 10 years. Theirnalysis, however, included all type A dissections, includingeBakey type II dissections which would be presumed toave a much more favorable course in terms of distal aorticroblems than DeBakey type I dissections, which involve theescending thoracic aorta. Despite this limitation, the au-hors did note that distal aortic growth rate was higher inatients with persistently patent false lumens (1.2 vs 0.8m/yr). Sabik et al3 at the Cleveland Clinic found that only

% of patients required distal aortic reintervention at 10ears.

Our initial experience with concomitant TEVAR and clas-ic type A dissection repair using a hemi-arch technique inatients with acute DeBakey I dissection was for patients withrimary tears that started or extended into the aortic arch, or

n patients with severe mesenteric malperfusion syndromes.ased on early encouraging results, we became increasingly

nterested in TEVAR in patients with DeBakey I dissectionven without specific malperfusion syndromes or arch tears,rovided we could accomplish the surgery without any in-rease in operative mortality and limited increase in technicalifficulty.

echniques ofybrid DeBakey Iortic Dissection Repairsybrid Hemi-Archeplacement With Antegradeeployment of a Standard TEVAR Graftur technique for hybrid hemi-arch repair with stent-graft

nvolves arterial cannulation using a variety of strategies in-luded femoral, axillary, and more recently, direct ascending

ortic cannulation over a guidewire with TEE (Trans Esoph- s

geal Echocardiography) guidance.4 Venous cannulation iserformed via a 2-stage cannula in the right atrium and aeparate superior vena cava cannula for retrograde cerebralerfusion. Although preferable, we do not require a fluoros-opy-enabled operating room table or endovascular suiteith this technique. Core cooling was carried out to flat line

lectroencephalogram when available or to 50-minute totalooling. The aorta is typically crossclamped as soon as ven-ricular fibrillation occurs. Direct coronary ostial antegradeyperkalemic cold blood cardioplegia, as well as retrogradeold blood cardioplegia, are used intermittently for myocar-ial protection. During systemic cooling, the proximal as-ending aorta is debrided to the sinotubular junction. Repairsere performed whenever feasible and consisted of commis-

ural resuspension with 4-0 pledgeted sutures and Tefloneomedia (DuPont, Wilmington, DE) reinforcement of theissected sinuses.Once adequate core hypothermia was reached, circulatory

rrest was initiated, with retrograde cerebral perfusion ad-inistered through the snared superior vena cava cannula, atows of 150-300 cm3/min of blood at 12°C to maintain a

ugular venous pressure between 25 and 30 mm Hg. Thentire residual ascending aorta and most of the lesser curva-ure of the arch are debrided. Selective antegrade perfusionia the axillary artery or self-inflating balloon-tipped perfu-ion cannulas in the arch vessels was performed in hybridatients, which we generally do not do in hemi-arch onlyatients. The lip of aorta containing the arch vessels isepaired with Teflon felt neomedia, which is extended ontohe proximal descending thoracic aorta to achieve proximalbliteration of the false lumen. The diameter of the proximalescending thoracic aorta had been measured from the pre-perative CT scan and (or) the intraoperative TEE. A Gore-AG (W. L. Gore & Associates, Flagstaff, AZ) thoracic aortictent-graft was chosen to be 10%-15% larger than the mea-

igure 2 Penn technique of hybrid type A dissection with hemi-archnd antegrade stent-graft deployment. (Color version of figure isvailable online at http://www.semthorcardiovascsurg.com.)

ured proximal aortic diameter. Early in our experience, 10

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m length grafts were chosen to limit paraplegia risk. Wehanged to 15 cm as this risk did not seem apparent. Ashown in Fig. 2, the stent-graft was deployed into the trueumen of the descending thoracic aorta under direct visionithout the use of a guidewire. The proximal scallops of theAG stent-graft were deployed to the origin of the left sub-lavian artery on the greater curve, and the edge of the re-ected aorta on the lesser curvature. The stent-graft is gentlyalloon-dilated along its entire length to achieve aortic appo-ition using a soft Foley catheter with a 30 mL balloon. Fix-tion of the stent-graft to the hemi-arch graft is accomplishedy placing multiple pledgeted sutures. The hemi-arch anas-omosis is completed in a standard fashion with the TAGtent-graft being incorporated into the arch suture line alonghe lesser curvature (Fig. 3). The new arch graft is directlyannulated for resumption of antegrade cardiopulmonaryypass and proximal reconstruction as requirement is com-leted.The flexibility of the Gore TAG graft and its speed of de-

loyment are advantageous. It also lacks bare springs orarbs which may cause injury to a freshly dissected aorta and

s symmetric allowing for antegrade deployment. The tem-erature-dependent flexibility of the stent metal may haveontributed to some of the failed false lumen obliteration ofhe stented thoracic aorta due to incomplete expansion dur-ng the hypothermic period. Placement of the TAG graft in aarm bath before deployment has been suggested,19 but weid not find a significant difference.Some authors have advocated a more aggressive approach

ith resection of the entire arch and distal stent-graft place-ent.20-22 Specially designed hybrid endograft prostheses,

uch as the E-Vita Open Plus (JOTEC, GmbH, Hechingen,

igure 3 Completion of the distal aortic anastomosis. (Color versionf figure is available online at http://www.semthorcardiovascsurg.om.)

ermany) or a similar hand-sewn versions have a distal stent- a

raft sealed to a proximal polyester graft for total arch re-lacement with a so-called “frozen elephant trunk” of stent-raft material extending into the descending thoracic aorta.he first commercially available hybrid arch stent-graft, the-Vita Open Plus prosthesis, is designed for total arch re-lacement (Fig. 4). In the technique described by Jakob etl20 in Essen, Germany, a stiff wire was advanced into theroximal descending aortic true lumen via the femoral arterysing TEE guidance. Standard circulation management tech-iques, including antegrade cerebral perfusion are used.pon initiation of circulatory arrest, the open arch is resectedeyond the innominate artery. An island patch of the headessels is maintained for later anastomosis. The previouslylaced wire is retrieved through the open arch and the de-cending thoracic aorta is sized using obturators. The E-Vitalus Open graft is placed over the guidewire and deployed

nto the descending thoracic aorta, beginning approximatelycm beyond the proximal extent of the transected thoracic

orta. Within the stent-graft, the inverted nonstented portionf the polyester graft is pulled back for arch reconstruction.he distal anastomosis is sewn to the proximal end of the

ransected descending thoracic aorta thereby creating thefrozen elephant trunk.” The arch vessels are sewn on assland patch and the proximal reconstruction is carried out asppropriate. The E-Vita graft is a flexible and versatile pros-hesis; however, the graft does require sealing with fibrin glueo decrease porosity in the open segment.

We recently published the University of Pennsylvania ex-erience with concomitant antegrade stent deployment inhe open distal aorta at the time of hemi-arch replacement forcute dissection.4 As part of a study protocol, we compared6 hybrid and 42 conventional hemi-arch repairs of DeBakeyype I dissection over a 3-year period. Initially, cases wereelected for this technique when the intimal tear extended or

igure 4 3D reconstruction of a fully thrombosed false lumen afterybrid stent-graft repair. (Color version of figure is available online

t http://www.semthorcardiovascsurg.com.)

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Distal aortic remodeling 391

riginated in the arch or descending thoracic aorta. Withxperience, one of 4 surgeons in the aortic surgery groupegan using the hybrid hemi-arch/stented elephant trunkechnique for the majority of DeBakey I aortic dissectionshile the other surgeons continued using only hemi-arch

eplacement. There were no differences in perioperative out-omes between stented hybrid and nonstented hemi-archepairs, including mortality (14% in both groups), strokehybrid, 3%; hemi-arch only, 10%, P � 0.3), postoperativeenal failure (17% in both groups), or spinal cord ischemiano permanent sequelae in either group, transient in 8% ofybrid and 2% of hemi-arch only cases). There was a slightlyigher incidence of gastrointestinal complications in the hy-rid group. Substantially more (80%) hybrid patients expe-ienced obliteration of the thoracic false lumen vs only 17%f control patients (P � 0.03). Also, open operation on theistal aorta over a 16-month follow-up period occurred in1% of hemi-arch only patients and no hybrid patients (P �.1). Conversely, no hemi-arch alone patients and 22% ofybrid patients underwent a second endovascular procedure

n the follow-up period (P � 0.001). This result was partiallyxplained by an aggressive approach to dealing with distalndoleaks in patients who did not fully thrombose the falseumen.

Similar results were obtained by Jakob et al20 using thesland patch total arch reimplantation technique using theybrid E-Vita prosthesis, with 89% and 10% false lumensbliterated for hybrid repairs and hemi-arch repairs, respec-ively (Fig. 5). Sun et al21 in Beijing, China recently reportedn 107 patients who underwent hybrid type A dissectionepair with a stent-graft (Microport, Medical Co. Ltd., Shang-ai, China) attached to a 4 branched polyester graft for use astotal arch/stented elephant trunk procedure. Selective an-

egrade cerebral perfusion was employed during the circula-ory arrest period. They reported 4.7% hospital mortality and1.9% incidence of paralysis. Over a 3-year follow-up pe-

iod, 95% of patients experienced thrombosis of the falseumen at the level of the stent-graft and 69% of patients hadhrombosed the false lumen at the level of the diaphragm.ixty-three percent of patients had positive remodeling of theortic wall with false lumen thrombosis, reabsorption, andhrinkage of overall aortic dimension to normal. Uchida etl22 in Hiroshima, Japan, reported 35 patients treated withotal arch replacement and stented elephant trunk for type A

Figure 5 Deployment of the Jotec E-Vita open prosthesifigure is available online at http://www.semthorcardiova

issection. Over 36 months, all patients had false lumen

hrombosis at the level of the stent-graft and two-thirds ofatients had thrombosis to the level of the diaphragm. Thereere no instances of spinal cord ischemia. Panos et al23 ineneva, Switzerland performed a hemi-arch repair with di-

ect antegrade deployment of the Endofit stent-graft (Endo-ed, Inc., Arizona) in 5 patients. In their technique, the

tent-graft was not incorporated into the distal suture line. Atyear, 4 of 5 patients had thrombosed the false lumen and

he other had partially thrombosed. No late dilatation wasbserved in this series.

onclusionsespite advances in surgical technique and perioperativeanagement, DeBakey type I aortic dissections continue toresent a significant management challenge. Although oper-tive outcomes have improved over time, a meaningful pro-ortion of patients in our practice have required furtheristal aortic intervention. Development of a procedurehat, without increasing operative mortality, can lead toealing more distal intimal tears, diminish malperfusion,nd mitigate late dilatation is attractive and feasible withurrently available technologies. Our preference, at thisoint, is to avoid the added complexity of total arch replace-ent and simply introduce an antegrade stent-graft into the

pen aorta with a standard hemi-arch completion. This sim-le procedure, which can be performed by most surgeonsamiliar with TEVAR and standard aortic dissection surgery,oes not significantly prolong the circulatory arrest periodnd is effective at sealing distal tears, re-expanding the trueumen, and causing false lumen thrombosis. Future deviceshat are highly flexible and designed for antegrade deploy-ent in a cold, bloodless field will facilitate this technique. Asith any new technique or technology, prospective clinical

tudies are required to truly determine safety and efficacy.

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