Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch.

BACKGROUND: In acute type A dissection, replacing the ascending aorta with the transverse aortic arch recently has been recommended for event-free long-term survival. Since 1994, we have performed our new transverse aortic arch replacement, in which the distal end of the graft is anastomosed between the left common carotid artery and the left subclavian artery to reduce the risk by obtaining a good surgical view, resulting in good hemostasis. The "elephant trunk technique" was used in anticipation of a staged descending aortic operation for residual dissecting aorta. We analyzed the surgical survival of patients with Stanford type A aortic dissection undergoing our operative procedure using hypothermic selective antegrade cerebral perfusion.

METHODS: We performed our new technique in 27 patients (aged 61 +/- 11 years, 15 male and 12 female patients, 22 patients with acute type A dissection, and 5 patients with chronic dissection).

RESULTS: One in-hospital death (3.7% in total: 4.5% in acute dissection, 0% in chronic dissection) occurred in patients undergoing our new technique. Actuarial survival (including early death) was 91% at 5 years after the operation. One late death occurred as the result of a malignant tumor. Four patients underwent a staged reoperation for aneurysmal dilatation of the residual descending aorta or renal and splenic embolism as the result of thrombus from the false lumen 2 to 11 months (mean interval 6 months) after the initial operation. They have been doing well since the reoperation.

CONCLUSIONS: Our "distal anastomosis to the proximal level of the distal aortic arch" technique made aortic arch replacement easier and improved the survival of the arch replacement for aortic dissection, especially for acute type A dissection, by securing hemostasis in the suture line. Combining the elephant trunk technique with our new procedure is useful to perform a staged aortic replacement for dilatation and complication of the false lumen in the descending aorta.