Antegrade thoracic stent grafting during repair of acute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms

Alberto Pochettino, William T Brinkman, Patrick Moeller, Wilson Y Szeto, William Moser, Katherine Cornelius, Frank W Bowen, Y Joseph Woo, Joseph E Bavaria
Annals of Thoracic Surgery 2009, 88 (2): 482-9; discussion 489-90

BACKGROUND: Acute DeBakey I dissection repair consists of ascending aortic resection, aortic root repair or replacement, and variable aortic arch replacement. This "proximal" strategy leaves most patients with a patent residual "type B" dissection which leads to greater than 30% distal "open" reoperations for dissecting aneurysm. This report tests whether antegrade stent-grafting of the proximal descending thoracic aorta during acute DeBakey I dissection decreases future distal aortic aneurysms without an increase in surgical risk.

METHODS: Between June 2005 and June 2008, 150 patients were treated surgically for acute type A aortic dissection at the Hospital of the University of Pennsylvania. Of these, 78 were DeBakey I dissections: 42 patients underwent standard open repair, while 36 underwent additional thoracic stent-grafting by the open arch. Arch repairs were performed with a combination of retrograde cerebral and selective antegrade perfusion.

RESULTS: Mean follow-up was 15.9 months. Hospital mortality was 5 of 36 (14%) for stented and 6 of 42 (14%) for nonstented repairs. Postoperative strokes were 1 of 36 (3%) in stented versus 4 of 42 (10%) in nonstented repairs (p = not significant [NS]) despite longer circulatory arrest times in the stented group; 60 +/- 13 minutes versus 41 +/- 18 minutes (p < 0.0001). Transient paraparesis was 3 of 36 (9%) in the stented versus 1 of 42 (2%) in the nonstented group (p = NS) with no permanent deficits. Stented thoracic false lumen obliteration was achieved in 24 of 30 (80%) with 5 of these (17%) achieving complete thoracoabdominal false lumen thrombosis. Eight of 31 (26%) stented patients underwent endovascular reintervention to achieve the desired false lumen obliteration. Open thoracoabdominal aortic aneurysm repairs were performed in 0 of 31 in the stented group and 4 of 36 (11%) in the standard group (p = 0.083).

CONCLUSIONS: Antegrade stent graft deployment during acute DeBakey I dissection repair is a safe method to obliterate the thoracic false lumen. Endovascular reinterventions were well-tolerated. "Elephant trunk" thoracic stent-grafting as part of the repair for acute DeBakey I dissection gives equal short-term results compared with standard repair, and lowers morbidity and mortality during follow-up.

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