Surgical Treatment Strategies in Type A Aortic Arch Dissection
Surgical Treatment Strategies in Type A Aortic Arch Dissection
The development of endovascular techniques has allowed surgeons to pursue novel strategies in an effort to further reduce the risk associated with surgery for acute type A dissection, and to address the residual type B dissection.
As experience with deploying stents in the proximal aorta increases, isolated endovascular repair of type A dissection may become a realistic possibility. Two recent studies evaluated pre-operative CT findings and found that up to 30–50% of patients may be candidates for an isolated endovascular approach. Anecdotal case reports of isolated TEVAR for acute type A dissection have been published, leading to the possibility of isolated ascending aortic TEVAR becoming a viable treatment option for patients previously considered too high risk for surgery.
Availability of off-the-shelf branched endovascular grafts and a hybrid suite may further advance the management of acute aortic dissection. In the future, we envision a strategy of complete endovascular repair in a proportion of cases. Whether this can improve short- and long-term results will need to be determined. We propose that a second, more likely option might involve open ascending aortic replacement with Dacron graft, and formal surgical attention to valve reconstruction, coronary arteries and pericardial effusion followed by branched endovascular repair of the arch. Timing of endovascular deployment could be immediate at the time of ascending aortic replacement or delayed based on a more refined understanding of risk factors for early and late complications. This type of strategy would simplify the current hybrid operations by removing the need to further de-branch the arch. Strategies such as these emphasize the need for cardiac surgeons to be trained in endovascular aortic surgery and help define future treatment algorithms. At our center, all thoracic endovascular cases are done by a collaborative team consisting of interventional radiology, cardiac surgery, and cardiac anesthesiology. We have found benefits to having more than one perspective in the treatment of these patients.
Future Strategies to Address the Arch at Time of Type A Repair
The development of endovascular techniques has allowed surgeons to pursue novel strategies in an effort to further reduce the risk associated with surgery for acute type A dissection, and to address the residual type B dissection.
As experience with deploying stents in the proximal aorta increases, isolated endovascular repair of type A dissection may become a realistic possibility. Two recent studies evaluated pre-operative CT findings and found that up to 30–50% of patients may be candidates for an isolated endovascular approach. Anecdotal case reports of isolated TEVAR for acute type A dissection have been published, leading to the possibility of isolated ascending aortic TEVAR becoming a viable treatment option for patients previously considered too high risk for surgery.
Availability of off-the-shelf branched endovascular grafts and a hybrid suite may further advance the management of acute aortic dissection. In the future, we envision a strategy of complete endovascular repair in a proportion of cases. Whether this can improve short- and long-term results will need to be determined. We propose that a second, more likely option might involve open ascending aortic replacement with Dacron graft, and formal surgical attention to valve reconstruction, coronary arteries and pericardial effusion followed by branched endovascular repair of the arch. Timing of endovascular deployment could be immediate at the time of ascending aortic replacement or delayed based on a more refined understanding of risk factors for early and late complications. This type of strategy would simplify the current hybrid operations by removing the need to further de-branch the arch. Strategies such as these emphasize the need for cardiac surgeons to be trained in endovascular aortic surgery and help define future treatment algorithms. At our center, all thoracic endovascular cases are done by a collaborative team consisting of interventional radiology, cardiac surgery, and cardiac anesthesiology. We have found benefits to having more than one perspective in the treatment of these patients.
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