Surgery for acute type A dissection with the tear in the descending aorta using a stented elephant trunk procedure

Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure.

Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography.

Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up.

Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.