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Novel and Innovative Hybrid Technique for Type A Aortic Dissection
Published on: March 28, 2025
One-stage repair of extensive thoracic aortic disease
1Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare System, St Louis, MO, USA. ntkouch@aol.com
Insights
A one-stage surgical repair of extensive thoracic aortic disease, prioritizing the aortic arch, offers a safe alternative to staged procedures. This approach reduces mortality associated with multiple operations and interval aortic rupture.
Area of Science:
- Cardiovascular Surgery
- Thoracic Aortic Disease Management
- Aortic Aneurysm and Dissection Repair
Background:
- Staged procedures for extensive thoracic aortic disease carry high cumulative mortality.
- Aortic rupture is a significant risk between staged surgical interventions.
- A novel one-stage approach aims to mitigate these risks.
Purpose of the Study:
- To evaluate the safety and efficacy of a one-stage surgical technique for extensive thoracic aortic disease.
- To compare the outcomes of the one-stage approach against traditional staged procedures.
- To assess the feasibility of repairing most or all of the thoracic aorta in a single operation.
Main Methods:
- Ninety-five patients underwent a one-stage repair using bilateral anterior thoracotomy and transverse sternotomy.
- Hypothermic circulatory arrest with early reperfusion of arch vessels was employed to minimize brain ischemia.
- Procedures included replacement of the ascending aorta and aortic arch, with resection of the descending aorta.
Main Results:
- In-hospital mortality was 8.4%.
- Key morbidities included reoperation for bleeding (11%), prolonged ventilation (48%), tracheostomy (17%), and renal dialysis (8%).
- Stroke occurred in only 1% of patients, with 7.6% requiring reoperation for graft or aortic issues post-discharge.
Conclusions:
- The one-stage, arch-first technique is a safe and suitable alternative for thoracic aortic disease repair.
- This method potentially reduces the risks associated with staged interventions.
- Long-term effectiveness compared to hybrid procedures requires further investigation.
Objective:
Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with substantial cumulative mortality for the 2 procedures and death in the interval in between, often from aortic rupture. We have used a 1-stage procedure for operative repair of most, or all, of the thoracic aorta.
Methods:
Ninety-five patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Fifty-six patients had chronic type A aortic dissections (all but 2 patients had a previous operation), 36 patients had degenerative aneurysms, and 3 patients had chronic type B aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of varying lengths of descending aorta.
Results:
In-hospital mortality was 8.4% (8 patients). Morbidity included reoperation for bleeding (11%), mechanical ventilation for more than 72 hours (48%), tracheostomy (17%), and renal dialysis (8%). Stroke occurred in 1 patient (1%). Seven of the 93 operative survivors (7.6%) have undergone successful reoperation on the graft (4 patients) or the contiguous aorta (3 patients).
Conclusions:
The 1-stage, arch-first technique is a safe and suitable alternative to 2-stage procedures for repair of thoracic aortic disease. Its effectiveness relative to more recently developed hybrid procedures awaits further analysis of long-term performance.
