Antegrade stenting of the descending thoracic aorta during DeBakey type 1 acute aortic dissection repair
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Published on: March 28, 2025
Marco Di Eusanio1, Sebastiano Castrovinci2, David H Tian3
1Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy The Collaborative Research (CORE) Group, Sydney, Australia marco.dieusanio2@unibo.it.
Insights
Antegrade stenting of the descending thoracic aorta (DTA) after DeBakey type 1 acute aortic dissection (DB1-AAD) surgery shows promise for false lumen obliteration. However, long-term outcomes and risks like spinal cord injury require further investigation.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Thoracic Surgery
Background:
- DeBakey type 1 acute aortic dissection (DB1-AAD) often leaves a dissected distal aorta, risking dilation, rupture, or malperfusion.
- Secondary interventions are frequently required for persistent distal aortic issues post-DB1-AAD surgery.
- Total thoracic aorta remodeling, including antegrade stenting, aims to improve outcomes but faces controversy regarding operative risks and unconfirmed long-term benefits.
Purpose of the Study:
- To evaluate the efficacy and safety of antegrade stenting of the descending thoracic aorta (DTA) during primary repair for DB1-AAD.
- To assess in-hospital mortality, morbidity, and long-term outcomes including aortic remodeling and reintervention rates.
Main Methods:
- Systematic review and analysis of existing studies on hybrid repair of DB1-AAD with antegrade DTA stenting.
- Focus on early outcomes: in-hospital mortality, stroke, and spinal cord injury.
- Evaluation of late outcomes: false lumen thrombosis, aortic remodeling, and freedom from reintervention.
Main Results:
- Hybrid repair with antegrade DTA stenting demonstrated acceptable in-hospital mortality (10.0%) and stroke rates (4.8%).
- Spinal cord injury risk was noted to be higher (4.3%) compared to historical controls.
- Promising rates of false lumen thrombosis (88.9%) in the persistent DTA were observed, suggesting potential for aortic remodeling.
Conclusions:
- Antegrade DTA stenting in DB1-AAD offers encouraging early results for false lumen obliteration and remodeling.
- While in-hospital outcomes are satisfactory, the increased risk of spinal cord injury warrants careful consideration.
- Further long-term studies are essential to confirm the sustained benefits and definitive safety profile of this approach.
Abstract:
Several studies have shown that after DeBakey type 1 acute aortic dissection (DB1-AAD) surgery, 70% of the surviving patients still present with a dissected distal aorta that can eventually dilate, rupture, lead to distal malperfusion or require secondary extensive interventions. In order to minimize these complications, different surgeons have advocated total thoracic aorta remodelling procedures during primary aortic repair to promote false-lumen obliteration and distal thrombosis. Such management, which includes arch replacement and antegrade stenting of the dissected descending thoracic aorta (DTA), remains controversial due to its perceived increased operative mortality. Furthermore, the desired long-term benefits remain to be confirmed. The present article aimed to evaluate results of antegrade stenting of DTA during surgery for DB1-AAD, focusing on in-hospital mortality and morbidity, and long-term survival, occurrence of distal aortic remodelling and freedom from aortic reinterventions. Early results from the identified studies suggested that hybrid repair of DB1-AAD with antegrade DTA stenting was associated with satisfactory in-hospital mortality (10.0%) and stroke (4.8%) rates, while the risk of spinal cord injury appeared to be higher (4.3%) than that reported from historical controls. Furthermore, antegrade stenting of DTA was associated with promising rates of partial/complete thrombosis of the peristent DTA false lumen (88.9%), suggesting that aortic remodelling is highly probable with this approach. Evidence on long-term results after proximal acute dissection repair is still sparse, and mostly jeopardized by limited data beyond 5 years. Further investigations with longer term follow-up and with specifically designed protocols to assess long-term clinical outcomes (late aortic mortality and freedom from distal aortic reinterventions) of total thoracic aortic remodelling procedures vs more conservative management are warranted to reach more definitive conclusions.
