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Central Repair With Antegrade TEVAR for Malperfusion Syndromes in Acute Debakey I Aortic Dissection
Prashanth Vallabhajosyula1, Jean Paul Gottret1, Rohan Menon1
1Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Adding thoracic endovascular aneurysm repair (TEVAR) to standard aortic dissection repair may improve survival in patients with malperfusion syndromes. This approach can be safely performed, potentially stabilizing the true lumen and benefiting those with multiorgan malperfusion.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Acute DeBakey I aortic dissection can present with life-threatening malperfusion syndromes.
- Standard open repair is the conventional treatment, but outcomes in complex cases remain a concern.
Purpose of the Study:
- To assess the efficacy of standard open repair combined with thoracic endovascular aneurysm repair (TEVAR) versus standard repair alone for acute DeBakey I aortic dissection with malperfusion.
- To evaluate the impact of TEVAR on patient outcomes, including mortality, stroke, paraplegia, and renal failure.
Main Methods:
- A retrospective review of a prospectively maintained aortic dissection database from 2005 to 2012.
- 104 patients with acute DeBakey I dissection and end-organ malperfusion were analyzed.
- Patients were divided into a Standard group (n=65) and a TEVAR group (n=39) receiving concomitant DTA TEVAR.
Main Results:
- Postoperative stroke, paraplegia, and renal failure rates were similar between groups.
- While in-hospital/30-day mortality was not significantly different, the TEVAR group showed a trend toward lower mortality (18% vs. 34%).
- A significant survival benefit was observed in the TEVAR group for patients with malperfusion involving multiple organ systems (28% vs. 58% mortality).
Conclusions:
- Standard repair with antegrade TEVAR for DeBakey I aortic dissection with malperfusion is a safe procedure.
- TEVAR may offer a survival advantage in patients with distal multiorgan malperfusion by stabilizing the true lumen.
Background:
In acute DeBakey I aortic dissection presenting with malperfusion syndromes, we assessed whether standard open repair with concomitant antegrade stent grafting (thoracic endovascular aneurysm repair; TEVAR) of the descending thoracic aorta (DTA) improves outcomes compared with standard repair alone.
Methods:
From 2005 to 2012, 277 patients with acute DeBakey I dissection underwent emergent operation. Of these, 104 patients (37%) presenting with end-organ malperfusion were divided into those undergoing standard distal repair entailing transverse hemiarch replacement (Standard group, n = 65) versus standard repair with concomitant DTA TEVAR during circulatory arrest (TEVAR group, n = 39). Prospectively maintained aortic dissection database was retrospectively reviewed.
Results:
Demographic characteristics and preoperative comorbidities were similar. Circulatory arrest (56 ± 12 versus 34 ± 14 minutes, p < 0.001) and cross-clamp (176 ± 43 versus 119 ± 80, p = 0.001) times were longer in the TEVAR group. Overall, postoperative stroke rate (5% [n = 2] versus 6% [n = 4], p = 1), paraplegia rate (5% [n = 2] versus 5% [n = 3], p = 1.0), and renal failure rate (10% [n = 4] versus 22% [n = 14], p = 0.2) were similar. In-hospital/30-day mortality rate was lower in the TEVAR group but was not significant (18% (n = 7) versus 34% [n = 22], p = 0.1). In patients presenting with malperfusion involving greater than one end-organ system, the mortality rate was significantly improved in the TEVAR group (28% [n = 6] versus 58% [n = 14], p = 0.05).
Conclusions:
Standard repair with antegrade TEVAR of the DTA for acute DeBakey I aortic dissection presenting with malperfusion syndromes can be safely performed. Further, true lumen stabilization achieved through DTA TEVAR may provide a survival benefit in patients with distal multiorgan malperfusion.
