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J Thorac Cardiovasc Surg 2009;138:1358-1362
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Experience with 107 patients

^a Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
^b Department of Cardiovascular Surgery, Tianjin Cardiovascular Institute and Tianjin Chest Hospital, Tianjin, China
^c Department of Radiology, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China

Received for publication December 19, 2008; revisions received March 31, 2009; accepted for publication April 17, 2009.

^_* Address for reprints: Li-Zhong Sun, MD, Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, 167 Beilishi Road, Beijing, 100037, China. (Email: slzh_2005{at}yahoo.com.cn).

Objective: In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation.

Methods: Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 ± 11 years; range, 17–78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up.

Results: Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 ± 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100).

Conclusion: Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.

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