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J Thorac Cardiovasc Surg 2006;132:734-735
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

A new surgical paradigm: Hybrid open and endovascular repair of the ascending aorta and aortic arch for acute type A dissection

Arizona Heart Institute, Phoenix, Ariz

To the Editor:

I read with interest the editorial by Dobrilovic and Elefteriades¹ reflecting on the potential future application of simultaneous hybrid endoluminal graft repair of the descending thoracic aorta after traditional open surgical repair of the ascending aorta and aortic arch for acute type A aortic dissection, as discussed in the article by Uchida and associates.²

Although the results reported by Uchida and associates² are noteworthy, stabilizing the true lumen in the descending thoracic aorta with an endoluminal graft after total aortic arch replacement may not be the final, or best, approach for acute type A aortic dissection. The current surgical paradigm is to treat the ascending aortic and arch pathology in the standard open surgical fashion and follow the progression of the descending thoracic aorta. As Dobrilovic and Elefteriades¹ expertly point out, expansion of the descending thoracic aorta after acute type A dissection may be a slow process. There may, however, be additional reasons to consider simultaneous hybrid repair in this situation.

Total arch replacement involves the use of deep hypothermic circulatory arrest (DHCA). The increased risks associated with this technique have been well documented, and eliminating DHCA for the treatment of acute Type A aortic dissections would potentially make this a safer and better tolerated procedure. Another alternative hybrid approach would be to repair the entry point tear in the ascending aorta with standard open surgical techniques (interposition graft or ascending conduit) and simultaneously bypass the great vessels with grafts off the newly completed ascending aortic graft. Simultaneous deployment of an endoluminal graft in an antegrade fashion through the ascending graft, across the aortic arch, and into the proximal descending thoracic aorta would accomplish a total arch reconstruction without the need for DHCA.³ This approach maximizes the advantages of endovascular technologies by making a complex procedure less invasive while stabilizing the true lumen of the descending thoracic aorta. We have shown that stabilizing the true lumen in the descending thoracic aorta is an active process that in time leads to progressive expansion of the true lumen and continued thrombosis of the false lumen.⁴ In addition to potentially preventing future complications and need for reoperation, stabilization of the true lumen and continued active true lumen expansion after thoracic endografting can potentially improve distal organ perfusion.

Hybrid approaches to complex aortic pathologies may allow us to offer surgical repair to patients with acute type A aortic dissection who might not otherwise tolerate DHCA. The less invasive advantages of simultaneous arch exclusion with an endoluminal graft after great vessel transposition could accelerate patient recovery and provide the added potential advantage of distal true lumen stabilization. I therefore believe that the surgical paradigm may be shifting toward hybrid approaches, not away from them.

	References

Top References

 

1. Dobrilovic N, Elefteriades JA. Stenting the descending aorta during repair of type A dissection. technology looking for an application?. J Thorac Cardiovasc Surg. 2006;131:777-778.[Free Full Text]
   
2. Uchida N, Ishihara H, Shibamura H, Kyo Y, Ozawa M. Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type A aortic dissection. J Thorac Cardiovasc Surg 2006;131:862-867.[Abstract/Free Full Text]
   
3. Diethrich EB, Ghazoul M, Wheatley GH, Alpern J, Rodriguez-Lopez J, Ramaiah V, et al. Surgical correction of ascending type a thoracic aortic dissection. simultaneous endoluminal exclusion of the arch and distal aorta. J Endovasc Ther 2005;12:660-666.[Medline]
   
4. Nathanson DR, Rodriguez-Lopez JA, Ramaiah VG, Williams J, Olsen DM, Wheatley GH, et al. Endoluminal stent-graft stabilization for thoracic aortic dissection. J Endovasc Ther 2005;12:345-349.
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Wheatley, G. H. Search for Related Content PubMed PubMed Citation Articles by Wheatley, G. H., III Related Collections Cardiac - other Related Article