Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Change of Proximal Descending Aortic False Lumen after Conventional Repair of Acute Type I Dissection: Is It Always Unfavorable?

  • Kim, Sue Hyun (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Kim, Jun Sung (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Shin, Yoon Cheol (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Kim, Dong Jung (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Lim, Cheong (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • Park, Kay-Hyun (Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine)
  • Received : 2014.09.12
  • Accepted : 2014.10.27
  • Published : 2015.08.05
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Abstract

Background: Some patients show favorable changes in the descending aortic false lumen after conventional repair of acute type A dissection, although the incidence of favorable changes has been reported to be low. We aimed to investigate the incidence of positive postoperative changes in the false lumen and the factors associated with positive outcomes. Methods: In 63 patients who underwent surgery for type A acute dissection as well as serial computed tomography (CT) scanning, morphological parameters were compared between the preoperative, early postoperative (mean interval, 5.4 days), and late CT scans (mean interval, 31.0 months) at three levels of the descending thoracic aorta. Results: In the early postoperative CT images, complete false lumen thrombosis and/or true lumen expansion at the proximal descending aorta was observed in 46% of the patients. In the late images, complete thrombosis or resolution of the proximal descending false lumen occurred in 42.9% of the patients. Multivariate analysis found that juxta-anastomotic false lumen thrombosis was predictive of favorable early changes, which were in turn predictive of continuing later improvement. Conclusion: Even after conventional repair without inserting a frozen elephant trunk, the proximal descending aortic false lumen showed positive remodeling in a substantial number of patients. We believe that the long-term prognosis of type A dissection can be improved by refining surgical technique, and particularly by avoiding large intimal tears at the anastomosis site during the initial repair.

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References

  1. Heinemann M, Laas J, Karck M, Borst HG. Thoracic aortic aneurysms after acute type A aortic dissection: necessity for follow-up. Ann Thorac Surg 1990;49:580-4. https://doi.org/10.1016/0003-4975(90)90304-O
  2. Bachet J, Goudot B, Dreyfus GD, et al. Surgery for acute type A aortic dissection: the Hopital Foch experience (1977-1998). Ann Thorac Surg 1999;67:2006-9. https://doi.org/10.1016/S0003-4975(99)00433-6
  3. Kirsch M, Soustelle C, Houel R, Hillion ML, Loisance D. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002;123:318-25. https://doi.org/10.1067/mtc.2002.119702
  4. Immer FF, Krahenbuhl E, Hagen U, et al. Large area of the false lumen favors secondary dilatation of the aorta after acute type A aortic dissection. Circulation 2005;112(9 Suppl): I249-52.
  5. Yeh CH, Chen MC, Wu YC, Wang YC, Chu JJ, Lin PJ. Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection. Chest 2003;124:989-95. https://doi.org/10.1378/chest.124.3.989
  6. Liu ZG, Sun LZ, Chang Q, et al. Should the "elephant trunk" be skeletonized?: total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection. J Thorac Cardiovasc Surg 2006;131:107-13. https://doi.org/10.1016/j.jtcvs.2005.09.015
  7. 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;131:862-7. https://doi.org/10.1016/j.jtcvs.2005.08.061
  8. Park KH, Lim C, Choi JH, et al. Midterm change of descending aortic false lumen after repair of acute type I dissection. Ann Thorac Surg 2009;87:103-8. https://doi.org/10.1016/j.athoracsur.2008.09.032
  9. Halstead JC, Meier M, Etz C, et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007;133:127-35. https://doi.org/10.1016/j.jtcvs.2006.07.043
  10. Sueyoshi E, Sakamoto I, Hayashi K, Yamaguchi T, Imada T. Growth rate of aortic diameter in patients with type B aortic dissection during the chronic phase. Circulation 2004; 110(11 Suppl 1):II256-61.
  11. Fattori R, Bacchi-Reggiani L, Bertaccini P, et al. Evolution of aortic dissection after surgical repair. Am J Cardiol 2000;86:868-72. https://doi.org/10.1016/S0002-9149(00)01108-5
  12. Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001;87:1378-82. https://doi.org/10.1016/S0002-9149(01)01556-9
  13. Bachet JE, Termignon JL, Dreyfus G, et al. Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994;108:199-205.
  14. Immer FF, Hagen U, Berdat PA, Eckstein FS, Carrel TP. Risk factors for secondary dilatation of the aorta after acute type A aortic dissection. Eur J Cardiothorac Surg 2005;27: 654-7. https://doi.org/10.1016/j.ejcts.2004.11.031
  15. Guthaner DF, Miller DC, Silverman JF, Stinson EB, Wexler L. Fate of the false lumen following surgical repair of aortic dissections: an angiographic study. Radiology 1979;133:1-8. https://doi.org/10.1148/133.1.1
  16. Miyamoto S, Hadama T, Anai H, et al. Simplified elephant trunk technique promotes thrombo-occlusion of the false lumen in acute type A aortic dissection. Ann Thorac Cardiovasc Surg 2006;12:412-6.
  17. Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications. Circulation 1998;98(19 Suppl):II299-302.
  18. Ando M, Takamoto S, Okita Y, Morota T, Matsukawa R, Kitamura S. Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg 1998;66:82-7. https://doi.org/10.1016/S0003-4975(98)00349-X
  19. Ergin MA, Phillips RA, Galla JD, et al. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994;57:820-4. https://doi.org/10.1016/0003-4975(94)90182-1
  20. Watanuki H, Ogino H, Minatoya K, et al. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 2007;84:1585-91. https://doi.org/10.1016/j.athoracsur.2007.06.045
  21. Takahara Y, Sudo Y, Mogi K, Nakayama M, Sakurai M. Total aortic arch grafting for acute type A dissection: analysis of residual false lumen. Ann Thorac Surg 2002;73:450-4. https://doi.org/10.1016/S0003-4975(01)03422-1
  22. Ando M, Nakajima N, Adachi S, Nakaya M, Kawashima Y. Simultaneous graft replacement of the ascending aorta and total aortic arch for type A aortic dissection. Ann Thorac Surg 1994;57:669-76. https://doi.org/10.1016/0003-4975(94)90565-7
  23. Bachet J, Teodori G, Goudot B, et al. Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection: report of 26 cases. J Thorac Cardiovasc Surg 1988;96:878-86.
  24. Kazui T, Kimura N, Yamada O, Komatsu S. Total arch graft replacement in patients with acute type A aortic dissection. Ann Thorac Surg 1994;58:1462-8. https://doi.org/10.1016/0003-4975(94)91936-4
  25. Shimamura K, Kuratani T, Matsumiya G, et al. Long-term results of the open stent-grafting technique for extended aortic arch disease. J Thorac Cardiovasc Surg 2008;135:1261-9. https://doi.org/10.1016/j.jtcvs.2007.10.056
  26. Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stentgrafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002;74:S1821-4. https://doi.org/10.1016/S0003-4975(02)04131-0
  27. Flores J, Kunihara T, Shiiya N, Yoshimoto K, Matsuzaki K, Yasuda K. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg 2006;131:336-42. https://doi.org/10.1016/j.jtcvs.2005.09.050