True Lumen Stabilization to Overcome Malperfusion in Acute Type I Aortic Dissection

• Published in: Seminars in thoracic and cardiovascular surgery 2019, Vol.31 (4), p.740-748
• Main Authors: Tsagakis, Konstantinos, Jánosi, Rolf A., Frey, Ulrich H., Schlosser, Thomas, Chiesa, Roberto, Rassaf, Tienush, Jakob, Heinz
• Format: Article
• Language: English
• Subjects: acute aortic dissection; Acute Disease; Adult; Aged; Aged, 80 and over; Aneurysm, Dissecting - diagnostic imaging; Aneurysm, Dissecting - physiopathology; Aneurysm, Dissecting - surgery; Aortic Aneurysm, Thoracic - diagnostic imaging; Aortic Aneurysm, Thoracic - physiopathology; Aortic Aneurysm, Thoracic - surgery; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - instrumentation; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Female; frozen elephant trunk; Humans; Ischemia - diagnostic imaging; Ischemia - physiopathology; Ischemia - surgery; Male; malperfusion; Middle Aged; Prosthesis Design; Regional Blood Flow; Risk Factors; stenting; Stents; Time Factors; Treatment Outcome
• ISSN: 1043-0679; 1532-9488
• DOI: 10.1053/j.semtcvs.2018.11.012

Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean ± standard deviation 3.44 ± 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen.