George Matalanis, BSc, MB, MS, FRACS, Shoane Ip, MBBS, BMedSc, FRACS

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Presentation transcript:

A new paradigm in the management of acute type A aortic dissection: Total aortic repair George Matalanis, BSc, MB, MS, FRACS, Shoane Ip, MBBS, BMedSc, FRACS The Journal of Thoracic and Cardiovascular Surgery Volume 157, Issue 1, Pages 3-11 (January 2019) DOI: 10.1016/j.jtcvs.2018.08.118 Copyright © 2018 Terms and Conditions

The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 1 Total aortic repair for acute type A aortic dissection commences with total arch replacement using the branch-first technique. In suitable patients, the second stage is implemented. This consists of covered stent grafting of the upper two-thirds of the descending aorta and uncovered stent grafting of the remaining thoraco-abdominal aorta. A complete septal fenestration using an angioplasty balloon is performed, from the junction of the covered and uncovered stent grafts, down to the aortic bifurcation. Visceral or iliac branch realignment is performed with covered stent grafts when required. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 2 After the establishment of cardiopulmonary bypass, the “branch-first” aortic arch reconstruction proceeds as follows: A, the innominate artery is clamped proximal to its bifurcation and distal to its origin from the arch. Right hemispheric cerebral perfusion is maintained through the left common carotid and subclavian arteries via collateral channels. Apart from the circle of Willis, there is a plethora of extracranial collateral channels that augment cerebral perfusion during individual clamping of branch vessels. These include collateral channels between the external and internal carotid arteries; the right and the left carotid arteries; the upper and lower body; and the subclavian and carotid arteries4; B, the innominate stump is ligated and the anastomosis to the first limb of the branched graft completed; C, antegrade right hemispheric cerebral perfusion is resumed via the perfusion side arm. Left hemispheric cerebral perfusion during construction of the left common carotid anastomosis is maintained via the same collaterals described previously; D, subclavian anastomosis is completed and all 3 arch branches are perfused; E, anastomosis of the arch graft to the distal arch. Note that the distal anastomoses can be performed in Zone 2, which is usually better-quality tissue, allows improved access to the anastomoses, and reduces the risk of recurrent laryngeal nerve injury. Antegrade flow is recommenced via the “ante flow” side arm of the graft. After completion of the root anastomosis, connection of the trifurcation arch graft with side perfusion port (TAPP graft) to the ascending graft proceeds without interruption of cerebral perfusion. Copyright Beth Croce, Bioperspective.com. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 3 A, A covered stent graft (Zenith TX2 TAA 112 Endovascular Graft, Cook Medical Inc, Bloomington, Ind) is introduced and positioned within the predesigned Dacron proximal landing zone. B, The first stent is deployed so that the distal end is positioned at the junction of middle and upper third of the descending thoracic aorta. Further covered stent grafts can be deployed down to the diaphragm/celiac trunk if required but increased coverage is associated with increased risk of spinal cord injury. C, Digital subtraction angiography demonstrating the covered stent extending from the Dacron landing zone into the upper descending aorta. Copyright Beth Croce, Bioperspective.com. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 4 The remaining thoracic (A) and abdominal (B) aorta down to the aortic bifurcation is then lined with bare metal uncovered stent grafts (Zenith Dissection Endovascular Stent, Cook Medical Inc). C, Deployment of the uncovered stent graft with small overlap of previous stent. Copyright Beth Croce, Bioperspective.com. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 5 An angioplasty balloon (Coda Balloon Catheter, Cook Medical Inc) is then used to sequentially expand the bare metal stents and rupture the septum between the TL and FL to create a single aortic channel. Copyright Beth Croce, Bioperspective.com. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 6 A, This patient also required stent grafting to the left renal artery and left common iliac artery. At the conclusion of the procedure, aortography is performed and the patency of the aortic lumen and the visceral and other branch vessels are confirmed. B, Digital subtraction angiography demonstrating restoration of flow to left renal artery after visceral branch stenting. Copyright Beth Croce, Bioperspective.com. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Figure 7 A, Computed tomography (CT) aortogram at 4 years post total aortic repair for acute type A aortic dissection with 3-dimensional reconstruction demonstrating a stable aorta with no false lumen patency. B, CT aortogram of visceral branches including left renal artery stent. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Total aortic repair: “branch first” total arch replacement and thoracoabdominal stenting. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

Video 1 Balloon dilation of bare metal stent, showing rupture of septum. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32616-3/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions

The Journal of Thoracic and Cardiovascular Surgery 2019 157, 3-11DOI: (10.1016/j.jtcvs.2018.08.118) Copyright © 2018 Terms and Conditions