Antegrade Stent Grafting of Descending Thoracic Aorta During Acute Debakey I Dissection: Early and Midterm Outcomes Prashanth Vallabhajosyula MD, Joseph.

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Antegrade Stent Grafting of Descending Thoracic Aorta During Acute Debakey I Dissection: Early and Midterm Outcomes Prashanth Vallabhajosyula MD, Joseph E. Bavaria MD, Wilson Y. Szeto MD, Y Joseph Woo MD, Patrick Moeller BS, Nimesh Desai MDPhd,, Alberto Pochettino MD

Background Mortality for type A dissection repair has decreased in large volume centers. (10-15%) Early survival of uncomplicated type B dissection remains excellent with medical management alone. Late survival of patients with residual dissection after proximal repair (Debakey I) has not changed despite improved proximal techniques Late survival of chronic type B dissection managed medically mimics the survival of Debakey I dissections after proximal repair. Geirsson A, et al. Ann Thorac Surg Song JM, et al. J Am Coll Cardiol. 2007

Background Most mortality in chronic dissections is secondary to development of thoracoabdominal aortic aneurysm Maximal diameters and ruptures of such aneurysm are usually in the distal arch and proximal thoracic aorta. Stabilization of this “at risk” portion of the thoracic aorta should improve long term survival In less regulated environments specifically designed stent- graft/open graft devices have been used in treatment of both acute and chronic Debakey I dissection Jacob H, et al. Ann Thorac Surg Gorlitzer M, et al. Ann Thorac Surg 2007

Type A Dissections Between 1993 and present, 308 patients were surgically treated for Debakey Type I Acute Aortic dissection at our institution –256 underwent standard surgical treatment : Valve resuspension/root repair or replacement plus hemiarch replacement –52 underwent the same proximal repair with the additional of an aortic stent graft deployed via the open arch

Preoperative Demographics Stents (N=52)Controls (N=256)P Age59±1260±14.63 Previous CVA2 (4%)14 (5%).47 Diabetes7 (13%)24 (9%).57 Hypertension40 (77%)202 (79%).43 Chronic Renal Insufficiency3 (6%)19 (7%).47 CPB Time (m)230±37231±59.9 Circ. Arrest Time (m)58±1242±40.004

Antegrade Stent Grafting

Postoperative Events Stents (N=52)Control (N=256)P Deaths 6 (11%)35 (13.6%).43 Stroke 2 (4%)16 (6.25%).9 Spinal Cord Ischemia 6 (11%)0 Permanent 0 Transient/Reversible 6 Postop Renal Failure 10 (19%)38 (14%).56 Requiring Hemodialysis 3 (5%)24 (9%)

Stented Aorta Remodeling Outcomes CTA follow up postoperatively –46 surviving patients in stented group: CTA follow-up on 45 Anatomic outcomes –No patent false lumen or obliteration of the false lumen within the thoracic aorta in 37/45 patients (82%) –11 distal endovascular re-interventions (additional TEVAR)

Late Mortality Stented Traditional P=.195 between groups N at risk

Distal Open Reoperation involving the Descending Aorta Stented Traditional N at risk P=.105 between groups No open distal reinterventions in stented group

Conclusions Antegrade stent graft deployment during acute Debakey I dissection repair is a safe method to obliterate the thoracic false lumen (82% of Patients). Endovascular re-interventions were well tolerated and increased the rate of thoracic false lumen obliteration (Aortic Remodeling) “Elephant trunk” thoracic stent-grafting as part of the repair for acute Debakey I dissection, lowers the risk of distal aortic aneurysmal degeneration possibly decreasing morbidity and mortality during follow-up.