1. Giampiero Esposito MD 2010-A-10-AATS Cardiovascular Surgery Unit CITTA’ DI LECCE HOSPITAL - ITALY GVM Hospitals of Care and Research Hybrid Approach to Type A acute aortic dissection: the Lupiae technique.

3. HYBRID TWO-STAGE “LUPIAE TECHNIQUE” Visceral vessels CT & SMA

4. Conception of HYBRID Two-Stage Strategy “LUPIAE TECHNIQUE” in Type A A.D.(De Bakey I) Intended two stage repair of Type A Aortic Dissection with “complicated” residual false lumen by combining ascending aorta, arch replacement and debranching of epiaortic vessels using a New Multibranched Dacron Prosthesis with subsequent retrograde transfemoral Stent grafting

5. HYBRID Two-Stage Strategy “LUPIAE TECHNIQUE” in Extensive Type A A.D. 1.“Easy” surgical procedure Easy distal OPEN anastomosisEasy distal OPEN anastomosis Short circulatory arrest timeShort circulatory arrest time Easy debranching of BCT, LCA, LSAEasy debranching of BCT, LCA, LSA 2.“Ideal” proximal landing zone Safe, Long, StableSafe, Long, Stable 3.“Easy” subsequent endovascular procedure Optimized sealingOptimized sealing Minimized risk of Type I endoleakMinimized risk of Type I endoleak False lume exclusionFalse lume exclusion OBJECTIVES

6. OPERATIVE METHODS in Type A Aortic Dissection LUPIAE Technique Rapid transfer to the operating room after diagnosis (TTE, CT-scan) Rapid transfer to the operating room after diagnosis (TTE, CT-scan) Intraoperative TEE to confirm diagnosis and plane type of surgery Intraoperative TEE to confirm diagnosis and plane type of surgery Arterial cannulation by right axillary artery, brachiocephalic trunk Arterial cannulation by right axillary artery, brachiocephalic trunk or left ventricular apex or left ventricular apex Cooling at 28°C, ascending aortic clamp, myocardial protection (Custodiol) Cooling at 28°C, ascending aortic clamp, myocardial protection (Custodiol) AVA resuspension, proximal aortic reconstruction AVA resuspension, proximal aortic reconstruction Circulatory arrest with cerebral anterograde perfusion and distal aortic Circulatory arrest with cerebral anterograde perfusion and distal aortic reconstruction (20-25 min) reconstruction (20-25 min) Distal aortic riperfusion, LCA and BCT reimplantation, off-ECC, Distal aortic riperfusion, LCA and BCT reimplantation, off-ECC, LSA reimplantation LSA reimplantation LSA debranching and perfusion LSA debranching and perfusion

7. LUPIAE Technique in TYPE A A.D. first surgical stage RESULTS May 2005 – April 2009 Number of patients: 38 (26 males and 12 females, mean age 64,7± 8,9 yrs) Number of patients: 38 (26 males and 12 females, mean age 64,7± 8,9 yrs) Intraoperative data: Intraoperative data: - ECC 103,2± 17,0 min - ECC 103,2 ± 17,0 min - Xclamp 44,8 ± 9,2 min - Xclamp 44,8 ± 9,2 min - CA 20 ± 2,5 min - CA 20 ± 2,5 min Mortality: 2/38 Mortality: 2/38 Morbidity: Morbidity: - 3 temporary neurological dysfunction - 2 temporary renal failure requiring dialysis - 2 temporary renal failure requiring dialysis - 4 temporary respiratory failure (2 requiring tracheo) - 4 temporary respiratory failure (2 requiring tracheo) - 3 reexplorations for bleeding - 3 reexplorations for bleeding

8. “LUPIAE TECHNIQUE” “Fixed” Elephant Trunk Ideal Proximal Aortic Landing Zone

9. LUPIAE Technique: Second Endovascular Stage

10. 3D CT-scan follow-up in Type A Aortic Dissection

11. LUPIAE Technique in TYPE A A.D. hybrid two stage RESULTS May 2005 – April 2009 Number of patients: 27 (19 males and 8 females, mean age 64,7± 8,9 yrs) Number of patients: 27 (19 males and 8 females, mean age 64,7± 8,9 yrs) Approach: Approach: - general/local anesthesia - surgical exposure of femoral artery - surgical exposure of femoral artery Mortality: 1/27 Mortality: 1/27 Morbidity: Morbidity: - 1 femoral artery dissection Devices: Vascutek ® Lupiae dacron & Medtronic ® Valiant Devices: Vascutek ® Lupiae dacron & Medtronic ® Valiant

12. CONCLUSIONS The Lupiae Technique in Type A aortic dissection with complicated false lumen achieves 2 important targets: 1.“Easy” replacement of dissected ascending aorta and arch with epiaortic vessels debranching using Vascutek ® and arch with epiaortic vessels debranching using Vascutek ® “Lupiae graft”. “Lupiae graft”. 2. A “safe, long and stable” proximal landing zone created by the “fixed” Elephant Trunk is ready to be used for the “fixed” Elephant Trunk is ready to be used for second endovascular stage in which stent graft deployment second endovascular stage in which stent graft deployment is performed in the residual dissected thoracic aorta. is performed in the residual dissected thoracic aorta.