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Does an Open Distal Anastomosis Confer Prognostic Benefit in Acute Dissection Surgery?

Chapter

Abstract

Acute type A aortic dissection should in the present era be treated surgically with reconstruction of the ascending aorta in order to prevent rupture, tamponade and dissection of the coronary ostia and aortic valve. How to handle the rest of the aorta in general, and the distal aortic anastomosis in particular, is at the present time more diffuse and controversial. A mainstay of surgical technique has for years been to construct this anastomosis in an open fashion to promote a secure anchoring of the graft in the friable aortic tissue and to enable an inspection of the inner side of the aorta with a subsequently more extensive resection should the tear go beyond the planned anastomosis level. However, a careful review of published results cannot demonstrate a survival benefit, or theoretically possible adverse effect, from this technical solution. Such a critical evaluation of surgical results reveals that the methodological difficulties we face when assessing surgical techniques are substantial for life threatening and relatively rare diseases like acute aortic dissections.

Keywords

Acute aortic dissection Surgical reconstruction Open distal anastomosis 

References

  1. 1.
    DeBakey ME, Henley WS, Cooley DA, Morris Jr GC, Crawford ES, Beall AC. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg. 1965;49:130–49.PubMedGoogle Scholar
  2. 2.
    Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg. 1970;10:237–47.PubMedCrossRefGoogle Scholar
  3. 3.
    Hagan P, Nienaber CA, Isselbacher E, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape L, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Dietrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb MG, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903.PubMedCrossRefGoogle Scholar
  4. 4.
    Trimarchi S, Eagle KA, Nienaber CA, Rampoldi V, Jonker FHW, De Vincentis C, Frigola A, Menicanti L, Tsai T, Froelich J, Evangelista A, Montgomery D, Bossone E, Cooper JV, Li J, Deeb MG, Meinhardt G, Sundt TM, Isselbacher EM. Role of age in acute type A aortic dissectio50n outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140:784–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type A dissection involving repair of the aortic arch? Circulation. 2011;123:971–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Umaňa JP, Miller DC, Mitchell RS. What is the best treatment for patients with acute type B aortic dissections—medical, surgical, or endovascular stent-grafting? Ann Thorac Surg. 2002;74:S1840–3.PubMedCrossRefGoogle Scholar
  7. 7.
    Kallenbach K, Oelze T, Salcher R, Hagl C, Karck M, Leyh RG, Haverich A. Evolving strategies for treatment of acute aortic dissection type A. Circulation. 2004;110 suppl 1:II243–9.PubMedGoogle Scholar
  8. 8.
    Tsgakis K, Pacini D, DiBartolomeo R, Gorlitzer M, Weiss G, Grabenwoger M, Mestres C, Benedik J, Cerny M, Jakob H. Multicenter early experience with extended repair in acute aortic dissection: is simultaneous descending stent graft justified? J Thoracic Cardiovasc Surg. 2010;140:S116–20.CrossRefGoogle Scholar
  9. 9.
    Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management. Part I: from etiology to diagnostic strategies. Circulation. 2003;108:628–35.PubMedCrossRefGoogle Scholar
  10. 10.
    Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dissection of ascending aorta. Should the arch be included? J Thorac Cardiovasc Surg. 1992;104:46–59.PubMedGoogle Scholar
  11. 11.
    Ergin MA, O’Connor J, Guinto R, Griepp RB. Experience with profound hypothermic and circulatory arrest in the treatment of aneurysms of the aortic arch. Aortic arch replacement for acute arch dissections. J Thorac Cardiovasc Surg. 1982;84:649–55.PubMedGoogle Scholar
  12. 12.
    Myrmel T, Lai DTM, Miller DC. Can the principle of evidence based medicine be applied to the treatment of aortic dissection? Eur J Cardiothorac Surg. 2004;25:236–45.PubMedCrossRefGoogle Scholar
  13. 13.
    Zierer A, Voeller RK, Hill KE, Kouchoukos NT, Damiano RJ, Moon MR. Aortic enlargement and late reoperation after repair of acute type A aortic dissection. Ann Thorac Surg. 2007;84:479–87.PubMedCrossRefGoogle Scholar
  14. 14.
    Stamou SC, Kouchoukos NT, Hagberg RC, Kabbaz KR, Robicsek F, Nussbaum M, Lobdell KW. Does the technique of distal anastomosis influence clinical outcomes in acute type A aortic dissection? Interact Cardiovasc Thorac Surg. 2011;12:404–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Tsai TT, Evangelista A, Nienaber CA, Trimarchi S, Sechtem U, Fattori R, Myrmel T, Pape L, Cooper JV, Smith DE, Fang J, Isselbacher E, Eagle KA. Long-term survival in patients with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006;114 Suppl 1:I350–6.PubMedGoogle Scholar
  16. 16.
    Lus F, Hagl C, Haverich A, Pichlmaier M. Elephant trunk procedure 27 years after Borst: what remains and what is new? Eur J Cardiothorac Surg. 2011;40:1–12.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  • Truls Myrmel
    • 1
  • Magnus Larsen
    • 2
  • Kristian Bartnes
    • 2
    • 3
  1. 1.Department of Cardiothoracic and Vascular SurgeryThe Institute of Clinical Medicine, The Heart and Lung Clinic, University Hospital North NorwayTromsøNorway
  2. 2.Department of Cardiothoracic and Vascular SurgeryThe Institute of Clinical Medicine, University Hospital North NorwayTromsøNorway
  3. 3.Institute of Clinical Medicine, University of Tromsø, The Arctic University of NorwayTromsøNorway

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