A modified total arch replacement combined with a stented elephant trunk implantation for acute type A dissection under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion

Abstract

Objectives: Since the optimal management of patients with acute aortic dissection is unclear, this study analyzed total arch replacement combined with stented elephant trunk implantation in the treatment of acute type A aortic dissection.

Methods: Between February 2008 and February 2013, 86 consecutive patients admitted to our hospital for acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under deep hypothermic circulatory arrest. The Bentall, David, and Wheat procedure was performed on 46, 12 and two patients, respectively. Ascending aorta replacement was performed on 26 patients, while two patients in Bentall group and 7 in ascending aorta replacement group underwent coronary artery bypass grafting as a concomitant procedure.

Results: Sixty-nine patients were male and 17 patients were female, with an average age of 45.2 ± 2.3 years. The in-hospital mortality rate was 5.8%. Two patients presented with persisting paraplegia. The cardiopulmonary bypass time was 186.3 ± 45.2 minutes and the myocardium ischemia time was 102.6 ± 28.1 minutes. Selective antegrade cerebral perfusion time was 29.4 ± 10.3 minutes. Low-body circulatory arrest time was 18.5 ± 8.4 minutes. Mechanical ventilation time was 80.7 ± 11.3 hours. ICU and hospital stays were 5.3 ± 4.8 and 16.8 ± 5.5 days, respectively. Seven patients underwent reoperation for bleeding. During a mean follow-up of 28.5 months, two patients died and 2 patients were lost to follow-up. Obliteration of the false lumen around the stented graft and at the diaphragmatic level occurred in 97.1% (68 of 70) and 70% (49 of 70) of the patients.

Conclusions: Modified total arch replacement combined with stented elephant trunk implantation using selective antegrade cerebral perfusion is a safe and effective alternative for patients with acute type A dissection and produces satisfactory clinical outcomes in our center.

Figure 1

Modified total arch replacement procedures. A Skeletoned elephant trunk was implanted; B The distal end of the prosthetic graft was anastomosed to the transected aorta wall in a sandwich-like fashion and low-body was reperfused; C The left common carotid was anastomosed and reperfused; D The proximal end of the graft was anastomosed and the perfusion of myocardium was resumed: E-F The innominate and left subclavian arteries were anastomosed.