Evolution of surgical therapy for Stanford acute type A aortic dissection

Abstract

Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

Keywords: Aortic dissection; aortic arch; aortic root; history.

Video 1

Evolution of surgical therapy for Stanford acute type A aortic dissection.

Figure 1

Limited aortic root remodeling operation known informally as a “uni-Yacoub” both at Stanford and in Leipzig: (A) extension of the primary intimal tear into the non-coronary sinus with extensive destruction of the wall; (B) resection of the entire primary intimal tear leaving an adequate rim of tissue for the remodeling procedure; (C) a custom tailored graft with a single tongue; (D) intraoperative photograph demonstrating the completed uni-Yacoub remodeling technique.

Figure 2

Intraoperative photograph of the Tirone David V re-implantation technique for valve sparing aortic root replacement: (A) sinuses are excised leaving a rim of aortic tissue around the valve itself; (B) the root graft is over-sized and then “necked down” to appropriate annular dimensions using the Feindel-David equation, and the commissures are positioned to optimize cusp coaptation (not seen: 12 interrupted sub-annular horizontal mattress sutures are placed to anchor the graft); (C) graft-to-graft anastomosis after re-implantation of the coronary ostia as carrel patches.

Figure 3

An 8-mm knitted double velour Dacron graft is used as an axillary perfusion limb for cardiopulmonary bypass and subsequent institution of selective antegrade cerebral perfusion with clamping of the innominate artery.

Figure 4

Peninsula-style transverse arch repair is our favored approach to the distal extent of operation: (A) artist’s rendition of an acute type A aortic dissection—dashed-line indicates dissection; (B) after excising the entire underside of the aortic arch, the head vessels are attached to the remainder of the aorta by a thin peninsula of tissue; (C) the graft is tailored to match the aorta, and a running suture on a fine needle is used to construct the distal anastomosis; (D) intraoperative photograph demonstrating the configuration of the distal anastomosis; (E) intraoperative photograph of completed peninsula-style transverse arch repair.

Figure 5

Intraoperative photographs of multibranch total arch replacement: (A) following completion of multibranch reconstruction with perfusion via side arm graft; (B) completed total arch reconstruction following completion of the graft-to-graft anastomosis and ligation of the side arm graft.

Figure 6

Frozen elephant trunk technique: (A) in conjunction with a peninsula-style transverse arch repair; (B) in conjunction with a multi-branch total arch replacement.