Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach

Abstract

Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi-disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41-56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi-arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re-exploration. Follow-up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.

Keywords: PETTYCOAT and STABILIZE technique; TEVAR; aortic arch; aortic team; hybrid approach; surgery; type B aortic dissection.

FIGURE 1

Surface shading reconstruction from CT angiogram. (A) Thoracic aortic aneurysms of the ascending and proximal descending thoracic aorta. (B) Repair with interposition graft to ascending aorta and proximally anastomosed bypass grafts to brachiocephalic, left common carotid, and left subclavian arteries. Remnant stumps of tied‐off great vessels are seen on the superior border of the aortic arch. The proximal and distal suture lines of the interposition graft are seen with a neo‐proximal landing zone created for completion of TEVAR. (C) Post‐TEVAR CT angiogram with successful exclusion of aortic aneurysm and patent bypass grafts

FIGURE 2

Angiography in steep LAO pre‐ and post‐TEVAR. Pre‐graft implantation shows no suitable native landing zone, but suitable seal zone within the ascending graft. Completion angiography shows successful exclusion of the proximal descending thoracic aortic aneurysm with patent bypass grafts

FIGURE 3

CT aortic angiogram. (A) Type B aortic dissection extending to the aortic bifurcation; additional retrograde extension with intramural hematoma extending to the aortic valve; absence of genuine proximal landing zone for TEVAR; evidence of end‐organ ischemia with shotgun right renal artery and delayed right nephrogram in the context of deteriorating renal function. (B) Surface shading reconstruction after surgical procedure with creation of a suitable landing zone for TEVAR and persistent dissection beyond the distal anastomosis. (C) Surface shading reconstruction 1‐year post‐intervention with widely patent true lumen and bypass grafts; total aortic remodeling and complete obliteration of the false lumen

FIGURE 4

(A) Angiography demonstrates suitable proximal landing zone in the ascending aortic interposition graft with patent bypass grafts. Gore cTAG thoracic graft partially deployed with 100% angulation applied to maximize inner curve wall apposition to prevent “bird‐beaking.” (B) CO2 angiography to minimize nephrotoxic iodinated contrast shows implanted Cook Zenith dissection stent through the abdominal aorta (PETTICOAT technique), but with compression in the true lumen and persistent flow in the false lumen. Middle fluoroscopic grab image shows molding balloon dilatation of true lumen (STABILIZE technique). Final angiogram shows widely patent true lumen and visceral vessels with obliteration of false lumen

FIGURE 5

CT aortic angiogram. (A) Type B aortic dissection with the entry tear at the level of the left subclavian artery and concurrent ascending aortic aneurysm; (B) surface shading reconstruction following surgery

FIGURE 6

CT aortic angiogram showing frontal (A), transverse (B), and longitudinal (C) views of the expanding lesion

FIGURE 7

(A) Postoperative CT aortic angiogram showing the position of the stent in the proximal descending thoracic aorta. (B) Surface shading reconstruction of CT angiogram with emphasis on the graft from the left subclavian sutured to the branch of the ascending aortic graft. (C) Further 3D reconstructed view showing a more complete overview of the anatomical relationships