A new minimal invasive technique with in-situ stent-graft fenestration for type A aortic dissection

Abstract

Background: Aortic surgery successfully improves the prognosis of patients with type A aortic dissection. However, total arch replacement and reconstruction remain challenging. This study presents a new surgical modality, the in-situ stent-graft fenestration (ISSF) technique, for simplifying aortic arch reconstruction and assesses its short-term efficacy and safety in patients with type A aortic dissection.

Methods: Data from 177 patients with type A aortic dissection who underwent aortic arch reconstruction were retrospectively analyzed. Sun's procedure was performed in 90 patients and ISSF was performed in the other 87.

Results: The in-hospital mortality rate was 7.8% in the Sun's procedure group and 3.4% in the ISSF group (p = 0.357). Compared to the Sun's procedure group, the ISSF group had significantly shorter surgical duration, cardiopulmonary bypass time, circulatory arrest time, mechanical ventilation time, and aortic cross-clamp time (p < 0.05). Additionally, intraoperative blood loss was lower in the ISSF group than in the Sun's procedure group (p < 0.05). Patients who underwent ISSF also had a lower incidence of postoperative complications, including lung injury, renal failure, peripheral nerve injury, and chylothorax, than those who underwent Sun's procedure (p < 0.05). During the 6-month follow-up period after surgery, both groups showed significant improvements in the true lumen diameter of the descending thoracic aorta post-operation compared with the pre-operation measurements; meanwhile, the false lumen diameter decreased (p < 0.05).

Conclusions: The ISSF technique appears to be an effective and safe alternative to conventional surgical procedures for patients with type A aortic dissection, with the potential to simplify the procedure, shorten the operation time, and yield satisfactory operative results. However, further investigation is needed to determine its long-term benefits.

Keywords: Aortic arch reconstruction; In-situ stent-graft fenestration technique; Sun's procedure; Type A aortic dissection.

Fig. 1

Procedure of the aortic arch reconstruction utilizing the ISSF technique. A1: Transection of the ascending aorta proximal to the innominate artery's origin; B1: Replacement of the ascending aorta utilizing a custom-fit surgical graft; C1: Positioning and deployment of an appropriate frozen elephant trunk stent within the TL of the aortic arch and descending aorta; D1: Crafting of three fenestrations corresponding to the supra-aortic branch openings using surgical scissors post stent graft deployment; E1: Suture fixation of the fenestrations to the aortic wall and attachment of the proximal stent end to the native aortic arch; F1: Attachment of the distal end of the surgical graft to both the stent graft and the native arch via suturing. A2–F2: Sequential surgical images displaying each stage of the ISSF procedure.

Fig. 2

Procedure of the modified “island” fenestration of ISSF technique. The “island” shaped fenestration method follows the fundamental steps of individual fenestration, differing chiefly in the method of fenestration. A: Implantation of a frozen elephant trunk stent in the TL of the aortic arch and descending aorta, with the stent positioned to span the openings of the three supra-aortic branches; B: Fabrication of a tailored “island” opening within the polyester fabric of the stent by using surgical scissors, tailored to align with the three supra-aortic branch openings; C: Detailed suturing at the “island” fenestration site on the stent graft, ensuring a robust anchorage to the aortic wall; D: Suture reinforcement at the proximal end of the stent, with subsequent attachment of the distal end of the surgical graft to both the proximal stent end and the native aortic arch.

Fig. 3

The CTA of patient with TAAD before and after ISSF technique. A: The CTA of a representative patient with TAAD before operation; B: Three-dimensional reconstruction of CTA in patient with TAAD before operation; the yellow arrow refers to the FL of the arch; C: The postoperative CTA of the patient with TAAD after ISSF technique. The yellow arrow refers to the elephant trunk stent; D: Three-dimensional reconstruction of CTA was performed in patient with TAAD after ISSF technique; the yellow arrow refers to the in-situ fenestration of the elephant trunk stent. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)