Asian Cardiovasc Thorac Ann 2008;16:249-251
© 2008 Asia Publishing EXchange Ltd
Entry Closure and Aortic Tailoring for Chronic Type B Aortic Dissection
Katsuhiko Matsuyama, MD,
Yuji Narita, MD1,
Akihiko Usui, MD1,
Toshiaki Akita, MD1,
Hideki Oshima, MD1,
Yuichi Ueda, MD1
Department of Cardiovascular Surgery, Chubu Rosai Hospital
1 Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine, Japan
For reprint information contact: Katsuhiko Matsuyama, MD, Tel: 81 52 652 5511, Fax: 81 52 653 3533, Email: k-matsuy{at}f3.dion.ne.jp, Department of Cardiovascular Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan.
 |
ABSTRACT
|
|---|
Although graft replacement for chronic type B dissection is the standard operation, this operation is invasive to some extent, and the mortality and morbidity remain high. We describe a simple and less invasive technique using initial entry closure and aortic tailoring of the dissected lumen.
|
INTRODUCTION
|
|---|
Among the surgical options for chronic type B dissection, graft replacement of the descending aorta is the standard operation. Although the operative procedures have improved remarkably, this operation is invasive to some extent, and the mortality and morbidity remain high.1 As an alternative to surgical treatment, endovascular stent grafting has also been used, but it has problems with displacement of the graft or proximal endoleakage.2 We describe a simple and less invasive technique using initial entry closure and aortic tailoring of the dissected lumen.
|
TECHNIQUES
|
|---|
Through a left thoracotomy, cardiopulmonary bypass (CPB) is established by right axillary artery and femoral vein cannulation. Under hypothermic circulatory arrest at a nasopharyngeal temperature of 20°C, a longitudinal adventitial incision is made into the false lumen at the dilated descending aorta. Only the false lumen is opened, and the intimal tear is identified through the false lumen. The number of intimal entries might be single or multiple. Moreover, small intimal entries might be present if the intercostal arteries are involved. Small tears at the level of the intercostal arteries are easily identified from bleeding into the false lumen when CPB is transiently started. Without any resection of the intima, all of these entries are closed directly with felt strip reinforcement or a small patch. Immediately after this, CPB is gently restarted for de-airing, and the adequacy of the sutures is checked. If necessary, a distal clamp is placed above the diaphragm to control back-flow bleeding from the distal false lumen. Although bleeding from the proximal false lumen is reinforced, back-flow bleeding from the distal descending aorta is not treated. Finally, under normal CPB, the adventitia of the dilated descending aorta is tailored to the size of the true lumen. The distal extent of the adventitial incision is sufficiently limited above the diaphragm to prevent paraplegia.
|
DISCUSSION
|
|---|
The indication for this operation is an aneurysm > 60 mm (Figure 1
). This technique was performed in 4 patients with chronic type B dissections. They were followed-up by computed tomography, with a mean follow-up of 4 years (range, 2–10 years). The false lumen of the proximal descending aorta was completely thrombosed in the early postoperative phase, with a normal size for the true lumen (Figure 2). Thereafter, the thrombosed false lumen was gradually resorbed, and finally disappeared at 6 months to 1 year postoperatively (Figure 3). Consequently, the diameter of the descending thoracic aorta normalized in all patients, although the thoracoabdominal aorta beneath the diaphragm had a patent false lumen without any further dilatation.
View larger version (122K):
[in this window]
[in a new window]
|
Figure 1. Preoperative computed tomography showing an extensive chronic type B dissection with a maximal aortic diameter of 6.5 cm.
|
|
View larger version (100K):
[in this window]
[in a new window]
|
Figure 2. Computed tomography at 1 month postoperatively showing a thrombosed false lumen and a mildly dilated descending aorta.
|
|
View larger version (87K):
[in this window]
[in a new window]
|
Figure 3. Computed tomography at 6 months postoperatively showing no false lumen and a normal-sized descending aorta; the thoracoabdominal aorta had a patent false lumen without further dilatation.
|
|
Aortic tailoring was first reported for thoracoabdominal dissecting aneurysms in 1994.3 Although this technique is simple, the tailored segments, which are reconstructed with the adventitia only, have a risk of late dilatation because of the intimal excision. The most important element in our technique is entry closure rather than aortic tailoring. Exclusion of the intimal tear is the fundamental principle for the treatment of aortic dissections, and decreases the pressure load on the false lumen. Although there are some risks of obstruction of the major arterial branches of the abdominal aorta, several re-entries are present in that area. Entry closure in the chronic phase is relatively easy because the dissected intima is thickened, as well as the adventitia. The average interval between acute dissection and operative treatment in the 4 patients was 5.5 years (range, 2–10 years). The intima could be sufficiently strong to undergo repair with 6 months or 1 year.
There are several advantages to this simple technique. The time of hypothermic circulatory arrest is very short, and this method also markedly reduces operative bleeding. We performed this operation in 4 patients with an average circulatory arrest time of 10 min, thus this technique may reduce neurological complications. In addition, there is no risk of graft infection because no prostheses are used. The exclusion criteria for this method are a true lumen that is extremely narrowed, significant aortic dilatation extending over the diaphragm and multiple or very complicated entries such as at the root of the subclavian artery. From a surgeon’s point of view, it is important to identify preoperatively the position and size of the intimal entry or the presence of a reentry at the abdominal level by computed tomography, angiography, magnetic resonance imaging or transesophageal echocardiography.
Although this technique needs further investigation, we believe that as it is less invasive it should decrease the risk of operative mortality and morbidity in selected patients with chronic type B aortic dissection.
|
REFERENCES
|
|---|
- Safi HJ, Miller CC 3rd, Reardon MJ, Iliopoulos DC, Letsou GV, Espada R, et al. Operation for acute and chronic aortic dissection: recent outcome with regard to neurologic deficit and early death. Ann Thorac Surg 1998;66:402–11.[Abstract/Free Full Text]
- Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1585–6.[Medline]
- Stone CD, Greene PS, Gott VL, Frank S, Williams GM. Single-stage repair of distal aortic arch and thoracoabdominal dissecting aneurysms using aortic tailoring and circulatory arrest. Ann Thorac Surg 1994;57:580–7.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
I. V Belov, A. B Stepanenko, A. P Gens, and D. D Savichev
The Issue of Entry Closure and Aortic Tailoring in Type B Aortic Dissection
Asian Cardiovasc Thorac Ann,
January 1, 2009;
17(1):
110 - 111.
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
