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LETTER TO THE EDITOR |
Department for Surgery of the Aorta and Its Branches, National Research Center of Surgery, 2 Abrikosovsky per., Moscow 119992, Russia
To the Editor:
The article entitled "Entry closure and aortic tailoring for chronic type B aortic dissection" was immensely interesting.1 We congratulate the authors on their publication, but we do not share their opinion on the advantages of this technique over standard repair, and we would like to add some brief comments on certain terms in the text and performance limitations of the procedure described.
The first point relates to the terminology. The Stanford University group classification was proposed by Daily and colleagues2 for acute aortic dissection only. This classification is based on the natural history and risk of aortic rupture, depending on ascending aorta involvement. For an exact definition of the anatomical characteristics of dissection, the authors should use the classification of DeBakey and colleagues.3 Moreover, the presence of type III chronic aortic dissection is not an indication in itself for operation. The authors should use the term "dissecting descending thoracic aortic aneurysm", rather than "chronic type B aortic dissection".
The second point relates to some performance limitations of the procedure. We agree with the authors that complete false channel exclusion from the bloodstream by this approach can lead to patient recovery. However, a false channel may persist if any intimal tear was missed. Unfortunately, computed tomography, aortography, magnetic resonance imaging, and transesophageal echo-cardiography do not always detect all intimal tears. Moreover, this procedure may be not curative, unless the dissection involved only the portion of the aorta included in the tailoring of the dissected lumen. In addition, this technique should not be applied in patients with Marfan syndrome, due to the weakness of the aortic wall. In these circumstances, subsequent aneurysm growth is unavoidable. Furthermore, the authors claim that this procedure demands extracorporeal circulation with hypothermic circulatory arrest, which means a prolonged cardiopulmonary bypass time (from cooling to rewarming) and marked coagulopathy despite a very short hypothermic circulatory arrest time. Standard repair is performed usually under normothermic or mild hypothermic left atrial femoral bypass. Thus, there are few or no advantages over standard thoracoabdominal aortic aneurysm repair at this stage in the technique.
The authors state that their technique is superior to standard repair because of less invasiveness for some extents of aortic dissection. Inherent to the modern approach to DeBakey type III aortic dissection is endovascular stent-grafting.4 Endovascular elimination of the false lumen and primary intimal tear coverage is an attractive option. Unfortunately, the ability to cover the primary intimal tear is an issue with large tears immediately adjacent to the left subclavian artery. Despite anatomical limitations and possible problems with displacement of the graft or proximal endo-leakage, descending aorta stent-grafting emerges as the therapeutic option of choice to reduce early mortality, shorten hospital stay, and deliver similar late results to open repair.5
We operated on an emergency basis on a 70-year-old man with type III B acute aortic dissection who presented with visceral ischemia, oliguria, and uncontrolled hypertension. Thoracoabdominal aorta and visceral arteries were exposed via a left-sided extraperitoneal incision through the 8th intercostal space. Maximal aortic diameter was 3.0 cm. The aorta was longitudinally opened between the clamps, and true and false channels were identified. The dissecting membrane was excised full-length, with unlocking of the renal and visceral ostia. The aortotomy was closed with continuous polypropylene suture buttressed with strips of polytetrafluorethylene felt, and the suture line was treated with a surgical adhesive. This operation did not require left atrial-femoral bypass. Aortic crossclamp time was 16 min. The postoperative course was uneventful. Unfortunately, contact was lost after discharge and we do not have late follow-up data.
Overall, we suppose that using similar techniques carries a considerable number of disadvantages over standard aneurysm repair or stent-grafting, but they may be generally advocated for some aortic dissections and aneurysms, especially in the elderly or high-risk patients in whom endovascular treatment is impossible.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:110-111
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102652
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