New hybrid sequential treatment of Stanford type A acute aortic dissections extending to the aortic arch.

Introduction. Stanford type A acute aortic dissections are surgicalemergencies whose morbidity and mortality are high in case ofsurgical replacement of the aortic arch with circulatory arrest underdeep hypothermia. We describe a hybrid sequential treatment ofacute type A aortic dissection in high risk patients who are unableto survive an emergency replacement of the aortic arch.Material and methods. From December 2004 to December 2005,four high-risk patients were hospitalized in emergency for a type Aacute dissection extending to the aortic arch. There were two malesand two females. Mean age was 57.5 years (ext. : 49-61). All hadsevere circulatory shock and were deemed unable to survive anemergency replacement of the aortic arch. The first step was thereplacement of the ascending aorta with a prosthesis associated witha by-pass from the aortic prosthesis to the brachio-cephalic artery.Two aortic valvuloplasties and one prosthetic replacement of theaortic valve were required in three patients and an aorto-coronaryby-pass in one. The second step of the treatment was performedlater in two patients. A carotid-to-carotid by-pass was carried outfollowed by the placement of an aortic endoprosthesis excluding thefalse channel of dissection. The devices were TAG® (WL Gore) andEndofit® (LeMaitre Vascular) endoprostheses, 20cm long, coveringthe aortic arch and the proximal segment of the descending aorta.The fourth patient had thrombosis of the false channel after the firststep and did not undergo the second step.Results. No nervous or cardiac complication occurred. After 7.6months follow-up, neither death nor complications affecting thebrain or the spinal cord were observed. In the two patients whounderwent a complete treatment, the false channel was thrombosedat the thoracic level and remained patent at the abdominal level.Conclusion. This hybrid sequential treatment may be performedwith acceptable efficiency and safety in high-risk patients, even bycardiac surgeons having less experience with aortic arch surgery.The increase of flexibility in future devices should improve theresults of this treatment.