True Lumen Stabilization of the Entire Thoracoabdominal Aorta in Acute Type I Aortic Dissection: A New Technique toward Complete Aortic Repair in One Stage

Objectives: DeBakey Type I acute aortic dissection (AAD) with thoracoabdominal true lumen (TL) collapse and malperfusion is associated with poor outcome despite immediate exclusion of the primary entry tear in the proximal aorta by open surgery. A new technique combining proximal aortic replacement with endovascular stabilization of the entire TL downstream via sole median sternotomy is presented.

Methods: Between April 2014 and August 2019, seven male patients, age (mean ± SD) 56 ± 9 years, presented with Type I AAD, complicated from TL collapse and malperfusion (visceral 6/7, peripheral 5/7), and underwent antegrade endovascular repair of the thoracoabdominal aorta through the surgically opened aortic arch via median sternotomy in combination with proximal aortic repair and frozen elephant trunk (FET). The TL distally was decompressed using uncovered self-expandable nitinol stents, which were introduced downstream over a stiff guide wire. Stent deployment was guided endoscopically using a flexible videoscope though the aortic arch (angioscope). The treatment was performed under selective cerebral perfusion and hypothermic circulatory arrest (26–28°C) distally.

Results: Success of insertion and deployment of the uncovered stents was 100%. Number of uncovered stents used was 2.3 ± 0.8 per patient. Coeliac trunk and mesenteric artery were overstented in six of seven patients. The most distal landing zone was infrarenal (5/7), juxtarenal (1/7), and suprarenal (1/7). The proximal landing zone was within the FET prosthesis (5/7) and distally (2/7). No death and no neurological or malperfusion-related complications occurred. One of seven patients underwent temporary renal replacement therapy. Survival after 20 ± 24 months was 100%. During follow-up, no visceral arteries malperfusion was observed and the false lumen was significantly reduced or disappeared in six of seven patients.

Conclusion: In Type I AAD, complete treatment of the entire true lumen through the opened aortic arch is feasible using the FET technique in combination with uncovered stents downstream. Furthermore, the study demonstrates the efficacy of angioscopy to evaluate the thoracoabdominal aorta and to guide endovascular procedures during open aortic arch surgery. Despite the small number of patients, the results demonstrate that complete treatment of a Type I AAD in one stage is possible by combining open with antegrade endovascular aortic surgery.