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The Journal of Cardiovascular Surgery 2020 Jan 23

DOI: 10.23736/S0021-9509.20.11259-X


language: English

Limited repair with tear-oriented approach for type A aortic dissection


Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA


In 1992, Crawford and colleagues1 reported 21% mortality after acute type A aortic dissection (ATAAD) repair. They also found that 30% of the patients required late distal reoperations. However, none of the patients who had elimination of the intimal tear needed reintervention.1 Ten years later, Westaby and colleagues proposed the “tear-oriented” approach, which has been widely accepted to treat ATAAD2: if the tear is located proximal to the arch vessels, simple limited repair with hemiarch replacement is selected; when the entry-tear is in the lesser curvature of the transverse arch, it can also be excluded with hemiarch replacement by beveling the distal anastomosis, extending the posterior graft suture line to the proximal descending aorta and preserving the arch vessels; and lastly, when the tear is present in the greater curvature of the transverse arch or extending to the arch vessels, total arch replacement is chosen. Other “irrefutable” indications for total arch replacement in patients with ATAAD beyond the tear-oriented approach are excessive enlargement and rupture of the false channel in the arch.1 ATAAD associated with large aortic arch aneurysm is also reasonably considered for total arch replacement. Due to improved survival after ATAAD repair over three decades, as well as the establishment of cerebral protection strategies, proponents of aggressive total arch repair have emerged to mitigate the risks of distal reoperation.3 Also, with the advent of endovascular aortic repair, extended aortic repair with concomitant antegrade stenting or the “frozen” elephant trunk (FET) have gained influence with expectations for resolving downstream malperfusion and positive aortic remodeling.4-6 Hybrid FET prostheses have been commercially available in Europe and Asia-and now a clinical trial is proceeding in the United States, which may further escalate the long-standing debate for what is the optimal treatment strategy for ATAAD: conservative, limited aortic repair to minimize the surgical mortality and morbidity for ongoing threat vs. aggressive, extended aortic repair to prevent future catastrophe, distal reoperations. In this article, we will discuss the indications and validity of limited vs. extended aortic repair based on updated outcomes after ATAAD repair in the past decade.

KEY WORDS: Acute type A aortic dissection; ATAAD

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