Distal Landing Zone Open Fenestration Facilitates Endovascular Elephant Trunk Completion and False Lumen Thrombosis

Article (PDF Available)inThe Annals of thoracic surgery 92(6):2078-84 · December 2011with52 Reads
DOI: 10.1016/j.athoracsur.2011.08.018 · Source: PubMed
Abstract
Controversy surrounds the endovascular treatment of chronic dissection because of inconsistent remodeling of the aorta. The purpose of this study was to assess efficacy and safety of a novel technique for repairing aneurysmal change associated with chronic descending aortic dissection. From July 2007 to April 2011, 24 patients with descending aortic aneurysmal change, consequent to previously repaired ascending aortic dissection or medically treated descending dissection, underwent combined open first-stage elephant trunk (ET) insertion and fenestration of the descending aorta intimal flap. Second-stage ET endovascular completion was performed with the index operation in 4 patients and later in 20 patients (median, 62 days). Repair was elective in 14 patients and urgent in 10 patients. Concomitant procedures were aortic valve replacement in 3 patients and coronary revascularization in 3 patients, and 16 procedures were reoperations. Chart review and analysis of 3-dimensional computed tomography (CT) scans were performed. Imaging follow-up was complete in 89% of patients during a median of 18 months (interquartile range [IQR], 10 to 28 months). Technical success was achieved in all patients. Moderate reduction in aortic size occurred in most patients, with no retrograde false lumen flow. Late reintervention was required in 5 patients: endovascular for distal type I endoleak in 2 patients, type II endoleak in 1 patient, pseudoaneurysm of the abdominal aorta in 1 patient, and 1 open repair for aneurysm of the untreated distal segment in 1 patient. One patient died of pulmonary embolism on postoperative day 19 after 1-stage repair (4.0%) and 1 patient (4%) had a transient stroke, but there was no renal failure, respiratory failure, or permanent spinal cord injury. Median length of stay was 13 days (IQR, 8 to 16 days) after first-stage ET and 8 days (IQR, 5 to 12 days) after endovascular ET completion. One patient died during a mean of 23 ± 11 months of follow-up. Open distal landing zone fenestration during first-stage ET facilitates endovascular completion for aneurysm associated with chronic distal dissection. Early results suggest that this technique is efficacious in eliminating retrograde false lumen filling and promoting aortic size reduction and is safe for patients.

Figures

Distal Landing Zone Open Fenestration Facilitates
Endovascular Elephant Trunk Completion and
False Lumen Thrombosis
Eric E. Roselli, MD, Edgardo Sepulveda, MD, Akshat C. Pujara, BA,
Jahanzaib Idrees, BS, and Edward Nowicki, MD
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Background. Controversy surrounds the endovascular
treatment of chronic dissection because of inconsistent
remodeling of the aorta. The purpose of this study was to
assess efficacy and safety of a novel technique for repair-
ing aneurysmal change associated with chronic descend-
ing aortic dissection.
Methods. From July 2007 to April 2011, 24 patients with
descending aortic aneurysmal change, consequent to previ-
ously repaired ascending aortic dissection or medically
treated descending dissection, underwent combined open
first-stage elephant trunk (ET) insertion and fenestration of
the descending aorta intimal flap. Second-stage ET endo-
vascular completion was performed with the index opera-
tion in 4 patients and later in 20 patients (median, 62 days).
Repair was elective in 14 patients and urgent in 10 patients.
Concomitant procedures were aortic valve replacement in 3
patients and coronary revascularization in 3 patients, and 16
procedures were reoperations. Chart review and analysis of
3-dimensional computed tomography (CT) scans were per-
formed. Imaging follow-up was complete in 89% of pa-
tients during a median of 18 months (interquartile range
[IQR], 10 to 28 months).
Results. Technical success was achieved in all patients.
Moderate reduction in aortic size occurred in most pa-
tients, with no retrograde false lumen flow. Late reinter-
vention was required in 5 patients: endovascular for
distal type I endoleak in 2 patients, type II endoleak in 1
patient, pseudoaneurysm of the abdominal aorta in 1
patient, and 1 open repair for aneurysm of the untreated
distal segment in 1 patient. One patient died of pulmo-
nary embolism on postoperative day 19 after 1-stage
repair (4.0%) and 1 patient (4%) had a transient stroke,
but there was no renal failure, respiratory failure, or
permanent spinal cord injury. Median length of stay was
13 days (IQR, 8 to 16 days) after first-stage ET and 8 days
(IQR, 5 to 12 days) after endovascular ET completion.
One patient died during a mean of 23 11 months of
follow-up.
Conclusions. Open distal landing zone fenestration
during first-stage ET facilitates endovascular completion
for aneurysm associated with chronic distal dissection.
Early results suggest that this technique is efficacious in
eliminating retrograde false lumen filling and promoting
aortic size reduction and is safe for patients.
(Ann Thorac Surg 2011;92:207884)
© 2011 by The Society of Thoracic Surgeons
M
ost survivors of acute aortic dissection are left with
residual disease and remain at late risk for aneu-
rysmal degeneration [1]. Open repair is the recom-
mended treatment for chronic distal aortic dissection
with aneurysm, but thoracic endovascular aortic repair
(TEVAR) is increasingly being used for this indication
because of concerns about the morbidity of sizable open
operations [2].
The objective during TEVAR in these patients is to cover
the proximal entry tear and optimize true lumen flow
thereby promoting false lumen thrombosis and reverse
remodeling of the treated segment. TEVAR for chronic
dissections is most successful when disease is limited to the
descending thoracic aorta and both the proximal and distal
landing zones are stable segments of aorta for fixation and
sealing [3]. However many patients with chronic dissection
have extensive aneurysm with a pattern of disease in which
neither of the landing zones is ideal. Open arch repair with
an elephant trunk (ET) procedure has been shown to
provide a stable proximal landing zone for the placement of
a stent-graft [4, 5]. When the distal landing zone has
residual dissection, however, the ability to predict throm-
boexclusion of the treated segment is unreliable because of
persistent retrograde filling and pressurization of the false
lumen (Fig 1) [3, 6 –10].
A novel hybrid technique involving arch and ET pro-
cedures with open fenestration of the distal landing zone
in the first stage followed by TEVAR extending from the
ET to the modified fenestrated segment has been devel-
oped at our institution to treat extensive chronic dissec-
tion with aneurysm. The objective of this study was to
Accepted for publication August 8, 2011.
Presented at the Poster Session of the Forty-seventh Annual Meeting of
The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
Address correspondence to Dr Roselli, Department of Thoracic and
Cardiovascular Surgery, Heart and Vascular Institute, The Cleveland
Clinic, 9500 Euclid Ave, J4-1, Cleveland, OH, 44195; e-mail:
roselle@ccf.org.
© 2011 by The Society of Thoracic Surgeons 0003-4975/$36.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.08.018
ADULT CARDIAC
describe the technique of this novel strategy, assess early
and intermediate outcomes with regard to safety and
efficacy, and describe the indications for its use.
Patients and Methods
Patient Characteristics
From July 2007 to April 2011, 24 patients underwent both
stages of the described novel technique. Two additional
patients not yet included in the analysis have successfully
undergone the first-stage operation and are awaiting the
second-stage TEVAR operation. The mean patient age
was 57 10.7 years. All patients were survivors of either
surgical proximal repair after acute extended type A
dissection (n 14), or medical therapy for acute type B
dissection with proximal extension (n 10) and had
experienced aneurysmal degeneration. One patient had
undergone previous coarctation repair, and 2 patients
had Kommerell’s diverticulum associated with an aber-
rant right subclavian artery that was dissected. Median
time from acute dissection to first-stage repair was 22
months (IQR, 11 to 46 months). Mean maximum aortic
diameter was 5.9 1.0 cm and the largest segment
consistently involved the proximal descending aorta, as
is most typical of patients with aneurysmal degeneration
of chronic dissection [11]. Data was prospectively col-
lected into the Cardiovascular Information Registry,
which is approved by the Institutional Review Board of
the Cleveland Clinic, and the need for informed consent
was waived for this study.
Operative Technique
FIRST STAGE. All patients underwent first-stage repair
through a median sternotomy; this was a redo median
sternotomy in 16 patients. The right axillary artery was used
for arterial inflow during cardiopulmonary bypass in all
patients, with construction of a conduit side graft as previ-
ously described [12]. All patients underwent hypothermic
circulatory arrest with selective antegrade brain perfusion.
Arch reconstruction was performed first during a period of
deep circulatory arrest for a mean of 18.5 6 minutes. This
was followed by ET insertion and open fenestration of the
distal descending aortic landing zone performed during the
period of selective antegrade brain perfusion (mean of 55
10 minutes) (Fig 2). The descending aorta was exposed with
assistance of a fixed retractor, and the aortotomy and length
of septum excised was typically about 5 to 6 cm (Fig 3). After
Fig 2. Distal landing zone open fenestration procedure. (A) Heart retracted cephalad to expose distal descending aorta through posterior peri-
cardium or left pleural space. (B) Dissection flap excised through anterior longitudinal aortotomy. Intraoperative view of chronic dissection flap
through aortotomy before (blue arrow in B) and after (blue arrow in C) open fenestration.
Fig 1. Endovascular controversy in the treatment of chronic dissection
with aneurysm: thromboexclusion of the false lumen is unpredictable
because of retrograde filling and continued pressurization (arrows).
2079Ann Thorac Surg ROSELLI ET AL
2011;92:207884 DISTAL LANDING ZONE FENESTRATION FOR HYBRID REPAIR
ADULT CARDIAC
establishing full flow, the proximal aortic reconstruction
was completed. Four patients also underwent aortic valve
replacement, and 3 patients had coronary artery bypass
grafting simultaneously.
SECOND STAGE. At a median delay of 62 days (IQR, 13 to 130
days) between stages, all patients underwent endovascu-
lar completion of the ET repair (Fig 4). Four patients
underwent both stages at the same time; 2 procedures
were planned and 2 procedures were completed as
emergencies because the descending aorta had ruptured
with the patient on the table after completion of the
first-stage reconstruction. In these 4 patients, the stent-
graft devices were delivered antegrade through a conduit
from the ascending aortic graft through the open sternot-
omy incision as previously described [13]. The rest of the
patients had the device delivered retrograde from the
femoral artery during a second trip to the operating
room. In all of the planned second-stage repairs (n 22),
the patient had a cerebrospinal fluid drain in position
preoperatively. All of the stent-graft devices were com-
mercially available (3 TAG, Gore Medical, Flagstaff, AZ;
21 Zenith, Cook Medical Inc, Bloomington, IN). The
median number of stent-graft devices used was 2 (range,
1to5).
Descending aortic repair extended to the midthoracic
aorta in 2 patients and to the level of the diaphragm in
the rest. Sizing of the devices is performed as is done for
degenerative thoracic aneurysms: 10% to 20% oversizing
Fig 3. Chronic aorta with aneurysm after first-stage repair. The arrow in the illustration in panel (A) marks planned distal landing zone for
second-stage endovascular completion. Axial computed tomographic scan of modified distal landing zone preoperatively (B) and postopera-
tively (C). Note the radiopaque metallic clip marking the modified distal landing zone.
Fig 4. (A) Illustration and (B) volume-ren-
dered computed tomography scan demonstrat-
ing completed 2-stage repair with stent graft
spanning from elephant trunk to modified dis-
tal landing zone with complete circumferential
seal to adventitia and exclusion of retrograde
false lumen filling.
2080 ROSELLI ET AL Ann Thorac Surg
DISTAL LANDING ZONE FENESTRATION FOR HYBRID REPAIR 2011;92:2078 84
ADULT CARDIAC
based on the adventitial-to-adventitial (or graft wall
proximally within the elephant trunks) diameter of the
aorta at the landing zones based on assessment of the
aorta orthogonal to the center line of flow.
Follow-Up and Imaging
Postoperative computed tomography (CT) was per-
formed using a standardized 3-phase protocol after the
stent graft was in place, including a noncontrast phase
through the treated segment and intravenous contrast
scans through the chest, abdomen, and pelvis timed for
the arterial and delayed venous phases. All of these
images were analyzed using 3-dimensional reconstruc-
tion software (Aquarius, TeraRecon, San Mateo, CA) to
assess for patency of the repair, device integrity, en-
doleaks, and morphologic characteristics of the
aneurysm.
Clinical and CT imaging assessment was performed
before discharge, within the first 6 months, 12 months
postoperatively, and annually thereafter. Mortality data
were available for all patients, and eligible patients were
compliant with 89% of their scheduled imaging follow-
ups. Patients who underwent concomitant valve surgery
or had left ventricular dysfunction also underwent echo-
cardiography during follow-up.
Survival was confirmed by query of the Social Security
Death Index at a median follow-up of 25 months (IQR, 13
to 31)
Outcome Definitions and Statistics
Technical success was defined by prosthesis implanta-
tion with patency of all intended arch and visceral
branches, no angiographic evidence of type I or type III
endoleak (for the endovascular stage only), and survival
at 24 hours. Stroke included neurologic deficit lasting
greater than 24 hours confirmed by cross-sectional imag-
ing of the brain or documentation by a neurologist.
Spinal cord injury was defined as paraplegia or parapa-
resis, and was confirmed by cross-sectional imaging of
the spinal cord or documentation by a neurologist. Renal
failure was defined as the need for hemodialysis. Respi-
ratory failure included the need for reintubation or
tracheostomy. Bleeding was defined as the need for
reoperation.
At follow-up, false lumen thrombosis was confirmed as
being complete by CT imaging performed in both the
arterial and venous (low flow) phases of the study.
Standard descriptive statistical analyses were used.
Continuous variables are presented as the mean stan-
dard deviation or median with the IQR (due to the small
sample size), and categorical variables are presented as
percentages. Survival was assessed by the Kaplan-Meier
method.
Results
Early Outcomes
Technical success was achieved in all patients during
each operation. In-hospital mortality and postoperative
complications are presented in Table 1. The only hospital
death occurred on postoperative day 19 as a result of
massive pulmonary embolus in a woman with a body
Fig 5. Estimated survival at median follow-up of 24 months.
Table 1. Hospital Outcomes
Variable Total Operations (n 46, %)
First stage
(n 25, %, includes 4 combined) Second Stage (n 21, %)
Technical Success 46 (100) 25 (100) 21 (100)
Complications
Mortality 1 (2.2) 1 (4) 0 (0)
Stroke 1 (2.2) 0 (0) 1 (4.8)
Paraparesis 1 (2.2) 1 (4) 0 (0)
Renal failure 0 (0) 0 (0) 0 (0)
Respiratory failure 0 (0) 0 (0) 0 (0)
Tracheostomy 0 (0) 0 (0) 0 (0)
Bleeding 4 (8.7) 2 (8) 2 (9.6)
Length of Stay (days, mean SD)
ICU . . . 5.1 5.2 2.6 1.3
Hospital . . . 14.7 8.2 9.3 5.2
ICU intensive care unit; SD standard deviation.
2081Ann Thorac Surg ROSELLI ET AL
2011;92:2078 84 DISTAL LANDING ZONE FENESTRATION FOR HYBRID REPAIR
ADULT CARDIAC
mass index of 45 kg/m
2
who presented with rapid growth
of a degenerative distal arch aneurysm 6 months after
surviving acute type A dissection repair with a supra-
coronary graft. She was also the only patient with spinal
cord injury that occurred in a delayed fashion, but she
had complete recovery of strength in 1 leg and progres-
sive recovery in the other before dying of the pulmonary
embolism.
Midterm Survival
One death occurred in 23 survivors for an overall survival
of 92% at a median follow-up of 24.2 months (IQR, 13 to
31) (Fig 5). Cause of death was pneumonia and sepsis in
a 70 year-old man 18 months after completion of repair. A
CT scan obtained 1 week before he died demonstrated a
stable aortic repair and aneurysm sac without endoleak
and complete thrombosis of the false lumen throughout
the treated segment. He was 1 of the patients who
underwent single-staged repair because of an on-table
rupture; he also required an additional intervention 11
months after the initial repair for a distal type I endoleak
that was successfully treated with placement of a distal
extension cuff into the fenestrated segment.
Reoperations
Five patients required reintervention: 1 open procedure
and the rest endovascular operations. Two patients had
continued aneurysmal degeneration of the abdominal
aorta despite adequate exclusion, thrombosis, and
shrinkage of the treated thoracic component. One patient
went on to open juxtarenal abdominal aortic repair 22
months after second-stage completion. The other had a
pseudoaneursym of the abdominal aorta several centi-
meters distal to the open fenestration and underwent
endovascular repair with extension of a distal stent-graft
into the true lumen to cover the origin of the entry tear to
the pseudoaneurysm 7 months after second-stage com-
pletion repair.
Two patients required placement of an extension graft
for distal type I endoleak. One was described previously
in the section Midterm Survival, and the other patient
required reintervention 20 months postoperatively. One
patient required endovascular coil embolization of the
native left subclavian artery for a type II endoleak, which
was performed through a percutaneous left brachial
puncture 2 months postoperatively.
Reverse Remodeling
Imaging follow-up was excellent in these patients. There
were 11 total endoleaks: 2 distal type I, both of which
underwent successful endovascular repair and 9 type II:
1 resolved with intervention, 4 without, and 4 persisted as
of this writing with no aortic growth and are being
followed expectantly. There have been no type III
endoleaks.
Of the 23 survivors with imaging follow-up, 16 dem-
onstrated shrinkage of the aneurysm sac, 5 have been
stable in size, and 2 grew. Both patients with growth had
late distal type I endoleaks that were treated, and none
has ruptured.
Comment
Principal Findings
The novel technique described here is a safe and effective
alternative for treating the complex population of pa-
tients with extensive chronic aortic dissection with aneu-
rysm. This hybrid approach not only allows for com-
plete thoracic aortic repair within a relatively short
time frame but also reliably excludes flow and pres-
surization of the false lumen in the treated segment of
aorta. With close imaging surveillance, there have been
no aortic-related deaths at intermediate-term follow-up.
Operative Technique
The 2-stage ET repair approach has been favored for
patients with extensive thoracic aortic disease with rea-
sonable results [14 –18]. One of the biggest criticisms of
this approach is the inherent risk of rupture when com-
pletion repair is delayed between stages. In fact, one fifth
to one half of patients do not return for the second stage
either because complications from the first repair have
rendered them unsuitable for further surgery or the
patients themselves have chosen not to undergo an
arguably bigger second operation. For those who do
complete the 2-stage repair, the combined mortality of
the 2 operations ranges from 8% to 20%.
Kouchoukos and colleagues [19] have championed a
single-stage strategy for dealing with this complex subset
of patients by approaching both the proximal and distal
thoracic aorta through a clamshell incision. The popula-
tion of patients in that experience is very similar to the
population described here. The results of this approach
are excellent and have been reported several times, with
the latest mortality in the series of 95 patients at 8.4%.
Although this technique eliminates the delay between
stages and therefore the risk of interval rupture, it is a
morbid procedure, with 17% of patients requiring trache-
ostomy and 8% requiring hemodialysis perioperatively.
Although exposure and management of the distal
descending thoracic aorta through a sternotomy is not a
simple task, by limiting this portion of the operation to
the anterior wall only it is safe and feasible. This tech-
nique does not include the technical difficulties and the
risk of bleeding associated with a complete open anasto-
mosis involving the posterior aortic wall and intercostal
branch handling. Nonetheless we did have 2 intraoper-
ative aortic ruptures and a distal pseudoaneurysm prob-
ably related to the altered flow dynamics and additional
manipulation of a chronically dissected aorta. When
addressing the dissection flap, resection is minimized
and longitudinal incision of the flap preferred. Thrombus
material within the false lumen is left alone if densely
adherent.
It is our belief that much of the morbidity from exten-
sive aortic repair using conventional 1- or 2-stage open
techniques is related to the distal aortic reconstruction.
Others have recently demonstrated excellent outcomes
for proximal aortic repair including the entire aortic arch
using various methods for brain protection with circula-
tory arrest [20, 21]. By completing these repairs endovas-
2082
ROSELLI ET AL Ann Thorac Surg
DISTAL LANDING ZONE FENESTRATION FOR HYBRID REPAIR 2011;92:2078 84
ADULT CARDIAC
cularly, it is expected that the majority of risk is incurred
during the first stage and therefore the overall risk of
total thoracic aortic repair may be improved [4, 5]. The
exception to this is the risk of spinal cord injury, which is
not eliminated by the endovascular approach but is most
closely associated with the extent of aorta repaired [22].
Recent animal studies conducted by Zoli and associates
[23], however, support the staged approach to aortic
repair as a means of reducing this dreaded complication.
The 1 patient in this series who experienced paraparesis
had undergone a single-stage repair, and that approach
has been abandoned since then unless absolutely neces-
sary (ie, rupture).
All patients offered the hybrid 2-stage approach as
described here have returned for the completion repair at
the appropriate time. Although they understand that the
endovascular descending aortic repair and potential for
spinal cord injury are serious issues, the prospect of
avoiding another large incision has encouraged them to
return for completion.
Patient Selection
The periprocedural benefits of reduced morbidity with
TEVAR over open repair have been demonstrated many
times for degenerative aneurysms, but the long-term
durability of endovascular repair in patients with chronic
dissection has come into question [2]. The main contro-
versy relates to the inconsistency with which the aneu-
rysmal false lumen heals in patients treated with this
technique. It is quite commonly the case that persistent
retrograde filling of the false lumen from downstream
reentry tears and fenestrations pressurizes the aneurys-
mal segment and the risk for growth or rupture persists
(Fig 1). Furthermore the chronic intimal flap is thickened
and fibrotic and will not expand to the adjacent adventi-
tial layer of the false lumen. With the approach described
here, the intimal flap is resected over the entire length of
the distal landing zone (approximately 6 cm) so that the
stent-graft device can seal to adventitia circumferentially,
thereby eliminating retrograde filling of the false lumen
in the treated segment (Fig 4).
The intended goal was achieved in all patients, but 2
required late reintervention for type I endoleaks occur-
ring within the distal landing zone. In both of these
patients, the device was not extended far enough across
the entire fenestrated segment. In 1 case this occurred
because the device was placed using a portable C-arm
because rupture had occurred intraoperatively during
the first-phase operation. In the other case, the segment
of aorta that was modified by fenestration was also
reduced in size to accommodate the stent-graft device by
performing an aortoplasty of the adventitia in addition to
the open fenestration. The same adventitial aortoplasty
procedure was performed in a second patient who had an
adequate initial result but later required reoperation for
aneurysmal degeneration of the abdominal aorta. For
TEVAR in a patient with a degenerative aneurysm, it is
recommended that the landing zone be at least 2 cm in
length in a relatively normal segment of aorta. Although
the newly fenestrated distal landing zone is not com-
pletely normal, we are now careful to select patients for
this procedure in whom the overall diameter of the distal
landing zone to be fenestrated is less than 4 cm to avoid
the risk of intermediate-term degeneration.
Although the need for later reintervention in these
patients was not trivial, it is well known that patients with
extensive chronic aortic dissection have a persistent life-
time risk for reintervention. The rate of reintervention in
the single-stage clamshell series was 7.4% and included
reoperations on the treated and untreated segments. The
occurrence of endoleaks is inherent to endovascular
procedures and is not seen with open procedures, but
disease progression can occur regardless of repair tech-
nique. Therefore, these patients should undergo lifetime
regularly scheduled surveillance imaging of their aortas,
especially the residually dissected segments.
Conclusions
Hybrid 2-stage repair—involving ET and open distal land-
ing zone fenestration followed by endovascular completion—
for aneurysm associated with extensive chronic distal
dissection is safe and effective for patients. Intermediate
term follow-up demonstrates that it eliminates retrograde
false lumen filling and promotes aortic size reduction. This
technique is recommended for patients with extensive
chronic dissection and aneurysmal degeneration involving
the thoracic aorta.
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INVITED COMMENTARY
In patients treated for extensive acute type A dissection with
ascending arch replacement and elephant trunk (ET), as well
as in those with uncomplicated type B dissection managed
medically, thoracic endovascular aortic repair (TEVAR) has
been proposed for treating descending chronic post-dissecting
aneurysms. Such an approach has used conventional thoracic
stent-grafts that were deployed in the true lumen, with the
concept that the simple proximal sealing might work to de-
pressurize the false lumen, and, of consequence, the aneu-
rysm. However, conventional TEVAR seems a reasonable
treatment modality for chronic dissections limited to the tho-
racic aorta and for the prevention of focal aortic growth in
extensive dissections. In patients with dissections extended
below the diaphragm, late complications at distal descending
or thoracoabdominal aorta often need secondary interven-
tions, related to the fate of chronic dissected aortas and,
probably, to the distal retrograde endoleak.
Roselli and coauthors [1] report a very interesting open
technique, describing the distal landing zone open fenestra-
tion for facilitating endovascular ET completion and false
lumen thrombosis in complex extensive chronic aortic dissec-
tions. Open arch repair with ET is an established method for
treating type A dissections and looks to be an increasing
surgical option also for patients with chronic type B dissection
who present with aneurysmal degeneration. In such cases of
chronic B dissection, patients may present with a too short
proximal neck that cannot be sealed safely with an endograft,
whereas ET, both classic and frozen, can provide a stable
segment of aorta for the proximal fixation. Although open arch
repair with ET requires hypothermic circulatory arrest, in
high-volume centers the incidence of mortality and cerebral
morbidity is low, owing to both the systematic brain perfusion
and the relatively young age of the patients, as in the series
reported by Roselli and colleagues (mean age, 57 years). In the
technique described by Roselli and coauthors, the open distal
fenestration during the first stage of the ET is of particular
interest. This approach provides an aortic segment with single
lumen at the level of the descending aorta, which will repre-
sent the distal landing zone during the deployment of the
stent-graft in the second endovascular stage. Such attractive
surgical fenestration creates a consistent anatomic condition to
seal with TEVAR, once and for all, the distal arch and the
proximal descending aorta, which are the aortic segments
more prone to a late post-dissecting dilatation.
Extensive chronic aortic dissection is a challenging surgical
problem, currently unresolved using only an endovascular
approach. Although this reported surgical technique is a
major operation, it looks very reasonable, safe, and effective.
We wish to congratulate Dr Roselli and coauthors for their
effort in better managing these patients and describing the
distal landing zone open fenestration for facilitating endovas-
cular ET completion. It represents another step in the devel-
opment of a definitive treatment of extensive chronic aortic
dissections.
Santi Trimarchi, MD
Carlo De Vincentiis, MD
Research Center for Thoracic Aortic Diseases
Policlinico San Donato I.R.C.C.S.
University of Milan
Piazza Malan 2
20097 San Donato Milanese, Italy
e-mail: santi.trimarchi@unimi.it
Reference
1. Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal
landing zone open fenestration facilitates endovascular ele-
phant trunk completion and false lumen thrombosis. Ann
Thorac Surg 2011;92:2078-84.
2084 ROSELLI ET AL Ann Thorac Surg
DISTAL LANDING ZONE FENESTRATION FOR HYBRID REPAIR 2011;92:2078 84
© 2011 by The Society of Thoracic Surgeons 0003-4975/$36.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.09.036
ADULT CARDIAC
    • "Roselli et al. [5] proposed an open fenestration at the distal landing zone to achieve the aspects mentioned above, but due to porcelain aorta, their technique as well as conventional surgery, be it through a left or a clamshell thoracotomy would not be feasible. Nevertheless, the Roselli's technique is connected with a weakening of the aortic wall at the site of the longitudinal incision, and this can result in additional complications [5]. The antegrade resection of the dissection membrane can be performed even in porcelain aorta, offering a very efficient feature for simultaneous repair of the aortic arch and descending aorta in chronic dissection with visceral arteries originating from different lumens. "
    [Show abstract] [Hide abstract] ABSTRACT: A rare case of aortic arch aneurysm combined with chronic aortic dissection is reported. Because the visceral arteries originated from different, equivalently perfused lumens and the descending aorta was circumferentially calcified (porcelain aorta) limiting the possibilities of anastomosing, careful planning of the surgical strategy was of utmost importance. The complex surgery consisted of ascending and total arch replacement using the ‘frozen elephant trunk’ technique with Thoraflex™ Hybrid Prosthesis (Vascutek, Terumo, Inchinnan, Scotland); however, before insertion of the stent graft, an angioscopic resection of the dissection membrane in the proximal part of the descending aorta was carried out to ensure a complete expansion of the distal edge of the stent within the entire common lumen of the aorta and unimpaired distal flow in both lumens below the stent graft. The surgery and the postoperative course were uneventful.
    Full-text · Article · Nov 2015
    • "Of the 85 total reinterventions 27(32%) were endovascular approaches. These included second-stage endovascular elephant trunk completion (n ¼ 12) and other TEVAR (n ¼ 15) (Fig 2) [8]. In all of these patients the proximal landing zone was a surgical graft from previous open repair such as the first-stage elephant trunk or previous open arch or descending repair. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Improvements in care have prolonged survival of patients with connective tissue disorders (CTDs), but their entire native aorta remains at risk. Little data are available to guide treatment. Objectives were to characterize patients, describe repair methods, and assess outcomes. Methods: From 1996 to 2012, 527 patients with CTDs underwent cardiovascular operations. Beyond the root, arch and descending repair was performed in 121 patients (23%) for aneurysm (n = 17), acute complicated dissection (n= 5), or chronic dissection with aneurysmal degeneration (n = 99). CTD diagnoses included Marfan (n = 107), marfanoid (n = 7), Ehlers-Danlos (n = 4), and Loeys-Dietz (n = 3) syndromes. Eighty-seven (72%) had a previous ascending aorta repair, including 51 (57%) for type A dissection. Median interval to distal operation was 8.4 years. Index procedures for repair beyond the root were elephant trunk (ET) stage I (n = 63), open descending repair (n = 26), thoracoabdominal repair (n = 13), total arch replacement (n = 13), and stent-grafting (n = 6: frozen ET 3, thoracic endovascular aortic repair [TEVAR] 3). Median follow-up was 4.4 years. Results: Operative mortality was 2.5% (3 of 121). No paralysis occurred, but 3 patients (2.5%) had nonpermanent stroke, 4 (3.3%) required dialysis, 12 (10%) required tracheostomy, and 13 (11%) underwent reoperation for bleeding. During follow-up, 67 patients underwent 85 additional distal aortic procedures (58 open, 27 endovascular, 49 of which were stage II ET). By 10 years, probability of at least 1 reintervention was 61%. At 1, 5, and 10 years, estimated survival was 91%, 79%, and 62%, and event-free survival was 52%, 35%, and 24%, respectively. Conclusions: Most patients with CTDs who require operations beyond the aortic root have aortic dissection and require multiple reinterventions. Staged repair strategies, including open repair in combination with TEVAR, are feasible, and benefits outweigh risks. These patients require lifelong imaging surveillance.
    Full-text · Article · Nov 2015
    • "Moreover, the Roselli's approach is connected with a weakening of the aorta at the site of the longitudinal incision through the aortic wall consisting of an adventitial layer only. The authors admitted fairly that this problem led to a rupture or false aneurysm formation in a total of 3 patients [16]. The need for a retrograde deployment of an additional stent graft in a second stage procedure as well as the high costs would complete the list of differences between this hybrid procedure and conventional surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: Surgical management of chronic aortic dissection is controversial, especially when the dissection extends into the abdominal aorta in which the visceral arteries originate from different lumens and is combined with aortic arch pathology necessitating surgery. The aim of the study was to evaluate the results of open surgery in this complex aortic pathology. Methods: Between June 2002 and 2015, a total of 17 patients (median age 57, range 32-76 years) necessitating complete arch replacement presented complex chronic dissection of the thoraco-abdominal aorta with the visceral arteries originating from different lumens. Fourteen patients (82%) had had previous cardiac surgery, which was performed on the proximal aorta in all but one because of acute type A dissection. Nine patients without considerable dilatation of the descending aorta received aortic arch replacement with distal resection of the dissection membrane, and 8 patients with progressive dilatation of the thoracic aorta underwent aortic arch and descending aorta replacement via clamshell approach. Results: No early (defined as 30-day, 90-day and in-hospital period) deaths, strokes or spinal cord injuries occurred. Only 1 patient (6%) presented temporary neurological dysfunctions (delirium, agitation), which resolved completely before discharge, and an injury of the recurrent laryngeal nerve was documented in 2 patients (12%). Temporary dialysis was necessary in 1 case. The follow-up was complete for all patients. All but one patient, who died due to leukaemia 23 months after surgery, were alive at the last follow-up (median duration 33 months, range 2-118 months). No patient needed a reoperation or an intervention on the thoracic and/or abdominal aorta. Moreover, no noticeable progression of the chronic dissection in the downstream aorta was documented in any patient. Conclusions: The results after conventional aortic arch repair with distal resection of the dissection membrane and, if necessary, with replacement of the progressively dilated chronic dissected thoracic aorta can offer excellent results in experienced hands and, therefore, this technique may be considered as a preferable option for surgical treatment of chronic aortic dissection with involvement of the aortic arch and the visceral arteries originating from different lumens.
    Full-text · Article · Oct 2015
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