Total Arch Replacement Combined With Stented Elephant Trunk Implantation
Key result
Total arch replacement with stented elephant trunk linked to ~38% lower in-hospital mortality versus conventional repair.
- n=411
Why the study?
Appropriate surgical management of type A dissection is critical for satisfactory outcomes, but the choice of optimal procedure remains controversial.
Does total arch replacement combined with stented elephant trunk implantation improve outcomes compared to conventional surgical repair in patients with type A dissection involving the arch?
Key Points
- This research aims to evaluate the outcomes of total arch replacement combined with stented elephant trunk implantation for type A dissection.
- Retrospective review of 411 patients undergoing aortic arch replacement from January 2003 to September 2008.
- Patients categorized into stented elephant trunk (291) and conventional repair (120) groups.
- Analysis included in-hospital mortality, spinal cord injury, stroke prevalence, and secondary intervention rates.
- In-hospital mortality was 3.09% for stented (acute 4.73%, chronic 1.40%) vs. 5.00% for conventional repairs (acute 6.06%, chronic 3.70%).
- Spinal cord injury occurred in 2.41% of stented patients compared to 0.83% in conventional group.
- Obliteration of the false lumen was observed in 94.2% of acute and 92.0% of chronic dissection patients treated with the stented approach.
Study Design
Type
Cohort (n=411)
Structured PICO
Does total arch replacement combined with stented elephant trunk implantation improve outcomes compared to conventional surgical repair in patients with type A dissection involving the arch?
P
Population
411 patients with type A aortic dissection involving the arch who underwent aortic arch replacement between 2003 and 2008.
E
Exposure
Total arch replacement combined with stented elephant trunk implantation
C
Comparator
Conventional surgical repair
O
Outcome
In-hospital mortalityhard clinical
Main Result
Absolute Event Rate: 3.09% vs 5%
Total arch replacement combined with stented elephant trunk implantation demonstrates low mortality and high rates of false lumen obliteration, suggesting it as a viable standard therapy for type A dissection involving the arch.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“But does this mean we should be doing [elephant-trunk] operation on every type A dissection patient?”
LSLi-Zhong SunCardiovascular surgeon, Capital Medical University, Beijing
“This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic patch wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results.”
WYWilson Y. SzetoCardiovascular surgeon, University of Pennsylvania
“then should we empirically dissect the arch vessels and perform total arch replacement in an emergent situation?”
Implication
May favor stented elephant trunk in arch-involved type A dissection; leaves open need for randomized trials before practice change.
Abstract
BACKGROUND: Appropriate surgical management of type A dissection is a critical factor for achieving satisfactory outcome, but the choice of optimal procedure is controversial. We retrospectively reviewed our experience with aortic arch replacement for type A dissection involving the arch. METHODS AND RESULTS: Excluding 14 cases of subtotal or total aortic replacement, 411 of 544 patients with type A dissection (stented elephant trunk=291, conventional surgical repair=120) underwent aortic arch replacement between January 2003 and September 2008. In-hospital mortality was 3.09% (9 of 291) for stented (acute=4.73%, 7 of 148; chronic=1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acute=6.06%, 4 of 66; chronic=3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stented=2.41%, 7 of 291; conventional=0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stented=1 and conventional=4; P=0.031) and 3.05% (6 of 197) for chronic dissection (stented=4 and conventional=2; P=0.661) during follow-up. Obliteration of the false lumen around the stented elephant trunk occurred in 94.2% (130 of 138) of patients with acute dissection and in 92.0% (126 of 137) of patients with chronic dissection. CONCLUSIONS: Total arch replacement combined with stented elephant trunk implantation demonstrated the superiority of the combination of the surgical and interventional approaches while avoiding the weaknesses associated with the individual methods. The encouraging surgical results could enable this procedure to become the new "standard" therapy for type A dissection involving repair of the aortic arch.
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Cite This Study
Sun et al. (2011) conducted a cohort in Type A aortic dissection involving the arch (n=411). Total arch replacement combined with stented elephant trunk implantation vs. Conventional surgical repair was evaluated on In-hospital mortality. Total arch replacement combined with stented elephant trunk implantation for type A dissection was associated with 3.09% in-hospital mortality versus 5.00% for conventional repair.