Hybrid approach for type Aaortic dissection

Gian Luca Martinelli MDCV Surgery Dept.

S Anna Hospital – Catanzaro - Italy

Possible scenarios

• Complete resection of dissected aorta

• Total thrombosis in the false lumen

• Partial thrombosis in the false lumen

• Perfused false lumen

Shrinkage of the false lumen

Our goal: remodeling the aorta

• Extensive repair of the aorta should prevent chronic progressive enlargement of the false lumen and further aortic complications.

• Hybrid approach:

extend the treatment without increasing mortality rate.

Two surgical options• Multibranched Frozen Elephant Trunk :

Ascending-arch repair with multibranched grafting + descending aortic stenting

• Two-step approach:

① Ascending-arch repair with multibranched grafting

② Carotid-subclavian bypass + TEVAR

with ideal landing zone

The choice depends on clinical presentation, site of the intimal tear and patient age

Multibranched Frozen Elephant TrunkClinical Case 1

59 yo man

Acute aortic Type A dissection: arch entering tear

Not complicated (Penn Class Aa)

Surgical treatment:

Multibranched – FET with Captivia-Medtronic-VAMC 32-32-150

Preoperative MSCT scan

Guide wire in the true lumen

S. ANNA HOSPITAL – Photografic archive

FINAL RESULT

Two-step approachClinical Case 2

• 57 yo man;

• Pain, syncope and 3 h transient drowsiness (no neurological damages);

• TTE: severe IA, without pericardial effusion;

• CT scan: full rupture (tear) in sino-tubular junction and absence of malperfusion.

Preoperative MSCT scan

Case 2: surgical strategy

Bentall operation;

Aortic arch replacement in Z1;

Proximal reimplantation of cerebral vessels;

Creation of an optimal landing zone for TEVAR C-Tag Gore 34-34-200

SECOND STEP

Ideal landing in zone 0

FINAL RESULT

CONCLUSIONS

Decision making key points:Clinical presentation

Site of intimal tear

Age

Two surgical options:

FET or Hybrid two step approach

Thank you

Tips and Tricks

• Use of branched graft

• Anterograde deployement wire guided

• Very “proximal” distal anastomosis (Z 0-1) in shorter circulatory arrest time, mild hypothermia, anterograde selective cerebral perfusion

Most patients after surgery for AAD remain at risk for dissection-related

aortic complications

Repair of acute type A aortic dissection prevents further

procedures?