Wrapping of the Ascending Aortain Acute Type A Retrograde AorticDissectionRamzi Ramadan, MD, Alexandre Azmoun, MD,Nawwar Al-Attar, FRCS, PhD, and Remi Nottin, MD

Department of Cardiac Surgery, Centre Chirurgical MarieLannelongue, Le Plessis-Robinson, and Department of CardiacSurgery, Bichat Hospital, Assistance Publique - Hôpitaux deParis, Paris, France

We describe off-pump wrapping of the ascending aortain 3 high-risk patients with acute type A aortic dissectionwhen the primary intimal tear was not located in theascending aorta and in the absence of aortic insufficiency.A Teflon plaque (Bard Inc, Murray Hill, NJ) was tailoredto tightly wrap the aorta from the coronary ostia to theinnominate artery. The mean age of the patients was 80.3years. All patients were at high risk for conventionalsurgery. A postoperative computed tomographic scanshowed a reapplication of the intimal flap and contain-ment of the false lumen in the reinforced ascending aortain all patients.

(Ann Thorac Surg 2011;92:e49–50)© 2011 by The Society of Thoracic Surgeons

Surgical treatment of the Stanford acute type A aorticdissection (AAD) is associated with a high incidence

of postoperative complications and considerable in-hospital mortality. The risk is greater when the primarytear is not located in the ascending aorta as the repairrequires more extensive aortic arch replacement. Fur-thermore, operative risk is higher in elderly patients, aspatient age is a significant and independent determinantof overall mortality. On the other hand, conservativetreatment is associated with poor outcome and a highrisk of aortic rupture.

We report a less invasive surgical approach consistingof wrapping of the dissected ascending aorta withoutcardiopulmonary bypass in three elderly high-risk pa-tients with retrograde type A AAD without intimal tear inascending aorta.

From October 2008 to October 2009, 3 patients withStanford type A AAD underwent external wrapping ofthe ascending aorta. Approval by the institutional reviewboard was obtained, and each patient gave informedconsent. Patient 1 was an 85-year-old man with tampon-ade and cardiogenic shock. Patient 2 was an 82-year-oldwoman suffering from severe chronic respiratory failurewith oxygen therapy at home. Patient 3 was a 76-year-oldman with hypertensive cardiomyopathy, poor left ven-tricular function, and metastatic prostate cancer. A com-puted tomographic scan showed that the entire aorta wasdissected (type A). The intimal tear was located at theaortic isthmus with a distal extension toward the thora-coabdominal aorta and retrograde extension into theaortic arch and ascending aorta. The aortic root and

Accepted for publication March 17, 2011.

Address correspondence to Dr Ramadan, Department of Cardiac Surgery,

133 Ave de la Résistance, Le Plessis-Robinson 92350, France; e-mail:ramadan.ramzi@wanadoo.fr.

© 2011 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

coronary ostia were not dissected, and there was noevidence of primary tear location in the dissected ascend-ing aorta (retrograde type A AAD) (Fig 1). Echocardiog-raphy confirmed pericardial effusion in all patients andexcluded significant aortic valve regurgitation. There wasno peripheral malperfusion syndrome.

Emergent off-pump surgery was performed through amedian sternotomy. The cardiopulmonary bypass pumpwas ready in the operating room. The ascending aortawas carefully separated from the pulmonary artery trunkand the right pulmonary artery. Care should be takenduring the dissection to avoid tearing the false lumen ofthe dissected aorta. A plaque of Teflon (15 cm � 15 cm)(Bard Inc, Murray Hill, NJ) was tailored, placed aroundthe aorta from the coronary ostia up to the innominateartery and was approximated with a running suture of3-0 Prolene (Ethicon, Somerville, NJ) to tightly wrap thedissected ascending aorta. The aim was to significantlyreduce the diameter of the aorta and provide maximumopposition of the false to the true lumen. Compression ofthe pulmonary artery to reduce blood pressure canfacilitate approximation of the edges of the plaquearound the aorta. The snug fitting secures the plaquearound the aorta and prevents migration. The overalloperation times were 120, 90, and 120 minutes, respec-tively, with no conversion to cardiopulmonary bypass.

There was no operative death. The postoperative hos-pital stays (12, 15, and 12 days, respectively) were un-eventful. Pre-discharge computed tomographic scansdemonstrated a single lumen with the reapplication ofthe false lumen in the reinforced ascending aorta in allpatients (Fig 2). At follow-up (21, 12, and 9 months,respectively), the patients were doing well and wereself-catering. Subsequent follow-up computed tomo-graphic scans confirmed the absence of dissection in thereinforced aorta.

Comment

In Stanford type A AAD, survival without operativeintervention is dismal [1]. The standard therapy is emer-gency surgical replacement of the dissected ascendingaorta, including the primary intimal tear. This carries ahigh, but acceptable, early mortality rate and providesgood long-term outcome among survivors [2, 3]. How-ever, the incidence of postoperative complications andin-hospital mortality rate are higher when the primarytear is not located in the ascending aorta, requiring moreextensive aortic arch replacement with selective brainperfusion or hypothermic circulatory arrest. Total archreplacement is indeed associated with a considerablyhigher mortality, as for isolated ascending aorta [2, 3].Furthermore, the risk is even higher in elderly patients orpatients in poor preoperative condition, as patient age isa significant and an independent determinant of overallmortality [4]. Therefore, despite acceptable results ofstandard surgery in the general population, there is stilldebate as to whether all elderly patients or patients inpoor preoperative conditions suffering from a type AAAD should be referred for standard surgery, given areported operative mortality rate superior of 40% in thisgroup [2, 4]. Performing less invasive surgery in thesehigh-risk patients is a key factor to reduce the mortality

rate. Hata and colleagues [5] described excellent out-

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e50 CASE REPORT RAMADAN ET AL Ann Thorac SurgWRAPPING OF DISSECTED ASCENDING AORTA 2011;92:e49–50

comes in octogenarians undergoing emergency surgeryfor type A AAD with a less invasive technique.

We performed wrapping the entire dissected ascend-ing aorta, precluding the need for cardiopulmonary by-pass in 3 high-risk patients with suitable anatomic con-ditions (retrograde type A AAD). This minimally invasiverepair should be reserved for high-risk patients requiringemergent surgical treatment. It aims to avoid intraperi-cardial aortic rupture, the major cause of death in thesepatients, and the complications of extensive aortic archreplacement. Early results and as much as 2 years fol-low-up of this procedure are encouraging with favorable

Fig 1. Preoperative computed tomographic scan showing type A aor-tic dissection.

outcomes in all patients.

References

1. Wu IH, Yu HY, Liu CH, Chen YS, Wang SS, Lin FY. Is old agea contraindication for surgical treatment in acute aortic dis-section? A demographic study of national database registry inTaiwan. J Card Surg 2008;23:133–9.

2. Piccardo A, Regesta T, Zannis K, et al. Outcomes after surgicaltreatment for type A acute aortic dissection in octogenarians:a multicenter study. Ann Thorac Surg 2009;88:491–7.

3. Ehrlich MP, Ergin MA, McCullough JN, et al. Results ofimmediate surgical treatment of all acute type A dissections.Circulation 2000;102(Suppl 3):III248–52.

4. Mehta RH, O’Gara PT, Bossone E, et al; International Registryof Acute Aortic Dissection (IRAD) Investigators. Acute type Aaortic dissection in the elderly: clinical characteristics, man-agement, and outcomes in the current era. J Am Coll Cardiol2002;40:685–92.

5. Hata M, Suzuki M, Sezai A, et al. Less invasive quickreplacement for octogenarians with type A acute aortic dis-

Fig 2. Postoperative computed tomographic scan of the same patientshowing containment of the ascending aorta with absence of the dis-section flap.

section. J Thorac Cardiovasc Surg 2008;136:489–93.