Prophylactic aortic arch debranching during type A aortic dissection repair

We read with interest the article of Uchida and co-workers [1] on their experience with a combined surgical and endovascular procedure in patients with acute type A aortic dissection. The aim of their hybrid approach is to obtain the thrombosis of the residual false lumen and in doing so, prevent the development of aneurysmatic dilatation of the dissected thoraco-abdominal aorta. However, when regarding the literature, many studies demonstrated that even though the residual dissected aorta tends to dilate, a long time is necessary for the development of a large aneurysm requiring surgery [2,3]. In a recent paper, Kimiura and co-workers [4] showed that the presence of a residual patent lumen does not affect the long-term outcome in patients who underwent standard surgical repair of type A aortic dissection. In addition their result demonstrated that a residual patent lumen is not necessarily associated with faster aortic growth rate.

Taking these data into consideration, probably only a few patients of Dr Uchida’s series will really benefit from this hybrid single stage approach while all patients, on the contrary, receive a supplementary risk related to the insertion of the thoracic stent-graft.

In our hands, a solution to overcome the problems related to possible enlargement of the residual dissected aorta has been represented by the use of a standard aortic arch replacement in concomitant with a prophylactic supra-aortic vessels debranching with a specially designed trifurcated vascular prosthesis (Vascutek, Gelweave™ Plexus Graft, Terumo Inc., USA). The use of this prosthesis allows, at the same time the replacement of the ascending aorta and arch and to relocate the origin of the supra-aortic vessels very proximally just above the sino-tubular junction, creating a safe and long proximal stent landing zone. In case of further descending thoracic aorta enlargement, if indicated, this preventing of debranching during acute surgery allows a safe and effective endovascular treatment.

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