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Antegrade Thoracic Stent Grafting During Repair of Acute Debakey I Dissection Promotes Distal Aortic Remodeling and Reduces Late Open Reoperation Rate
Vallabhajosyula, Prashanth1, Szeto, Wilson1, Desai, Nimesh1, Pulsipher, Aaron1, Musthaq, Shenara1, Pochettino, Alberto2, Bavaria, Joseph1
1Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 2Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA

Objective:
Acute Debakey I dissection repair consists of ascending aortic resection, aortic root and arch repair/replacement. This “proximal” strategy results in a 30% distal aortic re-operation rate within 7-10 years. Antegrade stent-grafting during acute Debakey I dissection repair can partially or fully thrombose the false lumen in the stented descending thoracic aorta (DTA), reducing future surgical risk by either completely obliterating the dissection in the descending aorta or allowing for future descending TEVAR to address the remaining false lumen.
Methods:
Debakey type I dissections between June 2005 and present were reviewed. 175 patients underwent standard open repair, with 55 undergoing hybrid endovascular and open therapies, either thoracic stent-grafting via the open arch or very rarely staged stent graft repair after debranching of the innominate and left common carotid. Arch repairs were performed with a combination of retrograde cerebral and selective antegrade perfusion.
Results:
Mean follow-up was 2.9 years. Hospital mortality was 6/55 (11%) for stented, and 24/175 (15%) for standard patients (p=.8). Post operative strokes occurred in 3/55 (5%) stented vs 15/175 (8%) standard repairs (p =.6) This was despite longer circulatory arrest times in the stented group: 51+/-16 min vs 34+/-38 min. (p<0.001). Transient spinal cord ischemia occurred in 4/55 (7%) in stented patients with no new permanent deficits. Thoracic (or complete) aortic “remodeling” with false lumen obliteration was 82% (45/55). Of the remodeling sucesses, 8/45 required an additional endovascular reintervention to achieve thoracic false lumen obliteration. There was no mortality with endovascular reintervention. No late distal aortic operations were required in the stented group, whereas 7 were required in the standard group, with 1 perioperative mortality (14%) (cumulative freedom from open distal reoperation at 5 years was 100% stented, 95% standard, p= .11). One year survival was 81% for both groups, and 70% (stented) and 74% (standard) at 5 years (p=.8).
Conclusions: Antegrade stent graft deployment during acute Debakey I dissection repair is a safe method to obliterate the residual thoracic false lumen. Endovascular re-interventions were well tolerated. Proximal descending thoracic aorta stenting gives equal mid term results and lower morbidity and mortality during follow-up.


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