Original Articles
Surgical Treatment of Acute Type B Aortic Dissection Using an Endoprosthesis (Elephant Trunk)

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Abstract

Background. The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates.

Methods. Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures.

Results. The mean arrest time was 31.4 ± 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line.

Conclusions. The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.

(Ann Thorac Surg 1997;63:1081–4)

Section snippets

Patients and Methods

From May 1988 to December 1995, 70 consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure performed through a me- dian sternotomy during deep hypothermic circulatory arrest. There were 57 male and 13 female patients ranging in age from 31 to 80 years. Diagnosis was confirmed in all patients by aortography, contrast-enhanced computed tomographic scanning, and transthoracic or transesophageal echocardiography. Ten patients had retrograde arch

Results

The mean duration of deep hypothermic circulatory arrest was 31.4 ± 8.7 minutes (maximum, 51 minutes). The total cardiopulmonary bypass time was 99 ± 22 minutes. Associated procedures included replacement of the ascending aorta or arch (11 cases) and myocardial revascularization (2 cases). Fourteen patients (20%) died during their hospital stay. Death was due primarily to neurologic events (2 patients), pulmonary insufficiency (2 patients), acute renal failure (3 patients), multiorgan failure

Comment

Since the mid-1960s and early 1970s when Wheat [[1]] and Daily [[7]] and their colleagues recommended that patients with a type B dissection be treated with medical therapy, surgical treatment has been reserved for patients with complications of the dissection, such as rupture, an aneurysm, or organ ischemia. However, medical therapy is associated with a high incidence of complications stemming from expansion of the false lumen and ischemic injury to different organs, with a 5-year mortality

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