Immediate outcomes of simultaneous and step-by-step reconstruction of aortic dissection: a single-center study

The aim. To evaluate the immediate outcomes after complete single-stage or step-by-step reconstruction of the primary and secondary distal aortic dissection using implantation of bare metal stents in the thoracoabdominal aorta.

Materials and methods. A prospective study was performed involving 21 patients (19 male) with aortic dissection: 8 had secondary distal dissection (group 1) and 13 had primary distal dissection (group 2). In all patients, indications for intervention were signs of malperfusion in one or more vascular regions. The following factors were evaluated: 30-day survival after surgery, causes of fatal outcomes, frequency and characteristics of non-fatal complications.

Results. The average age in group 1 was 43.0 ± 3.1 years, in group 2: 56.0 ± 3.9 years (p < 0.05). The most common cause of dissection in group 1 was connective tissue dysplasia, in group 2 – atherosclerosis in combination with arterial hypertension (p < 0.05). In group 1, 1 (13%) lethal outcome was registered, in group 2 – 4 (31%), the difference between the groups was not significant. Lethal complications were: multiple organ failure, stent implantation in the false aortic canal, aortic rupture, and thrombosis of the superior mesenteric artery. Non-fatal complications developed in group 1 in 3 (38%), in group 2 – in 3 (23%) patients, the difference between the groups is not significant. Among the non-lethal complications, malperfusion of the upper and lower extremities was diagnosed, requiring stent placement, prosthetics or bypass surgery; cerebrospinal circulation disorder, acute cerebrovascular accident, multiple organ failure, conservatively treated.

Conclusion. The survival rate for 30 days after a complete single-stage or step-by-step reconstruction of the primary and secondary distal aortic dissection using implantation of bare metal stents in the thoracoabdominal aorta is 76%, the frequency of non – fatal complications is 28%.

1. Evangelista A., Isselbacher E.M., Bossone E., et al. Insights from the international registry of acute aortic dissection: a 20- year experience of collaborative clinical research. Circulation. 2018; 137(17): 1846–1860. https://doi.org/10.1161/CIRCULATIONAHA.117.031264 PMID: 29685932

2. Debakey M.E., Henly W.S., Cooley D.A., et al. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg. 1965; 49: 130–149. https://doi.org/10.1016/S0022-5223(19)33323-9 PMID: 14261867

3. Smith H.N., Boodhwani M., Ouzounian M., et al. Classification and outcomes of extended arch repair for acute type A aortic dissection: a systematic review and meta-analysis dagger. Interact Cardiovasc Thorac Surg. 2017; 24(3): 450–459. https://doi.org/10.1093/icvts/ivw355 PMID: 28040765

4. Leontyev S., Haag F., Davierwala P.M., et al. Postoperative changes in the distal residual aorta after surgery for acute type A aortic dissection: impact of false lumen patency and size of descending aorta. Thorac Cardiovasc Surg. 2017; 65(2): 90–98. https://doi.org/10.1055/s-0036-1571813 PMID: 27111499

5. Rylski B., Hahn N., Beyersdorf F., et al. Fate of the dissected aortic arch after ascending replacement in type A aortic dissection. Eur J Cardiothorac Surg. 2017; 51(6): 1127–1134. https://doi.org/10.1093/ejcts/ezx062 PMID: 28369453

6. Li D., Peng L., Wang Y., et al. Predictor of false lumen thrombosis after thoracic endovascular aortic repair for type B dissection. J Thorac Cardiovasc Surg. 2020; 160(2): 360–367. https://doi.org/10.1016/j.jtcvs.2019.07.091 PMID: 31558276

7. Komarov R.N., Vinokurov I.A., Karavaikin P.A., et al. Ehtapnyi metod gibridnogo protezirovaniya torakoabdominal’noi aorty [Staged approach for hybrid thoracoabdominal aortic replacement]. Khirurgiya. Zhurnal im. N.I. Pirogova. 2018; 2: 21–27 (In Russian). https://doi.org/10.17116/hirurgia2018221-27 PMID: 29460875

8. Sokolov V.V., Rubtsov N.V., Redkoborodyi A.V., et al. Vybor optimal’noi taktiki lecheniya patsientov s rassloeniem niskhodyashchei aorty [Choice of optimal treatment policy in patients with descending aortic dissection]. Angiologiya i sosudistaya khirurgiya. 2019; 25(1): 115–119 (In Russian). https://doi.org/10.33529/angio2019116 PMID: 30994617

9. Riambau V., Böckler D., Brunkwall J., et al. Editor’s choice – management of descending thoracic aorta diseases: clinical practice guidelines of the european society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2017; 53(1): 4–52. http://dx.doi.org/10.1016/j.ejvs.2016.06.005 PMID: 28081802

10. Tanaka A., Sandhu H.K., Afifi R.O., et al. Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs. J Thorac Cardiovasc Surg. 2019; 161(1): 36–43. E6. https://doi.org/10.1016/j.jtcvs.2019.09.083 PMID: 31699416

11. Boufi M., Patterson B.O., Loundou A.D., et al. Endovascular versus open repair for chronic type B dissection: a meta-analysis. Ann Thorac Surg. 2019; 107(5): 1559–1570. https://doi.org/10.1016/j.athoracsur.2018.10.045 PMID: 30481516

12. Norton E., Williams D., Kim K., et al. Management of acute type B aortic dissection with malperfusion via endovascular fenestration/ stenting. J Thorac Cardiovasc Surg. 2020; 160(5): 1151–1161.e1. https://doi.org/10.1016/j.jtcvs.2019.09.065 PMID: 31669033

13. Burke C.R., Bavaria J.E. The role of thoracic endovascular repair in chronic type B aortic dissection. Semin Thorac Cardiovasc Surg. 2020; 32(1): 21–24. https://doi.org/10.1053/j.semtcvs.2019.08.010 PMID: 31493449

14. Wheat Jr. M.W., Palmer R.F., Bartley T.D., Seelman R.C. Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg. 1965; 50: 364–369 PMID: 14346544

15. Sirota D.A., Khvan D.S., Lyashenko M.M., et al. Primenenie nepokrytykh metallicheskikh stentov v khirurgii rassloeniya aorty [Use of uncoated metal stents in surgery of aortic dissection]. Angiologiya i sosudistaya khirurgiya. 2018; 24(4): 110–116 (In Russian). PMID: 30531778

16. Shlomin V.V., Korovin I.V., Drozhzhin I.G., et al. Likvidatsiya pozdnego ehndolika posle protezirovaniya rassloivsheisya torakoabdominal’noi anevrizmy aorty [Elimination of late endoleak after endovascular repair of a dissecting thoracoabdominal aortic aneurysm]. Angiologiya i sosudistaya khirurgiya. 2019; 25(4): 173–180 (In Russian). https://doi.org/10.33529/ANGIO2019413 PMID: 31855215

17. Sharafuddin M.J., Bhama J.K., Bashir M., et al. Distal landing zone optimization before endovascular repair of aortic dissection. J Thorac Cardiovasc Surg. 2019; 157(1): 88–98. https://doi.org/10.1016/j.jtcvs.2018.06.095 PMID: 30557960

18. Voigt S.L., Bishawi M., Ranney D., et al. Outcomes of carotidsubclavian bypass performed in the setting of thoracic endovascular aortic repair. J Vasc Surg. 2019; 69(3): 701–709. https://doi.org/10.1016/j.jvs.2018.07.022 PMID: 30528402

19. Kozlov B.N., Panfilov D.S., Saushkin V.V., et al. Znachenie urovnya implantatsii gibridnogo stent-grafta «E-vita open plus» v niskhodyashchuyu aortu v razvitii spinal’nykh ishemicheskikh oslozhnenii [Significance of the level of implantation of the “E-vita open plus” hybrid stent graft into the descending aorta in the development of spinal ischaemic complications]. Angiologiya i sosudistaya khirurgiya. 2017; 23(1): 82–86 (In Russian). PMID: 28574041

20. Chernyavskii M.A., Artyushin B.S., Chernov A.V., et al. Klinicheskii sluchai implantatsii golometallicheskogo stenta pri distal’nom rassloenii aorty [Bare metal stent implantation in treating distal aortic dissection: a case report]. Translyatsionnaya meditsina. 2018; 5(5): 12–17 (In Russian). https://doi.org/10.18705/2311-4495-2018-5-5-12-17