Simplified total aortic arch replacement with an in situ stent graft fenestration technique for acute type A aortic dissection.

Abstract

Total arch replacement combined with stented elephant trunk implantation in the descending aorta has successfully improved the outcomes of acute type A aortic dissection (AAAD). However, the optimal surgical strategy for the left subclavian artery (LSA) during the procedure remains a challenge. This study aimed to present our new technique of in situ stent graft fenestration to simplify the surgical procedure for suitable cases of AAAD. From August 2008 to December 2015, a total of 106 patients underwent simplified total aortic arch replacement with an in situ stent graft fenestration technique. The mean age of the patients was 50.71 ± 11.54 years (range, 24-78 years). Both perioperative variables and postoperative follow-up outcome of the procedure were assessed. The in-hospital mortality rate was 7.5%. The mean cardiopulmonary bypass time was 162.73 ± 68.49 minutes, cross-clamp time was 93.13 ± 22.29 minutes, and circulatory arrest time was 23.28 ± 5.56 minutes. Transient neurologic dysfunction was observed in five patients. No permanent neurologic dysfunction was observed, and no stroke or left arm ischemia occurred. During the follow-up period (mean, 43.4 ± 21.53 months), the survival rates of patients were 90.6%, 85.5%, and 78.8% at 1 year, 2 years, and 7 years, respectively. No stroke or left limb ischemia was observed. The LSA perfusion was well preserved in all surviving patients, and there was no endoleak or dissection around the LSA. All patients were free from reoperation. The in situ graft fenestration technique could simplify the procedure of LSA reconstruction during total arch replacement, provide a good surgical view for anastomosis and hemostasis, shorten the operation time, and yield satisfactory early and midterm results. It is a safe and effective alternative approach for suitable patients with AAAD. However, the long-term results of this technique need further evaluation.