title: Antegrade thoracic stent grafting during repair of acute DeBakey I dissection prevents development of thoracoabdominal aortic aneurysms.
abstract: BACKGROUND
  Acute DeBakey I dissection repair consists of ascending aortic resection, aortic root repair or replacement, and variable aortic arch replacement. This "proximal" strategy leaves most patients with a patent residual "type B" dissection which leads to greater than 30% distal "open" reoperations for dissecting aneurysm. This report tests whether antegrade stent-grafting of the proximal descending thoracic aorta during acute DeBakey I dissection decreases future distal aortic aneurysms without an increase in surgical risk.
  
  
  METHODS
  Between June 2005 and June 2008, 150 patients were treated surgically for acute type A aortic dissection at the Hospital of the University of Pennsylvania. Of these, 78 were DeBakey I dissections: 42 patients underwent standard open repair, while 36 underwent additional thoracic stent-grafting by the open arch. Arch repairs were performed with a combination of retrograde cerebral and selective antegrade perfusion.
  
  
  RESULTS
  Mean follow-up was 15.9 months. Hospital mortality was 5 of 36 (14%) for stented and 6 of 42 (14%) for nonstented repairs. Postoperative strokes were 1 of 36 (3%) in stented versus 4 of 42 (10%) in nonstented repairs (p = not significant [NS]) despite longer circulatory arrest times in the stented group; 60 +/- 13 minutes versus 41 +/- 18 minutes (p < 0.0001). Transient paraparesis was 3 of 36 (9%) in the stented versus 1 of 42 (2%) in the nonstented group (p = NS) with no permanent deficits. Stented thoracic false lumen obliteration was achieved in 24 of 30 (80%) with 5 of these (17%) achieving complete thoracoabdominal false lumen thrombosis. Eight of 31 (26%) stented patients underwent endovascular reintervention to achieve the desired false lumen obliteration. Open thoracoabdominal aortic aneurysm repairs were performed in 0 of 31 in the stented group and 4 of 36 (11%) in the standard group (p = 0.083).
  
  
  CONCLUSIONS
  Antegrade stent graft deployment during acute DeBakey I dissection repair is a safe method to obliterate the thoracic false lumen. Endovascular reinterventions were well-tolerated. "Elephant trunk" thoracic stent-grafting as part of the repair for acute DeBakey I dissection gives equal short-term results compared with standard repair, and lowers morbidity and mortality during follow-up.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-4283, USA. alberto.pochettino@uphs.upenn.edu
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
authors.forename: William T
authors.initials: WT
authors.lastname: Brinkman
authors.forename: Patrick
authors.initials: P
authors.lastname: Moeller
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.forename: William
authors.initials: W
authors.lastname: Moser
authors.forename: Katherine
authors.initials: K
authors.lastname: Cornelius
authors.forename: Frank W
authors.initials: FW
authors.lastname: Bowen
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000517:prevention & control*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D002404:Catheterization; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D015607:Stents; D016896:Treatment Outcome