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Dissection of the Ascending Aorta and Aortic Arch Chapter | 28 329
(A)
(B)
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is required [194,212,213]. Sun et al. used [214,215] this method and made some modifications: the whole length of the
elephant trunk is sustained by a self-expandable stent, and this is the so-called “skeletonized elephant trunk technique.”
In cases of Standford type A aortic dissection with an aberrant right subclavian artery (ARSA), and the intimal tear arising just near the origin of the ARSA, the ascending aorta could be replaced by a mono-branched vascular prosthesis, thus
furthermore bypassing to the ARSA. For repairing the aortic arch, a triple-branched stent graft could be inserted into the TL
of the arch and proximal descending aorta (covering the origin of the ARSA) with each sidearm graft being positioned into
the aortic branches. Afterward, the distal part of the mono-branched vascular prosthesis is anastomosed to the proximal end
of the triple-branched stent graft [216–222].
TOTAL THORACIC ENDOVASCULAR AORTIC REPAIR FOR ACUTE THORACIC AND
ASCENDING AORTA DISSECTION
Descending thoracic aortic dissection extending into the ascending aorta is a special subgroup of type A dissection [223], which
usually requires extensive aortic replacement. Total endovascular treatment of TAAD is currently in an experimental phase and
only few case reports have been reported [224,225] and has been used for retrograde type A aortic dissection with an entry in
the descending aorta (Fig. 28.19). Stent graft placement in the TAAD might be feasible in selected cases, as the landing zone
needs to be evaluated very accurately, being in the vicinity of the supraaortic branches and because the aortic wall is usually
thin and fragile and is debated because of that, but Von Segesser [226] proposed that it should be managed in accordance with
the site of the predominant lesion. So according to that, the main objective of endovascular repair is not to eliminate the blood
flow in the FL, but to seal the tears, restore the blood flow in the TL, relieve distal malperfusion, and prevent aortic rupture.
(C)
FIGURE 28.19 (A) Preoperative computed tomography (CT) scan with multiplanar reconstruction. The false lumen (FL) is thrombosed in the ascending and proximal descending aorta (stars). (B) Intraoperative angiogram shows the abdominal aorta separated into two lumens. The FL is patent (star).
(C) Intraoperative aortogram after stent graft placement reveals that the orifice of the left subclavian artery is covered. The left common carotid artery
(arrow) is patent. (D) CT image with maximum-intensity projection at 3-month follow-up shows that the TL in the ascending aorta has enlarged and the
FL has shrunk.
(D)
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Although primarily ATAAD repair with ascending custom-made stent graft (fitting the dimension of the ascending aorta -
from the sinotubular junction to the brachiocephalic trunk) introduced by Zimfer [227] and later on by Metcalfe [228] was
used in chronic dissection by Ihnken and Zhang [229], it is a new solution, now preferable to open surgery, thus with many
challenges—difficult proximal fixation close to the aortic valve and coronary ostia and distal fixation, which may impinge
on the innominate artery, and the potential for fatal retrograde dissection—but benefits by its less invasive fashion without
the use of sternotomy and avoiding the circulatory arrest.
In conclusion, the decision-making process in ascending and aortic arch dissection has expanded with the adoption of
novel strategies: open surgery under circulatory arrest with cerebral perfusion, which is the gold standard, moved to hybrid
procedures and endovascular procedures or palliative care.
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FURTHER READING
[1] Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type a dissection
involving repair of the aortic arch? Circulation 2011;123:971–8.
[2] Aoki K, Okamoto T, Sato H, Namura O, Onishi R, Hanzawa K, Tsuchida M. Endovascular repair for acute phase of retrograde type A aortic dissection
with an entry in the descending aorta. Kyobu Geka April 2016;69(4):276–81.
[3] Shu C, Wang T, Li Q-M, Li M, Jiang X-H, Lu M-Y, Li X. Thoracic endovascular aortic repair for retrograde type a aortic dissection with an entry
tear in the descending aorta. J Vasc Interv Radiol 2012;23(4):453–60. e1.
[4] Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to the ascending aorta. Circulation 2003;108. II-300–6.
Chapter 29
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Dissection of Thoracoabdominal Aorta
Debabrata Dash
1
Thumbay Hospital, Ajman, United Arab Emirates; 2Beijing Tiantan Hospital, Beijing, China; 3Tan Tao Medical School, Long An Province, Vietnam
Disease is very old and nothing about it has changed. It is we who change as we learn to recognize what was formally imperceptible.
1,2,3
Jean Martin Charcot
Chapter Outline
Introduction, Epidemiology, and Pathophysiology 339
Etiology and Natural History 340
Classification 341
Clinical Presentation 341
Diagnosis 342
Biomarkers 342
D-dimer 342
Smooth Muscle Myosin Heavy Chain 342
Matrix Metalloproteinase 9 343
Elastin Degradation Products 343
Transforming Growth Factor-Beta (TGF-β) 343
Management 343
Optimal Medical Treatment (OMT) 343
Open Surgical Repair (OSR) 344
Thoracic Endovascular Aortic Repair 344
Conclusion 344
References 345
INTRODUCTION, EPIDEMIOLOGY, AND PATHOPHYSIOLOGY
Diseases of the aorta are one of the most catastrophic conditions encountered in clinical practice. Thoracoabdominal aortic dissection (TAAD) is defined as separation of the layers of the tunica media by ingress of the blood, producing a false
lumen (FL) with variable proximal or distal extension. It is not an infrequent clinical entity and constitute 40% of all dissections. It is more common in males than females with male-to-female ratio of 2–3:1. The presentation is atypical in females
with much worse prognosis compared to males [1]. Approximately, 75% of dissections occur in those aged 40–70 years,
with a peak in the range of 50–65 years. Patients with Marfan syndrome present earlier, usually in the third and fourth
decades of life [1].
The thoracoabdominal aorta is the combination of the descending thoracic and abdominal aorta. With increasing age,
the elasticity and distensibility of the aorta decline, thus inducing the increase in pulse pressure observed in elderly individuals, which is exacerbated by hypertension, coronary artery disease, or hypercholesterolemia. Histologically, the loss
of distensibility is marked by fragmentation of elastin and the resultant increase in collagen and, thus, a higher collagento-elastin ratio. This, along with impairment in flow in the vasa vasorum, may be responsible for the age-related changes.
These factors cumulatively lead to increased left ventricular systolic pressure and wall tension with associated increases in
end-diastolic pressure and volume. Because of this high pulsatile pressure and shear stress, the aorta is vulnerable to injury
and disease from mechanical trauma. The aorta is more prone to rupture than any other vessel, especially with the development of aneurysmal dilatation because its wall tension, as governed by the Laplace law, is intrinsically high. It is widely
accepted that TAAD occurs when an intimomedial tear, or entry tear, allows blood flow to enter the aortic wall, thereby
creating an FL. The FL propagates distally in a spiraled (most often) or straight manner or proximally all the way to the
aortic valve. Not rarely, the true lumen (TL) becomes compressed by the pressurized FL, sometimes to the point of collapse
leading to ischemic complications below (malperfusion). Although the proximal thoracic aorta is almost always the site of
the entry tear, secondary or reentry tears (fenestrations) can occur either distally in the thoracic aorta or in the abdominal
aorta or iliac arteries. A diseased or weakened vessel wall is a probable prerequisite, rendering the aorta vulnerable on
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00029-8
Copyright © 2018 Elsevier Inc. All rights reserved.
339
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