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Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique

Total arch repair for acute type A aortic dissection with open placement of a modified... Background: In total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique. Methods and results: Total arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients. Conclusions: The modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it’s placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair. Keywords: Aorta, Dissection, Surgery, Stent Background dissection occurs, the chances of survival might remain Acute type A aortic dissection usually requires emergency in hazard, and difficult reoperation is inevitable. This surgical management to prevent death resulting from aor- unsatisfactory long-term prognosis would favor simul- tic rupture [1,2]. Although the dissection frequently in- taneous replacement of the ascending aorta and total volves entire aorta, the dissected ascending aorta is most arch in the same surgical field during the primary emer- common segment to rupture. Therefore, the simple as- gency operation [8]. cending aortic graft replacement is widely accepted as the Total arch replacement is very complex and highly in- conventional treatment for acute type A aortic dissection vasive if it is performed with the traditional method, [1-3]. This conventional operation has improved the life which makes the risk of this procedure very high in pa- prognosis for the acute phase, but residual dissection in tients with acute type A aortic dissection [2]. Whether the arch and downstream aorta can still occur after the this traditional total arch replacement with possible add- conventional ascending aortic replacement, which has itional operative risk can be justified from the viewpoint been widely proven to affect the long-term prognosis of potential long-term benefits remains controversial [4-7]. When continuous enlargement of the residual [9,10]. Therefore, traditional total arch replacement can’t be widely accepted as preferred surgical treatment for acute type A aortic dissection during the emergency * Correspondence: [email protected] repair. Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China © 2014 Chen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 2 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 It would be desirable if one technique could effectively The dissection had extension to the innominate artery in repair total arch while keeping the surgical invasion and 23 patients, to the left common carotid artery in 5 patients risk as low as possible. Recently, we developed open and to the left subclavian artery in 5 patients. A history of triple-branched stent graft placement technique, in which hypertension was found in 17 patients and 11 of them total arch repair could be simply completed by inserting a didn’t receive effective antihypertensive treatment. Four triple-branched stent graft into the proximal descending patients had diabetes melitus, 2 had classic Marfan syn- aorta, arch and 3 arch vessels through the same transverse drome and 1 had chronic renal dysfunction. There were aortic incision line as ascending aortic replacement [11]. some preoperative complications related to the aortic dis- Clinical results showed that our new technique could re- section including moderate or severe aortic valvular regur- duce the risk and technical difficulty of total arch repair to gitation in 5 patients, cardiac tamponade in 1, transient close to those of the conventional ascending graft replace- brain ischemia in 1, and acute renal dysfunction in 3. All ment with open distal anastomosis [11]. Therefore, this operations were performed within 4 hours after the diag- new simple technique could be an attractive alternative to nosis was confirmed. The average interval between the traditional total arch replacement for acute type A aortic onset of pain and operation was 3.0 ± 2.3 days (range, 1to dissection. However, in our practice with this new tech- 9 days). In this study, total arch repair for acute type A nique, two major problems were found. First, this new aortic dissection was on the basis of one of the following technique could not be applied in most patients, because indications: (1) the patient was < 55 years of age; (2) the the diameters of the native arch vessels and the distances intimal tear located in the transverse arch or proximal de- between 2 neighboring arch vessels did not always match scending aorta that could not be resected by hemiarch re- the available sizes of the triple-branched stent grafts. Sec- placement; (3) there was serious involvement of the arch ond, the arch vessel orifices and the true lumen of the de- vessels; or (4) Marfan syndrome was present. scending aorta could not be clearly seen through the distal ascending aortic incision in some cases, so inserting of the The modified triple-branched stent graft triple-branched stent graft in such cases was not easy. In The modified triple-branched stent graft (conceived and an effort to reduce those two problems, we modified the designed by two of us (LWC and CL) and manufactured triple-branched stent graft to the new generation, which by Yuhengjia Sci Tech Corp Ltd, Beijing, China) con- could provide a good match with the different diameters sisted of a self-expandable nitinol stent and polyester of the native arch vessels and the various distances be- vascular graft fabric. The polyester vascular graft fabric tween 2 neighboring arch vessels, and developed the arch was thin and soft enough to be easily folded. Each modi- open technique to make the placement much easier and fied triple-branched stent graft comprised a main tube safer. Here, we describe our application of this new gener- graft and 3 sidearm tube graft. ation of triple-branched stent graft and the arch open Our modified triple-branched stent graft was designed technique for total arch repair in patients with acute type to provide a good match with the different diameters of A aortic dissection. In addition, we report our initial clin- the native arch vessels and the various distances between ical results in 25 consecutive patients. 2 neighboring arch vessels. For this purpose, two major modifications were developed. First, the polyester tube Methods graft and the stent for each native arch vessel or arch Patients were not attached together before implantation, and they Between November 2012 and June 2013, 25 consecutive were implanted separately. Second, the diameter of the patients with acute Stanford type A aortic dissection sidearm polyester tube graft was designed to be bigger underwent total arch repair with open placement of a than that of most corresponding arch vessels, and the modified triple-branched stent graft and the arch open distance between 2 neighboring sidearm tube grafts was technique. This procedure was approved by the ethics longer than that between 2 corresponding arch vessels committee of Union Hospital, Fujian Medical University, of most Chinese adults. After a bigger sidearm tube graft and written informed consent was obtained from each was inserted into the corresponding smaller arch vessel, patient or legal representative. There were 21 men and 4 a stent with the size proportional to that of this arch women. The average patient age was 49.92 ± 13.04 years vessel was selected and inserted, which resulted in longi- (range, 20 to 74 years). Preoperative diagnosis was based tudinal fold of the implanted bigger sidearm tube graft on electron beam computed tomography, echocardiog- to match this arch vessel. When the implantation of 3 raphy and magnetic resonance imaging. The primary in- sidearm tube grafts and their stents into the corre- timal tears were located in the ascending aorta in 13 sponding arch vessels was completed, an arch stent with patients, in the arch in 4 patients, and in the proximal the size proportional to the arch size was inserted into descending aorta with retrograde extension of the dissec- the main tube graft. As a result, the main tube graft be- tion into the arch and the ascending aorta in 8 patients. tween two sidearm tube grafts was transversely folded Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 3 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 to match the distance between two corresponding native The main tube graft and 3 sidearm grafts were indi- arch vessels. vidually mounted on 4 catheters and restrained by 4 silk In this study, two types of our modified triple-branched strings. stent graft were produced. Type 1 was designed to provide a good match only with the various distances between 2 Stents for arch or arch vessel neighboring arch vessels, and type 2 was designed to pro- Stents for arch or arch vessel were multiple rings of self- vide a good match with both the different diameters of the expandable nitinol wire (Yuhengjia Sci Tech Corp Ltd, native arch vessels and various distances between 2 neigh- Beijing, China). In each stent, the multiple rings were boring arch vessels (Figure 1). connected to a polyester vascular fabric felt (Figure 2). In both types, the tapered main tube graft was 145 mm Therefore, the stent had bare stent portion and polyester in length, 32 mm in proximal diameter and 28 mm in dis- fabric portion. The arch stent was 60 mm long and 26 tal diameter. The proximal portion of the main tube graft to 34 mm in diameter, and the arch vessel stent was was unstented before implantation and designed for arch 30 mm long and 12 to 20 mm in diameter. The diameter repair while the distal portion was stented and acted as a of the stent selected was 10% to 20% bigger than the size stented elephant trunk. The distance between 2 neighbor- of the corresponding landing zone [12,13]. ing sidearm graft was 12 mm (longer than that between 2 corresponding arch vessels of most Chinese adults). All three sidearm tube grafts were 3.5 mm long in Operative technique both types. In type 1, all three sidearm tube grafts were All procedures were performed with patients under gen- stented before implantation. The first sidearm stent eral anesthesia and cardiopulmonary bypass. The patient graft was 14 or 16 mm in diameter, and both the second was placed in a supine position. The right axillary artery and third sidearm stent grafts were 12 or 14 mm in di- was exposed using subclavian incision and a median ameters. In type 2, all three sidearm tube grafts were sternotomy was performed. Cardiopulmonary bypass was unstented before implantation. The first sidearm tube established by 2 venous cannulas via the right atrium and graft was 20 mm in diameter (bigger than most innom- the arterial return cannula placed in the right axillary inate arteries), and both second and third sidearm tube artery. grafts were 16 mm in diameter (bigger than that of most Cardiopulmonary bypass flow was maintained between −1 −2 corresponding arch vessels). 2.4 and 2.6 L · min ·m . Myocardial protection was Figure 1 There were two types of our modified triple-branched stent graft. In type 1 modified triple-branched stent graft, all 3 sidearm tube grafts and distal portion of main tube graft were stented while the proximal portion of main tube graft was unstented before implantation (A). In type 2 modified triple-branched stent graft, only the distal portion of the main tube graft was stented while all 3 sidearm tube grafts and the proximal portion of main tube graft were unstented before implantation (B). The main tube graft and 3 sidearm grafts were individually mounted on 4 catheters and restrained by 4 silk strings (C). Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 4 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 achieved by multiple antegrade perfusion of cold blood cardioplegic solution (4°C). During core cooling, the innominate and left common carotid arteries were free from surrounding tissue and exposed as long as possible. When the patient was cooled to 32°C, the aorta was clamped just proximal to the in- nominate artery, and transected just above the sinotubular juncton. Manoeuvres such as aortic valve repair and sinus of Valsalva reconstruction were performed. The transected proximal stump of the ascending aorta was reconstructed and subsequently connected to the 1-branched Dacron tube graft (26 or 28 mm in diameter, a product of Inter- gard, Intervascular, Datascope Co, Montvale, NJ). When the rectal temperature reached 22°C, cardiopul- monary bypass was discontinued and selective ante- Figure 2 Stents for arch or arch vessel. The stent made of grade cerebral perfusion via the right axillary artery was multiple rings of self-expandable nitinol wire, and those rings were −1 −1 established at a rate of 10 to 15 mL · kg ·min .After connected to a polyester vascular fabric felt. the innominate and left common carotid arteries were cross-clamped (4 cm above the arch), the distal ascend- ing aorta was transected at the base of the innominate artery and the arch was longitudinally opened at the an- terior wall (Figure 3A). Through those aortic incisions, the main tube graft was placed into the true lumen of Figure 3 Schematic diagram of the operation. After the distal ascending aorta was transected at the base of the innominate artery and the arch was longitudinally opened at the anterior wall (A), the arch vessel orifices and the true lumen of the descending aorta could be clearly seen (B). The modified triple-branched stent graft was inserted and deployed into the true lumen of arch, proximal descending aorta and 3 arch vessels (C, D). Each sidearm stent with the size proportional to that of corresponding arch vessel was selected and anchored into the implanted sidearm tube graft (E, F, G). The arch longitudinal incision was closed with incorporation of the main tube graf (H). Finally, the arch stent was inserted and deployed into the main tube graft (I, J). The transected distal stump incorporating the main tube graft and the polyester fabric felt of the arch stent was directly anastomosed to the distal end of the 1-branched Dacron tube graft (K). If type 1 modified triple-branched stent graft was used, only the tube graft for arch and the arch stent were implanted separately (L). Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 5 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 the arch and proximal descending aorta, and then each measure of those diameters have been described in the sidearmtubegraft wasimplanted onebyone into the literature [13]. corresponding arch vessel (Figure 3B, C). Once the main tube graft and sidearm tube grafts were properly positioned, Statistical analysis the restraining strings were withdrawn and tube grafts Continuous data were expressed as mean ± SD. A repeated were deployed (Figure 3D). Each sidearm stent with the measures ANOVA was used to compare the diameters of size proportional to that of corresponding arch vessel was the dissected aorta and false lumen before surgery, before selected and anchored into the implanted sidearm tube discharge, and at 3 months after surgery. The differences graft (If type 2 modified triple-branched stent graft was over the 3 time points were compared with a 2-df test; the used), which resulted in longitudinal fold of the sidearm individual time point could then be compared each other tube graft inside the corresponding arch vessel to match by use of a mixed model approach if the differences were this arch vessel (Figure 3E, F, G). Then, a continuous 4–0 significant. All analyses were performed with SAS 9.0 soft- polypropylene suture was used to close the arch longitu- ware (SAS Institute Inc, Cary, NC). A value of P < 0.05 was dinal incision with incorporation of the main tube graf considered significant. (Figure 3H). Finally, the arch stent with the size propor- tional to the arch diameter was inserted and deployed into Results the proximal portion of the main tube graft (the bare stent Operative data portion towards the arch vessel orifices), which resulted in Placement of the modified triple-branched stent graft transverse fold of the main tube graft between two side- into the true lumen of the proximal descending aorta, arm tube graft to match the distance between two corre- arch and 3 arch vessels was technically successful in all 25 sponding arch vessels (Figure 3I, J). The transected distal patients, and insertion of the stents for the 3 arch vessels stump incorporating the main tube graft and the polyester and the arch into the corresponding tube grafts could be fabric felt of the arch stent was directly anastomosed to easily completed. Type 1 modified triple-branched stent the distal end of the 1-branched Dacron tube graft with a graft was used in 23 patients and type 2 was used in 2 continuous 4–0 polypropylene suture (Figure 3K, L). patients. Postoperative chest X-ray indicated that all im- After the air was carefully flushed out from the modified planted stents were in a good position and wide expan- triple-branched stent graft, antegrade systemic perfusion sion. Complete resection or sealing of the targeted entry from the branch of the 1-branched Dacron tube graft was sites with this procedure were confirmed by intraopera- started, and the patient was rewarmed. During the tive transesophageal echocardiography. rewarming, arterial banding at the dissected arch vessel’s The mean cardiopulmonary bypass time was 165.24 ± base was applied in the patients with type 1 modified 20.81 minutes (range, 122 to 203 minutes), aortic cross- triple-branched stent graft implantation. The banding felt clamp time was 65.23 ± 15.60 minutes (range, 40 to was Dacron tube graft ring with 3 mm in width and 5- 119 minutes), and selective cerebral perfusion and lower- 10% shorter than the size of the implanted sidearm stent body arrest time was 28.40 ± 7.45 minutes (range, 15 to graft in length. 48 minutes). Concomitant procedures included aortic valve repair Follow-up in 2 patients (not including commissural resuspension), Patients were followed up after they were discharged. Bentall procedure in 2 patients and sinus of Valsalva re- They were contacted by telephone or direct interview in construction in 21 patients. our department. Contrast-enhanced computed tomo- graphic scan and echocardiographic examination were Mortality and morbidity prospectively performed on the following schedule: be- In this series, there was 1 in-hospital death. This patient fore discharge, 3 months after the operation, and annu- had preoperative cardiac tamponade and acute renal dys- ally thereafter. The effectiveness of the open placement function. Although the patient had an uneventful opera- of a modified triple-branched stent graft was estimated tive course and was extubated on 3rd postoperative day, by complete thrombus obliteration of the false lumen heart arrest occurred on 7th postoperative day during the surrounding the modified triple-branched stent graft. blood dialysis. After the resuscitation, hemodynamics was To demonstrate the fate of the descending thoracic and stable and transesophageal echocardiographic examination abdominal aorta after surgery, the diameter of the dis- showed that no re-dissection or rupture in repaired aorta sected aorta at the diaphragmatic level and diameters of was found. But this patient died of multi-organ failure both the dissected aorta and false lumen at the level of 10 days after the operation. the superior mesenteric artery were collected in each Hemostasis was not a problem in those patients. No computed tomographic examination, including the pre- patients required additional surgery to correct excessive operative computed tomographic scan. Methods used to postoperative bleeding. Postoperative cerebral complications Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 6 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 include infarction in 1 patient and global temporary neuro- before discharge, and 26.92 ± 2.16 mm at 3 months after logic dysfunction in 2 patients, but they fully recovered be- surgery. A significant difference in the aortic diameters fore hospital discharge. Acute renal failure complicated at this level over the 3 time point was found (P < 0.05). postoperative care in 3 patients with 2 requiring dialysis. Compared with the preoperative data, both aortic diame- No pulmonary complication resulted. The postoperative ters before discharge and at 3 months after surgery re- mechanical ventilation support period was 22 ± 7.9 hours duced significantly (P < 0.05 for each), but there was no (range, 15 to 48 hours) and the duration of intensive care significant difference in the aortic diameter between before unit stay was 2.2 ± 1.2 days (range, 1 to 6 days). discharge and at 3 months after surgery (P = 0.54). At the superior mesenteric arterial level, a patent false Computed tomography lumen present in all survivors’ first and second postoper- Postoperative computed tomography showed that all ative computed tomographic images. The aortic diam- stents were fully opened and not kinked; there was no eter at this level was 26.25 ± 2.74 mm preoperatively, space or blood flow surrounding the modified triple- 26.21 ± 2.08 mm before discharge, and 25.58 ± 2.06 mm branched stent graft. The false lumen in the arch and at 3 months after surgery. There was not significantly the descending aorta covered by the modified triple- different in those aortic diameters over the 3 time points branched stent graft closed with thrombus in all survi- (P = 0.63). The diameter of the false lumen was 14.71 ± vors (Figure 4). No significant sidearm graft stenosis or 1.97 mm preoperatively, 9.0 ± 2.4 mm before discharge, occlusion was found. Disappearance of the false lumen and 8.5 ± 2.0 mm at 3 months after surgery. A significant and recovery of the true lumen was observed in all dis- difference in the diameters of the false lumen at this sected arch vessels. level over the 3 time points was found (P < 0.05). Com- At the diaphragmatic level, the false lumen of the de- pared with preoperative data, both diameters of the false scending aorta distal to the stent graft closed with lumen before discharge and at 3 months after surgery thrombus in 20 of 24 patients at their first and second reduced significantly (P < 0.05 for each), but there was postoperative images. At this level, the aortic diameter no significant difference in the false lumen diameter was 29.42 ± 2.18 mm preoperatively, 27.29 ± 2.55 mm between before discharge and at 3 months after surgery (P = 0.21). Follow-up All survivors were followed up to the end date of this study (September, 2013). The follow-up was 100% complete. The mean follow-up period was 5.2 ± 2.1 months (range, 3 to 10 months). During the follow-up, no any severe complica- tion related to the surgery or residual dissection was found, and there were no late deaths and no need for reoperation. All survivors resumed normal activities. Discussion Endovascular stent graft placement has widely been con- firmed as an effective and less invasive alternative to sur- gical repair for acute aortic dissection [14-16]. In this study, we successfully applied our open modified triple- branched stent graft placement for total arch repair in 25 consecutive patients with acute type A aortic dissec- tion. Placement of these modified triple-branched stent grafts and stents into the descending aorta, 3 arch ves- sels and arch could be easily completed in 2–3 minutes. Most patients had an uneventful postoperative course and were discharged from hospital without complica- tions. Their postoperative computed tomographic scans Figure 4 Postoperative computed tomographic scan showing showed that all stent grafts were fully opened and not that all stents were fully opened and not kinked and that there was no space or blood flow surrounding the stent graft. A, type kinked, there was no space or blood flow surrounding 1 modified triple-branched stent graft placement combined with the modified triple-branched stent graft and no sidearm banding at the dissected annominate arterial base. B, type 2 modified graft stenosis or occlusion. These preliminary results triple-branched stent graft placement. demonstrated that our modified triple-branched stent Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 7 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 graft placement technique can be used in most patients to our preference. The implanted arch stent could make with acute type A aortic dissection for effective total arch the main tube graft closely contact to the arch wall, shrink repair. the false lumen and promote thrombosis of the false lumen In the first generation of triple-branched stent graft in the dissected arch. Moreover, once bleeding occurred placement technique, the stent graft was inserted into from the posterior suture line in the hemiarch replacement, the proximal descending aorta, arch and 3 arch vessels hemostasis in this deep portion is difficult. In our tech- through the distal ascending transverse incision. How- nique, we performed the distal aortic anastomosis at ever, insertion of the stent graft in some cases was not the distal ascending aorta and the arch open at it’san- so easy, because the arch vessel orifices and the true terior wall, which provided a better surgical view, and lumen of the descending aorta could not be clearly seen hemostasis was much easier. through this distal ascending incision. To reduce this In our practice with open placement of the first gener- problem, we introduced the arch open technique in this ation of triple-branched stent graft in more than 100 pa- study. Through this arch open, the arch vessel orifices tients with acute type A aortic dissection, we found that and the true lumen of the descending aorta could be most arch vessels could be easily matched by our prefab- clearly seen, which resulted in easier and safer implant- ricated sidearm stent grafts and difficult match occurred ation of the modified triple-branched stent graft. Al- in the distances between two arch vessels and in a few though the arch open and close process took 2–4 dissected arch vessels with larger false lumen and minutes, the stent graft implantation became easier and smaller real lumen. For a dissected arch vessel with a lar- faster. Therefore, compared with the first generation of ger false lumen, it was not easy to determine the proper triple-branched stent graft placement technique, time size of the sidearm stent graft, and unusual large sidearm for total arch repair didn’t increase in our series. In type stent graft was frequently necessary. Recently, banding A aortic dissection, the anterior wall of the arch is usu- at the bases of those dissected arch vessels was applied ally involved by the dissection. Therefore, the arch open by us. Since we routinally used banding technique for and close are frequently performed at the dissected site. dissected arch vessels, no any sidearm stent graft endo- After an acute dissection, the dissected arch wall is so leak or stenosis was found. This result suggested that fragile that the arch close often results in intraoperative banding technique is an effective alternative to our or postoperative hemorrhage owing to tissue tearing at modified triple-branched stent graft for the good match the suture line [17]. In our technique, although the arch between the sidearm stent graft and the corresponding open was directly closed with incorporation of the main arch vessel. Based on these findings, two types (type 1 tube graft without any other reinforcement, there was and type 2) of our modified triple-branched stent graft no problem with bleeding from the suture site either were produced. In this series, type 1 modified triple- intraoperatively or postoperatively. Actions of the im- branched stent graft placement combined with arch ves- planted main tube graft and arch stent may contribute sel banding technique was applied more often than type to this good result. The implanted stent graft effectively 2 modified triple-branched stent graft placement, mainly approximated the dissected layers of the arch wall, se- because we believed type 1 modified triple-branched curely closed the false lumen, and consequently inter- stent graft placement combined with arch vessel banding rupted back flow from the false lumen, which often is a technique was simpler and had less chance of sidearm source of bleeding at the suture site. Furthermore, after graft stenosis. the arch open was closed with incorporation of main Implantation of sidearm stent graft and fold of sidearm tube graft, antegrade blood leakage from the suture site polyester tube graft inside the corresponding arch vessel into the residual false lumen was completely prevented. might produce sidearm graft stenosis or occlusion. Al- Theoretically, our modified triple-branched stent graft though no sidearm graft stenosis or occlusion was ob- served in our series, the long-term patency of those could be easily implanted through the same arch incision as hemiarch replacement, and the Dacron prosthesis re- sidearm grafts should be carefully evaluated. Fortunately, placing ascending aorta and hemiarch could directly con- fold of sidearm polyester tube graft inside the smaller arch vessel could be easily avoided by using our type 1 nect to the modified triple-branched stent graft at this arch incision. This hemiarch replacement combined with modified triple-branched stent graft. The long-term pa- open placement of a modified triple-branched stent graft tency of the sidearm stent grafts of the type 1 modified triple-branched stent graft is expected to be satisfactory technique could eliminate the arch open and close, obvi- ate the need of the arch stent, and consequently appear because simple endovascular stenting for arch vessel simpler than our technique described in this study. How- provides satisfactory long-term patency even in stenotic ever, this hemiarch replacement technique could not be obstructive pathologies [18-20]. preferred by us. Two major advantages of our technique In the traditional total arch replacement for acute type over this hemiarch replacement technique might contribute A aortic dissection, the elephant trunk was routinally Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 8 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 applied to achieve a stronger distal anastomosis and to the distances between 2 neighboring sidearm graft were facilitate subsequent surgery on the distal aorta [21]. decided by each patient’s corresponding sizes which However, placement of the elephant trunk into the true were determined by the measuring results using pre- lumen of the dissected descending aorta is difficult and operative computed tomography. Therefore, it is impos- some complications, such as kinking and obstruction sible to be commercial. Our modified triple-branch of the graft, embolization and paraplegia, have been stent graft was designed to provide a good match with found [22]. To reduce such problems, stented elephant the different diameters of the native arch vessels and the trunk technique was developed [14,15]. This stented various distances between two neighboring arch vessels, elephant trunk has been proven to be an effective way so it can be commercial and be used in most patients. of closing the residual false lumen of the descending aorta, which might contribute to better long-term out- Conclusions comes for acute type A aortic dissection [23]. In our The modified triple-branched stent graft could provide a modified triple-branched stent graft, the distal part of good match with the different diameters of the native arch the main graft was designed to be a stented elephant vessels and the various distances between 2 neighboring trunk. Therefore, both the scope of the repaired thor- arch vessels, and it’s placement could become much easier acic aorta and the outcome of residual false lumen of by the arch open technique. Therefore, placement of a our modified triple-branched stent graft placement modified triple-branched stent graft could be easily used technique should be comparable with the traditional in most patients with acute type A aortic dissection for total arch replacement combined with stented elephant effective total arch repair. Rigorous long-term follow-up trunk technique. and further extensive clinical trials are necessary to Recently, some other techniques have been developed completely evaluate the efficacy of the modified triple- to simplify total arch repair for acute type A aortic dissec- branched stent graft and the arch open technique before tion. Total endovascular arch repair using a fenestrated this combined technique can become a reliable alterna- stent graft or using a conventional straight stent graft with tive to conventional total arch repair. arch debranching is an effective technique to complete arch repair for acute aortic dissection [24]. This technique Competing interests can be performed off-pump. Consequently it would be less The authors declare that they have no competing interests. invasive than our technique. We also performed this tech- Authors’ contributions nique for some patients with acute aortic dissection and CLW, LC participated in reseach design; CLW, WXJ, DXF, LDS, LQZ performed satisfied results were obtained. However, only normal as- the experiments; CLW, LL, LC participated in the writing of the manuscript cending aorta can provide a proximal landing zone in this and indata analysis; LL, LC carried out the follow up. All authors read and approved the final manuscript. technique. Therefore, it can not be used in the patient with a patent false lumen of ascending aorta. Enlightened Received: 16 April 2014 Accepted: 17 July 2014 by this total endovascular arch repair technique, some sur- Published: 2 August 2014 geons developed a new hybrid operation to get the effect- ive total arch repair for acute type A aortic dissection, in References 1. Fuster V, Ip JF: Medical aspects of acute aortic dissection. Semin Thorac which the dissected ascending aorta is replaced with a Cardiovasc Surg 1991, 3:219–224. Dacron tube graft under cardiopulmonary bypass with 2. DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ: Aortic dissection. moderate systemic hypothermia, and arch vessel bypasses N Engl J Med 1987, 317:1060–1067. 3. DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, from the Dacron tube graft and antegrade or retrograde Lawrie G: Dissection and dissecting aneurysms of the aorta: twenty-year deployment of a conventional straight stent graft into the follow-up of five hundred twenty-seven patients treated surgically. arch and the proximal descending aorta are performed Surgery 1982, 92(6):1118–1134. 4. Fann JI, Smith JA, Miller DC, Mitchelll RS, Moore KA, Grunkemeier G, Stinson EB, [25]. This hybrid technique eliminates the need of deep Oyer PE, Reitz BA, Shumway NE: Surgical management of aortic dissection hypothermic circulatory arrest, but arch vessel bypasses during a 30-year period. Circulation 1995, 92(9 supp):113–121. are difficulty if arch vessels are seriously involved by the 5. Haverich A, Miller DC, Scott WC, Mitchell RS, Oyer PE, Stinsion EB, Shumway NE: Acute and chronic aortic dissections–determinants of long–term outcome dissection and their long-term patency should be carefully for operative survivors. Circulation 1985, 72:1122–1134. evaluated. Shimamura et al. also developed open branched 6. Ergin MA, Philips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS, endoprosthesis placement technique [26]. Although the Griepp RB: Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994, 57:820–825. branched endoprosthesis used in their technique seems 7. Bachet JE, Termignon JL, Dreyfus G, Goudot B, Martinelli L, Piquois A, similar to our modified triple-branched stent graft, the Brodaty D, Dubois C, Delentdecker P, Guilmet D: Aortic dissection. original idea of the design is totally different. In shima- Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994, 108:199–206. mura’s branched endoprosthesis, sidearm stent grafts were 8. Ochiai Y, Imoto Y, Sakamoto M, Ueno Y, Sano T, Baba H, Sese A: Long-term connected to the main graft in the side dish during the effectiveness of total arch replacement for type A aortic dissection. procedure, and the size of each sidearm stent graft and Ann Thorac Surg 2005, 80:1297–1302. Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 9 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 9. Massimo CG, Presenti LF, Marranci P, Favi PP, Poma AG, Ponzalli M, Viligiardi RG: Extended and total aortic resection in thesurgical treatment of acutetypeA aortic dissection: experience with 54 patients. Ann Thorac Surg 1988, 46:420–424. 10. Minale C, Splittgerber FH, Reifschneider HJ: Replcaement of the entire thoracic aorta in a single stage. Ann Thorac Surg 1994, 57:850–855. 11. Chen LW, Dai XF, Zhang GZ, Cao H: Extensive primary repair of the thoracic aorta in acute type A aortic dissection by means of ascending aorta replacement combined with open placement of triple-branched stent graft: early results. Circulation 2010, 122:1373–1378. 12. Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, Matsuda H, Kato M, OhnishiK,Kaneko M,Ueda T,Kishi D, MizushimaT,Matsuda H: New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996, 94(suppl):II-188–II-193. 13. Kato M, Matsuda T, Kaneko M, Kuratani T, Mizushima T, Seo Y, Uchida K, Kichikawa K, Maeda M, Ohnishi K: Outcomes of stent-graft treatment of false lumen in aortic dissection. Circulation 1998, 98(suppl):II-305–II-312. 14. Liu ZG, Sun LZ, Chang Q, Zhu JM, Dong C, Yu CT, Liu YM, Zhang HT: Should the “elephant trunk” be skeletonized? Total arch replacement combined with stented elephant trunk implantation for stanford type A aortic dissection. J Thorac Cardiovasc Surg 2006, 131:107–113. 15. Shimamura K, Kuratani T, Matsumiya G, Kato M, Shirakawa Y, Takano H, Ohta N, Sawa Y: Long-term results of the open stent-grafting technique for extended aortic arch disease. J Thorac Cardiovasc Surg 2008, 135(6):1261–1269. 16. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, Nicolas V, Pierangeli A: Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999, 340:1539–1545. 17. Mori Y, Hirose H, Takagi H, Umeda Y, Fukumoto Y, Shimabukuro K, Matsuno Y: Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch. JThorac Cardiovasc Sur 2003, 126:415–419. 18. De Vries JP, Jager L, Van den Berg JC, Overtoom TT, Ackerstaff RG, Van de Pavoordt ED, Moll FL: Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg 2005, 41:19–23. 19. Bates MC, Broce M, Lavigne PS, Stone P: Subclavian artery stenting: factors influencing long-term outcome. Catheter Cardiovasc Interv 2004, 61:5–11. 20. de Borst GJ, Ackerstaff RG, de Vries JP, vd Pavoordt ED, Vos JA, Overtoom TT, Moll FL: Carotid angioplasty and stenting for postendarterectomy stenosis:lonr-term follow-up. J Vasc Surg 2007, 45:118–123. 21. Ando M, Takamoto S, Okita Y, Morota T, Matsukawa R, Kitamura S: Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg 1998, 66:82–87. 22. Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR: Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990, 211:521–537. 23. Sun LZ, Qi R, Zhu JM, Liu YM, Zheng J: Total arch replacement combined with stented elephant trunk implantation: A new “standard” therapy for type A dissection involving repair of the aortic arch? Circulation 2001, 123:971–978. 24. Czermy M, Gottardi R, Zimpfer D, Schoder M, Grabenwoger M, Lammer J, Wolner E, Grimm M: Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. Eur J Cardiothorac Surg 2007, 31:623–627. 25. Diethrich EB, Ghazoul M, Wheatley GH, Alpern J, Rodriguez-Lopez J, Ramaiah V, Williams J: Surgical correction of ascending type A thoracic aortic dissection: simultaneous endoluminal exclusion of the arch and distal aorta. J Endovasc Ther 2005, 12:660–666. 26. Shimamura K, Kuratani T, Matsumiya G, Shirakawa Y, Takeuchi M, Takano H, Submit your next manuscript to BioMed Central Sawa Y: Hybrid endovascular aortic arch repair using branched and take full advantage of: endoprosthesis: the second-generation “branched” open stent-grafting technique. J Thorac Cardiovasc Surg 2009, 138:46–53. • Convenient online submission doi:10.1186/s13019-014-0135-3 • Thorough peer review Cite this article as: Chen et al.: Total arch repair for acute type A aortic • No space constraints or color figure charges dissection with open placement of a modified triple-branched stent graft and the arch open technique. Journal of Cardiothoracic Surgery 2014 9:135. • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cardiothoracic Surgery Springer Journals

Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique

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Springer Journals
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Copyright © 2014 by Chen et al.; licensee BioMed Central
Subject
Medicine & Public Health; Cardiac Surgery; Thoracic Surgery
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1749-8090
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10.1186/s13019-014-0135-3
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25085259
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Abstract

Background: In total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique. Methods and results: Total arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients. Conclusions: The modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it’s placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair. Keywords: Aorta, Dissection, Surgery, Stent Background dissection occurs, the chances of survival might remain Acute type A aortic dissection usually requires emergency in hazard, and difficult reoperation is inevitable. This surgical management to prevent death resulting from aor- unsatisfactory long-term prognosis would favor simul- tic rupture [1,2]. Although the dissection frequently in- taneous replacement of the ascending aorta and total volves entire aorta, the dissected ascending aorta is most arch in the same surgical field during the primary emer- common segment to rupture. Therefore, the simple as- gency operation [8]. cending aortic graft replacement is widely accepted as the Total arch replacement is very complex and highly in- conventional treatment for acute type A aortic dissection vasive if it is performed with the traditional method, [1-3]. This conventional operation has improved the life which makes the risk of this procedure very high in pa- prognosis for the acute phase, but residual dissection in tients with acute type A aortic dissection [2]. Whether the arch and downstream aorta can still occur after the this traditional total arch replacement with possible add- conventional ascending aortic replacement, which has itional operative risk can be justified from the viewpoint been widely proven to affect the long-term prognosis of potential long-term benefits remains controversial [4-7]. When continuous enlargement of the residual [9,10]. Therefore, traditional total arch replacement can’t be widely accepted as preferred surgical treatment for acute type A aortic dissection during the emergency * Correspondence: [email protected] repair. Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China © 2014 Chen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 2 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 It would be desirable if one technique could effectively The dissection had extension to the innominate artery in repair total arch while keeping the surgical invasion and 23 patients, to the left common carotid artery in 5 patients risk as low as possible. Recently, we developed open and to the left subclavian artery in 5 patients. A history of triple-branched stent graft placement technique, in which hypertension was found in 17 patients and 11 of them total arch repair could be simply completed by inserting a didn’t receive effective antihypertensive treatment. Four triple-branched stent graft into the proximal descending patients had diabetes melitus, 2 had classic Marfan syn- aorta, arch and 3 arch vessels through the same transverse drome and 1 had chronic renal dysfunction. There were aortic incision line as ascending aortic replacement [11]. some preoperative complications related to the aortic dis- Clinical results showed that our new technique could re- section including moderate or severe aortic valvular regur- duce the risk and technical difficulty of total arch repair to gitation in 5 patients, cardiac tamponade in 1, transient close to those of the conventional ascending graft replace- brain ischemia in 1, and acute renal dysfunction in 3. All ment with open distal anastomosis [11]. Therefore, this operations were performed within 4 hours after the diag- new simple technique could be an attractive alternative to nosis was confirmed. The average interval between the traditional total arch replacement for acute type A aortic onset of pain and operation was 3.0 ± 2.3 days (range, 1to dissection. However, in our practice with this new tech- 9 days). In this study, total arch repair for acute type A nique, two major problems were found. First, this new aortic dissection was on the basis of one of the following technique could not be applied in most patients, because indications: (1) the patient was < 55 years of age; (2) the the diameters of the native arch vessels and the distances intimal tear located in the transverse arch or proximal de- between 2 neighboring arch vessels did not always match scending aorta that could not be resected by hemiarch re- the available sizes of the triple-branched stent grafts. Sec- placement; (3) there was serious involvement of the arch ond, the arch vessel orifices and the true lumen of the de- vessels; or (4) Marfan syndrome was present. scending aorta could not be clearly seen through the distal ascending aortic incision in some cases, so inserting of the The modified triple-branched stent graft triple-branched stent graft in such cases was not easy. In The modified triple-branched stent graft (conceived and an effort to reduce those two problems, we modified the designed by two of us (LWC and CL) and manufactured triple-branched stent graft to the new generation, which by Yuhengjia Sci Tech Corp Ltd, Beijing, China) con- could provide a good match with the different diameters sisted of a self-expandable nitinol stent and polyester of the native arch vessels and the various distances be- vascular graft fabric. The polyester vascular graft fabric tween 2 neighboring arch vessels, and developed the arch was thin and soft enough to be easily folded. Each modi- open technique to make the placement much easier and fied triple-branched stent graft comprised a main tube safer. Here, we describe our application of this new gener- graft and 3 sidearm tube graft. ation of triple-branched stent graft and the arch open Our modified triple-branched stent graft was designed technique for total arch repair in patients with acute type to provide a good match with the different diameters of A aortic dissection. In addition, we report our initial clin- the native arch vessels and the various distances between ical results in 25 consecutive patients. 2 neighboring arch vessels. For this purpose, two major modifications were developed. First, the polyester tube Methods graft and the stent for each native arch vessel or arch Patients were not attached together before implantation, and they Between November 2012 and June 2013, 25 consecutive were implanted separately. Second, the diameter of the patients with acute Stanford type A aortic dissection sidearm polyester tube graft was designed to be bigger underwent total arch repair with open placement of a than that of most corresponding arch vessels, and the modified triple-branched stent graft and the arch open distance between 2 neighboring sidearm tube grafts was technique. This procedure was approved by the ethics longer than that between 2 corresponding arch vessels committee of Union Hospital, Fujian Medical University, of most Chinese adults. After a bigger sidearm tube graft and written informed consent was obtained from each was inserted into the corresponding smaller arch vessel, patient or legal representative. There were 21 men and 4 a stent with the size proportional to that of this arch women. The average patient age was 49.92 ± 13.04 years vessel was selected and inserted, which resulted in longi- (range, 20 to 74 years). Preoperative diagnosis was based tudinal fold of the implanted bigger sidearm tube graft on electron beam computed tomography, echocardiog- to match this arch vessel. When the implantation of 3 raphy and magnetic resonance imaging. The primary in- sidearm tube grafts and their stents into the corre- timal tears were located in the ascending aorta in 13 sponding arch vessels was completed, an arch stent with patients, in the arch in 4 patients, and in the proximal the size proportional to the arch size was inserted into descending aorta with retrograde extension of the dissec- the main tube graft. As a result, the main tube graft be- tion into the arch and the ascending aorta in 8 patients. tween two sidearm tube grafts was transversely folded Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 3 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 to match the distance between two corresponding native The main tube graft and 3 sidearm grafts were indi- arch vessels. vidually mounted on 4 catheters and restrained by 4 silk In this study, two types of our modified triple-branched strings. stent graft were produced. Type 1 was designed to provide a good match only with the various distances between 2 Stents for arch or arch vessel neighboring arch vessels, and type 2 was designed to pro- Stents for arch or arch vessel were multiple rings of self- vide a good match with both the different diameters of the expandable nitinol wire (Yuhengjia Sci Tech Corp Ltd, native arch vessels and various distances between 2 neigh- Beijing, China). In each stent, the multiple rings were boring arch vessels (Figure 1). connected to a polyester vascular fabric felt (Figure 2). In both types, the tapered main tube graft was 145 mm Therefore, the stent had bare stent portion and polyester in length, 32 mm in proximal diameter and 28 mm in dis- fabric portion. The arch stent was 60 mm long and 26 tal diameter. The proximal portion of the main tube graft to 34 mm in diameter, and the arch vessel stent was was unstented before implantation and designed for arch 30 mm long and 12 to 20 mm in diameter. The diameter repair while the distal portion was stented and acted as a of the stent selected was 10% to 20% bigger than the size stented elephant trunk. The distance between 2 neighbor- of the corresponding landing zone [12,13]. ing sidearm graft was 12 mm (longer than that between 2 corresponding arch vessels of most Chinese adults). All three sidearm tube grafts were 3.5 mm long in Operative technique both types. In type 1, all three sidearm tube grafts were All procedures were performed with patients under gen- stented before implantation. The first sidearm stent eral anesthesia and cardiopulmonary bypass. The patient graft was 14 or 16 mm in diameter, and both the second was placed in a supine position. The right axillary artery and third sidearm stent grafts were 12 or 14 mm in di- was exposed using subclavian incision and a median ameters. In type 2, all three sidearm tube grafts were sternotomy was performed. Cardiopulmonary bypass was unstented before implantation. The first sidearm tube established by 2 venous cannulas via the right atrium and graft was 20 mm in diameter (bigger than most innom- the arterial return cannula placed in the right axillary inate arteries), and both second and third sidearm tube artery. grafts were 16 mm in diameter (bigger than that of most Cardiopulmonary bypass flow was maintained between −1 −2 corresponding arch vessels). 2.4 and 2.6 L · min ·m . Myocardial protection was Figure 1 There were two types of our modified triple-branched stent graft. In type 1 modified triple-branched stent graft, all 3 sidearm tube grafts and distal portion of main tube graft were stented while the proximal portion of main tube graft was unstented before implantation (A). In type 2 modified triple-branched stent graft, only the distal portion of the main tube graft was stented while all 3 sidearm tube grafts and the proximal portion of main tube graft were unstented before implantation (B). The main tube graft and 3 sidearm grafts were individually mounted on 4 catheters and restrained by 4 silk strings (C). Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 4 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 achieved by multiple antegrade perfusion of cold blood cardioplegic solution (4°C). During core cooling, the innominate and left common carotid arteries were free from surrounding tissue and exposed as long as possible. When the patient was cooled to 32°C, the aorta was clamped just proximal to the in- nominate artery, and transected just above the sinotubular juncton. Manoeuvres such as aortic valve repair and sinus of Valsalva reconstruction were performed. The transected proximal stump of the ascending aorta was reconstructed and subsequently connected to the 1-branched Dacron tube graft (26 or 28 mm in diameter, a product of Inter- gard, Intervascular, Datascope Co, Montvale, NJ). When the rectal temperature reached 22°C, cardiopul- monary bypass was discontinued and selective ante- Figure 2 Stents for arch or arch vessel. The stent made of grade cerebral perfusion via the right axillary artery was multiple rings of self-expandable nitinol wire, and those rings were −1 −1 established at a rate of 10 to 15 mL · kg ·min .After connected to a polyester vascular fabric felt. the innominate and left common carotid arteries were cross-clamped (4 cm above the arch), the distal ascend- ing aorta was transected at the base of the innominate artery and the arch was longitudinally opened at the an- terior wall (Figure 3A). Through those aortic incisions, the main tube graft was placed into the true lumen of Figure 3 Schematic diagram of the operation. After the distal ascending aorta was transected at the base of the innominate artery and the arch was longitudinally opened at the anterior wall (A), the arch vessel orifices and the true lumen of the descending aorta could be clearly seen (B). The modified triple-branched stent graft was inserted and deployed into the true lumen of arch, proximal descending aorta and 3 arch vessels (C, D). Each sidearm stent with the size proportional to that of corresponding arch vessel was selected and anchored into the implanted sidearm tube graft (E, F, G). The arch longitudinal incision was closed with incorporation of the main tube graf (H). Finally, the arch stent was inserted and deployed into the main tube graft (I, J). The transected distal stump incorporating the main tube graft and the polyester fabric felt of the arch stent was directly anastomosed to the distal end of the 1-branched Dacron tube graft (K). If type 1 modified triple-branched stent graft was used, only the tube graft for arch and the arch stent were implanted separately (L). Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 5 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 the arch and proximal descending aorta, and then each measure of those diameters have been described in the sidearmtubegraft wasimplanted onebyone into the literature [13]. corresponding arch vessel (Figure 3B, C). Once the main tube graft and sidearm tube grafts were properly positioned, Statistical analysis the restraining strings were withdrawn and tube grafts Continuous data were expressed as mean ± SD. A repeated were deployed (Figure 3D). Each sidearm stent with the measures ANOVA was used to compare the diameters of size proportional to that of corresponding arch vessel was the dissected aorta and false lumen before surgery, before selected and anchored into the implanted sidearm tube discharge, and at 3 months after surgery. The differences graft (If type 2 modified triple-branched stent graft was over the 3 time points were compared with a 2-df test; the used), which resulted in longitudinal fold of the sidearm individual time point could then be compared each other tube graft inside the corresponding arch vessel to match by use of a mixed model approach if the differences were this arch vessel (Figure 3E, F, G). Then, a continuous 4–0 significant. All analyses were performed with SAS 9.0 soft- polypropylene suture was used to close the arch longitu- ware (SAS Institute Inc, Cary, NC). A value of P < 0.05 was dinal incision with incorporation of the main tube graf considered significant. (Figure 3H). Finally, the arch stent with the size propor- tional to the arch diameter was inserted and deployed into Results the proximal portion of the main tube graft (the bare stent Operative data portion towards the arch vessel orifices), which resulted in Placement of the modified triple-branched stent graft transverse fold of the main tube graft between two side- into the true lumen of the proximal descending aorta, arm tube graft to match the distance between two corre- arch and 3 arch vessels was technically successful in all 25 sponding arch vessels (Figure 3I, J). The transected distal patients, and insertion of the stents for the 3 arch vessels stump incorporating the main tube graft and the polyester and the arch into the corresponding tube grafts could be fabric felt of the arch stent was directly anastomosed to easily completed. Type 1 modified triple-branched stent the distal end of the 1-branched Dacron tube graft with a graft was used in 23 patients and type 2 was used in 2 continuous 4–0 polypropylene suture (Figure 3K, L). patients. Postoperative chest X-ray indicated that all im- After the air was carefully flushed out from the modified planted stents were in a good position and wide expan- triple-branched stent graft, antegrade systemic perfusion sion. Complete resection or sealing of the targeted entry from the branch of the 1-branched Dacron tube graft was sites with this procedure were confirmed by intraopera- started, and the patient was rewarmed. During the tive transesophageal echocardiography. rewarming, arterial banding at the dissected arch vessel’s The mean cardiopulmonary bypass time was 165.24 ± base was applied in the patients with type 1 modified 20.81 minutes (range, 122 to 203 minutes), aortic cross- triple-branched stent graft implantation. The banding felt clamp time was 65.23 ± 15.60 minutes (range, 40 to was Dacron tube graft ring with 3 mm in width and 5- 119 minutes), and selective cerebral perfusion and lower- 10% shorter than the size of the implanted sidearm stent body arrest time was 28.40 ± 7.45 minutes (range, 15 to graft in length. 48 minutes). Concomitant procedures included aortic valve repair Follow-up in 2 patients (not including commissural resuspension), Patients were followed up after they were discharged. Bentall procedure in 2 patients and sinus of Valsalva re- They were contacted by telephone or direct interview in construction in 21 patients. our department. Contrast-enhanced computed tomo- graphic scan and echocardiographic examination were Mortality and morbidity prospectively performed on the following schedule: be- In this series, there was 1 in-hospital death. This patient fore discharge, 3 months after the operation, and annu- had preoperative cardiac tamponade and acute renal dys- ally thereafter. The effectiveness of the open placement function. Although the patient had an uneventful opera- of a modified triple-branched stent graft was estimated tive course and was extubated on 3rd postoperative day, by complete thrombus obliteration of the false lumen heart arrest occurred on 7th postoperative day during the surrounding the modified triple-branched stent graft. blood dialysis. After the resuscitation, hemodynamics was To demonstrate the fate of the descending thoracic and stable and transesophageal echocardiographic examination abdominal aorta after surgery, the diameter of the dis- showed that no re-dissection or rupture in repaired aorta sected aorta at the diaphragmatic level and diameters of was found. But this patient died of multi-organ failure both the dissected aorta and false lumen at the level of 10 days after the operation. the superior mesenteric artery were collected in each Hemostasis was not a problem in those patients. No computed tomographic examination, including the pre- patients required additional surgery to correct excessive operative computed tomographic scan. Methods used to postoperative bleeding. Postoperative cerebral complications Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 6 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 include infarction in 1 patient and global temporary neuro- before discharge, and 26.92 ± 2.16 mm at 3 months after logic dysfunction in 2 patients, but they fully recovered be- surgery. A significant difference in the aortic diameters fore hospital discharge. Acute renal failure complicated at this level over the 3 time point was found (P < 0.05). postoperative care in 3 patients with 2 requiring dialysis. Compared with the preoperative data, both aortic diame- No pulmonary complication resulted. The postoperative ters before discharge and at 3 months after surgery re- mechanical ventilation support period was 22 ± 7.9 hours duced significantly (P < 0.05 for each), but there was no (range, 15 to 48 hours) and the duration of intensive care significant difference in the aortic diameter between before unit stay was 2.2 ± 1.2 days (range, 1 to 6 days). discharge and at 3 months after surgery (P = 0.54). At the superior mesenteric arterial level, a patent false Computed tomography lumen present in all survivors’ first and second postoper- Postoperative computed tomography showed that all ative computed tomographic images. The aortic diam- stents were fully opened and not kinked; there was no eter at this level was 26.25 ± 2.74 mm preoperatively, space or blood flow surrounding the modified triple- 26.21 ± 2.08 mm before discharge, and 25.58 ± 2.06 mm branched stent graft. The false lumen in the arch and at 3 months after surgery. There was not significantly the descending aorta covered by the modified triple- different in those aortic diameters over the 3 time points branched stent graft closed with thrombus in all survi- (P = 0.63). The diameter of the false lumen was 14.71 ± vors (Figure 4). No significant sidearm graft stenosis or 1.97 mm preoperatively, 9.0 ± 2.4 mm before discharge, occlusion was found. Disappearance of the false lumen and 8.5 ± 2.0 mm at 3 months after surgery. A significant and recovery of the true lumen was observed in all dis- difference in the diameters of the false lumen at this sected arch vessels. level over the 3 time points was found (P < 0.05). Com- At the diaphragmatic level, the false lumen of the de- pared with preoperative data, both diameters of the false scending aorta distal to the stent graft closed with lumen before discharge and at 3 months after surgery thrombus in 20 of 24 patients at their first and second reduced significantly (P < 0.05 for each), but there was postoperative images. At this level, the aortic diameter no significant difference in the false lumen diameter was 29.42 ± 2.18 mm preoperatively, 27.29 ± 2.55 mm between before discharge and at 3 months after surgery (P = 0.21). Follow-up All survivors were followed up to the end date of this study (September, 2013). The follow-up was 100% complete. The mean follow-up period was 5.2 ± 2.1 months (range, 3 to 10 months). During the follow-up, no any severe complica- tion related to the surgery or residual dissection was found, and there were no late deaths and no need for reoperation. All survivors resumed normal activities. Discussion Endovascular stent graft placement has widely been con- firmed as an effective and less invasive alternative to sur- gical repair for acute aortic dissection [14-16]. In this study, we successfully applied our open modified triple- branched stent graft placement for total arch repair in 25 consecutive patients with acute type A aortic dissec- tion. Placement of these modified triple-branched stent grafts and stents into the descending aorta, 3 arch ves- sels and arch could be easily completed in 2–3 minutes. Most patients had an uneventful postoperative course and were discharged from hospital without complica- tions. Their postoperative computed tomographic scans Figure 4 Postoperative computed tomographic scan showing showed that all stent grafts were fully opened and not that all stents were fully opened and not kinked and that there was no space or blood flow surrounding the stent graft. A, type kinked, there was no space or blood flow surrounding 1 modified triple-branched stent graft placement combined with the modified triple-branched stent graft and no sidearm banding at the dissected annominate arterial base. B, type 2 modified graft stenosis or occlusion. These preliminary results triple-branched stent graft placement. demonstrated that our modified triple-branched stent Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 7 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 graft placement technique can be used in most patients to our preference. The implanted arch stent could make with acute type A aortic dissection for effective total arch the main tube graft closely contact to the arch wall, shrink repair. the false lumen and promote thrombosis of the false lumen In the first generation of triple-branched stent graft in the dissected arch. Moreover, once bleeding occurred placement technique, the stent graft was inserted into from the posterior suture line in the hemiarch replacement, the proximal descending aorta, arch and 3 arch vessels hemostasis in this deep portion is difficult. In our tech- through the distal ascending transverse incision. How- nique, we performed the distal aortic anastomosis at ever, insertion of the stent graft in some cases was not the distal ascending aorta and the arch open at it’san- so easy, because the arch vessel orifices and the true terior wall, which provided a better surgical view, and lumen of the descending aorta could not be clearly seen hemostasis was much easier. through this distal ascending incision. To reduce this In our practice with open placement of the first gener- problem, we introduced the arch open technique in this ation of triple-branched stent graft in more than 100 pa- study. Through this arch open, the arch vessel orifices tients with acute type A aortic dissection, we found that and the true lumen of the descending aorta could be most arch vessels could be easily matched by our prefab- clearly seen, which resulted in easier and safer implant- ricated sidearm stent grafts and difficult match occurred ation of the modified triple-branched stent graft. Al- in the distances between two arch vessels and in a few though the arch open and close process took 2–4 dissected arch vessels with larger false lumen and minutes, the stent graft implantation became easier and smaller real lumen. For a dissected arch vessel with a lar- faster. Therefore, compared with the first generation of ger false lumen, it was not easy to determine the proper triple-branched stent graft placement technique, time size of the sidearm stent graft, and unusual large sidearm for total arch repair didn’t increase in our series. In type stent graft was frequently necessary. Recently, banding A aortic dissection, the anterior wall of the arch is usu- at the bases of those dissected arch vessels was applied ally involved by the dissection. Therefore, the arch open by us. Since we routinally used banding technique for and close are frequently performed at the dissected site. dissected arch vessels, no any sidearm stent graft endo- After an acute dissection, the dissected arch wall is so leak or stenosis was found. This result suggested that fragile that the arch close often results in intraoperative banding technique is an effective alternative to our or postoperative hemorrhage owing to tissue tearing at modified triple-branched stent graft for the good match the suture line [17]. In our technique, although the arch between the sidearm stent graft and the corresponding open was directly closed with incorporation of the main arch vessel. Based on these findings, two types (type 1 tube graft without any other reinforcement, there was and type 2) of our modified triple-branched stent graft no problem with bleeding from the suture site either were produced. In this series, type 1 modified triple- intraoperatively or postoperatively. Actions of the im- branched stent graft placement combined with arch ves- planted main tube graft and arch stent may contribute sel banding technique was applied more often than type to this good result. The implanted stent graft effectively 2 modified triple-branched stent graft placement, mainly approximated the dissected layers of the arch wall, se- because we believed type 1 modified triple-branched curely closed the false lumen, and consequently inter- stent graft placement combined with arch vessel banding rupted back flow from the false lumen, which often is a technique was simpler and had less chance of sidearm source of bleeding at the suture site. Furthermore, after graft stenosis. the arch open was closed with incorporation of main Implantation of sidearm stent graft and fold of sidearm tube graft, antegrade blood leakage from the suture site polyester tube graft inside the corresponding arch vessel into the residual false lumen was completely prevented. might produce sidearm graft stenosis or occlusion. Al- Theoretically, our modified triple-branched stent graft though no sidearm graft stenosis or occlusion was ob- served in our series, the long-term patency of those could be easily implanted through the same arch incision as hemiarch replacement, and the Dacron prosthesis re- sidearm grafts should be carefully evaluated. Fortunately, placing ascending aorta and hemiarch could directly con- fold of sidearm polyester tube graft inside the smaller arch vessel could be easily avoided by using our type 1 nect to the modified triple-branched stent graft at this arch incision. This hemiarch replacement combined with modified triple-branched stent graft. The long-term pa- open placement of a modified triple-branched stent graft tency of the sidearm stent grafts of the type 1 modified triple-branched stent graft is expected to be satisfactory technique could eliminate the arch open and close, obvi- ate the need of the arch stent, and consequently appear because simple endovascular stenting for arch vessel simpler than our technique described in this study. How- provides satisfactory long-term patency even in stenotic ever, this hemiarch replacement technique could not be obstructive pathologies [18-20]. preferred by us. Two major advantages of our technique In the traditional total arch replacement for acute type over this hemiarch replacement technique might contribute A aortic dissection, the elephant trunk was routinally Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 8 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 applied to achieve a stronger distal anastomosis and to the distances between 2 neighboring sidearm graft were facilitate subsequent surgery on the distal aorta [21]. decided by each patient’s corresponding sizes which However, placement of the elephant trunk into the true were determined by the measuring results using pre- lumen of the dissected descending aorta is difficult and operative computed tomography. Therefore, it is impos- some complications, such as kinking and obstruction sible to be commercial. Our modified triple-branch of the graft, embolization and paraplegia, have been stent graft was designed to provide a good match with found [22]. To reduce such problems, stented elephant the different diameters of the native arch vessels and the trunk technique was developed [14,15]. This stented various distances between two neighboring arch vessels, elephant trunk has been proven to be an effective way so it can be commercial and be used in most patients. of closing the residual false lumen of the descending aorta, which might contribute to better long-term out- Conclusions comes for acute type A aortic dissection [23]. In our The modified triple-branched stent graft could provide a modified triple-branched stent graft, the distal part of good match with the different diameters of the native arch the main graft was designed to be a stented elephant vessels and the various distances between 2 neighboring trunk. Therefore, both the scope of the repaired thor- arch vessels, and it’s placement could become much easier acic aorta and the outcome of residual false lumen of by the arch open technique. Therefore, placement of a our modified triple-branched stent graft placement modified triple-branched stent graft could be easily used technique should be comparable with the traditional in most patients with acute type A aortic dissection for total arch replacement combined with stented elephant effective total arch repair. Rigorous long-term follow-up trunk technique. and further extensive clinical trials are necessary to Recently, some other techniques have been developed completely evaluate the efficacy of the modified triple- to simplify total arch repair for acute type A aortic dissec- branched stent graft and the arch open technique before tion. Total endovascular arch repair using a fenestrated this combined technique can become a reliable alterna- stent graft or using a conventional straight stent graft with tive to conventional total arch repair. arch debranching is an effective technique to complete arch repair for acute aortic dissection [24]. This technique Competing interests can be performed off-pump. Consequently it would be less The authors declare that they have no competing interests. invasive than our technique. We also performed this tech- Authors’ contributions nique for some patients with acute aortic dissection and CLW, LC participated in reseach design; CLW, WXJ, DXF, LDS, LQZ performed satisfied results were obtained. However, only normal as- the experiments; CLW, LL, LC participated in the writing of the manuscript cending aorta can provide a proximal landing zone in this and indata analysis; LL, LC carried out the follow up. All authors read and approved the final manuscript. technique. Therefore, it can not be used in the patient with a patent false lumen of ascending aorta. Enlightened Received: 16 April 2014 Accepted: 17 July 2014 by this total endovascular arch repair technique, some sur- Published: 2 August 2014 geons developed a new hybrid operation to get the effect- ive total arch repair for acute type A aortic dissection, in References 1. Fuster V, Ip JF: Medical aspects of acute aortic dissection. Semin Thorac which the dissected ascending aorta is replaced with a Cardiovasc Surg 1991, 3:219–224. Dacron tube graft under cardiopulmonary bypass with 2. DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ: Aortic dissection. moderate systemic hypothermia, and arch vessel bypasses N Engl J Med 1987, 317:1060–1067. 3. DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, from the Dacron tube graft and antegrade or retrograde Lawrie G: Dissection and dissecting aneurysms of the aorta: twenty-year deployment of a conventional straight stent graft into the follow-up of five hundred twenty-seven patients treated surgically. arch and the proximal descending aorta are performed Surgery 1982, 92(6):1118–1134. 4. Fann JI, Smith JA, Miller DC, Mitchelll RS, Moore KA, Grunkemeier G, Stinson EB, [25]. This hybrid technique eliminates the need of deep Oyer PE, Reitz BA, Shumway NE: Surgical management of aortic dissection hypothermic circulatory arrest, but arch vessel bypasses during a 30-year period. Circulation 1995, 92(9 supp):113–121. are difficulty if arch vessels are seriously involved by the 5. Haverich A, Miller DC, Scott WC, Mitchell RS, Oyer PE, Stinsion EB, Shumway NE: Acute and chronic aortic dissections–determinants of long–term outcome dissection and their long-term patency should be carefully for operative survivors. Circulation 1985, 72:1122–1134. evaluated. Shimamura et al. also developed open branched 6. Ergin MA, Philips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS, endoprosthesis placement technique [26]. Although the Griepp RB: Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994, 57:820–825. branched endoprosthesis used in their technique seems 7. Bachet JE, Termignon JL, Dreyfus G, Goudot B, Martinelli L, Piquois A, similar to our modified triple-branched stent graft, the Brodaty D, Dubois C, Delentdecker P, Guilmet D: Aortic dissection. original idea of the design is totally different. In shima- Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994, 108:199–206. mura’s branched endoprosthesis, sidearm stent grafts were 8. Ochiai Y, Imoto Y, Sakamoto M, Ueno Y, Sano T, Baba H, Sese A: Long-term connected to the main graft in the side dish during the effectiveness of total arch replacement for type A aortic dissection. procedure, and the size of each sidearm stent graft and Ann Thorac Surg 2005, 80:1297–1302. Chen et al. Journal of Cardiothoracic Surgery 2014, 9:135 Page 9 of 9 http://www.cardiothoracicsurgery.org/content/9/1/135 9. Massimo CG, Presenti LF, Marranci P, Favi PP, Poma AG, Ponzalli M, Viligiardi RG: Extended and total aortic resection in thesurgical treatment of acutetypeA aortic dissection: experience with 54 patients. Ann Thorac Surg 1988, 46:420–424. 10. Minale C, Splittgerber FH, Reifschneider HJ: Replcaement of the entire thoracic aorta in a single stage. Ann Thorac Surg 1994, 57:850–855. 11. Chen LW, Dai XF, Zhang GZ, Cao H: Extensive primary repair of the thoracic aorta in acute type A aortic dissection by means of ascending aorta replacement combined with open placement of triple-branched stent graft: early results. Circulation 2010, 122:1373–1378. 12. Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, Matsuda H, Kato M, OhnishiK,Kaneko M,Ueda T,Kishi D, MizushimaT,Matsuda H: New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996, 94(suppl):II-188–II-193. 13. Kato M, Matsuda T, Kaneko M, Kuratani T, Mizushima T, Seo Y, Uchida K, Kichikawa K, Maeda M, Ohnishi K: Outcomes of stent-graft treatment of false lumen in aortic dissection. Circulation 1998, 98(suppl):II-305–II-312. 14. Liu ZG, Sun LZ, Chang Q, Zhu JM, Dong C, Yu CT, Liu YM, Zhang HT: Should the “elephant trunk” be skeletonized? Total arch replacement combined with stented elephant trunk implantation for stanford type A aortic dissection. J Thorac Cardiovasc Surg 2006, 131:107–113. 15. Shimamura K, Kuratani T, Matsumiya G, Kato M, Shirakawa Y, Takano H, Ohta N, Sawa Y: Long-term results of the open stent-grafting technique for extended aortic arch disease. J Thorac Cardiovasc Surg 2008, 135(6):1261–1269. 16. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, Nicolas V, Pierangeli A: Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999, 340:1539–1545. 17. Mori Y, Hirose H, Takagi H, Umeda Y, Fukumoto Y, Shimabukuro K, Matsuno Y: Aortic arch repair for Stanford type A aortic dissection with distal anastomosis to the proximal level of the distal aortic arch. JThorac Cardiovasc Sur 2003, 126:415–419. 18. De Vries JP, Jager L, Van den Berg JC, Overtoom TT, Ackerstaff RG, Van de Pavoordt ED, Moll FL: Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg 2005, 41:19–23. 19. Bates MC, Broce M, Lavigne PS, Stone P: Subclavian artery stenting: factors influencing long-term outcome. Catheter Cardiovasc Interv 2004, 61:5–11. 20. de Borst GJ, Ackerstaff RG, de Vries JP, vd Pavoordt ED, Vos JA, Overtoom TT, Moll FL: Carotid angioplasty and stenting for postendarterectomy stenosis:lonr-term follow-up. J Vasc Surg 2007, 45:118–123. 21. Ando M, Takamoto S, Okita Y, Morota T, Matsukawa R, Kitamura S: Elephant trunk procedure for surgical treatment of aortic dissection. Ann Thorac Surg 1998, 66:82–87. 22. Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR: Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990, 211:521–537. 23. Sun LZ, Qi R, Zhu JM, Liu YM, Zheng J: Total arch replacement combined with stented elephant trunk implantation: A new “standard” therapy for type A dissection involving repair of the aortic arch? Circulation 2001, 123:971–978. 24. Czermy M, Gottardi R, Zimpfer D, Schoder M, Grabenwoger M, Lammer J, Wolner E, Grimm M: Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. Eur J Cardiothorac Surg 2007, 31:623–627. 25. Diethrich EB, Ghazoul M, Wheatley GH, Alpern J, Rodriguez-Lopez J, Ramaiah V, Williams J: Surgical correction of ascending type A thoracic aortic dissection: simultaneous endoluminal exclusion of the arch and distal aorta. J Endovasc Ther 2005, 12:660–666. 26. Shimamura K, Kuratani T, Matsumiya G, Shirakawa Y, Takeuchi M, Takano H, Submit your next manuscript to BioMed Central Sawa Y: Hybrid endovascular aortic arch repair using branched and take full advantage of: endoprosthesis: the second-generation “branched” open stent-grafting technique. J Thorac Cardiovasc Surg 2009, 138:46–53. • Convenient online submission doi:10.1186/s13019-014-0135-3 • Thorough peer review Cite this article as: Chen et al.: Total arch repair for acute type A aortic • No space constraints or color figure charges dissection with open placement of a modified triple-branched stent graft and the arch open technique. Journal of Cardiothoracic Surgery 2014 9:135. • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Journal of Cardiothoracic SurgerySpringer Journals

Published: Aug 2, 2014

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