To the Editor
We read with a great interest the review by Sabe and associates.1 The authors underscore the challenge of emergency surgery for acute type A aortic dissection (ATAAD) in high-risk patients. The question is probably even more difficult for elderly patients without comorbidities.
Our group considers urgent off-pump aortic wrapping for the most fragile patients referred for ATAAD (Figure 1 ).2 This technique is often considered as a palliative approach because it was initially applied before the advent of cardiopulmonary bypass in the late 1950s. Aortic wrapping allows for pericardial drainage in emergency combined with securing of the aorta using a Teflon (Chemours, Wilmington, DE) plaque. In our experience, ATAAD with location of the intimal tear in the aortic arch is the best indication for off-pump aortic wrapping. Over the last decade in our institution, aortic wrapping for ATAAD was associated with 91% (95% confidence interval: 0.87-0.96) and 78% (95% confidence interval: 0.66-0.82) actuarial survival in 52 octogenarians at 1 and 5 years, respectively. Postoperative computed tomography scan imaging showed complete regression of the false lumen in the ascending aorta after surgery, except in 4 patients who underwent successful complementary endovascular stenting due to persistent circulating false lumen.3 In case of secondary aneurysmal evolution of the non-wrapped aortic arch, we recently reported that 88% of our cohort could be candidates for additional endovascular arch repair.4
Figure 1.
Schematic diagram of an aortic wrapping performed around the dissected ascending aorta using a Teflon (Chemours, Wilmington, DE) plaque. The primary intimal tear was located in the aortic arch leading to retrograde and antegrade aortic dissection.
In summary, the review by Sabe and colleagues1 supports evidence for alternate interventional procedures to improve ATAAD outcomes in patients deemed inoperable. We trust that off-pump aortic wrapping could be considered as a first step hybrid approach in high-risk patients, especially in octogenarians who cannot be reasonably exposed to circulatory arrest. Recent advances in endovascular repair for complex aortic disease are promising and should be taken into account before potential deferral of surgery for ATAAD.
References
- 1.Sabe A.A., Percy E.D., Kaneko T., Plichta R.P., Hughes G.C. When to consider deferral of surgery in acute type A aortic dissection: a review. Ann Thorac Surg. 2021;111:1754–1762. doi: 10.1016/j.athoracsur.2020.08.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Demondion P., Ramadan R., Azmoun A., et al. Aortic wrapping for Stanford type A acute aortic dissection: short and midterm outcome. Ann Thorac Surg. 2014;97:1590–1596. doi: 10.1016/j.athoracsur.2013.11.052. [DOI] [PubMed] [Google Scholar]
- 3.Verscheure D., Ramadan R., Azmoun A., et al. Ascending aorta stenting after off-pump aortic wrapping in Stanford A retrograde aortic dissection. Ann Thorac Surg. 2017;104:e115–e117. doi: 10.1016/j.athoracsur.2017.02.038. [DOI] [PubMed] [Google Scholar]
- 4.Vento V., Multon S., Ramadan R., et al. Outcomes of urgent aortic wrapping for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2022;164:1412–1420. doi: 10.1016/j.jtcvs.2020.10.136. [DOI] [PubMed] [Google Scholar]