Surgery for Type A Dissection

Unfortunately intimal tear couldn't been found during this operation. In this situation, the most common site of intimal tear is in distal arch. I suggest to replace the ascending aorta and aortic arch, with a fresh elephant trunk placed in the proximal 1/3 of the descending thoracic aorta. I would like to share with you my technique of this kind of surgery. Please watch this site: www.youtube.com/watch?v=KC8hZOm6mfE, or use keywords of aortic dissection and vascular ring connector, so that you can watch my movies in Youtube. Thanks! From: Jeng Wei, MD, MSD, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan

Terrific video, Jeng. The major question in the years to come is, when you encounter a type A dissection without an evident tear in the asending aorta and arch, what is the best strategy? Are you better off with a simpler and shorter operation that gets the patient through the procedure and at the same time addresses the lethal consequences of Type A Dissection? Alternatively, should you be more aggressive in trying to address the tear whose site of origin is unclear? Time will tell. Thanks for your comments and video reference.

Thank you for your comments! In the past, I would do the same thing like you. Now I will replace the ascending aorta (AsA), arch, and upper 1/3 of descending thoracic aorta (DTA) at the same time. Before sternotomy, I will anastomose two 8 mm vascular grafts to bilateral carotid arteries for systemic circulation and brain perfusion during circulatory arrest. Longitudinal incision is made on the AsA. A Dacron graft re-enforced with a vascular ring connector (VRC) is inserted into the aortic root. The graft was fixed with tapes from outside of the aortic and cardioplegia was infused into the coronary arteries through this proximal aortic Dacron graft. If I cannot find the intimal tear at the AsA, I will extend the incision to the proximal aortic arch. A VRC is inserted into the middle portion of a 25 cm long Dacron graft corresponding to the size of the true lumen (usually 20-24 mm in diameter). One end of this aortic Dacron graft will be used as a fresh elephant trunk (usually 13-15 cm) to cover the upper 1/3 of the DTA. The free end of the elephant trunk is inserted into the true lumen of the DTA with the guide wire pulling technique (will be mentioned in the attached movie). The VRC is secured with umbilical tapes from the outside of the aorta at the level between the innominate artery and the left carotid artery. The two 8 mm vascular grafts of the two carotid arteries are anastomosed to the anterior wall of the other end of the aortic Dacron graft that is further anastomosed to the proximal aortic Dacron graft. If the mean blood pressure of the left radial artery is lower than 60 mm Hg, I will do left carotid to left subclavian bypass, which is easy if the left sternocleidomastoid muscle is divided. You can watch my new movie entitled "Redo Surgery for Type A Dissection - Case 2" https://www.youtube.com/watch?v=3ampHfYzyfk I should say that the trick of the use of elephant trunk in open surgery is that the back flow from the intimal tear can be minimized immediately after the surgery. The VRC had been licensed by FDA but we cannot find a dealer in the USA. The VRC is used to reduce the time for anastomosis, but you still can do it by suture technique. The elephant trunk can be used to minimize bleeding from the anastomosis too. Since the intima is very fragile, thus bleeding may come from the suture holes. But if you have an elephant trunk inside the distal part of the aorta, the bleeding from the suture holes will be much reduced because the intima had been replaced by Darcon graft. As to the technique of insertion of the fresh elephant trunk, pulling technique is certainly superior to the antegrade insertion method. Stent graft is easy to place into the DTA, but I worry about the SINE in the future. Our data had shown good remodeling of the true lumen after the use of fresh elephant trunk. Thank you for your attention! Jeng Wei, MD, MSD, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan