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J Thorac Cardiovasc Surg 2008;135:1268-1269
© 2008 The American Association for Thoracic Surgery
Invited Commentary |
Also, our experience shows that the descending aorta is not commonly problematic, even in the long term, after successful type A repair, raising doubt about whether adjunctive stent therapy in the descending aorta is really necessary.
I have 3 questions. My first question has to do with early mortality. You list your hospital mortality as 3%, but by 6 months 19% of the patients are dead. How did another 16% of the patients die within 6 months of hospital discharge? What was going on clinically and radiographically with their aortas and their brains before death?
My second question has to do with anatomic morphology and selection for operation. It appears that a large proportion of cases in this paper are not really extended arch lesions, as the title indicates, but rather typical type A and type B dissections. I am uncomfortable with the classification of the large number of patients with chronic type B dissection in this series as having "arch" lesions. Descending dissections are nearly always limited to the region distal to the subclavian artery. These lesions are well treated by a relatively straightforward resection via left thoracotomy on left atrial–femoral artery bypass. With a clamp placed between the left carotid and left subclavian arteries, one has excellent exposure for the proximal anastomosis. Why did the authors classify these as arch lesions and perform their complex extra-anatomic repair?
For the third question, let us consider the failures of therapy. How do you explain the persistence or progressive enlargement of the aneurysm in 25% of your patients?
Congratulations on an excellent presentation.
Dr Shimamura. Thank you, Dr Elefteriades, for your kind comments and important questions.
Regarding the first question about mortality, the early mortality included 3 patients with postoperative strokes, and we lost these 3 patients within 1 year. It could be said that we have lowered the quality of life of the patients postoperatively, but the death is not associated directly to the stent graft. Also, there is a patient who had an fatal aortoesophageal fistula, as I showed in my slides. We lost this patient after successful treatment for a ruptured aneurysm however, this endoluminal treatment does not resect the whole aneurysm, so this kind of problem needs more investigation. Most of the late deaths are associated with the relatively high risk of the background of the patients. We introduced stent-graft treatment in clinical use in 1993, and this is the very first in Japan. Many patients with severe comorbidities were sent to our institution, and we have to deal with these high-risk patients. This could explain the relatively poor overall survival in the long term. However, we believe that avoidance of the aortic arch–related deaths is satisfactory.
Your second question concerned the indication for this procedure. Yes, we include type B dissection for this procedure, but the indication is only for the complication-specific treatment for type B dissection. We undertook this procedure for the patient with type B dissection who has a very proximal intimal tear near to the subclavian artery. These tears cannot be treated with endovascular repair. Of course, there are options to do graft replacement with a left thoracotomy, but we think that closure of the intimal tear via a median approach is compatible with this treatment, and the results are satisfactory in our study.
Regarding the third question, the majority of the aneurysms have an extension distally, and it was thought to be difficult to treat that extension with conventional treatment via a median sternotomy. Our series contains about 20% of patients who have a relatively proximal location of the distal end of the aneurysms, and these could be treated with traditional surgical repair. However, this procedure has an advantage even in these aneurysms, because with the stent graft you can alternate your distal anastomosis and manipulate only in the proximal arch. This could be a very easy way to control the bleeding.
Dr Bruce W. Lytle (Cleveland, Ohio). Regardless of the specific indications for how often you do a debranching or whether this is just an extension of a conventional arch repair, the concept of putting in a stent graft during an open aortic operation, perhaps to extend it to the descending aorta, makes a lot of sense. We certainly have tried to do this. One of the things I have been really disappointed in is the lack of response of our industrial partners to this issue. We have tried to get a number of the companies interested in making devices specifically for the purpose of being put in at the time of surgery. They just cannot seem to get this.
The way you wrap the string around the graft is very clever, but are you still doing it that way after 14 years? Has there not been some company that has agreed to manufacture that on sort of a prospective basis?
Dr Shimamura. We do not use the sheath to deliver the stent graft, but we have no company that makes this kind of commercially available stent graft. I hear that that kind of device is available in Germany, and I think the production of such a device could expand this technique widely.
Dr Lytle. I invite our colleagues to help our industrial partners to understand that we are interested in this, because regardless of the specific indication, there is no doubt that this concept will have some degree of usefulness.
Related Article
J. Thorac. Cardiovasc. Surg. 2008 135: 1261-1269.
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