Re: Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair.

Bartosz Rylski et al. have evaluated the outcomes following open versus endovascular approaches to distal aortic pathologies after surgery for acute dissection at two tertiary centres in the USA and Europe [1]. A total of 141 patients underwent aortic reintervention for pathologies of the aortic arch, thoracic or descending or abdominal aorta between 2000 and 2014. Most of these patients had a history of DeBakey type I aortic dissection. Overall survival was 74 ± 8, 70 ± 8 and 65 ± 9% in the open and 96 ± 3, 92 ± 5 and 92 ± 5% in the endovascular group at 1, 2.5 and 5 years with 13 and 12 patients remaining at risk at 5 years, respectively. Freedom from distal re-reintervention was 100 ± 0, 100 ± 0 and 93 ± 7% in the open patients and 96 ± 3, 90 ± 5 and 90 ± 5% in the endovas-cular patients at 1, 2.5 and 5 years, respectively. Although open surgical repair has been regarded as the gold standard for treating aortic events following type I or II dissection repair, in-hospital mortality after descending aorta reintervention was lower in patients classified for endovascular treatment in this study. However, despite a technically successful endovascular rein-tervention, over 10% of patients attained threshold aortic diameter values for re-reintervention during this study. In addition, patients with aortic arch involvement received an open repair (58 vs 7%), explaining to some extent this difference in mortality. Although regarded as controversial until now, this study may lead to more endovascular procedures to treat patients with residual dissection after proximal aortic repair for type I or II dissection. The authors have rightly quoted Dr Crawford's saying 'No patients should be considered cured of the disease'. This study also demonstrates that it is of utmost importance to keep the patients after aortic dissection in strict follow-up. This way, surgeons can 'catch' the patients early enough so that either of the two techniques: open or endovascular repair can be performed tailored to suit the patients. Another lesson from this study is that it may be better to treat the patients more 'aggressively' during initial surgery for acute De Bakey type I aortic dissections. The main goal of emergency surgery for acute aortic dissec-tion, type A (AADA) is to prevent rupture of the ascending aorta causing pericardial tamponade. Therefore, many surgeons advocate only an ascending aortic replacement with or without …