One-stage hybrid approach for type A acute aortic dissection repair: just because we can, should we do it?

trunk procedure combined with ascending aorta and arch replacement for acute type A aortic dissection. Should the 'elephant trunk' be skeletonized? Total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection. Kitamura S. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection?grafting through the aortic arch: an alternative approach for distal arch aortic aneurysm. A contemporary analysis of outcomes for operative repair of type A aortic dissection in the United States. We read with interest the article of Chen and coworkers w1x who report their experience with the stented elephant trunk during type A aortic dissection (TAAD) repair. They tested new endovascular technology appropriate for aortic dissection and demonstrated its safety in the short-term. From our point of view, it is unclear whether this therapy will indeed improve the long-term prognosis or lead to lower rates of late surgical re-intervention. The rationale to use this technique consists in obtaining an early thrombosis of the patent false lumen in the descending aorta and in doing so, prevent late thoraco-abdominal aneurysm formation. However, stenting the descending aorta during emergent repair of TAAD has raised some conceptual and technical concerns w2x. The role of a patent false lumen in the residual dissected aorta after type A acute aortic dissection is still a question of matter. Many studies have demonstrated that a residual patent lumen does not affect the long-term outcome in patients who underwent standard surgical repair of TAAD and its presence is not necessarily associated with a faster aortic growth rate w3, 4x. This information is consonant with the documented benignity of the dissected descending aorta after recovery from acute type B dissection w5x. In addition, introducing a stented graft into an acutely dissected aorta may be cumbersome and may carry the risk of kinking or wrinkling of the graft, aortic disruption, peripheral embolization, paraplegia and malperfusion syndrome. To summarize it would seem that only a few patients will really benefit from this one-stage hybrid approach, while all of them run a supplementary risk to a higher mortality and morbidity procedure. A possible alternative to this one-stage hybrid repair could come from a surgical technique which guarantees a radical surgical TAAD repair and at the same time creates the requisites for a future stent-graft deployment in case of subsequent descending thoracic aorta enlargement. Based on these considerations, we …