Open repair of chronic thoracic, thoracoabdominal aortic dissection with deep hypothermia ups 10-year survival

Open repair of chronic thoracic and thoracoabdominal aortic dissection using hypothermia offers many advantages in suitable patients with this complex pathology and continues to represent the gold standard, according to new research. 

The procedure has good operative outcomes and long-term survival, according to the new study published in the August 2017 issue of the Journal of Thoracic and Cardiovascular Surgery.

“The advantages of this technique include organ and spinal cord protection, the flexibility to extend the repair proximally into the arch, and the ability to limit ischemic injury to important vascular beds,” wrote lead author Joel Corvera, director of thoracic vascular surgery with the Indiana University School of Medicine in Indianapolis. “They disadvantage include longer perfusion times and limited applicability to the ruptured aneurysm.”

The study cohort comprised 664 patients (74 percent male) with a mean age of 58 + 14 years who underwent open thoracic (by left thoracotomy) or thoracoabdominal aneurysm repair using deep hypothermia and circulatory arrest. Surgeries were performed between 1995 and 2015.

Patients’ overall operative mortality was 3.6 percent, and they experienced a permanent stroke rate of 1 percent. The need for reintervention was low, and patients had good long-term survival, with 10-year survival at approximately 60 percent. 

The researchers found that open and endovascular repair should not be viewed as competing modalities, but rather as complementary ones. For young or otherwise appropriate candidates, they wrote, open repair should continue to be considered the gold standard, and under ideal circumstances all patients with connective tissue disorders should have open repair.

Other types of patients, older or with multiple comorbidities, might be better served with endovascular repair, they stated. They predicted that the paradigm for open versus endovascular repair will probably shift as the technology for endovascular devices advances and as branched or fenestrated thoracoabdominal systems become available.

In an accompanying editorial, Joseph S. Coselli, who is with division of cardiothoracic surgery within the Michael E. DeBakey department of surgery at Baylor College of Medicine in Houston, commended Corvera and colleagues for their outstanding surgical skill and results.

Coselli reported that despite the fact that endovascular techniques are being used and reported with growing frequency of late, until such techniques become safe and established, the use of open techniques to repair chronic aortic dissection will remain the standard of therapy.