Marty, Bettina

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K. Tanaka et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 864—870 869procedures, such as routine aortic arch replacement andtotal aortic root replacement or valve sparing aortic rootreconstruction, should be performed [22—25]. In ourexperience, as long as the primary intimal tear was resected,there was no patent false lumen left postoperatively in eitherthe aortic root or aortic arch in any of the patients usingadventitial inversion technique. Therefore, ascending aorta/hemiarch replacement with supracoronary tube graft wouldsuffice for most of the patients with acute type A aorticdissection in the absence of Marfan or annuloaortic ectasia.4.4. Limitations of this studyThe main limitation of the present study was that it wasretrospective in nature without control group. Furthermore,the follow-up period is relatively short to prove thesuperiority of this technique in preventing late pseudoaner-ysm formation or redissection compared to conventionalanastomotic techniques using felt strips or biological glues. Alarge-scale prospective randomized clinical controlled studywould be necessary to address these issues.5. ConclusionThe adventitial inversion technique provides an excellentimmediate hemostasis and facilitates thrombotic closure ofthe proximal and the distal false lumen in the treatment foracute aortic dissection. This technique is a promisingalternative procedure to Teflon felt or biologic glues forrestoring the integrity of the aortic wall in the surgicaltreatment of acute type A aortic dissection.References[1] Immer FF, Hagen U, Berdat PA, Eckstein FS, Carrel TP. Risk factors forsecondary dilatation of the aorta after acute type A aortic dissection. EurJ Cardiothorac Surg 2005;27:654—71.[2] Moore NR, Parry AJ, Trottman-Dickenson B, Pillai R, Westaby S. Fate of thenative aorta after repair of acute type A dissection: a magnetic resonanceimaging study. Heart 1996;75:62—6.[3] Fattori R, Bacchi-Reggiani L, Bertaccini P, Napoli G, Fusco F, Longo M,Pierangeli A, Gavelli G. Evolution of aortic dissection after surgical repair.Am J Cardiol 2000;86:868—72.[4] Bernard Y, Zimmermann H, Chocron S, Litzler JF, Kastler B, Etievent JP,Meneveau N, Schiele F, Bassand JP. False lumen patency as a predictor oflate outcome in aortic dissection. Am J Cardiol 2001;87:1378—82.[5] Driever R, Botsics S, Schmitz E, Donovan J, Vetter HO. Long-term effec-tiveness of operative procedures for Stanford type A aortic dissections.Cardiovasc Surg 2003;11:265—72.[6] Floten HS, Ravichandran PS, Furnary AP, Gately HL, Starr A. Adventitialinversion technique in repair of aortic dissection. Ann Thorac Surg1995;59:771—2.[7] Garcia-Rinaldi R, Carballido JC, Mojica J, Soltero ER, Curcic S, Barcelo J,Porro R. Surgical treatment of aortic dissections: initial experiencewith the adventitial inversion technique. Ann Thorac Surg 1998;65:1255—9.[8] Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM.Long-term effectiveness of operations for ascending aortic dissections. JThorac Cardiovasc Surg 2000;119:946—62.[9] Kazui T, Washiyama N, Muhammad BAH, Terada H, Yamashita K, TakinamiM, Tamiya Y. Extended total arch replacement for acute type A aorticdissection: experience with seventy patients. J Thorac Cardiovasc Surg2000;119:558—65.[10] Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of theaorta and dissecting aortic aneurysms. Improving early and long-termsurgical results. Circulation 1990;82:IV24—38.[11] Bachet J, Goudot B, Dreyfus G, Banfi C, Ayle NA, Aota M, Brodaty D,Dubois C, Delentdecker P, Guilmet D. The proper use of glue: a 20-yearexperience with the GRF glue in acute aortic dissection. J Card Surg1997;12:243—53.[12] Raanani E, Georghiou GP, Kogan A, Wandwi B, Shapira Y, Vidne BA.‘BioGlue’ for the repair of aortic insufficiency in acute aortic dissection.J Heart Valve Dis 2004;13:734—7.[13] Hoschtitzky JA, Crawford L, Brack M, Au J. Acute coronary syndromefollowing repair of aortic dissection. Eur J Cardiothorac Surg2004;26:860—2.[14] Mastroroberto P, Chello M, Onorati F, Renzulli A. Embolisation, inflam-matory reaction and persistent patent false lumen: is biological gluereally effective in repair of type A aortic dissection? Eur J CardiothoracSurg 2005;27:529—32.[15] Fukunaga S, Karck M, Harringer W, Cremer J, Rhein C, Heverich A. The useof gelatin—resorcin—formalin glue in acute aortic dissection type A. Eur JCardiothorac Surg 1999;15:564—70.[16] Bingley JA, Gardner MAH, Stafford G, Mau TK, Pohlner PG, Tam RKW,Jalali H, Tesar PJ, O’Brien MF. Late complications of tissue glues in aorticsurgery. Ann Thorac Surg 2000;69:1764—8.[17] Kazui T, Washiyama N, Bashar AHM, Terada H, Suzuki K, Yamashita K,Takinami M. Role of biologic glue repair of proximal aortic dissection inthe development of early and midterm redissection of the aortic root.Ann Thorac Surg 2001;72:509—14.[18] Suehiro K, Hata T, Yoshitaka H, Tsushima Y, Matsumoto M, Hamanaka S,Mohri M, Ohtani S, Nagao A, Kojima T. Late aortic root redissectionfollowing surgical treatment for acute type A aortic dissection usinggelatin—resorcin—formalin glue. Jpn J Thorac Cardiovasc Surg2002;50:195—200.[19] Von Oppell UO, Karani Z, Brooks A, Brink J. Dissected aortic sinus repairedwith gelatin—resorcin—formaldehyde (GRF) glue are not stable on followup. J Heart Valve Dis 2002;11:249—57.[20] Ergin MA, Phillips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS,Griepp R. Significance of distal false lumen after type A dissection repair.Ann Thorac Surg 1994;57:820—5.[21] Nguyen B, Muller M, Kipfer B, Berdat P, Walpoth B, Althaus U, Carrel T.Different techniques of distal aortic repair in acute type A dissection:impact on late aortic morphology and reoperation. Eur J CardiothoracSurg 1999;15:496—501.[22] Ando M, Nakajima N, Adachi S, Nakaya M, Kawashima Y. Simultaneousgraft replacement of the ascending aorta and total aortic arch for type Aaortic dissection. Ann Thorac Surg 1994;57:669—76.[23] Ergin MA, McCullough J, Galla JD, Lansman SL, Griepp RB. Radicalreplacement of the aortic root in acute type A dissection: indicationsand outcome. Eur J Cardiothorac Surg 1996;10:840—4.[24] Niederhauser U, Rudiger H, Vogt P, Kunzli A, Zund G, Turina M. Compositegraft replacement of the aortic root in acute dissection. Eur J Cardi-othorac Surg 1998;13:144—50.[25] Kallenbach K, Pethig K, Leyh RG, Baric A, Harringer W. Acute dissection ofthe ascending aorta: first results of emergency valve sparing aortic rootreconstruction. Eur J Cardiothorac Surg 2002;22:218—22.Editorial commentReinforcing the anastomotic cuff in aortic dissectionThe dissected aorta is prone to anastomotic complicationssuch as bleeding and dehiscence. The aortic wall is friable dueto medial cystic necrosis, fragmentation of the elasticlamellae, focalfibrosis, and thedissecting hematomabetweenthemiddleand theouter third of themedia.Yet theadventitiallayer remains intact [1]. Current methods to reinforce theK. Tanaka et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 864—870870* Tel.: +41 21 314 2596; fax: +41 21 314 2278.E-address: martyb@hopcantfr.chdoi:10.1016/j.ejcts.2005.10.009aorta make use of Teflon or Dacron strips and biologic glue.Resulting possible disadvantages are difficulties to accuratelylocalize anastomotic bleeding and a bulky anastomosispredisposing to luminal narrowing and pressure decrease.Therefore, reference surgeons recommended neither to useprosthetic reinforcement nor the inclusion technique [2].Tanaka et al. present the formerly described adventitialinversion technique for the repair of acute type A aorticdissection with respect to closure of the false lumen [3,4].The dissected flap is trimmed back 1 cm distal to theresection line. The redundant layer of adventitia includingthe adherent outer third of media is folded into the lumenand tacked down. Thereby the resulting anastomotic cuffconsists of two adventitial and external elastic lamina layers‘‘sandwiching’’ two thirds of the friable media. A tough butsoft cuff for anastomosis is created, with a low profileenabling accurate suturing and precise localization ofbleeding points. Besides, the cuff has a desirable sealingeffect by activation of the extrinsic coagulation pathway viaexposed adventitial collagen and tissue factor [5]. The latteris a cell membrane bound glycoprotein, and upon exposure toblood, binds to factor VII. The tissue factor—factor VIIacomplex activates factor X and thence generates thrombin.This technique carries the potential risk of thrombusformation at the adventitial anastomotic rim with subse-quent embolization. In small caliber anastomoses withintima—adventitia apposition, thrombus deposition has beenobserved only at the adventitial rim not causing luminalnarrowing [6]. It is unlikely that in a high-flow system such asthe aorta, protruding thrombus is developing at theanastomotic site. However, surface irregularities are cer-tainly filled up by thrombus that becomes subsequentlyreplaced by neointima during anastomotic remodeling [7].The embolic potential is probably very low.The proposed technique ensures that the false lumen isexcluded from antegrade flow at the anastomotic level.Although important, Tanaka et al. show that other means areequally crucial in contributing to the closure of the intimaltear at the entry site. They underscore the importance ofexploration of the aortic arch including replacementwhenever necessary and avoidance of distal clamping toprevent damage to the aorta beyond the anastomosis.References[1] Cotran RS, Kumar V, Collins T, Robbins SL. Robbins pathologic basis ofdisease, 6th ed., Elsevier Science Health Science; 1998.[2] Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of theaorta and dissecting aortic aneurysms. Improving early and long-termsurgical results. Circulation 1990;82(Suppl. IV):IV24—38.[3] Floten HS, Ravichandran PS, Furnary AP, Gately HL, Starr A. Adventitialinversion technique in repair of aortic dissection. Ann Thorac Surg1995;59:771—2.[4] Garcia-Rinaldi R, Carballido J, Mojica J, Soltero ER, Curcic S, Barcelo J,Porro PR. Surgical treatment of aortic dissections: initial experiencewith the adventitial inversion technique. Ann Thorac Surg 1998;65:1255—9.[5] Dumanian GA, Heil BV, Khouri RK, Hing C, Labadie K, Wun T-C, Johnson PC.Tissue factor and its inhibition at the human microvascular anastomosis. JSurg Res 1996;60:263—9.[6] Heijmen RH, Gru¨ndeman PF, Borst C. Intima—adventitia apposition in end-to-side arterial anastomosis: an experimental study in the pig. Ann ThoracSurg 1998;65:705—11.[7] Marty B, Maeder B, Gallino A, Mucciolo A, von Segesser LK. Does largeoversizing of self-expandable endoprostheses compensate for aorticgrowth? J Vasc Surg 2003;38:1368—75.Bettina Marty*Department of Cardiovascular Surgery,University Hospital CHUV,Rue de Bugnon 46, 1011 Lausanne,Switzerland

Editorial comment: Reinforcing the anastomotic cuff in aortic dissection

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