Type B aortic dissection residual after proximal aortic repair: an innovative open surgical approach in patients not eligible for endovascular treatment

Background: Residual type B aortic dissection (R-TBAD) is a challenging kind of disease affecting an increasing number of patients. Management of R-TBAD has not been specifically addressed in current literature and many of those patients are not eligible for endovascular treatment. Aim of the study was to evaluate the efficacy and feasibility of a specifically conceived procedure the "saguaro branched graft technique" to treat R-TBAD distal to a proximal stent-graft. Methods: Data of patients treated between 2015 and 2019 were prospectively collected and retrospectively analyzed. Indication for surgery was R-TBAD with chronic malperfusion, aortic enlargement >55 mm or rapid growth, and symptomatic aortic enlargement. A Dacron graft with four branches has been tailored on the back table by implanting two bifurcated grafts to a tube or bifurcated graft. After left thoracoabdominal incision the proximal endograft has been used as a solid starting point for the distal branched graft. Sequential revascularization of the visceral vessels was performed step by step by suturing each artery outside the aneurysm before opening the distal aorta, while a continued retrograde aortic and visceral perfusion was maintained by a left pump atriofemoral bypass. After that all visceral branches had been regularly perfused from above, the thoraco-abdominal aorta was open and repaired. Outcome measures were 30-day mortality and 30-day major complications as were long-term all-cause mortality, aorta-related mortality, reintervention and patency rates of the branches. Results: Thirteen patients with R-TBAD were treated during the study period. Indication for surgery was chronic malperfusion in one patient (7.7%), aortic enlargement >55 mm or rapid growth in 9 patients (69.2%), persistent pain with aortic enlargement >50 mm in 3 patients (23.1%). All patients were considered not eligible for endovascular repair. At 30-days no deaths or re-interventions occurred and major complications including acute cardiovascular events and renal function impairment were not reported; one patient (7.7%) developed postoperative paraplegia. At a mean follow-up period of 19.6 +/- 10.2 (range, 8-48) months, reintervention and mortality rates were null. Visceral malperfusion and late-onset renal failure were not reported, and all visceral branches were still patent. Conclusions: Despite the potential high risk of open surgery, the "saguaro branched graft technique" appears to be a safe surgical solution for R-TBAD. (Cite this article as: Spinelli F, Montelione N, Benedetto F, Spinelli D, Tomaselli E, Stilo F. Type B aortic dissection residual after proximal aortic repair: an innovative open surgical approach in patients not eligible for endovascular treatment. Int Angiol 2022;41:110-7. DOI: 10.23736/S0392-9590.22.04611-9)