1. This document discusses surgical approaches for treating type A aortic dissection, including a hybrid approach combining surgery and stenting. 2. It presents two clinical cases where different surgical strategies were used - a multibranched frozen elephant trunk procedure and a two-step approach combining ascending-arch repair with later TEVAR. 3. The key decision points for surgical treatment are the clinical presentation, site of the intimal tear, and patient age, and the document advocates for extensive aortic repair to prevent chronic enlargement of the false lumen and further complications.

1. Hybrid approach for type A
aortic dissection
Gian Luca Martinelli MD
CV Surgery Dept.
S Anna Hospital – Catanzaro - Italy

2. Possible scenarios
• Complete resection of dissected aorta
• Total thrombosis in the false lumen
• Partial thrombosis in the false lumen
• Perfused false lumen
Shrinkage of the false lumen

3. Our goal: remodeling the aorta
• Extensive repair of the aorta should prevent
chronic progressive enlargement of the false lumen
and further aortic complications.
• Hybrid approach:
extend the treatment without increasing mortality
rate.

4. Two surgical options
• Multibranched Frozen Elephant Trunk :
Ascending-arch repair with multibranched grafting
+ descending aortic stenting
• Two-step approach:
① Ascending-arch repair with multibranched grafting
② Carotid-subclavian bypass + TEVAR
with ideal landing zone
The choice depends on clinical presentation,
site of the intimal tear and patient age

5. Multibranched Frozen Elephant Trunk
Clinical Case 1
59 yo man
Acute aortic Type A dissection: arch entering tear
Not complicated (Penn Class Aa)
Surgical treatment:
Multibranched – FET with Captivia-
Medtronic-VAMC 32-32-150

6. Preoperative MSCT scan

7. Guide wire in the true lumen

8. S. ANNA HOSPITAL – Photografic archive

9. FINAL RESULT

10. Two-step approach
Clinical Case 2
• 57 yo man;
• Pain, syncope and 3 h transient drowsiness (no
neurological damages);
• TTE: severe IA, without pericardial effusion;
• CT scan: full rupture (tear) in sino-tubular
junction and absence of malperfusion.

11. Preoperative MSCT scan

13. Case 2: surgical strategy
Bentall operation;
Aortic arch replacement in Z1;
Proximal reimplantation of cerebral vessels;
Creation of an optimal landing zone for TEVAR C-Tag
Gore 34-34-200

14. SECOND STEP
Ideal landing in zone 0

15. FINAL RESULT

16. CONCLUSIONS
Decision making key points:
Clinical presentation
Site of intimal tear
Age
Two surgical options:
FET or Hybrid two step approach

17. Thank you

18. Tips and Tricks
• Use of branched graft
• Anterograde deployement wire guided
• Very “proximal” distal anastomosis (Z 0-1) in
shorter circulatory arrest time, mild
hypothermia, anterograde selective cerebral
perfusion

19. Repair of acute type A aortic
dissection prevents further
procedures?
Most patients after surgery for AAD
remain at risk for dissection-related
aortic complications