Potential Indications for Arch Replacement in Acute Type A Dissection
The nuances of aortic dissection and risk factors for acute and long-term complications will continue to evolve. Based on the current understanding of aortic dissection, the following might be conditions where we would consider arch replacement at time of type A surgery:
Pre-existing arch aneurysm
Primary intimal tear identified on pre-operative CT in the distal arch or descending thoracic aorta
Secondary intimal tear in the arch measuring >10 mm
Clinical signs of visceral or peripheral extremity malperfusion
Radiologic signs of potential visceral, renal and peripheral compromise such as a severely effaced true lumen in descending thoracic aorta
False lumen diameter > than 22 mm
Descending thoracic aorta diameter >35 mm
It is also worth questioning whether young age should be an indication for a more aggressive approach to the arch. On one hand, these patients have a more aggressive disease process and are at risk for complications over the years, while on the other hand, the long-term outcome of an endovascular prosthesis in the angulated arch has not been delineated. Review of our local database revealed one late complication in 15 patients with Zone 0 TEVAR at up to 47 months of follow up, with mean radiological follow up of 545 days and cumulative follow up of 8,176 days (in submission).