“Double Jacket Wrapping” Root Reconstruction for Acute Type A Aortic Dissection

This report describes a simple and effective method of aortic root repair and reconstruction in acute type A aortic dissection to reduce the risks of hemorrhage and late aortic root new intimal tear and dilation. “Double jacket wrapping” (DJW) has 2 steps: the first jacket is used for aortic root “sandwich” repair, with a patch between the outer and inner layers; and the second jacket is wrapped outside the reconstructed root at the level of the supracoronary ostium. Compared with aortic root replacement, the DJW method may avoid prosthetic valve–related complications and decrease the complexity of valve-sparing root replacement; thus, DJW is a method worthy of wide use. This report describes a simple and effective method of aortic root repair and reconstruction in acute type A aortic dissection to reduce the risks of hemorrhage and late aortic root new intimal tear and dilation. “Double jacket wrapping” (DJW) has 2 steps: the first jacket is used for aortic root “sandwich” repair, with a patch between the outer and inner layers; and the second jacket is wrapped outside the reconstructed root at the level of the supracoronary ostium. Compared with aortic root replacement, the DJW method may avoid prosthetic valve–related complications and decrease the complexity of valve-sparing root replacement; thus, DJW is a method worthy of wide use. Acute type A aortic dissection (aTAAD) is a lethal disease with high rates of natural death and surgical mortality. The 30-day mortality with surgical therapy decreased from 17.5% in 1996 to 2003 to 12.2% in 2010 to 2016, and this trend matches that seen in our center, The Affiliated Drum Tower Hospital of Nanjing University Medical School in Nanjing, China.1Parikh N. Trimarchi S. Gleason T.G. et al.Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program.J Thorac Cardiovasc Surg. 2017; 153: S74-S79Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Although the proximal extent of repair in aTAAD did not affect survival in experienced centers, the surgeons tended to choose simple and effective methods in the setting of acute phase and critical situations. Root reinforcement repair with direct suture, surgical glue, Dacron (Invista, Kennesaw, GA) patch, or prosthetic vessel has been discussed previously.2Yang B. Malik A. Waidley V. et al.Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2018; 155: 1360-1370.e1361Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Ikeno Y, Yokawa K, Yamanaka K, et al. The fate of aortic root and aortic regurgitation after supracoronary ascending aortic replacement for acute type A aortic dissection [e-pub ahead of print]. J Thorac Cardiovasc Surg. https://doi.org/10.1016/j.jtcvs.2019.09.183, accessed May 5, 2020.Google Scholar, 4Xue Y. Zhou Q. Pan J. et al.Root reconstruction for proximal repair in acute type A aortic dissection.J Thorac Dis. 2019; 11: 4708-4716Crossref PubMed Scopus (5) Google Scholar Here we describe a modified and reformed root reconstruction and wrapping technique for cases of aTAAD. After systemic heparinization, extracorporeal circulation is established by intubation of the femoral or right subclavian artery and right atrium. When the nasopharyngeal temperature drops to 18° to 22°C, whole cardiopulmonary bypass arrest and selective cerebral perfusion are performed. Once the distal aortic arch repair is completed, extracorporeal circulation is resumed, and warming is started. Aortic root treatment occurs during the rewarming phase. The indications for root replacement (Bentall or valve-sparing root replacement [VSRR]) are as follows: patients with Marfan syndrome or other connective tissue disease, aortic root diameter of 4.5 cm or more, intimal tears in the root, and severe coronary artery involvement. The Bentall procedure, with a mechanical or biologic prosthesis and artificial vessel, is performed according to standard processes. Otherwise, the double jacket wrapping (DJW) method is used to repair and reconstruct the aortic root. The DJW method is as follows: First, the aortic root is fully freed above the left and right coronary artery openings, and care is taken to avoid damage to the coronary arteries (Figure1A). The inner and outer membranes of the aortic root are retained, and the thrombus is completely removed in the aortic root dissection. Then, an appropriately shaped polyester or artificial vessel patch is tailored on the basis of the configuration of the aortic root dissection. This patch or “first-layer jacket” is then inserted between the adventitia and intima, and an extra polyester strip is placed inside the inner layer of the native aorta (Figures 1B and 2A ). Continuous sutures with 5-0 polypropylene are used to stitch the “sandwich” root and polyester strip together, thereby creating the newly reinforced and reconstructed root (Figures 1C and 2B). At the same time, aortic valve leaflet resuspension therapy is used in patients with prolapsed leaflets, to maintain normal function of the aortic valve. Next, a second piece of polyester or artificial blood vessel (a whole tubular prosthetic vessel that is 1 size larger) is placed on the outer layer of the reconstructed root and is anastomosed with 5-0 polypropylene suture and fixed to the root epicardium; this is the “second-layer jacket” (Figures 1D, 2C, and 2D). During this step, the “second-layer jacket” is still above the level of the coronary opening, and care must be taken to avoid damage to the left and right coronary arteries. Coronary location and travel can be explored with right-angle clamps. The suture line of the second-layer jacket needs to be fixed only lightly; deep anastomosis may cause bleeding and damage to the coronary artery and aortic leaflets. After the root operation is completed, the patient is weaned from extracorporeal circulation, and the chest is closed. Transesophageal echocardiography is used intraoperatively to check the severity of aortic regurgitation after repair, and an immediate repeat repair is necessary for patients with more than moderate regurgitation noted on this imaging.Figure 2(A) to (D) Schematic diagrams of the double jacket wrapping method.View Large Image Figure ViewerDownload Hi-res image Download (PPT) From 2018 to 2019, 507 patients with aTAAD underwent surgical therapy in our center. Among them, 399 patients (73.5%) had DJW repair, and 97 patients (19.1%) underwent a Bentall procedure. Compared with the Bentall procedure, cardiopulmonary bypass time and cardiac ischemia time were significantly shortened (218.8 ± 68.4 minutes vs 240.2 ± 59.8 minutes; P = .011; 150.6 ± 47.9 minutes vs 181.3 ± 45.6 minutes; P = .000, respectively). The 30-day mortality was 10.5% (42 of 399). No intraoperative repeat repair procedures were performed because of aortic regurgitation after DJW repair. During the follow-up period, no death or reintervention was related to the aortic root even without pseudoaneurysm in the aortic root. The Bentall procedure is used in patients with aTAAD with aortic valve regurgitation and dissection involving the aortic root; this operation can completely eliminate root dissection and avoid the risk of expansion and rupture caused by long-term residual dissection. However, anticoagulation-related complications of mechanical valves and long-term failure of biologic valves limit the application of the Bentall procedure. More recently, VSRR has been used in patients with aTAAD and normal leaflets and has achieved good results.5Rosenblum J.M. Leshnower B.G. Moon R.C. et al.Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2019; 157: 14-23.e11Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar However, in our experience, only 10% of all patients with aTAAD should undergo aortic root replacement, and after excluding patients with connective tissue diseases such as Marfan syndrome, the remaining 5% to 8% of patients have an average age of 60 to 65 years. Is it necessary to spend more energy and time on complicated root surgery for patients of this age? In addition, the VSRR procedure is a technically demanding operation with high risk.6David T.E. Feindel C.M. Webb G.D. et al.Long-term results of aortic valve-sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar Reintervention because of aortic regurgitation after VSRR is another limitation. Beckmann and colleagues7Beckmann E. Martens A. Pertz J. et al.Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients.Eur J Cardiothorac Surg. 2017; 52: 319-324Crossref PubMed Scopus (31) Google Scholar reported 109 cases of aTAAD in patients who underwent VSRR, and the rate of freedom from valve-related reoperation at 10 years was 85%. In our center’s experience with a single-layer jacket, the rate of freedom from valve-related reoperation at 10 years was more than 90%.4Xue Y. Zhou Q. Pan J. et al.Root reconstruction for proximal repair in acute type A aortic dissection.J Thorac Dis. 2019; 11: 4708-4716Crossref PubMed Scopus (5) Google Scholar Therefore, the DJW method can avoid complications related to valve replacement compared with Bentall surgery and can avoid the potential risks of complex surgical operations compared with VSRR surgery. Two risks of root repair with dissected native tissue are as follows: (1) bleeding after suture of the fragile root tissue during the operation, where blood flow will enter the residual root dissection, thereby resulting in increased pressure in the dissected root; and (2) dilation of residual dissected root after repair in long-term follow-up. The single-layer jacket, or sandwich, technique and surgical glue could decrease the first risk. However, in some patients with severely dissecting roots and unmatched adventitia and intima, the adventitia is stretched so thin that sandwich repair may not strengthen the root enough. The DJW repair method limits the possibility of continuous pressurization in the residual dissection during the operation, and it can also avoid long-term root dilation. Although we performed VSRR on all patients who did not undergo root replacement, we believe that patients who still have aortic root dissections and who are at risk for aortic root dilation will benefit from DJW repair. Unlike the Florida sleeve procedure, the DJW method does not require manipulation of the coronary artery and thus reduces the risk of coronary artery injury. In conclusion, this technique is simple and effective for aortic root repair both for avoiding early bleeding risk and for reducing late root dilation. It is worthwhile to introduce and promote this method, especially for surgeons with limited experience.