Aortic remodelling hybrid stent insertion during surgical repair of an acute type A aortic dissection

Evidence-based recommendations on aortic remodelling hybrid stent insertion for acute type A aortic dissection. This involves inserting a stent with material sewed on one end into part of the aorta.

# Recommendations
Evidence on the safety and efficacy of aortic remodelling hybrid stent insertion during surgical repair of an acute type A aortic dissection is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do aortic remodelling hybrid stent insertion during surgical repair of an acute type A aortic dissection should:
Inform the clinical governance leads in their healthcare organisation.
If possible, give patients (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
If possible, ensure that patients (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Enter details about all patients having aortic remodelling hybrid stent insertion during surgical repair of an acute type A aortic dissection into the NICOR Adult Cardiac Surgery Audit. Contact nicor.auditenquiries@nhs.net for details.
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for every patient having this procedure.
Regularly review data on outcomes and safety for this procedure.
This procedure should only be done in specialised centres by surgeons experienced in aortic surgery and with special training in this procedure.
Further research could include randomised controlled trials or analysis of registry data. It should include details of patient selection and report 30day mortality, quality of life, and long-term outcomes including aortic remodelling and complications.# The condition, current treatments and procedure

# The condition
An aortic dissection is a serious condition in which a tear occurs in the inner layer of the aorta. Blood flows through the tear and into the wall of the aorta. This forces the inner and middle layers of the aorta to split apart (dissect), creating 2 passages (a true lumen and a false lumen). As more blood flows into the new false lumen the dissection extends along the aorta. This can lead to aortic rupture or decreased blood flow (ischaemia or malperfusion) to organs.
Aortic dissections are classified into 2 types, depending on which part of the aorta is affected. Type A dissection involves a tear in the ascending part of the aorta. The tear may also occur in the aortic arch, which may extend into the abdomen or back into the ascending aorta. Type B dissection involves a tear in the aorta beyond the arch, usually in the descending thoracic aorta. Dissections can be acute or chronic.

# Current treatments
Treatments for aortic dissection include medicines (to control hypertension) and surgery (to repair the aorta, and possible replacement of the aortic valve). Type of treatment depends on the chronicity, site location, and whether there are complicating features. Acute type A aortic dissection is life threatening and needs immediate surgery. The goals of surgical repair are to seal the false lumen and resolve malperfusion.

# The procedure
Insertion of aortic remodelling hybrid stent is incorporated into open hemiarch repair for an acute type A aortic dissection, under general anaesthesia. The device is a self-expanding bare-metal stent with a short felt sewing cuff end. It aims to resolve malperfusion and promote positive remodelling of the aorta.
During the hemiarch aortic reconstruction, once circulatory arrest is established, the ascending aorta is transected and resected in the standard manner. A hybrid stent is then inserted until the entire device is inside the true lumen. This is usually done under direct vision, although it can be implanted using a guidewire. The cuff end of the stent is placed level with the edge of the transected aorta and attached with interrupted sutures. The uncovered portion of the stent expands along the aortic arch into the descending aorta. The remainder of the surgical hemiarch aortic reconstruction is completed in the usual way.