Total Aortic Arch Debranching with Antegrade Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Arch Dissection

Total Aortic Arch Debranching with Antegrade Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Arch Dissection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Total Aortic Arch Debranching with Antegrade Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Arch Dissection Aaron Gilani, Benjamin Schachner, Elizabeth Wood, Bartlomiej Imielski This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4009216/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 22 You are reading this latest preprint version Abstract BACKGROUND The surgical evaluation and management of aortic arch dissections, in the absence of ascending aortic involvement, remains a grey area. It is during these scenarios where thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention. CASE PRESENTATION We present a patient with a physically demanding lifestyle, history of medical non-adherence, and family history of aortic dissections who presented with acute aortic arch dissection. He was spared a total arch replacement, by undergoing a hybrid approach of total aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of total aortic cross clamp, circulatory arrest, and hypothermic circulation for ischemic organ protection. CONCLUSIONS This patient’s unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR. TEVAR High-risk surgical repair debranching aortic arch dissection hybrid therapy Figures Figure 1 Figure 2 Figure 3 BACKGROUND While aortic dissections are largely divided into Types A and B based on the Stanford Classification, aortic dissections with intimal tears extending between the innominate artery and left subclavian artery are a more controversial area regarding their classification and surgical management 1 . It is in these scenarios that synthesis and contextualization of all available clinical information is of paramount importance. It is in these patients that a hybrid approach using both open surgical aortic debranching and Thoracic Endovascular Aortic Repair (TEVAR) can be of additive value while decreasing exposure to risks associated with longer CPB times, total aortic cross-clamping, circulatory arrest, and hypothermic circulation. In this report, we document the management of a young patient with aortic arch dissection by utilizing a hybrid approach of aortic arch debranching and TEVAR given his athletic lifestyle, failed medical therapy, family history of early age aortic dissections, as well as consideration of his clinical anatomy and pathophysiology. Informed consent was obtained from the patient regarding publishing of case details and images. CASE PRESENTATION A 38-year-old high-performance athlete with a past medical history of uncontrolled hypertension and family history of first-degree relative with aortic dissection at similar young age presented to outside hospital with four days of chest pain. Patient underwent subsequent CT chest which revealed intimal tear in Zone 3 of the aorta with retrograde dissection into the left subclavian artery (Figs. 1A-1C: Initial presentation CT angiogram with Zone 3 aortic dissection with retrograde extension into left subclavian artery; 1A: Sagittal cross-section; 1B: Axial cross-section; 1C: Coronal cross-section). Following this finding, the patient was emergently transferred to a nearby hospital for operative assessment and intervention. Upon arrival and evaluation of patient, he was taken to operating room with plan for total aortic arch debranching with antegrade TEVAR. Intra-op transesophageal echocardiogram (TEE) revealed preserved left-ventricular ejection fraction of 55% with insignificant valvular dysfunction. The patient underwent full conventional sternotomy with 14mm Hemashield Gold trifurcated graft to establish flow to innominate, left subclavian, and left common carotid arteries, as well as antegrade TEVAR placement, via a fourth sewn on 10mm graft, using a 34mm x 15mm Gore thoracic aortic endograft (Fig. 2: Immediately post-operative chest x-ray showing positioning of 34mm x 15mm Gore thoracic endograft). Only partial aortic cross-clamp was used, the heart was not arrested, and total CPB time was 187 minutes. Post-operative TEE revealed LVEF of 55% with borderline normal right ventricular function. After the operation, the patient recovered in the Cardiovascular Intensive Care Unit (CVICU) where he was weaned off vasopressor support, extubated on post-operative day one without complication, and transferred to the floor on post-operative day two. On post-operative day four, the patient underwent CT angiogram of the chest, abdomen, and pelvis to evaluate the graft which revealed improving false lumen opacification at the grafted aorta (Fig. 3: Post-operative day 4 CT angiogram showing positioning of 34mm x 15mm Gore thoracic endograft; sagittal cross-section). The remainder of his post-operative course was unremarkable, and the patient was discharged home on post-operative day six with oral antihypertensive regimen and extensive counseling. DISCUSSION/CONCLUSIONS In patients with physically demanding lifestyle, history of failed medical therapy, and/or family history of early onset aortic dissections, a holistic approach to pre-operative planning is essential, whilst maintaining the urgency associated with the pathophysiology of an acute aortic arch dissection. In this patient, we were able to identify three key inflection points involving our decision-making process: validity of conservative management, appropriateness of TEVAR-only intervention, feasibility of total arch replacement. Hypertension is considered a key risk factor for acute aortic dissection. Hypertensive patients with acute aortic dissections have had a longer history, higher stage, worse medication compliance, and poor control of hypertension 2 . Additionally, poor compliance was associated with increased healthcare costs to the patient 3 . Unfortunately, this patient’s history of poor medical compliance, and subsequently uncontrolled hypertension, made him less-than-suitable for medical therapy alone. Additionally, performance athletes engaged in rigorous weight-training can have acute rises in systolic blood pressure to 300mmHg, further increasing risk of development of acute aortic dissection 4 . As such, this patient’s baseline physically demanding lifestyle as a performance athlete leaves him vulnerable to wide variations in his blood pressure in the absence of optimal control. The patient’s family history was also notable for first-degree relative with a Stanford Type A aortic dissection at a young age. Elucidating a thorough history in patients presenting with acute aortic dissection, even in the absence of a known genetic mutation, is of a great importance given that non-syndromic familial thoracic aortic dissections are inherited in an autosomal dominant pattern with variable age of disease onset 5 . This patient also posed a variety of anatomic and physiologic considerations. Given insufficient proximal landing zone for a TEVAR-only approach, and lack of need for total arch replacement, the hybrid utilization of aortic debranching and TEVAR was advantageous in multiple areas. The hybrid approach allowed for shorter CPB bypass time (187 minutes) versus average CPB for total aortic arch replacement of 241 minutes 6 . A shorter CPB is associated with longer duration of ventilation, longer CVICU stay, and longer overall hospital stay 7 . Additionally, given this hybrid approach, the patient did not require total aortic cross clamp or circulatory arrest. Prolonged aortic cross clamp is associated with low cardiac output, prolonged ventilation, renal complication, blood transfusion, mortality and prolonged hospital stay 8 . Patients undergoing total arch replacement also require utilization of hypothermic circulation for prevention of organ ischemia, of which approximately 15% suffer the sequela of post-operative hypothermia 9 . We were able to avoid the need for hypothermic circulation given the utilization of the hybrid debranching and TEVAR technique. Management of aortic arch dissections remains a fluid area of management which requires thorough, yet expeditious, evaluation of a patient’s clinical picture. Particularly, our patient case provided a number of considerations including elevated baseline physiological demand as a performance athlete, history of medical therapy non-adherence, and presence of family history of aortic dissection made our patient a suitable candidate for hybrid technique utilizing total aortic debranching and antegrade TEVAR. Declarations Ethics Approval : N/A; Consent to Participate : Informed consent to publication obtained from the patient Availability of Data and Materials : N/A Competing Interests : None Funding : Department of Cardiothoracic Surgery, Wake Forest University School of Medicine Authors’ Contributions : All authors were involved in the project conception, data collection, manuscript writing, and review portions of this submissions Acknowledgements : Department of Vascular Surgery, Wake Forest University School of Medicine References Lempel JK, Frazier AA, Jeudy J, Kligerman SJ, Schultz R, Ninalowo HA, Gozansky EK, Griffith B, White CS. Aortic arch dissection: a controversy of classification. Radiology. 2014;271(3):848–55. https://doi.org/10.1148/radiol.14131457 . Dong N, Piao H, Li B, Xu J, Wei S, Liu K. Poor management of hypertension is an important precipitating factor for the development of acute aortic dissection. J Clin Hypertens (Greenwich Conn). 2019;21(6):804–12. https://doi.org/10.1111/jch.13556 . Rizzo JA, Simons WR. Variations in compliance among hypertensive patients by drug class: implications for health care costs. Clin Ther. 1997;19(6):1446–1425. https://doi.org/10.1016/s0149-2918(97)80018-5 . Mayerick C, Carré F, Elefteriades J. Aortic dissection and sport: physiologic and clinical understanding provide an opportunity to save young lives. J Cardiovasc Surg. 2010;51(5):669–81. Hasham SN, Lewin MR, Tran VT, Pannu H, Muilenburg A, Willing M, Milewicz DM. Nonsyndromic genetic predisposition to aortic dissection: a newly recognized, diagnosable, and preventable occurrence in families. Ann Emerg Med. 2004;43(1):79–82. https://doi.org/10.1016/s0196-0644(03)00818-7 . Abjigitova D, Mokhles MM, Papageorgiou G, Bekkers JA, Bogers AJJC. Outcomes of different aortic arch replacement techniques. J Card Surg. 2020;35(2):367–74. https://doi.org/10.1111/jocs.14386 . Martins RS, Ukrani RD, Memon MK, Ahmad W, Akhtar S. Risk factors and outcomes of prolonged cardiopulmonary bypass time in surgery for adult congenital heart disease: a single-center study from a low-middle-income country. J Cardiovasc Surg. 2021;62(4):399–407. https://doi.org/10.23736/S0021-9509.21.11583-6 . Al-Sarraf N, Thalib L, Hughes A, Houlihan M, Tolan M, Young V, McGovern E. Cross-clamp time is an independent predictor of mortality and morbidity in low- and high-risk cardiac patients. Int J Surg (London England). 2011;9(1):104–9. https://doi.org/10.1016/j.ijsu.2010.10.007 . Liu H, Wang X, Liu S, Cong S, Lu Y, Yang Y, Wang W, Lai H, Li X, Wei L, Wang C. Postoperative hypothermia after total aortic arch replacement in acute type A aortic dissection-multivariate analysis and risk identification for postoperative hypothermia occurrence. J Thorac disease. 2020;12(12):7089–96. https://doi.org/10.21037/jtd-20-1709 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Apr, 2024 Reviews received at journal 22 Apr, 2024 Reviews received at journal 20 Apr, 2024 Reviews received at journal 20 Apr, 2024 Reviews received at journal 19 Apr, 2024 Reviews received at journal 18 Apr, 2024 Reviews received at journal 15 Apr, 2024 Reviewers agreed at journal 12 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviews received at journal 11 Apr, 2024 Reviews received at journal 11 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers invited by journal 10 Apr, 2024 Editor assigned by journal 04 Mar, 2024 Submission checks completed at journal 04 Mar, 2024 First submitted to journal 03 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4009216","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":276188293,"identity":"8a69ee3d-a04d-4b3a-ae2d-ea9da0e733e7","order_by":0,"name":"Aaron Gilani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYFACxsYDDAwScgwMbAzMQK4MgwSQ5MGvpQGkxRimhYeHsBYGBqAWhsQGorXw9y9uOPBzh0X6huPHEh8XVNjx2Es3MD5424Zbi8SNhw0He89I5G44k3bYeMaZZB4emQPMhnPxaGG4cbDhAG+bRO62A+lt0rxtzECHJbABGbh1yAO1HPzbJpFudv55+2/ef/UgLey/8WkxON/YcBhoS4LZjbRjzLwNh8G2MOPTYniDseGwbJuE4f4bz5KleY4d5+G5kdgsOeccbi1y548/fPi2rU5esj/N8DNPTbUc+4zkgx/elOHxvkQChhBjAx71QMB/AL/8KBgFo2AUjAIGAHNTVMehPlgiAAAAAElFTkSuQmCC","orcid":"","institution":"Wake Forest University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Gilani","suffix":""},{"id":276188294,"identity":"81e7d28c-cd53-4b27-ac5e-f375c329ba86","order_by":1,"name":"Benjamin Schachner","email":"","orcid":"","institution":"Wake Forest University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Schachner","suffix":""},{"id":276188295,"identity":"eaa72539-4630-4c46-92a9-272ecf219132","order_by":2,"name":"Elizabeth Wood","email":"","orcid":"","institution":"Wake Forest University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Wood","suffix":""},{"id":276188296,"identity":"e532060c-f28e-42e5-98d1-9711aef77372","order_by":3,"name":"Bartlomiej Imielski","email":"","orcid":"","institution":"Wake Forest University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Bartlomiej","middleName":"","lastName":"Imielski","suffix":""}],"badges":[],"createdAt":"2024-03-03 16:32:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4009216/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4009216/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52183231,"identity":"0a6558d7-b1fc-42df-97df-6646832ee722","added_by":"auto","created_at":"2024-03-07 18:11:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":340177,"visible":true,"origin":"","legend":"\u003cp\u003eInitial presentation CT angiogram with Zone 3 aortic dissection with retrograde extension into left subclavian artery; 1A: Sagittal cross-section; 1B: Axial cross-section; 1C: Coronal cross-section\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4009216/v1/218f3556131d54c3401dc78e.png"},{"id":52184294,"identity":"cdeedb47-3c13-4bd3-ab9d-a5ff90a51409","added_by":"auto","created_at":"2024-03-07 18:19:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116326,"visible":true,"origin":"","legend":"\u003cp\u003eImmediately post-operative chest x-ray showing positioning of 34mm x 15mm Gore thoracic endograft\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4009216/v1/6f5e3d9e023545a504259522.png"},{"id":52183233,"identity":"82024f17-50ed-4045-af2b-f7ae45b92846","added_by":"auto","created_at":"2024-03-07 18:11:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":101427,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative day 4 CT angiogram showing positioning of 34mm x 15mm Gore thoracic endograft; sagittal cross-section\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4009216/v1/362de93052d49b3a6d38dfdb.png"},{"id":52186418,"identity":"6a0170b5-c530-4460-8589-5d382d1d3174","added_by":"auto","created_at":"2024-03-07 18:27:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":812059,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4009216/v1/54181c0d-8a0f-49b9-8e95-360f561e3931.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total Aortic Arch Debranching with Antegrade Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Arch Dissection","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eWhile aortic dissections are largely divided into Types A and B based on the Stanford Classification, aortic dissections with intimal tears extending between the innominate artery and left subclavian artery are a more controversial area regarding their classification and surgical management \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It is in these scenarios that synthesis and contextualization of all available clinical information is of paramount importance. It is in these patients that a hybrid approach using both open surgical aortic debranching and Thoracic Endovascular Aortic Repair (TEVAR) can be of additive value while decreasing exposure to risks associated with longer CPB times, total aortic cross-clamping, circulatory arrest, and hypothermic circulation.\u003c/p\u003e \u003cp\u003eIn this report, we document the management of a young patient with aortic arch dissection by utilizing a hybrid approach of aortic arch debranching and TEVAR given his athletic lifestyle, failed medical therapy, family history of early age aortic dissections, as well as consideration of his clinical anatomy and pathophysiology. Informed consent was obtained from the patient regarding publishing of case details and images.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 38-year-old high-performance athlete with a past medical history of uncontrolled hypertension and family history of first-degree relative with aortic dissection at similar young age presented to outside hospital with four days of chest pain. Patient underwent subsequent CT chest which revealed intimal tear in Zone 3 of the aorta with retrograde dissection into the left subclavian artery (Figs.\u0026nbsp;1A-1C: Initial presentation CT angiogram with Zone 3 aortic dissection with retrograde extension into left subclavian artery; 1A: Sagittal cross-section; 1B: Axial cross-section; 1C: Coronal cross-section). Following this finding, the patient was emergently transferred to a nearby hospital for operative assessment and intervention.\u003c/p\u003e \u003cp\u003eUpon arrival and evaluation of patient, he was taken to operating room with plan for total aortic arch debranching with antegrade TEVAR. Intra-op transesophageal echocardiogram (TEE) revealed preserved left-ventricular ejection fraction of 55% with insignificant valvular dysfunction. The patient underwent full conventional sternotomy with 14mm Hemashield Gold trifurcated graft to establish flow to innominate, left subclavian, and left common carotid arteries, as well as antegrade TEVAR placement, via a fourth sewn on 10mm graft, using a 34mm x 15mm Gore thoracic aortic endograft (Fig.\u0026nbsp;2: Immediately post-operative chest x-ray showing positioning of 34mm x 15mm Gore thoracic endograft). Only partial aortic cross-clamp was used, the heart was not arrested, and total CPB time was 187 minutes. Post-operative TEE revealed LVEF of 55% with borderline normal right ventricular function.\u003c/p\u003e \u003cp\u003eAfter the operation, the patient recovered in the Cardiovascular Intensive Care Unit (CVICU) where he was weaned off vasopressor support, extubated on post-operative day one without complication, and transferred to the floor on post-operative day two. On post-operative day four, the patient underwent CT angiogram of the chest, abdomen, and pelvis to evaluate the graft which revealed improving false lumen opacification at the grafted aorta (Fig.\u0026nbsp;3: Post-operative day 4 CT angiogram showing positioning of 34mm x 15mm Gore thoracic endograft; sagittal cross-section). The remainder of his post-operative course was unremarkable, and the patient was discharged home on post-operative day six with oral antihypertensive regimen and extensive counseling.\u003c/p\u003e"},{"header":"DISCUSSION/CONCLUSIONS","content":"\u003cp\u003eIn patients with physically demanding lifestyle, history of failed medical therapy, and/or family history of early onset aortic dissections, a holistic approach to pre-operative planning is essential, whilst maintaining the urgency associated with the pathophysiology of an acute aortic arch dissection. In this patient, we were able to identify three key inflection points involving our decision-making process: validity of conservative management, appropriateness of TEVAR-only intervention, feasibility of total arch replacement.\u003c/p\u003e \u003cp\u003eHypertension is considered a key risk factor for acute aortic dissection. Hypertensive patients with acute aortic dissections have had a longer history, higher stage, worse medication compliance, and poor control of hypertension \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Additionally, poor compliance was associated with increased healthcare costs to the patient \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Unfortunately, this patient\u0026rsquo;s history of poor medical compliance, and subsequently uncontrolled hypertension, made him less-than-suitable for medical therapy alone. Additionally, performance athletes engaged in rigorous weight-training can have acute rises in systolic blood pressure to 300mmHg, further increasing risk of development of acute aortic dissection \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. As such, this patient\u0026rsquo;s baseline physically demanding lifestyle as a performance athlete leaves him vulnerable to wide variations in his blood pressure in the absence of optimal control.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s family history was also notable for first-degree relative with a Stanford Type A aortic dissection at a young age. Elucidating a thorough history in patients presenting with acute aortic dissection, even in the absence of a known genetic mutation, is of a great importance given that non-syndromic familial thoracic aortic dissections are inherited in an autosomal dominant pattern with variable age of disease onset \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis patient also posed a variety of anatomic and physiologic considerations. Given insufficient proximal landing zone for a TEVAR-only approach, and lack of need for total arch replacement, the hybrid utilization of aortic debranching and TEVAR was advantageous in multiple areas. The hybrid approach allowed for shorter CPB bypass time (187 minutes) versus average CPB for total aortic arch replacement of 241 minutes \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. A shorter CPB is associated with longer duration of ventilation, longer CVICU stay, and longer overall hospital stay \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Additionally, given this hybrid approach, the patient did not require total aortic cross clamp or circulatory arrest. Prolonged aortic cross clamp is associated with low cardiac output, prolonged ventilation, renal complication, blood transfusion, mortality and prolonged hospital stay \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Patients undergoing total arch replacement also require utilization of hypothermic circulation for prevention of organ ischemia, of which approximately 15% suffer the sequela of post-operative hypothermia \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. We were able to avoid the need for hypothermic circulation given the utilization of the hybrid debranching and TEVAR technique.\u003c/p\u003e \u003cp\u003eManagement of aortic arch dissections remains a fluid area of management which requires thorough, yet expeditious, evaluation of a patient\u0026rsquo;s clinical picture. Particularly, our patient case provided a number of considerations including elevated baseline physiological demand as a performance athlete, history of medical therapy non-adherence, and presence of family history of aortic dissection made our patient a suitable candidate for hybrid technique utilizing total aortic debranching and antegrade TEVAR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e: N/A;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e: Informed consent to publication obtained from the patient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e: N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Department of Cardiothoracic Surgery, Wake Forest University School of Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e: All authors were involved in the project conception, data collection, manuscript writing, and review portions of this submissions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Department of Vascular Surgery, Wake Forest University School of Medicine \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLempel JK, Frazier AA, Jeudy J, Kligerman SJ, Schultz R, Ninalowo HA, Gozansky EK, Griffith B, White CS. Aortic arch dissection: a controversy of classification. Radiology. 2014;271(3):848\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1148/radiol.14131457\u003c/span\u003e\u003cspan address=\"10.1148/radiol.14131457\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDong N, Piao H, Li B, Xu J, Wei S, Liu K. Poor management of hypertension is an important precipitating factor for the development of acute aortic dissection. J Clin Hypertens (Greenwich Conn). 2019;21(6):804\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jch.13556\u003c/span\u003e\u003cspan address=\"10.1111/jch.13556\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRizzo JA, Simons WR. Variations in compliance among hypertensive patients by drug class: implications for health care costs. Clin Ther. 1997;19(6):1446\u0026ndash;1425. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0149-2918(97)80018-5\u003c/span\u003e\u003cspan address=\"10.1016/s0149-2918(97)80018-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayerick C, Carr\u0026eacute; F, Elefteriades J. Aortic dissection and sport: physiologic and clinical understanding provide an opportunity to save young lives. J Cardiovasc Surg. 2010;51(5):669\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasham SN, Lewin MR, Tran VT, Pannu H, Muilenburg A, Willing M, Milewicz DM. Nonsyndromic genetic predisposition to aortic dissection: a newly recognized, diagnosable, and preventable occurrence in families. Ann Emerg Med. 2004;43(1):79\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0196-0644(03)00818-7\u003c/span\u003e\u003cspan address=\"10.1016/s0196-0644(03)00818-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbjigitova D, Mokhles MM, Papageorgiou G, Bekkers JA, Bogers AJJC. Outcomes of different aortic arch replacement techniques. J Card Surg. 2020;35(2):367\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jocs.14386\u003c/span\u003e\u003cspan address=\"10.1111/jocs.14386\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartins RS, Ukrani RD, Memon MK, Ahmad W, Akhtar S. Risk factors and outcomes of prolonged cardiopulmonary bypass time in surgery for adult congenital heart disease: a single-center study from a low-middle-income country. J Cardiovasc Surg. 2021;62(4):399\u0026ndash;407. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.23736/S0021-9509.21.11583-6\u003c/span\u003e\u003cspan address=\"10.23736/S0021-9509.21.11583-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Sarraf N, Thalib L, Hughes A, Houlihan M, Tolan M, Young V, McGovern E. Cross-clamp time is an independent predictor of mortality and morbidity in low- and high-risk cardiac patients. Int J Surg (London England). 2011;9(1):104\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijsu.2010.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ijsu.2010.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu H, Wang X, Liu S, Cong S, Lu Y, Yang Y, Wang W, Lai H, Li X, Wei L, Wang C. Postoperative hypothermia after total aortic arch replacement in acute type A aortic dissection-multivariate analysis and risk identification for postoperative hypothermia occurrence. J Thorac disease. 2020;12(12):7089\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/jtd-20-1709\u003c/span\u003e\u003cspan address=\"10.21037/jtd-20-1709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"TEVAR, High-risk surgical repair, debranching, aortic arch dissection, hybrid therapy","lastPublishedDoi":"10.21203/rs.3.rs-4009216/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4009216/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eThe surgical evaluation and management of aortic arch dissections, in the absence of ascending aortic involvement, remains a grey area. It is during these scenarios where thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention.\u003c/p\u003e\u003ch2\u003eCASE PRESENTATION\u003c/h2\u003e \u003cp\u003eWe present a patient with a physically demanding lifestyle, history of medical non-adherence, and family history of aortic dissections who presented with acute aortic arch dissection. He was spared a total arch replacement, by undergoing a hybrid approach of total aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of total aortic cross clamp, circulatory arrest, and hypothermic circulation for ischemic organ protection.\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eThis patient\u0026rsquo;s unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.\u003c/p\u003e","manuscriptTitle":"Total Aortic Arch Debranching with Antegrade Thoracic Endovascular Aortic Repair (TEVAR) in Acute Aortic Arch Dissection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-07 18:11:01","doi":"10.21203/rs.3.rs-4009216/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-30T08:46:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-22T05:03:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-20T18:35:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-20T17:22:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-19T14:41:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-18T14:55:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-15T09:36:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a0a7986f-ba74-4856-ba8d-7293c73abd9f","date":"2024-04-12T10:10:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3ddeb7e0-33cd-478b-93f4-0262bd070b6c","date":"2024-04-11T19:17:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-11T19:01:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-11T16:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c3e463b1-d475-43b0-a5aa-b3e7ff685847","date":"2024-04-11T07:17:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69521120-6d90-44bf-bca8-d2645e9284c5","date":"2024-04-11T03:02:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a2cac048-1ca3-4f32-88ae-24b9bee88be0","date":"2024-04-10T15:05:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c8ac568e-5acf-4ea4-a912-7f67fe0a11c4_SNPRID","date":"2024-04-10T14:41:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7d738089-bf7d-48b3-890b-bc50497a9c87","date":"2024-04-10T12:37:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79b5cc11-d468-4b40-bdca-773183661a53","date":"2024-04-10T10:56:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"fa96d69a-4dfb-4159-b749-248b1fdf6617","date":"2024-04-10T10:49:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-10T09:59:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-04T10:16:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-04T10:16:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-03-03T16:27:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e2f8c61-9826-4bdf-953a-249d5d7b14bc","owner":[],"postedDate":"March 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-15T11:23:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-07 18:11:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4009216","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4009216","identity":"rs-4009216","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}