Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection?

Abstract

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement.

Aims: This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches.

Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase.

Results: TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair.

Conclusion: Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.