In patients with physically demanding lifestyle, history of failed medical therapy, and/or family history of early onset aortic dissection, a holistic approach to pre-operative planning is essential, whilst maintaining the urgency associated with the pathophysiology of an acute non-A non-B aortic 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 300 mmHg, 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 conventional total arch replacement given absence of ascending aortic dissection or intramural hematoma, the hybrid utilization of aortic debranching and TEVAR was advantageous in multiple areas. The hybrid approach allowed for shorter CPB bypass time (187 min) versus average CPB for total aortic arch replacement of 241 min [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. Additionally, this method utilized minimal anastomoses, therefore leaving the patient less susceptible to bleeding from anastomotic sites and a potentially decreased need for transfusion and its subsequently associated complications.

Management of acute non-A non-B aortic dissections remains infrequently documented, as well as a fluid area of management which requires thorough, yet expeditious, evaluation of a patient’s clinical picture [10]. 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, which made our patient a suitable candidate for hybrid technique utilizing total aortic debranching and antegrade TEVAR.