Acute type I aortic dissection remains one of the greatest challenges in cardiovascular surgery, particularly when complicated by cerebral malperfusion. This study examines the use of a hybrid prosthesis designed to stabilize the true lumen and prevent distal re-entries, used as an adjunct to aortic repair. It is part of the PERSEVERE trial, a prospective multicenter study conducted across 26 North American centers.

The authors aimed to assess whether this new technology could enhance cerebral perfusion and promote aortic remodeling in patients with type I dissection complicated by cerebral malperfusion, potentially reshaping the surgical paradigm for this condition.

Acute type I aortic dissection represents one of the most demanding surgical emergencies, with persistently high morbidity and mortality despite significant technical progress. Among its most severe complications, cerebral malperfusion is a major determinant of poor prognosis. In these patients, the combination of preoperative cerebral ischemia and the inherent risk of circulatory arrest during aortic repair often leads to unpredictable neurological recovery and a postoperative stroke rate exceeding 20%. In recent years, various approaches—from the Frozen Elephant Trunk to selective revascularization techniques—have been explored, yet no consensus exists on the optimal strategy to restore cerebral blood flow in this context.

In this setting, the hybrid AMDS® (Artivion®, Atlanta) prosthesis emerges as an innovative solution. It consists of a self-expanding nitinol stent with a proximal PTFE cuff, designed to maintain true lumen patency and prevent new distal re-entries at the anastomosis, thus promoting more stable aortic remodeling. The study by Brinkman et al., published in the European Journal of Cardio-Thoracic Surgery, focuses on whether this technology can improve neurological outcomes in patients with type I dissection and cerebral malperfusion, a cohort traditionally associated with the worst outcomes.

The study is part of the PERSEVERE multicenter project—a prospective, non-randomized trial conducted at 26 North American centers. It included 93 adult patients with type I aortic dissection undergoing proximal repair with device implantation. Among them, 30 presented clinical or radiologic evidence of cerebral malperfusion. The analyzed variables included postoperative neurological evolution and morphologic changes assessed by computed tomography angiography, evaluated by an independent core lab. Statistical comparisons between pre- and postoperative measurements were performed using paired t tests, with significance defined as p < .05.

Among patients with clinical cerebral malperfusion who survived the immediate postoperative period (n = 18), 61% experienced complete resolution of symptoms, 28% remained stable, and only 11% developed a new disabling stroke. In the radiographic analysis, the true lumen–to–total arterial diameter ratio significantly improved in the brachiocephalic trunk (from 30.9% to 64.4%; p = .002) and the left common carotid artery (from 33.8% to 60.6%; p = .005), along with an increase in false lumen thrombosis. The authors conclude that the use of this hybrid prosthesis as an adjunct to hemiarch repair may promote neurological recovery and favorable remodeling of the supra-aortic trunks, representing a promising alternative for type I dissection with cerebral malperfusion.

COMMENTARY:

The PERSEVERE study addresses one of the most complex situations in aortic surgery: type I dissection with cerebral malperfusion. Traditionally, these patients have posed a therapeutic dilemma—delaying surgery worsens prognosis, but early repair in the presence of active cerebral ischemia carries a high risk of stroke and mortality. In this context, the study by Brinkman et al. offers an encouraging perspective on a technology designed to stabilize the true lumen and enhance flow to the supra-aortic branches without increasing surgical complexity through extensive procedures such as the Frozen Elephant Trunk.

The most significant contribution of the study goes beyond the favorable results—it reinforces the concept that intervening on aortic flow dynamics in the arch and descending aorta can improve cerebral perfusion even without direct manipulation of the supra-aortic vessels. The AMDS hybrid prosthesis appears to offer an intermediate option between conventional surgery and more aggressive endovascular strategies, providing anatomic stabilization through a reproducible technique during hemiarch repair. Its technical simplicity, combined with potential neurological benefit, may favor broader adoption in high-volume type A dissection centers.

Nevertheless, caution is warranted in interpreting these results. The study is exploratory, lacks a control group, includes a limited number of patients, and features relatively short follow-up. Although the improvement in true lumen/total diameter ratio and reduction in neurological events are promising, it remains uncertain whether the prosthesis alone reduces stroke risk. Key questions persist: does the benefit sustain over time? What role does it play in patients with multiple malperfusions? And how does it compare with standard hemiarch repair or the Frozen Elephant Trunk approach?

Despite these limitations, this work represents a meaningful step toward a more physiologic and less invasive surgical approach to type I aortic dissection. It introduces a tool that not only repairs the aorta but also restores perfusion and promotes early vascular remodeling—opening a promising avenue for future research. Hybrid technologies, rather than replacing conventional techniques, may complement them by offering safer options in patients at higher neurological risk.

REFERENCE:

Brinkman W, Squiers JJ, Jassar A, Fukuhara S, Fleischman F, Takayama H, et al.; PERSEVERE Investigators. Cerebral malperfusion resolution after repair of acute DeBakey type I dissection with a novel hybrid prosthesis: early results of the PERSEVERE Study. Eur J Cardiothorac Surg. 2025 Jul 1;67(7):ezaf199. doi: 10.1093/ejcts/ezaf199.