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Impact of Frozen and Conventional Elephant Trunk on Aortic New-Onset Thrombus and Inflammatory Response. Diagnostics (Basel) 2022; 12:diagnostics12102511. [PMID: 36292200 PMCID: PMC9600078 DOI: 10.3390/diagnostics12102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/07/2022] Open
Abstract
(1) Aim: The primary endpoint of this study was to evaluate the impact of frozen elephant trunk (FET) and conventional elephant trunk (CET) on aortic mural thrombus. The secondary endpoint was to investigate the incidence of persistent inflammatory response (IR) in the form of post-implantation syndrome (PIS) or persistent fever without infection focus after FET and CET, respectively, as well as the risk factors associated with its occurrence. (2) Methods: A single-center, retrospective, observational study of 57 consecutive patients treated with FET and CET between April 2015 and June 2020 was performed. Demographics, procedural data, perioperative laboratory exams as well as vital parameters were recorded. Pre- and postoperative computer tomography angiography (CTA) scans were analyzed with a dedicated software. IR was defined as the presence of continuous fever (>38°, lasting > 24 h) and leukocytosis (white blood cell count > 12 × 1000/µL) developing after surgery in the absence of an infection focus. (3) Results: Fifty-seven consecutive patients (mean age 58.4 ± 12.6 years, 36.8% females) treated with FET (66.6%) or CET (33.3%) for acute aortic dissection (56.1%), post-dissection-aneurysm (19.2%) or aortic aneurysm (24.5%) were included. The median thrombus volume on CTA preoperatively was 10.1 cm3 (range 2−408 cm3). After surgery, the median new-onset mural thrombus was 9.7 cm3 (range 0.2−376 cm3). Nineteen (33.3%) patients developed IR; patients with IR were significantly younger (p = 0.027), less frequently of female gender (p = 0.003) and more frequently affected from acute dissection (p = 0.002) and stayed in the intensive care unit (ICU) significantly longer (p = 0.033) than those without IR. Postoperatively, the volume of new-onset thrombus was significantly greater in the IR group (84.4 vs. 3.2 cm3, p < 0.001). (4) Conclusions: In the context of CET and FET, the persistent inflammatory response occurred in 33.3% of the patients with persistent fever without infection focus. IR was associated with a higher volume of new-onset thrombus and significantly prolonged ICU stay. Further studies to investigate these observations are needed.
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Neri E, Muzzi L, Tucci E, Cini M, Barabesi L, Tommasino G, Ricci C. Arch replacement with collared elephant trunks: The Siena approach. JTCVS Tech 2020; 6:13-27. [PMID: 34318130 PMCID: PMC8300570 DOI: 10.1016/j.xjtc.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Objective To illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported. Methods All aortic arch–replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes. Results Of 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n = 16); 5.4% stroke (n = 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n = 97 endovascular [66.4%], n = 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median follow-up was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference (P = .22) between dissection and aneurysm groups. Conclusions Siena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery.
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Key Words
- CI, confidence interval
- CSF, cerebrospinal spinal fluid
- CT, computed tomography
- ET, elephant trunk
- IQR, interquartile range
- LCL, lower confidence limit
- OR, odds ratio
- OSR, open surgical repair
- PAU, penetrating aortic ulcer
- SINE, stent graft–induced new entry tear
- TEVAR, thoracic endovascular aortic repair
- aorta
- aortic arch surgery
- elephant trunk technique
- thoracic endovascular repair
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Affiliation(s)
- Eugenio Neri
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
- Address for reprints: Eugenio Neri, MD, Azienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte,” Viale M. Bracci, 53100 Siena, Italy.
| | - Luigi Muzzi
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
| | - Enrico Tucci
- Aortic Surgery Unit, Siena University Hospital, Siena, Italy
| | - Marco Cini
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
| | - Lucio Barabesi
- Department of Statistics, Università degli Studi di Siena, Siena, Italy
| | | | - Carmelo Ricci
- Interventional Radiology Unit, Siena University Hospital, Siena, Italy
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Rukosujew A, Usai MV, Martens S, Ibrahim A, Shakaki M, Bruenen A, Dell'Aquila AM. [Present-day policy of surgical treatment for type A acute aortic dissection]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:82-101. [PMID: 33063755 DOI: 10.33529/angio2020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A surgical intervention for type A acute aortic dissection is the only effective method of treatment making it possible to prevent the development of life-threatening complications and to attain clinical recovery of the patient. Supracoronary replacement of the ascending aorta and the proximal portion of the aortic arch is considered to be the classical and most commonly used method of an open operative intervention. On the one hand, it is technically the simplest and shortest operation, and on the other, this surgical technique is often accompanied by long-term proximal and distal complications, and first of all those caused by a persistent false lumen. The accumulated surgical experience and contemporary operative techniques, as well as advances of intensive therapy in treatment of type A acute aortic dissection make it possible to currently perform more extensive primary resections in order to improve the remote results. Total aortic arch replacement, including the use of the 'frozen elephant trunk' technique leads to fast thrombosis of the false lumen, preventing progression of the disease of the thoracic aorta and promoting its positive remodelling. The article describes the perioperative therapeutic policy accepted and pursued in our medical facility, also presenting the authors' opinion on the role and place of the 'frozen elephant trunk' technique in rendering medical care for patients with type A acute aortic dissection.
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Affiliation(s)
- A Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - M V Usai
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - S Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - A Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - M Shakaki
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - A Bruenen
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - A M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
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Colli A, Carrozzini M, Francescato A, Galuppo M, Comisso M, Toto F, Gregori D, Gerosa G. Acute DeBakey Type I aortic dissection without intimal tear in the arch: is total arch replacement the right choice? Interact Cardiovasc Thorac Surg 2017; 26:84-90. [DOI: 10.1093/icvts/ivx229] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/11/2017] [Indexed: 01/16/2023] Open
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Dell'Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, Del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016. [PMID: 27770195 DOI: 10.1007/s00380-016-0907-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.
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Affiliation(s)
- Angelo M Dell'Aquila
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Francesco Pollari
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, Maria Eleonora Hospital GVM Care and Research, Palermo, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Julia Hillebrand
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany.
| | - Stefan Schneider
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Jan Landwerht
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Giuseppe Nasso
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Renato Gregorini
- Department of Cardiovascular Surgery, Cardiac Surgery Unit, Città di Lecce Hospital GVM Care and Research, Lecce, Italy
| | - Mauro Del Giglio
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Elisa Mikus
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Alberto Albertini
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Heinz Deschka
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Sven Martens
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Alina Gallo
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
| | | | - Giuseppe Speziale
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Tommaso Regesta
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
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Dell’Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016; 32:566-573. [DOI: 10.1007/s00380-016-0907-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/14/2016] [Indexed: 12/25/2022]
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Colli A, Carrozzini M, Galuppo M, Comisso M, Toto F, Gregori D, Gerosa G. Analysis of early and long-term outcomes of acute type A aortic dissection according to the new international aortic arch surgery study group recommendations. Heart Vessels 2015; 31:1616-24. [PMID: 26577993 DOI: 10.1007/s00380-015-0770-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/30/2015] [Indexed: 01/16/2023]
Abstract
To evaluate predictors of early and long-term outcomes of surgical repair of acute Type A aortic dissection. Retrospective single-centre study evaluating patients surgically treated between 1998 and 2013. Clinical follow-up was performed. Complications were classified according to the International Aortic Arch Surgery Study Group recommendations. Statistical analysis included univariate and multivariate analysis of preoperative and operative data. One hundred eighty-five patients were evaluated. The follow-up was complete for 180 patients (97 %). Mean age was 63 years, 82 % had a DeBakey type I aortic dissection, 18 % a type II. Eleven patients (6 %) died intraoperatively, 119 of the remaining (68 %) had postoperative complications. Thirty-day mortality was 21 % (38 patients). Average ICU and hospital stay were 6 and 14 days, respectively. During a mean follow-up time of 6 ± 4 years we observed 44 deaths (31 %). Twenty patients (14 %) needed late thoracic aorta reoperation. Results from the multivariate analysis are as follows. Thirty-day mortality was associated with abdominal pain at presentation (p < 0.01). The incidence of postoperative complications was related to older age at intervention (p < 0.01) and longer cross-clamp time (p < 0.01). Mortality at follow-up was significantly increased by older age at intervention (p < 0.01), with a logarithmic growth after 60 years, female sex (p < 0.01), preoperative limb ischemia (p = 0.02) and DHCA (p < 0.01). The surgical results of type A aortic dissection are affected by age at intervention with a logarithmic increase of late mortality in patients older than 60 years.
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Affiliation(s)
- Andrea Colli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy.
| | - Massimiliano Carrozzini
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marco Galuppo
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marina Comisso
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesca Toto
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dario Gregori
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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