Redo proximal thoracic aortic surgery: challenges and controversies

Reoperations on the ascending aorta and aortic arch: A retrospective series of 453 patients

OBJECTIVE

The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality.

METHODS

Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations.

RESULTS

The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P > .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P < .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P < .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P < .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P < .01).

CONCLUSIONS

In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.

Tips and tricks in redo aortic surgery

Redo aortic surgery is challenging, and the operative risk is higher than that in primary aortic surgery. Preoperative imaging is a crucial guide for a safe re-entry. Scrutinized preparing in cannulation and organ protection strategies have affected surgical outcomes. With comprehensive planning and meticulously executed surgery, mortality and morbidity can be acceptable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-021-01322-x.

Management and Outcomes of Proximal Aortic Graft Infection: A Systematic Review

OBJECTIVE

Proximal aortic graft infection (PAGI) is a rare but often fatal postoperative complication. Its management often relied on surgical preferences and resource availability of each centre, until the recent unifying guidelines published by the European Society for Vascular Surgery (ESVS). This paper aimed to amalgamate the published experience in managing PAGI and their outcomes.

METHODS

PubMed, Scopus and Cochrane Library databases were searched systematically. All primary studies besides single-patient case reports were included. Data extracted included study and patient characteristics, type of index surgery, type of microorganisms involved, definitive treatment modality, and any outcome measures reported.

RESULTS

Of the 20 studies included, 157 of the 290 PAGI patients underwent complete graft explantation and replacement, 106 underwent graft-preservation interventions (debridement and/or irrigation), and 25 had antibiotics alone. Adjunctive interventions included graft coverage, vacuum-assisted closure, use of infection-resistant graft materials, and lifelong suppressive therapy. In-hospital mortality was 20.8% (n=60), with postoperative sepsis and multiorgan failure (n=24) being the most common cause. Recurrent infection occurred in 10 post-discharge patients. Post-discharge mortality rate was 11.4% (n=33), with cardiac complications and stroke being the most common cause in surgically-treated and medically-treated patients, respectively.

CONCLUSIONS

Given the risk of mortality, the management approach of PAGI highly depends on the fitness of the patient. We believe that early referral to specialised aortic centres is essential to plan for optimal management strategies and improve patient outcomes. Further studies are also required to parse out the most effective adjunctive interventions to maximise patient outcomes.

The effect of in situ laser fenestration for total endovascular arch repair in redo aortic dissection

OBJECTIVE

Treatment of aortic arch pathologies in redo cases is technically challenging. In this study, we assessed early and mid-term outcomes of total endovascular arch repair combined with a new method of in situ laser fenestration.

METHODS

Between January 2018 and March 2019, five patients with a history of cardiovascular surgery underwent in situ laser fenestration procedures using the "squid capture technique" for aortic arch pathologies with dissection. All patients were followed up regularly and imaging examinations were performed. The technical success, procedural complications, as well as the early and mid-term mortality and morbidity rates were evaluated.

RESULTS

All patients survived the operation and fenestration was technically successful in all of the patients. There was no in-hospital mortality. No patients developed major complications, such as peri-operative strokes, transient ischemic attacks, or spinal cord ischemia. The 11-22 months follow-up (mean, 17 months) was completed by all patients. No endoleaks were discovered; false lumen thromboses and subsequent positive remodeling of the aorta were demonstrated and all in situ laser-fenestrated arteries were patent.

CONCLUSIONS

In situ laser fenestration combined with "squid capture technique" was shown to may be an effective and safe option for reconstruction of aortic arch during thoracic endovascular aortic repair. In situ laser fenestration combined with "squid capture technology" was shown to be an effective treatment option for patients with prior history of cardiovascular surgery and who are at high risk for redo open operations.

Re-Operative Aortic Arch Surgery in a Contemporary Series

Re-operative aortic arch operations (REDO) following previous cardiac surgery are challenging procedures associated with significant morbidity and mortality. We investigated post-operative outcomes for patients undergoing REDO and identified risk-factors for mortality in a contemporary series. From 1/2005-6/2018, 365 consecutive patients at an academic center underwent REDO: 257 HEMIARCH and 108 COMPLETE arch (45 stage I elephant trunk, 63 total arch) replacements. Outcomes included mortality and major adverse events. Long-term survival was determined with Kaplan-Meier analysis, and risk-factors for mortality were assessed with Cox proportional hazards regression. Operative mortality for the entire cohort was 6.8%, and rates of stroke, cardiac arrest, and renal failure were 6.0%, 7.4%, and 10.4%. Compared to HEMIARCH, COMPLETE patients had an increased incidence of renal failure requiring dialysis (15.7% vs 8.2%, p = 0.031) and re-exploration for bleeding or delayed chest closure (19.4% vs. 11.7%, p = 0.051). Although operative mortality was similar in both cohorts, long-term follow-up mortality (38.0% vs 26.8%, p = 0.047) was higher among COMPLETE vs. HEMIARCH. Predictors of overall mortality among all-comers undergoing REDO included older age, low body surface area, endocarditis, ejection fraction <30%, emergent status of operation, extended cardiopulmonary bypass duration, intra-aortic balloon pump use, and a more extensive arch operation. Previous aortic surgery was not a risk-factor for mortality. Among all-comers undergoing REDO, survival was 81.4% at 1 year, 66.7% at 5 years, and 56.4% at 10 years of follow-up. While early postoperative outcomes are similar among HEMIARCH and COMPLETE, a more extensive arch-replacement is an independent risk-factor for overall mortality in REDO. Using appropriate clinical indications in the current era, REDO remains a viable option for selected patients.

Dissecting the Management and Outcomes of Thoracic Aortovascular Disease During the COVID-19 Pandemic

Objective

The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic.

Methods

Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury.

Results

Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 (P = 1.00). There were no significant differences (P ≥ 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively.

Conclusions

Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Innominate artery cannulation in aortic surgery: A systematic review

OBJECTIVE

The innominate artery is considered an alternative site for establishing cardiopulmonary bypass in surgical procedures involving the thoracic aorta. This systematic review examines the use of innominate artery cannulation in aortic surgery.

METHODS

A systematic literature search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all studies that utilized innominate artery cannulation for establishing cardiopulmonary bypass and providing cerebral perfusion in thoracic aortic surgery. The data were reviewed up to September 2018.

RESULTS

Acute type A aortic dissection contributed to 36% (n = 818) of the total 2,290 patients. 31.5% (n = 719) underwent surgery on the aortic root only; 54.5% (n = 1246) had ascending and hemi-arch replacement, while 11.5% had total aortic arch replacement and 2.5% had a frozen elephant trunk inserted. Postoperative stroke rate was 1.25% (n = 28), temporary neurological deficit was 4.8% (n = 111). All-cause 30-day mortality rate was 2.7% (n = 61).

CONCLUSION

Innominate artery cannulation is a safe technique in patients who undergo thoracic aortic surgery. It can be utilized, in selected cases, as a reliable route for establishing cardiopulmonary bypass and maintaining cerebral perfusion.