Early Outcomes After Aortic Arch Replacement by Using the Y-Graft Technique

Contemporary Midterm Outcomes After Primary Repair of Chronic Type A Aortic Dissection

BACKGROUND

Without surgical repair, acute type A aortic dissection (TAAD) is usually fatal. However, some patients survive without an early operation and progress to the chronic phase. Contemporary outcomes of primary surgical repair of chronic TAAD are unclear, so we evaluated them at our single-practice service.

METHODS

During 1990 to 2021, 205 patients underwent repair of TAAD in the chronic phase (>60 days after onset). The 2 relevant DeBakey classifications were nearly equally represented: type I, 52% (n = 107), and type II, 48% (n = 98). The median interval between dissection onset and repair was 7 months (interquartile range, 3-25 months). Kaplan-Meier and competing-risk analyses provided time-dependent outcomes.

RESULTS

At the time of intervention, most patients (40%) had chronic symptoms. Type I patients were younger than type II patients; however, comorbidities were similar. Most patients (n = 183 [87%]) underwent hemiarch or total arch repair, although total arch replacement was more common in type I dissection (P < .001). There were 15 operative deaths (7%), and 7 strokes (3%) persisted to the time of death or discharge. No patient had persistent paraplegia. Median follow-up was 5 years (interquartile range, 2-11 years). The 5-year reoperation-free survival was 61% (95% CI, 54%-68%), and the incidence of reoperation was 3% (95% CI, 0.4%-5%). Patients with type I and type II dissection did not differ significantly in survival (P = .2).

CONCLUSIONS

Durable repair can be achieved with reasonable operative risk. Treatment is individualized and is associated with low rates of persistent neurologic complications. Despite differing operative approaches by DeBakey type, early and late outcomes were similar.

Reoperative total arch replacement after previous cardiovascular surgery: Outcomes in 426 consecutive patients

OBJECTIVE

Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR.

METHODS

The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation.

RESULTS

The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024).

CONCLUSIONS

Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure.

Aortic arch repair: lessons learned over three decades at Baylor College of Medicine

The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.

Staged Repair of Extensive Aneurysms of the Thoracic Aorta by Using the Elephant Trunk Technique

BACKGROUND

Staged open repair of extensive aortic aneurysm by using the elephant trunk (ET) technique has facilitated the treatment of aortic aneurysms that affect the entire thoracic aorta. We describe our nearly 3-decade experience with classic ET repairs.

METHODS

From 1990 through 2021, we performed 363 stage-1 ET repairs to replace the transverse aortic arch in patients with a median age of 65 years [interquartile range: 56-71]. Fifty-six patients (15.4%) presented with acute symptoms, and 182 (50.1%) underwent redo sternotomy. After a median interval of 3.2 months [IQR: 2.0-7.3], 203 (55.9%) patients underwent stage-2 ET completion; few (n=16; 7.9%) had acute symptoms. Stage-2 repairs comprised 162 (80.6%) extent I or II thoracoabdominal aortic replacements. We examined postoperative outcomes including operative mortality, adverse event (a composite end point), survival, and repair failure.

RESULTS

Operative mortality was 12.4% (45/363) after stage-1 and 10.3% (21/203) after stage-2. The rates of adverse event were 18.5% (67/363) for stage-1 and 18.4% (38/203) for stage-2. Acute symptoms independently predicted operative mortality and adverse event for both stage-1 and stage-2 repairs; additional predictors for stage-2 repairs were older age and extent II repair. Survival was significantly worse for patients who did not receive their stage-2 completion repair than for those who did (p <0.001).

CONCLUSIONS

Treating extensive aortic aneurysms by using the ET technique for staged repair is associated with substantial morbidity and mortality. Patients who present with acute symptoms are at greater risk of operative mortality and adverse event. Diligent surveillance is needed between stages.

Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada

Background

To explore evolving surgical techniques and outcomes for aortic arch surgery.

Methods

A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined.

Results

From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases.

Conclusions

Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.

Transthoracic minimally invasive closure for the treatment of arch penetrating aortic ulcer: a case report

Penetrating aortic ulcer (PAU) is one of the three subtypes of acute aortic syndrome. PAUs occur at any point throughout the aorta, most commonly in the descending thoracic aorta and less frequently in the aortic arch. Open surgical repair and total/hybrid endovascular repair are currently available to treat aortic arch PAUs. Herein, we present a patient with aortic arch PAU who underwent transthoracic minimally invasive closure, which is a novel method for the treatment of PAU. We describe a 52-year old Asian man who presented with sudden chest and back pain for 8 h. Computed tomography angiography showed that the PAU occurred in the aortic arch and had a diameter of 16 mm and a depth of 6 mm. The opening was successfully closed via transthoracic minimally invasive closure with an atrial septal defect occluder.

Open Repair of Acute Type A Intramural Hematoma in 3 Patients

Acute aortic syndrome encompasses classic aortic dissection and less common aortic phenomena, including intramural hematoma (IMH), a hemorrhage within the aortic media that occurs without a discrete intimal tear. We reviewed our experience with treating acute type A IMH to better understand this acute aortic syndrome. A review of our clinical database identified 1,902 proximal aortic repairs that were performed from January 2006 through December 2018; of these, 266 were for acute aortic syndrome, including 3 (1.1%) for acute type A IMH. Operative technique varied considerably. All IMH repairs involved hemiarch or total arch replacement. In all 3 patients, the IMH extended distally into the descending thoracic aorta. There were no operative deaths or major adverse events (stroke, paraplegia, paraparesis, or renal failure necessitating dialysis) that persisted to hospital discharge. Length of hospitalization ranged from 5 to 20 days. All 3 patients were alive at follow-up (range, 2-6 yr) and needed no aortic reintervention after their index or staged repairs. In our experience, repair of acute type A IMH was infrequent and could be either simple or complex. Despite our limited experience with this disease, we found that it can be repaired successfully in urgent and emergency cases. Following treatment guidelines for aortic dissection appears to be a reasonable strategy for treating IMH.

Aortic arch stenting: current strategies, new technologies and future directions

Operating on the aortic arch is a formidable challenge. Open operations remain the gold standard, but despite improvement in technique and outcomes, they are still associated with significant morbidity and mortality. The last 20 years have seen a remarkable reduction in the operative morbidity associated with treatment of the descending thoracic aorta using thoracic endovascular aneurysm repair (TEVAR). To improve outcomes following arch repair, new TEVAR devices, including both single-branched and multibranched designs, have come to clinical trial. This review discusses the modern state of open and hybrid repairs while introducing the reader to technology for endovascular therapy of the aortic arch. We describe important anatomical and operative considerations for the devices. Given these nuances, we believe the future of the aortic arch to be patient-individualised hybrid repairs, involving both open and endovascular options with a multidisciplinary 'thoracic aorta team' at the helm.

Arch replacement with collared elephant trunks: The Siena approach

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.

A 23-year experience with the reversed elephant trunk technique for staged repair of extensive thoracic aortic aneurysm

OBJECTIVE

The reversed elephant trunk technique permits staged repair of extensive thoracic aortic aneurysm in patients whose distal (ie, descending thoracic and thoracoabdominal) aorta is symptomatic or disproportionately large compared with their proximal aorta (ie, ascending aorta and transverse aortic arch). We present our 23-year experience with the reversed elephant trunk approach.

METHODS

Between 1994 and 2017, 94 patients (median age 62 [46-69] years) underwent stage 1 reversed elephant trunk repair of the distal aorta. Fifty-three patients (56%) had aortic dissection, and 31 patients (33%) had heritable thoracic aortic disease. Eighty-eight operations (94%) were Crawford extent I or II thoracoabdominal aortic repairs. Twenty-seven patients (29%) underwent subsequent stage 2 repair of the proximal aorta; 14 patients (52%) required redo median sternotomy. The median time between the stage 1 and 2 operations was 18.8 (4.8-69.3) months.

RESULTS

The operative mortality was 10% (9/94) for stage 1 repairs and 4% (1/27) for stage 2 repairs; 1 patient with heritable thoracic aortic disease died after stage 1 repair (1/31, 3%), and 1 patient died after stage 2 repair (1/13, 8%). Two patients (2%) had ruptures after stage 1 repair; 1 resulted in death, and 1 precipitated emergency stage 2 repair. In total, 36 patients (38%) who survived stage 1 repair died before stage 2 reversed elephant trunk completion repair could be performed.

CONCLUSIONS

Managing extensive aortic aneurysm with the 2-stage reversed elephant trunk technique yields acceptable short-term outcomes. This technique is useful for the reversed elephant trunk in patients who require distal aortic repair before proximal repair and is particularly effective in patients with heritable thoracic aortic disease. The low number of patients returning for completion repair is concerning. Rigorous surveillance is needed.

A modified frozen elephant trunk technique for acute Stanford type A aortic dissection

BACKGROUND

Acute Stanford type A aortic dissection is often fatal, with a high mortality rate and requiring emergency intervention. Salvage surgery aims to keep the patient alive by addressing severe aortic regurgitation, tamponade, primary tear, and organ malperfusion and, if possible, prevent the late dissection-related complications in the proximal and downstream aorta. Unfortunately, no optimal standard treatment or technique to treat this disease exists. Total arch replacement with frozen elephant trunk technique plays an important role in treating acute type A aortic dissection. We aim to describe a modified elephant trunk technique and report its short-term outcomes.

METHODS

From February 2018 to August 2019, 16 patients diagnosed with acute Stanford type A aortic dissection underwent surgery with the modified frozen elephant trunk technique at Xiamen Heart Center (male/female: 9/7; average age: 56.1 ± 7.6 years). All perioperative variables were recorded and analyzed. We measured the diameters of the ascending aorta, aortic arch, and descending aorta on the bifurcation of the pulmonary and abdominal aortas and compared the diameters at admission, before discharge, and 3 months after discharge.

RESULTS

Fifteen patients (93.8%) had hypertension. The primary tears were located in the lesser curvature of the aortic arch and ascending aorta in 5 (31.3%) and 9 patients (56.3%), respectively, and no entry was found in 2 patients (12.5%). The dissection extended to the iliac artery and distal descending aorta in 14 (87.6%) and 2 patients (12.5%), respectively. The duration of cardiopulmonary bypass (CPB), cross-clamping, and antegrade cerebral perfusion were 215.8 ± 40.5, 140.8 ± 32.3, and 55.1 ± 15.2 min, respectively. Aortic valve repair was performed in 15 patients (93.8%). Bentall procedure was performed in one patient (6.3%). Another patient received coronary artery repair (6.3%). The diameters at all levels were greater on discharge than those on admission, except the aortic arch. After 3 months, the true lumen diameter distal to the frozen elephant trunk increased, indicating false lumen thrombosis and/or aortic remodeling.

CONCLUSIONS

The modified frozen elephant trunk technique for acute Stanford type A aortic dissection is safe and feasible and could be used for organ malperfusion. Short-term outcomes are encouraging, but long-term outcomes require further investigation.

Short-term outcomes of modified Y-graft technique in acute type a aortic dissection using the femoral artery bypass and one minute systemic circulatory arrest technique

Objective

Aortic arch replacement in acute type A aortic dissection patients remains the most challenging cardiovascular operation. Herein, we described our modified Y-graft technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) technique, and assessed the short-term outcomes of the patients.

Methods

Between February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients underwent FAB while 28 patients underwent both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previously reported studies.

Results

In the FAB group, two patients died due to pulmonary infection (30-day survival rate, 91.3%), and two patients were paralyzed from the waist down. Hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received respiratory support for more than 2-days and eight patients (34.8%) for more than 5-days. These follow-up results were comparable or better than the patients with traditional Y-graft technique. Furthermore, compared to the FAB group, the morbidity due to neurological dysfunction and acute renal failure was significantly reduced in the FAB+OSCA group. Moreover, the respiratory support, length of postoperative stay and ICU stay were shortened.

Conclusions

This study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients showed less surgical complications and favorable short-term outcomes after this surgery.

The Jailed Coiling Technique for the Treatment of Penetrating Ulcers and Saccular Aneurysms of the Aortic Arch

OBJECTIVE

To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique.

METHODS

A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter.

RESULTS

All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention.

CONCLUSION

PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.

"Aorta-clamp" technique for surgical repair of acute type A aortic dissection-5 min circulatory arrest at 30 °C

Background

Deep hypothermic circulatory arrest (HCA), which causes perioperative complications, is the foundation of surgical treatment for acute type A aortic dissection (AAAD). To extensively replace the dissected aorta and avoid the negative impacts of HCA, we developed an "aorta-clamp" technique and examined its efficacy in repairing AAAD.

Methods

From November 2014 to August 2016, we recruited 59 consecutive patients (51.3±10.9 years) with AAAD into this study. We performed total arch replacement combined with an elephant trunk implantation using the "aorta-clamp" technique under a 30 °C HCA with continual bilateral antegrade cerebral perfusion.

Results

The average HCA time was 4.9±1.0 min. Twenty-three patients had increased serum creatinine (sCr) before surgery, suggesting an AAAD-associated acute kidney injury (AKI). The sCr level returned to normal in five patients after operation and in 15 before discharge. Six patients (10.2%) with preoperative AKI required postoperative dialysis, and two of these patients (3.4%) died of multiple organ failure. Two patients (3.4%) required re-exploration due to bleeding. One patient (1.7%) exhibited temporary neurologic deficits. There were no late deaths. Computed tomography (CT) examination confirmed the patency of the anastomotic sites and thrombus obliteration of the residual false lumen.

Conclusions

Using the "aorta-clamp" technique with continual bilateral antegrade cerebral perfusion, total arch replacement combined with an elephant trunk implantation can be performed under five minutes of mild (30 °C) HCA. Our data suggest that this technique for the surgical repair of AAAD is a safe, feasible and effective surgical approach with satisfactory early outcomes.

Art of operative techniques: treatment options in arch penetrating aortic ulcer

Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background

Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods

From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results

In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions

Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

Zone zero hybrid arch exclusion versus open total arch replacement

Open total aortic arch replacement is one of the most technically demanding operations in cardiothoracic surgery, requiring operator expertise and intraoperative and postoperative teamwork. Despite current advancements in the field of open aortic surgery with regard to intraoperative brain protection and postoperative care, the morbidity and mortality associated with open total arch operations varies. Endovascular and hybrid procedures involving the use of zone 0 as a landing zone allow fair comparison between open total arch and hybrid operations. Hybrid procedures involving all of the other landing zones [1-4] should not be compared with open total arch replacement, as the extent of the pathology is different.

Immediate ICU Care for Patients Following Aortic Arch Surgery

Patients undergoing aortic arch surgery are at high risk for stroke, delirium, low cardiac output, respiratory failure, renal failure, and coagulopathy. A significantly higher mortality is seen in patients experiencing any of these complications when compared with those without complications. As surgical, perfusion, and anesthetic techniques improve, the incidence of major complications have decreased. A recent paradigm shift in cardiac surgery has focused on rapid postoperative recovery, and a similar change has affected the care of patients after arch surgery. Nevertheless, a small subset of patients experience significant morbidity and mortality after aortic arch surgery, and rapid identification of any organ dysfunction and appropriate supportive care is critical in these patients. In this article, the current state of postoperative care of the patient after open aortic arch surgery will be reviewed.

Aortic Arch Replacement in Patients With Chronic Dissection: Special Considerations

The progressive expansion of residual, chronic DeBakey type I dissection often necessitates repair of the aortic arch and the distal aorta (ie, descending thoracic and thoracoabdominal aorta). The vast majority of patients with chronic aortic dissection facing aortic arch surgery are survivors of emergent proximal aortic repair for acute dissection, and thus, these patients now face a reoperative procedure necessitating a redo median sternotomy. One approach for repairing the chronic type I aortic dissection incorporates total transverse aortic arch replacement with and without an elephant trunk extension; an elephant trunk extension is a useful strategy, because the proximal descending thoracic aorta is commonly ectatic or aneurysmal at the time of aortic arch repair-using an elephant trunk approach facilitates subsequent repair in the distal aorta. Patients with chronic DeBakey type I dissection should participate in an imaging surveillance protocol.

Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease

OBJECTIVE

Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes.

METHODS

From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]).

RESULTS

Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively.

CONCLUSIONS

Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.

Application of the Bolton Relay Device for Thoracic Endografting In or Near the Aortic Arch

Endovascular correction of aortic arch pathology remains a challenge, with a variety of techniques proposed over the years to minimize complications and enhance the probability of a successful result. A variety of approaches have been developed in order to deal with the aortic arch pathology and its idiosyncrasies. We review potential interventional techniques for the repair of aortic arch pathologies, beginning with conventional aortic arch surgery, followed by hybrid treatments and those along the endovascular spectrum (parallel and fenestrated endografts, scalloped endografts, and ascending and new branched endografts). We finish with an overview of all the Bolton Medical (Barcelona, Spain and Sunrise, FL, USA) thoracic platforms. Endovascular techniques show acceptable results in selected cases. Both proximal Bolton Relay configurations (with and without a bare stent) offer conformability and accuracy on deployment with very low rates of stroke. Fenestrated and scalloped designs are also useful for selected cases. Ascending and branched Bolton devices are very promising platforms for a serious, full endovascular approach to the aorta.

Total aortic arch replacement: superior ventriculo-arterial coupling with decellularized allografts compared with conventional prostheses

Background

To date, no experimental or clinical study provides detailed analysis of vascular impedance changes after total aortic arch replacement. This study investigated ventriculoarterial coupling and vascular impedance after replacement of the aortic arch with conventional prostheses vs. decellularized allografts.

Methods

After preparing decellularized aortic arch allografts, their mechanical, histological and biochemical properties were evaluated and compared to native aortic arches and conventional prostheses in vitro. In open-chest dogs, total aortic arch replacement was performed with conventional prostheses and compared to decellularized allografts (n = 5/group). Aortic flow and pressure were recorded continuously, left ventricular pressure-volume relations were measured by using a pressure-conductance catheter. From the hemodynamic variables end-systolic elastance (Ees), arterial elastance (Ea) and ventriculoarterial coupling were calculated. Characteristic impedance (Z) was assessed by Fourier analysis.

Results

While Ees did not differ between the groups and over time (4.1±1.19 vs. 4.58±1.39 mmHg/mL and 3.21±0.97 vs. 3.96±1.16 mmHg/mL), Ea showed a higher increase in the prosthesis group (4.01±0.67 vs. 6.18±0.20 mmHg/mL, P<0.05) in comparison to decellularized allografts (5.03±0.35 vs. 5.99±1.09 mmHg/mL). This led to impaired ventriculoarterial coupling in the prosthesis group, while it remained unchanged in the allograft group (62.5±50.9 vs. 3.9±23.4%). Z showed a strong increasing tendency in the prosthesis group and it was markedly higher after replacement when compared to decellularized allografts (44.6±8.3dyn·sec·cm⁻⁵ vs. 32.4±2.0dyn·sec·cm⁻⁵, P<0.05).

Conclusions

Total aortic arch replacement leads to contractility-afterload mismatch by means of increased impedance and invert ventriculoarterial coupling ratio after implantation of conventional prostheses. Implantation of decellularized allografts preserves vascular impedance thereby improving ventriculoarterial mechanoenergetics after aortic arch replacement.

Open aortic arch repair: state-of-the-art and future perspectives

Surgical procedures for the treatment of complex aortic arch pathology remain among the most challenging cardiovascular operations, incurring considerable risk for death and stroke. The purpose of this article is to describe the evolution of our approach to open repair of the aortic arch. Our arterial cannulation strategy has shifted from femoral and direct aortic to right axillary and more recently innominate artery cannulation. This transition has facilitated the administration of continuous antegrade cerebral perfusion and more moderate levels of hypothermia during complex repairs. Modifications in surgical technique, including arch reconstruction with the trifurcated graft, and the classical and frozen elephant trunk techniques have simplified the conduct of the operation. Experimental and clinical research supporting the evolution of our approach is discussed in this paper.

Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch

OBJECTIVES

It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable.

METHODS

Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK).

RESULTS

Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80).

CONCLUSIONS

Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival.

Open aortic repair after prior thoracic endovascular aortic repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has been applied to increasingly complex aortic pathology, resulting in an increase in late complications. We characterized patients undergoing open repair after prior TEVAR including indications, operative techniques, and outcomes.

METHODS

Chart review and query of a prospectively collected database identified 50 patients who underwent thoracic aortic operation after prior TEVAR. Active follow-up was supplemented by Social Security information for vital status.

RESULTS

From July 2001 to January 2012 open arch (n = 25), descending (n = 6), thoracoabdominal (n = 17), or extra-anatomic bypass (n = 2) operations were performed after previous TEVAR (median interval from TEVAR to open surgical procedure: 13.9 months; interquartile range, 0.5 to 24 months). Indications for open operation included type 1 endoleaks (n = 19), retrograde aortic dissection (n = 9), chronic aortic dissection with persistent growth of the false lumen (n = 16), and graft infection (n = 6). Sixty percent had prior cardiovascular surgical procedures and 18% were done as emergencies. Circulatory support was required in 78% and hypothermic arrest in 48%. Hospital mortality occurred in 3 (6%) patients with no strokes and 1 patient with myocardial infarction; 5 (10%) patients required tracheostomy and 1 required dialysis. Survival was 67% at a median follow-up of 2.9 years.

CONCLUSIONS

Conversion to open repair after thoracic stent-grafting may be indicated for type 1 endoleak, retrograde dissection, chronic aortic dissection with persistent false lumen growth, or graft infection. These salvage operations are complex but can be completed safely with good early outcomes and preservation of the stent-graft in most cases. Late outcomes are consistent with the chronic disease state of these patients.

Total aortic arch replacement: current approach using the trifurcated graft technique

Since the pioneering work of DeBakey, Cooley, and colleagues more than 50 years ago, surgical treatment of aneurysms involving the transverse aortic arch has been associated with substantial morbidity and mortality. Over the past 15 years, techniques for replacing the diseased aortic arch have evolved substantially. Previously, our approach to these operations involved femoral cannulation, profound-to-deep hypothermic circulatory arrest and retrograde cerebral perfusion, and the island technique for reattaching the brachiocephalic vessels. In contrast, we currently use innominate artery cannulation, deep-to-moderate hypothermic circulatory arrest with antegrade cerebral perfusion, bilateral cerebral monitoring with near-infrared spectroscopy, and the trifurcated graft (Y-graft) technique for reattaching the arch branches. Cannulating the innominate artery to provide an inflow site for cardiopulmonary bypass has facilitated the use of antegrade cerebral perfusion as a cerebral protection strategy; the left common carotid artery is additionally perfused to provide bilateral cerebral perfusion. Despite having a systemic circulatory arrest time that often exceeds 60 minutes, these improved perfusion strategies make it possible to consistently avoid cerebral circulatory arrest all together. A moderate temperature target of between 18 and 23 °C is now used; this appears to reduce the risk of hypothermic coagulopathy and improve hemostasis. Y-graft techniques, such as the trifurcated graft approach, have the advantages of eliminating residual aortic arch tissue and being easily tailored to the needs of the individual patient. This report describes total aortic arch replacement in patients with aneurysms that are confined to the ascending aorta and transverse aortic arch.

Alternative perfusion technique without axillary artery cannulation during combined aortic root and total arch replacement

This report describes an effective cerebral perfusion method using an additional 4th side limb graft sewn to a trifurcated graft in patients undergoing redo aortic root reconstruction combined with total aortic arch replacement. This method is useful in cases where the origin of the innominate artery is unsuitable for clamping or when axillary perfusion is not employed, and assures continuous brain protection and minimizes circulatory arrest time.

Innominate artery cannulation: an alternative to femoral or axillary cannulation for arterial inflow in proximal aortic surgery

OBJECTIVE

To evaluate the effectiveness of innominate artery cannulation in proximal aortic procedures, including those involving hypothermic circulatory arrest.

METHODS

A total of 68 patients underwent innominate artery cannulation with a side graft during proximal aortic surgery performed by way of a median sternotomy. The indications for surgery were proximal arch aneurysm in 43 patients (63.2%), aortic dissection in 11 patients (16.2%), total arch aneurysm in 10 patients (14.7%), and ascending aortic aneurysm in 4 patients (5.9%). Six patients (8.8%) had undergone previous sternotomy. Hypothermic circulatory arrest with antegrade cerebral perfusion was used in 64 patients (94.1%). Of the 68 patients, 63 (92.6%) received antegrade cerebral perfusion to both cerebral hemispheres. The median antegrade cerebral perfusion time was 20 minutes (range, 15.0-33.0 minutes). Seven patients had periods of circulatory arrest without antegrade cerebral perfusion for a median of 20 minutes (range, 6-33 minutes).

RESULTS

One patient died, for 30-day mortality of 1.5%. Three patients (4.4%) had strokes, two of whom had a partial recovery. Seven patients (10.3%) developed temporary postoperative confusion that resolved successfully in all cases.

CONCLUSIONS

Cannulating the innominate artery for arterial inflow is an alternative technique for proximal aortic surgery procedures. It is especially useful in cases requiring hypothermic circulatory arrest to deliver antegrade cerebral perfusion.

Contemporary results for proximal aortic replacement in North America

OBJECTIVES

The purpose of this study was to characterize operative outcomes for ascending aorta and arch replacement on a national scale and to develop risk models for mortality and major morbidity.

BACKGROUND

Contemporary outcomes for ascending aorta and arch replacement in North America are unknown.

METHODS

We queried the Society of Thoracic Surgeons Database for patients undergoing ascending aorta (with or without root) with or without arch replacement from 2004 to 2009. The database captured 45,894 cases, including 12,702 root, 22,048 supracoronary ascending alone, 6,786 ascending plus arch, and 4,358 root plus arch. Baseline characteristics and clinical outcomes were analyzed. A parsimonious multivariable logistic regression model was constructed to predict risks of mortality and major morbidity.

RESULTS

Operative mortality was 3.4% for elective cases and 15.4% for nonelective cases. A risk model for operative mortality (c-index 0.81) revealed a risk-adjusted odds ratio for death after emergent versus elective operation of 5.9 (95% confidence interval: 5.3 to 6.6). Among elective patients, end-stage renal disease and reoperative status were the strongest predictors of mortality (adjusted odds ratios: 4.0 [95% confidence interval: 2.6 to 6.4] and 2.3 (95% confidence interval: 1.9 to 2.7], respectively; p < 0.0001).

CONCLUSIONS

Current outcomes for ascending aorta and arch replacement in North America are excellent for elective repair; however, results deteriorate for nonelective status, suggesting that increased screening and/or lowering thresholds for elective intervention could potentially improve outcomes. The predictive models presented may serve clinicians in counseling patients.

No association of paraoxonase-1 Q192R genotypes with platelet response to clopidogrel and risk of stent thrombosis after coronary stenting

AIMS

In clopidogrel-treated patients undergoing coronary stenting, high on-treatment platelet reactivity was linked to a higher risk of stent thrombosis (ST). Platelet response to clopidogrel is significantly influenced by genetic factors. Recently published findings showed a highly significant impact of a common polymorphism (Q192R) within the paraoxonase-1 (PON1) gene on clopidogrel treatment efficacy but no influence of the CYP2C19*2 genetic variant as previously demonstrated. The aim of this study was to assess the impact of the PON1 Q192R genotype in parallel to that of CYP2C19*2 on the antiplatelet effect of clopidogrel and the risk of ST in clopidogrel-treated patients.

METHODS AND RESULTS

In 1524 patients undergoing percutaneous coronary intervention, ADP-induced platelet aggregation was assessed in relation to PON1 Q192R and CYP2C19*2 genotypes. The clinical impact of genetic variants was investigated by comparing genotype frequencies of both genetic variants in a registry of 127 cases with early ST vs. an early ST-free control cohort (n = 1439). For PON1 Q192R genotypes, platelet aggregation values were similar across all genotype groups (P = 0.65). For CYP2C19*2 genotypes, significantly higher aggregation values were found in CYP2C19 wt/*2 and *2/*2 patients when compared with wt/wt allele carriers (P < 0.0001). Comparing genotype frequencies between ST cases and controls, no differences were observed for PON1 Q192R genotype distributions (P = 0.23), whereas the genotype distribution differed for CYP2C19*2 genotypes (P = 0.019).

CONCLUSION

The PON1 Q192R genotype did not influence platelet response to clopidogrel or the risk of ST in clopidogrel-treated patients, whereas the CYP2C19*2 genotype impacted on both antiplatelet effect of clopidogrel and risk of coronary ST.