Evolution and Current Applications of the Cabrol Procedure and Its Modifications

Cabrol procedure and its modifications: a systematic review and meta-analysis

BACKGROUND

The Cabrol procedure has undergone various modifications and developments since its invention. However, there is a notable gap in the literature regarding meta-analyses assessing it.

METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and long-term outcomes of the Cabrol procedure and its modifications. Pooling was conducted using random effects model. Outcome events were reported as linearized occurrence rates (percentage per patient-year) with 95% confidence intervals.

RESULTS

A total of 14 studies involving 833 patients (mean age: 50.8 years; 68.0% male) were included in this meta-analysis. The pooled all-cause early mortality was 9.0% (66 patients), and the combined rate of reoperation due to bleeding was 4.9% (17 patients). During the average 4.4-year follow-up (3,727.3 patient-years), the annual occurrence rates (linearized) for complications were as follows: 3.63% (2.79-4.73) for late mortality, 0.64% (0.35-1.16) for aortic root reoperation, 0.57% (0.25-1.31) for hemorrhage events, 0.66% (0.16-2.74) for thromboembolism, 0.60% (0.29-1.26) for endocarditis, 2.32% (1.04-5.16) for major valve-related adverse events, and 0.58% (0.34-1.00) for Cabrol-related coronary graft complications.

CONCLUSION

This systematic review provides evidence that the outcomes of the Cabrol procedure and its modifications are acceptable in terms of mortality, reoperation, anticoagulation, and valve-related complications, especially in Cabrol-related coronary graft complications. Notably, the majority of Cabrol procedures were performed in reoperations and complex cases. Furthermore, the design and anastomosis of the Dacron interposition graft for coronary reimplantation, considering natural anatomy and physiological hemodynamics, may promise future advancements in this field.

Peripheral bare-metal stent implantation for a very-late stenosis of an aortic-left main Cabrol graft: a case report

Background

The surgical ascending aorta repair according to the Cabrol procedure involves the interposition of a prosthetic conduit between the aortic prosthesis and the native coronary ostia. Previous cases of the Cabrol conduit stenosis have been described, most of which presented as acute coronary syndromes due to thrombotic occlusion of the graft.

Case summary

We present a case of stable exertional angina due to very-late stenosis of the coronary prosthetic conduit, successfully treated with trans-femoral percutaneous angioplasty and off-label implantation of a balloon-expandable bare-metal stent designed for peripheral artery disease. The multimodality imaging approach gave an essential contribution both to the assessment of the lesion and to the procedural planning. Despite the concerns about long-term results, a peripheral bare-metal stent was preferred over a standard coronary drug-eluting stent due to the remarkable dimension of the Cabrol conduit. Three years after the procedure, the patient is free from angina, and coronary computed tomography showed no significative luminal loss of the stent.

Conclusion

Elective angioplasty of a Cabrol graft requires a careful planning through a multimodality stenosis assessment. Conventional coronary stents can be not large enough to ensure adequate apposition to the wide prosthetic conduit and peripheral bare-metal stents may be taken into consideration, at the price of unknown long-term outcomes.

Combined Replacement of Aortic Valve and Ascending Aorta-A 70-Year Evolution of Surgical Techniques

Simultaneous replacement of the ascending aorta and aortic valve has always been a challenging procedure. Introduction of composite conduits, through various ingenious procedures and their modifications, has changed the outlook of patients with aortic valve disease and ascending aorta pathology. In the past 70 years, progress of surgical techniques and prosthetic materials has allowed such patients to undergo radical procedures providing excellent early and long-term results in both young and elderly patients. This article aims to review the most important technical advances in the treatment of aortic valve disease and ascending aorta aneurysms recognizing the important contributions in this field.

Short-term outcomes of a novel modified Bentall procedure in acute type A aortic dissection

BACKGROUND

The Bentall procedure is a common surgical treatment for aortic root replacement in acute type A aortic dissection (ATAAD) with some complications which affect postoperative efficacy. We innovatively modified the Bentall procedure and investigated its short-term efficacy.

METHODS

From March 2017 to March 2019, 77 cases with ATAAD in our department underwent total arch replacement and frozen elephant trunk technique following prior Bentall procedure. They were divided into three groups. In modified-Bentall group, 20 patients underwent a modified Bentall surgery. In Bentall-inclusion group, coronary ostia inclusion anastomosis and Cabrol shunt were performed in 32 patients. In Bentall-button group, coronary ostia button anastomosis was used to 25 cases.

RESULTS

No intraoperative deaths occurred in three groups. Operation time, CPB time, and aortic cross-clamp time in modified-Bentall group was longer than those in Bentall-inclusion group (P<0.05), but the number of RBC transfusion and postoperative drainage volume decreased compared with Bentall-button group (P<0.05). One patient with mesenteric malperfusion syndrome died after surgery in modified-Bentall group, 2 patients died in Bentall-inclusion group, and 1 patient died in Bentall-button group. No coronary anastomotic leak and vena cava-right atrium shunt signal occurred in modified-Bentall group, and there was no contrast extravasation and no pseudoaneurysm formation in the aortic root. The cardiac function of patients was grade I-II.

CONCLUSIONS

This novel modified procedure is feasible and can significantly reduce postoperative complications with satisfactory short-term efficacy in ATAAD.

Concomitant Aortic Root Replacement With Anterior Konno Annular Enlargement

The need for concomitant aortic annular enlargement and aortic root replacement may be necessary in situations of multilevel left ventricular outflow tract obstruction and/or prior aortic or aortic valve surgery, particularly in the setting of congenital heart disease. It can be extremely tedious and fraught with numerous complications. Major challenges include bleeding in difficult-to-reach areas and the potential need for subsequent operations. This article describes a technique of concomitant aortic annular enlargement and aortic root replacement that minimizes the risk of significant blood loss and facilitates future surgery should it be necessary.

Remote ALCAPA Repair-Total Arterial Reconstruction Using Free Aortic Graft Technique

A late presenting anomalous left coronary artery from pulmonary artery (ALCAPA) with remote origin may be associated with several technical caveats due to distance for coronary transfer and inadequate autologous tissues for reconstruction. A technique using full circumferential aortic wall as a free graft that is sutured as a posterior hood on an anterior pulmonary arterial flap is used to achieve reconstruction of a neo-left coronary that is tension free, with laminar flow and without the use of any prosthetic material. The technique with potential modifications described could potentially be applied to any variant of ALCAPA to achieve total arterial reconstruction to yield an optimal long-term outcome.

Feasibility and Durability of the Modified Cabrol Coronary Artery Reattachment Technique

BACKGROUND

This study evaluated the feasibility and durability of the modified Cabrol coronary reattachment technique after aortic root replacement.

METHODS

The study retrospectively reviewed 370 patients who underwent aortic root replacement, during 1991 and 2018, and who were separated into 2 groups: a modified Carol (mCabrol) group (n = 84), consisting of patients with 1 or both coronary ostia reimplanted using a modified Cabrol technique; and a Carrel group (n = 286), consisting of patients with both coronary ostia reimplanted using the Carrel button technique.

RESULTS

Baseline characteristics were similar in the 2 groups, except the mCabrol group had higher rates of redo sternotomy (74% vs 16%), chronic aortic dissection (58% vs 19%), and infection (14% vs 3%). In the mCabrol group, 60% had both coronary arteries reattached with the technique, and 40% of the procedures were unilateral. Operative mortality was significantly higher in mCabrol group compared with the Carrel group. However, in the stratified analysis for resternotomy, operative mortality between 2 groups were similar (16% vs 13%; P = .786). The survival rate at 5 years and 10 years was 68 ± 6% and 44 ± 6%, respectively, in the mCabrol group and 87 ± 2% and 80 ± 3%, respectively, in the Carrel group (log-rank P < .001). After propensity adjustment, chronic kidney disease and prior coronary artery bypass grafting, but not the modified Cabrol technique, were independent predictors of both operative mortality and follow-up mortality (operative, P = .518; follow-up, P = .080). A total of 47 (66%) of 71 discharged patients in the mCabrol group had follow-up imaging, and no Cabrol graft was occluded. Two patients in the mCabrol group required interventions related to the reattachment technique: 1 coronary ostial anastomosis stenosis and 1 graft-to-graft anastomosis pseudoaneurysm.

CONCLUSIONS

The modified Cabrol reattachment technique was not predictive of increased mortality and has excellent patency.

In Situ Composition of Valved Conduit for Complex Reoperative Aortic Root Replacement

We describe a novel technique, in situ composition of a valved conduit, for complex reoperative aortic root replacement. The absence of a rigid stented aortic valve prosthesis facilitates left ventricular outflow tract (LVOT) reconstruction and coronary reimplantation. First, a Dacron graft, inverted and inserted into the LVOT, is sewn to the LVOT, followed by coronary button reimplantation and then prosthetic valve implantation. For cases that require LVOT reconstruction, the graft below the prosthetic valve serves as a circumferential patch. Our technique requires only surgical materials that are readily available without the need for a specialized skillset.

Extracorporeal membrane oxygenation-supported percutaneous angioplasty of coronary button stenosis after aortic root replacement

BACKGROUND AND AIM

A 73-year-old female patient had right coronary button stenosis following aortic root replacement.

METHODS

Myocardial ischemia led to hemodynamic instability followed by cardiogenic shock, which was successfully managed using venoarterial extracorporeal membrane oxygenation-supported right coronary button angioplasty.

RESULTS AND CONCLUSION

Although the incidence of such complications is low, it is a life-threatening event that requires prompt diagnosis and it may pose a challenging clinical scenario for the treating team.

Mimics of Complications in the Postsurgical Aorta at CT

Various surgical techniques of the aorta result in expected imaging appearances on CT images that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of these mimics are essential for accurate interpretation. CT imaging techniques such as electrocardiographic gating and inclusion of a precontrast series can help distinguish an expected postsurgical finding from a complication. Information in the medical record, particularly the operative note, can clarify challenging cases with unusual imaging features. This review article provides examples of expected postsurgical findings at CT mimicking complications. © RSNA, 2019.

Long-Term Postoperative Complication of the Cabrol Procedure Presenting as Recurrent Anterior ST-Segment Elevation Myocardial Infarction

•

Development of fistulae between the aneurysm sac and aortic graft can be a potential source of thrombi in patients treated with surgical aortic root replacement.

•

Transesophageal echocardiography is an effective tool to assess post-operative complications of the Cabrol procedure.

•

Post-operative complications of the Cabrol procedure can have a very delayed initial presentation.

An acutely occluded Cabrol graft presenting as an acute coronary syndrome

The Cabrol technique employs a synthetic graft to connect the coronary arteries to an aortic graft in patients with complex disease of the ascending aorta. Acute Cabrol graft thrombosis is a life-threatening situation that presents as acute coronary syndrome, as it leads to acute coronary hypoperfusion. We present a patient with unstable anginal symptoms who had undergone aortic surgery 6 months prior to presentation. Cardiac catheterisation was concerning for aortic dissection yet was later revealed to be acute occlusion of a Cabrol graft. The patient ultimately died of cardiogenic shock. We review the Cabrol technique, complications and management of acute graft thrombosis.

Use Side Branch of the Aortic Graft to Facilitate Coronary Reconstruction During Complex Aortic Surgery

The interposition graft could be used for difficult coronary reconstruction during aortic root replacement. We introduced a new technique that utilizes side branch of an aortic graft to facilitate coronary reconstruction. The present study describes this technique and its outcomes. We retrospectively reviewed 234 patient charts of those who underwent aortic root replacement between January 2013 and November 2017. Within this group, 6 patients required coronary reconstruction with branches of aortic graft and were included in this study. All patients were reoperative cases, 3 of which were for acute type A aortic dissection. The mean cardiopulmonary and aortic cross clamp times were 317.2 ± 35.1 minutes and 153.3 ± 75.4 minutes, respectively. All patients survived to discharge with a median hospital stay of 20.5 days (interquartile range: 13.75-27.75). During a median follow-up of 221 days (interquartile range: 197.78-1208), no patients experienced major adverse cardiovascular events. Four patients underwent radiographic follow-up, which confirmed patent interposition grafts (5/5). The use of branches from the aortic graft for coronary reconstruction is feasible with satisfactory outcomes.

CT angiography for depiction of complications after the Bentall procedure

Following a Bentall procedure, which comprises a composite replacement of both the aortic valve and the ascending aorta, the imaging modality of choice to depict known or suspected complications is CT angiography. An update and extension of the literature regarding complications after the Bentall procedure is provided. The wider availability of ECG-gating has allowed for a clearer depiction of the aortic valve and ascending aorta. This resulted not only in the identification of previously undetectable complications, but also in a more precise assessment of the pathophysiology and morphology of known ones, reducing the need for additional imaging modalities. Moreover, the possibility to combine positron emission tomography images with CT angiography offers new insights in case of suspected infection. Due to the complexity of the operation itself and concomitant or subsequent additional procedures, as well as the wide spectrum of underlying pathology, new scenarios with multiple complications can be expected.

Single stage repair for aortic root aneurysm in a patient with coexisting coarctation incorporating the Cabrol technique: a case report

Background

A 44 year old man who presented with a history of chest pain and dyspnoea was found to have an aneurysm of the aortic root, aortic valve insufficiency, and coarctation of the aorta.

Case presentation

The patient underwent a single stage procedure to treat the aortic root, valve and coarctation with a composite valved conduit and extra-anatomic bypass of the coarctation. The modified Cabrol technique was necessary to attach the coronary buttons due to grossly abnormal anatomy. The patient made a remarkable recovery and was discharged on the 8th post-operative day.

Conclusion

This case report highlights the feasibility and efficacy of performing a single stage procedure on complex coarctation with associated cardiac defects. To the best of our knowledge, this is the first report of the modified Cabrol technique being used in this particular setting.

Postoperative imaging of the aorta

Considerable progress has been made in the management of diseases of the thoracic and abdominal aorta over the past decades, ranging from advances in open repair to the advent of minimally invasive endovascular techniques. Along with this comes an equivalent rise in imaging necessity for these patients, both in preoperative planning and postoperative surveillance. With the growing complexity and diversity of vascular procedures and techniques, it is essential to have a solid understanding of the imaging features and postoperative complications of these procedures to avoid imaging pitfalls. This review is an attempt to define the normal postoperative appearance and important complications of various open and endovascular surgical techniques of the thoracic and abdominal aorta.

Aortic Root Reconstruction with a New Dacron Graft Featuring Prefabricated Coronary Side Branches: Lessons Learned from the Cabrol Procedure

BACKGROUND

Coronary button reimplantation can represent a technical challenge of aortic root reconstruction that can be associated with significant morbidity and mortality. With the goal of simplifying coronary reimplantation and reducing the incidence of related complications, we designed a new Dacron graft with prefabricated coronary branches to minimize coronary artery mobilization and prevent the potential mechanical complications of reattachment to the body of the graft.

METHODS

Between June 2010 and May 2012, we implanted the graft in eight patients (six males, two females) ranging in age from 42-68 years (mean, 54 years). Six procedures were modified Bentall reconstructions, and two procedures were valve-sparing root replacements using the reimplantation technique.

RESULTS

There were no complications and no morbidity or mortality related to coronary reattachment. All patients were alive and doing well at a mean follow-up of 26 months (range, 17-38 months). At an extended mean follow-up of 42 months (range, 25-56 months), one patient died of stroke-related complications. No radiologic or clinical evidence of impairment of coronary perfusion was identified in any patient.

CONCLUSIONS

The use of this new graft model may simplify the technique of root reconstruction and potentially lower the incidence of mechanical complications related to coronary button reimplantation.

Imaging of the Postsurgical Thoracic Aorta: A State-of-the-Art Review

Techniques for repair of the aorta currently include open and endovascular methods, hybrid approaches, minimally-invasive techniques, and aortic branch vessel reimplantation or bypass. Collaboration among radiologists and vascular and cardiothoracic surgeons is essential. An awareness of the various surgical techniques, expected postoperative appearance, and potential complications is essential for radiologists. This review will cover the postoperative appearance of the thoracic aorta with a focus on the ascending aorta. The value of three-dimensional image evaluation will also be emphasized.

Redo aortic root replacement reutilizing 22-year patent modified Cabrol grafts

Long-term patency of modified Cabrol technique in composite aortic root replacement is not well documented. We report a unique case in which a patient presented for prosthetic valve dysfunction with patent Cabrol grafts 22 years after composite root replacement requiring redo aortic root. This case also demonstrates how modified Cabrol grafts can be reutilized in aortic root replacement without compromising adequate fluid dynamics.

A simple modified Bentall technique for surgical reconstruction of the aortic root - short and long term outcomes

Background

Since the first introduction of the Bentall technique, several modifications have been proposed to improve patient outcomes and decrease intra- and post-operative complications. We describe a simplified modification of the technique that tries to lessen the intra-operative time, improve homeostasis and miminize early and late complications. Our experience with the technique and short- and long-term patient outcomes are reported.

Methods

From August 1996 to October 2013, 110 consecutive patients underwent this modified technique. The procedure used Dacron composite graft with a mechanical valve (St. Jude Medical®) for aortic root replacement. To avoid intra-operative complications, no mobilization of coronary ostia was done. Additionally, the tubular aorta was kept minimally unchanged.

Results

Total bleeding after the operation was 450 ± 105 mL. The mean duration of intensive care unit and hospital stay were 2 ± 1 and 5 ± 2 days, respectively. Sixty-six patients (60 %) were discharged from the surgical intensive care unit on the first postoperative day, 34 patients (30.9 %) were discharged on the second day and ten patients (9.1 %) needed more time to stay in the intensive care unit due to haemodynamic or respiratory problems. At 5-years follow up, survival rate was 97 %. In the three deceased patients, causes of death were mediastinitis, sepsis and myocardial infarction. No operation-related complications such as anticoagulant-related hemorrhage, valve or graft thrombosis, or coronary pseudoaneurysm were occurred during follow-up.

Conclusions

The proposed modification of the Bentall technique seems to minimize late intra-operative blood loss, improves homeostasis, shortens the operation time and is associated with excellent long-term outcomes in patients undergoing composite graft replacement of the aortic root.

Coronary reimplantation in aortic root surgery: the trapdoor technique for adults

Coronary ostial reimplantation during aortic root replacement is a key stage of the operation. The "button technique" is the most used method, but there are still concerns about the incidence of coronary pseudoaneurysm formation, bleeding, and distortion of the coronary geometry. We describe how we adapted the trapdoor technique, commonly used in the arterial switch operation in children, to reimplant the coronary ostia in adult patients undergoing aortic root replacement.

Homograft subclavian interposition graft to left main coronary artery ostium in aortic root replacement

Performing a reoperative root replacement in cases of prosthetic valve endocarditis (PVE) can often be challenging due to significant inflammation and scarring. During these cases, surgeons may decide to utilize an interpositional graft when mobilization of the coronary ostia becomes too hazardous. The authors describe their experience performing a reoperative root replacement on a patient with PVE. In this case, the authors utilize a segment of the homograft left subclavian artery as an interpositional graft to provide an infection-resistant bioprosthetic graft that maintains coronary anatomy.

Technique of Aortic Root Reconstruction Using a New Model of Dacron Graft with Prefabricated Coronary Branches

Aortic root reconstruction is a demanding surgical procedure still associated with a significant morbidity. Arguably, the most demanding aspect of the operation is reestablishing continuity between the prosthetic graft replacing the aortic root and the coronary arteries. With the objective of simplifying the possible challenges of coronary reimplantation, we designed a new model of aortic root graft with prefabricated coronary branches. We used this technique in 8 patients (6 males, 2 females; mean age, 54 years). There were 6 modified Bentall procedures and 2 valve-sparing root replacements with the “reimplantation” technique. There was no mortality or morbidity related to the use of this new prosthetic graft. Our purpose was to report in detail the technique of aortic root reconstruction using this new graft with prefabricated coronary branches. The use of this graft may simplify the procedure and offer a valuable tool for aortic root reconstruction in cases where the reimplantation of the coronary buttons may represent a technical challenge.

Surgery for detached coronary ostial anastomosis 21 years post-Bentall procedure

Though a high frequency of postoperative complications after an original Bentall procedure has been reported, several procedures that reduce the incidence of complications have been developed. Complications relating to anastomoses of the interposed graft are infrequent but life-threatening. This report describes a case of a 61-year-old man who presented with heart failure secondary to bilateral detachment of coronary ostial anastomoses and graft stenosis 21 years after undergoing a modified Bentall procedure. These complications were successfully repaired by reconstructing the conduit and coronary arteries.

Midterm experience with modified Cabrol procedure: safe and durable for complex aortic root replacement

OBJECTIVE

To evaluate the early and late outcomes of the modified Cabrol technique as a method of coronary reimplantation during complex composite graft replacement of the ascending aorta.

METHODS

Between 1995 and 2012, 348 patients (mean age, 56 ± 14 years; 283 males and 65 females) underwent composite graft replacement of the ascending aorta, 40 of whom (mean age, 60 ± 12 years; 35 males and 5 females) had one or both coronary ostia reimplanted using a modified Cabrol technique with an 8- to 10-mm Dacron interposition graft. The mean clinical and radiologic (computed tomographic scan) postoperative follow-up was 39 months (range, 1-171 months), via our aortic database, patient interviews, and Social Security Death Index.

RESULTS

Cabrol reimplantation was necessitated by reoperations with anatomically fixed coronary ostia (n = 16, 40%), severely displaced coronary arteries (n = 15, 37.5%), button calcification (n = 4, 10%), coronary anomalies (n = 3, 7.5%), and coronary aneurysm (n = 2, 5%). Of the operations, 20% (8 patients) were urgent interventions. Early mortality was 3 (7.5%) of 40, none related to the Dacron interposition graft. Total late mortality was 16.2%, also not related to the coronary graft. Actuarial survivals were 0.88 ± 0.05, 0.79 ± 0.07, and 0.73 ± 0.08 at 1, 3, and 6 years, respectively. Radiologic follow-up was available for 31 (83.8%) of the surviving patients and revealed that the interposition graft was widely patent in all.

CONCLUSIONS

The modified Cabrol technique using a Dacron interposition graft showed good survival rates and excellent durability over time, confirmed radiographically. These data confirm that it is appropriate to use the Cabrol technique when technical complexity prevents bringing coronary buttons to the main aortic graft.

Repair of Aortic Regurgitation due to Takayasu Arteritis

<p><b>Background:</b> Prosthetic valve detachment after aortic valve replacement and pseudoaneurysm formation are the most important postoperative complications in patients with Takayasu arteritis with aortic regurgitation. We reviewed our experience of surgical treatment of aortic regurgitation in patients with Takayasu disease.</p><p>Methods: Between November 1997 and September 2011, 11 patients (4 women and 7 men) with Takayasu arteritis with aortic regurgitation underwent surgical treatment. The age of the patients ranged from 26 to 56 years (mean, 40 � 9 years). Primary isolated aortic valve replacement was performed in 1 patient, David procedure in 1 patient, Wheat procedure in 1 patient, Bentall procedure in 2 patients, and Cabrol procedure in 6 patients (including 2 patients who underwent primary aortic valve replacement in other hospitals before being admitted to our surgical team).</p><p><b>Results:</b> There was no in-hospital death. All patients had an uneventful recovery during the postoperative course and were discharged. Prosthetic valve detachment, pseudoaneurysm formation at the suture line, and dilatation of the ascending aorta were not found in patients with composite aortic root replacement during a mean follow-up of 98 � 45 months. One patient died during follow-up.</p><p><b>Conclusion:</b> Valve detachment after composite aortic root replacement was not observed in patients with Takayasu disease with aortic regurgitation. Satisfactory surgical outcomes were obtained using composite aortic root replacement. However, close follow-up was needed to assess the effectiveness of the Cabrol procedure in patients with Takayasu disease with aortic regurgitation.</p>