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Walter T, Berger T, Kondov S, Gottardi R, Benk J, Discher P, Rylski B, Czerny M, Kreibich M. Thoracic aortic emergencies involving the aortic arch: An integrated cardiovascular surgical treatment approach. Semin Vasc Surg 2023; 36:150-156. [PMID: 37330229 DOI: 10.1053/j.semvascsurg.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.
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Affiliation(s)
- Tim Walter
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Julia Benk
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Phillip Discher
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwig's University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Kreibich M, Siepe M, Berger T, Beyersdorf F, Soschynski M, Schlett CL, Czerny M, Rylski B. Intervention rates and outcomes in medically managed uncomplicated descending thoracic aortic dissections. J Thorac Cardiovasc Surg 2023; 165:958-965.e4. [PMID: 34001355 DOI: 10.1016/j.jtcvs.2021.03.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections. METHODS Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention. RESULTS Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality. CONCLUSIONS The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients.
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Affiliation(s)
- Maximilian Kreibich
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.
| | - Matthias Siepe
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Soschynski
- Faculty of Medicine, Department for Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Department for Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Carrel T, Czerny M. Commentary: Modified branch-first technique in thoracoabdominal aortic aneurysm repair: Does simpler mean safer? JTCVS Tech 2021; 7:32-33. [PMID: 34318198 PMCID: PMC8312136 DOI: 10.1016/j.xjtc.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center, Freiburg-Bad Krozingen, Germany
- Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
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Berger T, Kreibich M, Rylski B, Kondov S, Fagu A, Beyersdorf F, Siepe M, Czerny M. The 3-step approach for the treatment of multisegmental thoraco-abdominal aortic pathologies. Interact Cardiovasc Thorac Surg 2021; 33:269-275. [PMID: 33674825 DOI: 10.1093/icvts/ivab062] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/17/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this study was to describe our 3-step approach to treat multisegmental thoraco-abdominal aortic disease due to aortic dissection and to present our initial clinical results. METHODS Nine patients with multisegmental thoraco-abdominal aortic pathology due to aortic dissection underwent our 3-step approach, which consisted of total aortic arch replacement via the frozen elephant trunk technique, thoracic endovascular aortic repair for distal extension down to the level of the thoraco-abdominal transition and, finally, open thoraco-abdominal aortic replacement for the remaining downstream aortic segments. We assessed their baseline and aortic characteristics, previous aortic procedures, intraoperative details, clinical outcomes and follow-up data. RESULTS The median age was 58 (42-66) years; 4 patients (44%) presented connective tissue disease. Eight patients (89%) had undergone previous aortic surgery for aortic dissection. In-hospital mortality was 0% (n = 0). None suffered symptomatic spinal cord injury or disabling stroke. During the follow-up period, 1 patient died of acute biliary septic shock 6 months after thoraco-abdominal aortic replacement. CONCLUSIONS The 3-step approach to treat multisegmental thoraco-abdominal aortic pathology due to aortic dissection, which involves applying both open and endovascular techniques, is associated with an excellent clinical outcome and low perioperative risk. Distal shifting of the disease process through the thoracic endovascular aortic repair extension-and thereby necessitating limited open thoraco-abdominal aortic repair-seems to be the major factor enabling these favourable results. IRB APPROVAL IRB approval was obtained (No. 425/15) from the institutional review board of the University of Freiburg.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Czerny M, Eggebrecht H, Rousseau H, Mouroz PR, Janosi RA, Lescan M, Schlensak C, Böckler D, Ante M, Weijde EV, Heijmen R, Eckstein HH, Reutersberg B, Trimarchi S, Schmidli J, Wyss T, Frey R, Makaloski V, Brunkwall J, Mylonas S, Szeberin Z, Klocker J, Gottardi R, Schusterova I, Morlock J, Berger T, Beyersdorf F, Rylski B. Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC. Ann Thorac Surg 2020; 110:1494-1500. [PMID: 32283085 DOI: 10.1016/j.athoracsur.2020.02.079] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. METHODS In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. RESULTS The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. CONCLUSIONS dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany.
| | | | - Herve Rousseau
- Department of Radiology, Centre Hospitalier Universitaire de Rangueil, Toulouse, France
| | - Paul Revel Mouroz
- Department of Radiology, Centre Hospitalier Universitaire de Rangueil, Toulouse, France
| | - Rolf-Alexander Janosi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
| | - Mario Lescan
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Dittmar Böckler
- Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
| | - Marius Ante
- Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
| | - Emma Vdr Weijde
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Germany
| | - Robin Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Germany
| | - Hans Henning Eckstein
- Munich Aortic Centre, Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich Germany
| | - Benedikt Reutersberg
- Munich Aortic Centre, Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich Germany
| | - Santi Trimarchi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Romina Frey
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Roman Gottardi
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Julia Morlock
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany
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Czerny M. New treatment approaches create new disease processes: A short guide on how to reduce unexpected events to a minimum. J Thorac Cardiovasc Surg 2018; 157:107-108. [PMID: 30557938 DOI: 10.1016/j.jtcvs.2018.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Martin Czerny
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
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Czerny M, Kreibich M, Morlock J, Kondov S, Scheumann J, Schröfel H, Kari FA, Berger T, Siepe M, Beyersdorf F, Rylski B. Chronic type B "residual" after type A: what I would do? J Vis Surg 2018; 4:14. [PMID: 29445600 DOI: 10.21037/jovs.2017.12.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/05/2017] [Indexed: 11/06/2022]
Abstract
"The major goal of surgery for acute type A aortic dissection is to have an alive patient." This motto still remains the most important directive. However, also depending onto the extent of the underlying pathology and consecutively depending onto the extent of primary surgery, there is and will be need for additional classical surgical or interventional treatment sooner or later during follow-up in a substantial number of patients having had surgery for acute type A aortic dissection. This article shall guide the interested reader through the underlying mechanisms as well as treatment options in patients with chronic type B "residual" after type A repair and shall finally suggest preventive strategies to reduce the occurrence of this pathology to a minimum.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Morlock
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Scheumann
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Albert Ludwigs University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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