Acute type A dissection without intimal tear in arch: proximal or extensive repair?

Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria

BACKGROUND

Type A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient's conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD.

METHODS

Four leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT00591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding.

DISCUSSION

This multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.

Aortic arch surgery for DeBakey type 1 aortic dissection in patients aged 60 years or younger

BACKGROUND

Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study.

METHODS

The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta.

RESULTS

Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172).

CONCLUSIONS

In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04831073.

The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection

PURPOSE

To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD).

METHODS

We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed.

RESULTS

There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications.

CONCLUSION

Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase.

CLINICAL IMPACT

This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.

Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes.

METHODS

All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient.

RESULTS

A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L.

CONCLUSION

The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique

The surgical management of acute and chronic complex diseases involving the aortic arch and the descending thoracic aorta remains challenging. Hybrid procedures associating total open arch replacement and stent-grafting of the proximal descending aorta were developed to allow a potential single-stage treatment, promote remodeling of the downstream aorta, and facilitate a potential second-stage thoracic endovascular aortic repair by providing an ideal landing zone. While these approaches initially used various homemade combinations of available conventional prostheses and stent-grafts, the so-called frozen elephant trunk technique emerged with the development of several custom-made hybrid prostheses. The aim of this study was to review the contemporary outcomes of this technique in the management of complex aortic diseases, with a special focus on procedural planning, organ protection and monitoring, refinements in surgical techniques, and long-term follow-up.

Total aortic arch replacement in acute type A aortic dissection - a single institutional experience

Aim

Total arch replacement in the presence of acute aortic dissections is one of the most challenging areas of aortic surgery. Data on outcome in the Indian scenario is sparse. The aim of this study was to assess the outcome of arch replacements in a single tertiary care center.

Material and methods

In this single-center experience, 20 patients underwent total arch replacement between 2012 and 2022. Demographic, intraoperative, and postoperative data were abstracted from hospital records. Only patients with acute type A aortic dissection needing an arch repair were included. Patients with hemi-arch repairs, hybrid repairs, and those operated upon due to aneurysmal disease were excluded from the study. Comparison was made between survivors and non-survivors. Temporal trends for the procedure were assessed.

Results

The study included 20 patients who underwent total aortic arch replacement (TAR) during the study period (2012-2022). The mean age was 49.3 ± 12.5 years, and 15 (75%) of the patients were males. Seven (35%) patients were operated within 24 h of symptom onset. Permanent stroke was seen in 1 (5%) patient and temporary neurological dysfunction was observed in 1 (5%) patient. The re-exploration rate was 6 (30%) in the entire cohort and in-hospital mortality was 4 (20%). Follow-up was complete in 18 (90%) of the study population and 14 (87.5%) among survivors. There was one late death in our study which occurred after 46 months of the index operation. The overall mean survival was 76.1 months (95% CI: 49.86-102.43).

Conclusion

TAR can be performed both with acceptable mortality and morbidity in the presence of acute aortic dissections.

Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study

Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.

Risk factors for in-hospital mortality after total arch procedure in patients with acute type A aortic dissection

Object

Knowledge about the risk factors of in-hospital mortality for acute type A aortic dissection (ATAAD) patients who received total arch procedure is limited. This study aims to investigate preoperative and intraoperative risk factors of in-hospital mortality of these patients.

Methods

From May 2014 to June 2018, 372 ATAAD patients received the total arch procedure in our institution. These patients were divided into survival and death groups, and patients` in-hospital data were retrospectively collected. Receiver operating characteristic curve analysis was adopted to determine the optimal cut-off value of continuous variables. Univariate and multivariable logistic regression analyses were used to detect independent risk factors for in-hospital mortality.

Results

A total of 321 patients were included in the survival group and 51 in the death group. Preoperative details showed that patients in the death group were older (55.4 ± 11.7 vs. 49.3 ± 12.6, P = 0.001), had more renal dysfunction (29.4% vs. 10.9%, P = 0.001) and coronary ostia dissection (29.4% vs. 12.2%, P = 0.001), and decreased left ventricular ejection fraction (LVEF) (57.5 ± 7.9% vs. 59.8 ± 7.3%, P = 0.032). Intraoperative results showed that more patients in the death group experienced concomitant coronary artery bypass grafting (35.3% vs. 15.3%, P = 0.001) with increased cardiopulmonary bypass (CPB) time (165.7 ± 39.0 vs. 149.4 ± 35.8 min, P = 0.003), cross-clamp time (98.4 ± 24.5 vs. 90.2 ± 26.9 min, P = 0.044), and red blood cell transfusion (913.7 ± 629.0 vs. 709.7 ± 686.6 ml, P = 0.047). Logistic regression analysis showed that age >55 years, renal dysfunction, CPB time >144 min, and RBC transfusion >1,300 ml were independent risk factors for in-hospital mortality in patients with ATAAD.

Conclusion

In the present study, we identified that older age, preoperative renal dysfunction, long CPB time, and intraoperative massive transfusion were risk factors for in-hospital mortality in ATAAD patients with the total arch procedure.

Distal Aortic Progression After Hemiarch, Zones 1-3 Arch Replacement in Acute Type A Aortic Dissection

BACKGROUND

There is debate regarding aortic arch repair extent for acute type A aortic dissection (ATAAD) patients.

METHODS

From 1996 to 2021, 756 ATAAD patients underwent open arch replacement. The cohort was divided into hemiarch (n = 481), zone 1 (n = 65), zone 2 (n = 148), and zone 3 (n = 62) arch replacement groups. Cross-group comparison of aortic growth was modeled using data from interval postoperative computed tomography or magnetic resonance imaging of the distal aorta.

RESULTS

Demographics were not significantly different except the hemiarch group had more coronary artery disease and less stroke. Intraoperatively, zones 1, 2, and 3 had greater cardiopulmonary bypass, cross-clamp, and hypothermic circulatory arrest times and required more intraoperative blood transfusion than the hemiarch group. Perioperative outcomes were similar among groups except zone 3 had more reoperation for bleeding. Ten-year cumulative incidence of reoperation was hemiarch, 16.7%; zone 1, 16.3%; zone 2, 21.5%; and zone 3, 17.6% (P = .70). Ten-year survival was similar: hemiarch, 66%; zone 1, 60.3%; zone 2, 68.0%); and zone 3 66.1% (P = .20). Aortic arch, descending aorta, and abdominal aorta growth rates were not significantly different among groups over 10 years. In the whole cohort, the growth rate over time for aortic arch was 0.38 mm per year (P < .001), descending aorta 0.84 mm per year (P < .001), and abdominal aorta 0.69 mm per year (P < .001).

CONCLUSIONS

There was no significant difference in long-term survival, distal aorta growth, or reoperation rate for distal aortic aneurysm after hemiarch or zones 1, 2, or 3 arch replacement. Patient-specific arch replacement strategies may be used rather than defaulting to aggressive arch replacement for all ATAAD patients.

Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study

Background: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. Methods: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. Results: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491–1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561–1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133–1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361–319.017) were significantly associated with increased operative mortality. Conclusions: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.

Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection

Objective

This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection.

Subjects

From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta.

Methods

Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed.

Results

The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134).

Conclusions

No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data

OBJECTIVES

To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD).

METHODS

We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.

RESULTS

Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025).

CONCLUSION

The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.

Outcomes of hemi- vs. total arch replacement in acute type A aortic dissection: A systematic review and meta-analysis

Background

Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD.

Methods

The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022.

Results

We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70–0.97; P = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; P = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; P = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; P = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia.

Conclusion

In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis.

Systematic review registration:

[INPLASY.COM], identifier [INPLASY202250088].

Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis

BACKGROUND

The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm.

MATERIALS AND METHODS

A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted.

RESULTS

A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01-0.06, I²  = 78%) and 3% (95% CI 0.01-0.11, I²  = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I²  = 89%) while the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I²  = 92%). After subgroup analysis, heterogeneity for distal stent-graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E-Vita stent-grafts were used (both I²  = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I²  = 15.1%) and Frozenix stent-grafts (I²  = 1%).

CONCLUSION

Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results.

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

OBJECTIVE

We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1.

METHODS

We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the TAR group, the HAR group was older (68.1 vs 60.9 years; P < .01) and had more thrombosed false lumen (28.8% vs 4.1%, P < .01).

RESULTS

In-hospital death occurred for 7 patients in the HAR group and 1 patient in the TAR group (P = .17). More patients in the TAR group had a postoperative thrombosed false lumen, compared with the HAR group (68% vs 54%, P = .03). In patients with preoperative nonthrombosed false lumen in the HAR group, the rate of postoperative thrombosis was significantly lower than with versus without an open stent (31% vs 65%, P = .01). The rate of freedom from an aortic arch event in the TAR group at 5 years was significantly greater than that in the HAR group (100% vs 83.7%, P = .01).

CONCLUSIONS

Stented elephant trunk with TAR provided a high rate of false lumen thrombosis and a low incidence of arch events, whereas an open stent during HAR was not beneficial in terms of false lumen thrombosis and arch event prevention.

Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis

INTRODUCTION

The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET.

EVIDENCE ACQUISITION

In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET.

EVIDENCE SYNTHESIS

Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I²=76%) and 12% for renal failure (95% CI 0.09-0.15; I²=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I²=0%) and 6% (95% CI 0.05-0.08; I²=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I²=0%).

CONCLUSIONS

Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.

Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis

OBJECTIVES

Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD).

METHODS

A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed.

RESULTS

A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm.

CONCLUSIONS

In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.

Extensive Arch Repair with a Novel Two-Branched Stent Graft in Acute Type A Aortic Dissection

Purpose: In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.

Methods: Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).

Results: The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.

Conclusion: Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.

Correlation of coagulopathy and frozen elephant trunk use in aortic arch surgery: A systematic review and meta-analysis

BACKGROUND

The advent of frozen elephant trunk (FET) for reconstruction of elective and nonelective aortic arch surgery has augmented the treatment of complex aortic pathologies in a single-stage operation. To date, no studies have been focused on the prevalence and predictors of coagulopathy potentiated by FET procedure.

METHODS

In a systematic review, we searched databases up to June 2020 to find studies reporting coagulopathy complications after FET procedure. A proportional meta-analysis was carried out using STATA software (StataCorp).

RESULTS

A total of 46 studies consisting of 6313 patients were eligible. The pooled estimation of reoperation for postoperative bleeding was 7% (95% confidence interval [CI:] 5-8; I²  = 84.73%; reported by 39 studies including 4796 patients). The mean volume of transfused packed blood cells and fresh frozen plasma was 1677 ml (95% CI: 1066.4-2287.6) and 1016.5 ml (95% CI: 450.7-1582.3). The subgroup by the stent type showed a decrease in the heterogeneity (I²  = 0.01%, I²  = 53.95%, I²  = 0.01%, and I²  = 54.41% for Thoraflex® Hybrid, E-vita®, Frozenix®, and Cronus®, respectively). The subgroup by the chronicity of operation resulted in less heterogeneity among patients undergoing elective compared with nonelective operation (I²  = 29.22% vs. I²  = 80.56% in nonelective). Meta-regression analysis showed that age and male gender significantly impacted on the reoperation for postoperative bleeding.

CONCLUSIONS

The FET procedure for arch replacement is associated with coagulopathy complications and the transfusion of blood products. Male, age, and selective choice of FET use were found to be the heterogeneity sources of reoperation for postoperative bleeding.

Hypothermic circulatory arrest time affects neurological outcomes of frozen elephant trunk for acute type A aortic dissection: A systematic review and meta-analysis

BACKGROUND

The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes.

METHODS

A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA).

RESULTS

Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 - 9; I²  = 68.65%), 5% (95% CI 4 - 7; I²  = 63.93%), and 3% (95% CI 2 - 4; I²  = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances.

CONCLUSIONS

It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.

Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization

BACKGROUND AND AIM OF THE STUDY

The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta-analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization.

METHODS

We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR).

RESULTS

A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in-hospital mortality were 7.104 (95% confidence interval [CI], 5.691-8.661; I²  = 78.53%), 3.465 (95% CI, 2.852-4.136; I²  = 15.96), 14.969 (95% CI, 11.361-18.977; I²  = 91.26%), and 8.933 (95% CI, 7.128-10.919; I²  = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36-0.81; p = .003; I²  = 0%).

CONCLUSIONS

The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

A tailored strategy for repair of acute type A aortic dissection

OBJECTIVE

Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.

METHODS

We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis.

RESULTS

From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01).

CONCLUSIONS

A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.

Alternatives to the frozen elephant trunk in acute type A aortic dissection

Acute type A aortic dissection remains one of the most challenging condition in cardiothoracic surgery, with a high mortality rate. Various improvements and innovations have happened over the years to better the outcome of this lethal condition. The frozen elephant trunk prosthesis has been developed to negate the long-term complications of acute type A aortic dissection, but at the cost of increased morbidity compared to hemiarch replacement. Although hemiarch and total arch replacement seem have less morbidity than the frozen elephant trunk technique, they do not address the long-term complications of the distal dissected aorta. Few surgeons now suggest hybrid aortic arch repair as a solution for acute type A aortic dissection. The long-term results need to be studied in all procedures before standardizing them. Although multiple strategies are evolving, the short-term goal of acute type A aortic dissection has not changed: to save the patient's life. The surgical strategy has to be tailored according to the patient's condition and the surgeon's experience.

Long-term outcomes of the frozen elephant trunk procedure: a systematic review

Background

The frozen elephant trunk (FET) procedure remains an increasingly popular approach to address complex multi-segmental aortic pathologies, owing to their ability to promote false lumen thrombosis and reduce the need for second-stage operations. While the short-term outcomes of such procedures have been shown to be acceptable, much less is known regarding long-term outcomes. This systematic review evaluates long-term outcomes of the FET procedure.

Methods

Studies with at least 12 months follow-up data on FETs were identified in four electronic databases. All studies were reviewed by two independent researchers and relevant data extracted. Long-term outcomes, including overall survival, freedom from reintervention, and freedom from aortic events, were evaluated using patient data recreated from digitized Kaplan-Meier curves.

Results

Thirty-seven studies with 4,178 patients were identified. The majority of the studies focused solely on acute dissections. Average follow-up was 3.2 years. Overall survival at 1-, 3-, and 5-year was 89.6%, 85.2%, and 82.0%, respectively. Freedom from reintervention at the same timepoints were 93.9%, 89.3%, and 86.8%, respectively. Mortality, permanent neurological deficit and spinal cord injury were 10.2%, 7.7%, and 6.5%, respectively.

Conclusions

Survival after the FET procedure is favorable, though ongoing close serial monitoring is essential to assess for the need for further reintervention. Larger multi-institutional registries are required to provide more robust evidence to better elucidate the patient cohort that would most benefit from the FET.

Current status in decision making to treat acute type A dissection: limited versus extended repair

Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.

Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection

OBJECTIVE

The aim of this study was to investigate the effect of frozen elephant trunk deployment from the zone 0 aorta to the descending aorta on early and midterm postoperative results in patients with acute type A aortic dissection.

METHODS

Between October 2014 and April 2018, 108 patients underwent a combined strategy of frozen elephant trunk deployment, ascending aortic replacement, and arch vessel reconstruction ("zone 0 arch repair" strategy) for acute type A aortic dissection (excluding DeBakey type II). Of the 108 patients, 32 (29.6%) had primary tears of the aortic arch or descending aorta.

RESULTS

The 30-day mortality rate was 2.8% (3 patients), and in-hospital mortality rate was 6.5% (7 patients). New-onset permanent neurologic dysfunction and spinal cord injury occurred in 3.7% and 0% of patients, respectively. Five of the 101 survivors underwent thoracic endovascular aortic repair during hospitalization (2 for rapid false lumen enlargement; 3 for true lumen stenosis). The overall survival was 89.8%, 88.1%, and 88.1% at 1, 2, and 3 years, respectively. The cumulative incidence of distal aortic reintervention was 5.8%, 9.1%, and 9.1% at 1, 2, and 3 years, respectively. Two patients underwent thoracic endovascular aortic repair for distal aortic enlargement after discharge.

CONCLUSIONS

The use of the "zone 0 arch repair" strategy can eliminate the need for invasive aortic arch resection. It also eliminates the false lumen and produces satisfactory early and midterm postoperative results. Therefore, it can be an alternative to hemiarch and total arch replacements, which are based on a conventional "tear-oriented resection" strategy.

Impact of Supraaortic Intimal Tears on Aortic Diameter Changes After Nontotal Arch Replacement

BACKGROUND

This study evaluated the impact of the intimal tear location on aortic dilation and reintervention after nontotal arch replacement (non-TAR) for acute type I aortic dissection.

METHODS

Between 2009 and 2017, 92 patients who underwent non-TAR for acute type I aortic dissection were enrolled. Intimal tears were analyzed at the supraaortic (SA) segment; segment 1, proximal descending thoracic aorta (DTA); segment 2, distal DTA; and segment 3, abdominal aorta. Aortic diameter was measured at the pulmonary artery bifurcation, celiac axis, maximal abdominal aorta, and maximal thoracoabdominal aorta using serial follow-up computed tomographic scans. The Fisher exact or χ² test, independent t or Mann-Whitney U test, and log-rank test were used in the statistical analyses.

RESULTS

The significant factors for increasing aortic diameter were the first location of intimal tear in the SA segment and segments 1 and 2. In the adjusted analysis, the first location of intimal tear in the SA segment and segment 1 was statistically significant. In the additional adjusted analysis, a segment 1 tear without SA tear was the only significant factor for increasing aortic diameter. The 5-year freedom from reintervention rate was significantly higher in patients with no intimal tear than in those with a segment 1 intimal tear with/without SA tear.

CONCLUSIONS

We confirmed that SA and proximal DTA intimal tears are associated with subsequent aortic dilation and reintervention. These proximal aortic intimal tears might warrant aggressive surgical treatment at the initial operation or close postoperative follow-up.

Late outcomes of strategic arch resection in acute type A aortic dissection

OBJECTIVE

To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD).

METHODS

From 1996 to 2017, we compared outcomes of hemiarch (n = 322) versus aggressive arch replacements (zones 2 and 3 arch replacement with implantation of 2-4 arch branches, n = 150) in ATAAD. Indications for aggressive arch were arch aneurysm >4 cm or intimal tear in the aortic arch that was not resectable by hemiarch replacement, or dissection of arch branches with malperfusion.

RESULTS

Patients in the aggressive arch group were significantly younger (mean age: 57 vs 61 years old) and had significantly longer hypothermic circulatory arrest, cardiopulmonary bypass, and aortic crossclamp times. There were no significant differences in perioperative outcomes between hemiarch and aggressive arch groups, including 30-day mortality (5.3% vs 7.3%, P = .38) and postoperative stroke rate (7% vs 7%, P = .96). Over 15 years, Kaplan-Meier survival was similar between hemiarch and aggressive arch groups (log-rank P = .55, 10-year survival 70% vs 72%). Given death as a competing factor, incidence rates of reoperation over 15 years (2.1% vs 2.0% per year, P = 1) and 10-year cumulative incidence of reoperation (14% vs 12%, P = .89) for arch and distal aorta pathology were similar between the 2 groups.

CONCLUSIONS

Both hemiarch and aggressive arch replacement are appropriate approaches for select patients with ATAAD. Aggressive arch replacement should be considered for an arch aneurysm >4 cm or an intimal tear at the arch unable to be resected by hemiarch replacement, or dissection of the arch branches with malperfusion.

Aortic Arch Reconstructive Surgery With Conventional Techniques vs Frozen Elephant Trunk: A Systematic Review and Meta-Analysis

BACKGROUND

Frozen elephant trunk (FET) surgery offers a new alternative in the management of complex thoracic aortic aneurysms and dissections. We performed a systematic review and meta-analysis of comparator observational studies evaluating the efficacy of FET compared with conventional aortic arch surgery, primarily focusing on mortality and stroke as well as the secondary outcomes of spinal cord ischemia, major bleeding, and operative time.

METHODS

We searched MEDLINE, EMBASE, PubMed, and the Cochrane Library for trials and studies comparing the FET technique with conventional surgery in patients with aortic aneurysms or dissections, or both. The overall quality of evidence was low, as assessed by Grading of Recommendations, Assessment, Development, and Evaluation, based primarily on the risk of bias secondary to study design, plausible confounding, and imprecision.

RESULTS

Meta-analysis revealed a significant reduction in mortality (12 studies, 1803 patients: odds ratio [OR], 0.55; 95% CI, 0.39-0.78) and a nonsignificant reduction in stroke (12 studies, 1803 patients: OR, 0.78; 95% CI, 0.52-1.15) favouring FET; however, FET was associated with a significant increase in spinal cord ischemia (9 studies, 1476 patients: OR, 2.20; 95% CI, 1.10-4.37). No significant differences between groups were observed regarding major bleeding, cardiopulmonary bypass time, or cross-clamp time.

CONCLUSIONS

Current evidence suggests that FET surgery is associated with lower mortality in patients with thoracic aneurysmal disease and dissections, without a significant increase in stroke, bleeding, or operative times. However, the risk of spinal cord ischemia is increased in patients who undergo FET. A well-powered randomized trial is needed to evaluate this evolving field.

Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy

BACKGROUND

The optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy.

METHODS AND RESULTS

All aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included organ-specific morbidity and 1- and 5-year outcomes as estimated using the Kaplan-Meier method. The majority of initial reoperations were proximal aortic (aortic valve, aortic root, or ascending) or aortic arch procedures (62.5%, n=55); most initial reoperations were performed in the elective setting (83.1%, n=74). Additional nonstaged second or more reoperations were required in 21 patients (23.6%) after the initial reoperation, during a median follow-up of 2.5 years after the initial reoperation. Thirty-day or in-hospital mortality for all reoperations was 7.0% (elective: 6.3%; nonelective: 11.1%) with acceptable rates of organ-specific morbidity, given the procedural complexity. One- and 5-year overall survival after initial reoperation was 85.9% and 64.9%, respectively, with aorta-specific survival of 88% at 5 years.

CONCLUSIONS

Reoperation after acute type A aortic dissection repair is associated with low rates of mortality and morbidity. These data support more limited index repair for acute type A dissection, especially for patients undergoing index repair in lower volume centers without expertise in extensive repair, because reoperations, if needed, can be performed safely in referral aortic centers.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m² (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Long-Term Changes in the Distal Aorta after Aortic Arch Replacement in Acute DeBakey Type I Aortic Dissection

BACKGROUND

We analyzed the long-term results of ascending aortic replacement and arch aortic replacement in acute DeBakey type I aortic dissections to measure the differences in the distal aortic changes with extension of the aortic replacement.

METHODS

We reviewed 142 cases of acute DeBakey type I aortic dissections (1996-2015). Seventy percent of the cases were ascending aortic replacements, and 30% of the cases underwent total arch aortic replacement, which includes the aorta from the root to the beginning of the descending aorta with the 3 arch branches. Fourteen percent (20 cases) resulted in surgical mortality and 86% of cases that survived had a mean follow-up period of 6.6±4.6 years. Among these cases, 64% of the patients were followed up with computed tomography (CT) angiograms with the duration of the final CT check period of 4.9±2.9 years.

RESULTS

There were 15 cases of reoperation in 13 patients. Of these 15 cases, 13 cases were in the ascending aortic replacement group and 2 cases were in the total arch aortic replacement group. Late mortality occurred in 13 cases; 10 cases were in the ascending aortic replacement group and 3 cases were in the total arch aortic replacement group. Eight patients died of a distal aortic problem in the ascending aortic replacement group, and 1 patient died of distal aortic rupture in the total arch aortic replacement group. The follow-up CT angiogram showed that 69.8% of the ascending aortic replacement group and 35.7% of the total arch aortic replacement group developed distal aortic dilatation (p=0.0022).

CONCLUSION

The total arch aortic replacement procedure developed fewer distal remnant aortic problems from dilatation than the ascending aortic replacement procedure in acute type I aortic dissections.

Descending endografts for type A dissections: con

An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. Studies on the fate of residual dissection after acute type A aortic dissection repair in the past decade have driven surgeons to seek procedures to avoid distal reoperation. Aggressive surgical approach with total arch replacement in acute type A dissection has demonstrated lower incidence of distal reoperation and slower aortic growth rate compared to less aggressive ascending/hemiarch repair. Recently, successful results of thoracic endovascular aortic repair (TEVAR) in type B aortic dissection have encouraged surgeons to further attack acute type A aortic dissection with hybrid approach: antegrade endografting in the descending thoracic true lumen as an adjunct to hemiarch or total arch repair. However, is the hybrid approach with simultaneous descending endografting justified in all the acute type A aortic dissection cases? The outcomes of the hybrid approach reported by the several groups have demonstrated 80-100% of false lumen thrombus formation in the proximal descending aorta (stented segment); however, the complete obliteration of the false lumen is only 17-50%. The incidence of distal reoperation/reintervention after hybrid approach is as high as 14% and an adjunctive procedure is often performed. Moreover, there are concerns about additional risks associated with the hybrid procedures, such as spinal cord injury (SCI), stent graft induced new entry and stroke. The data on this new approach are still very limited. Hence, further study is warranted to prove its safety and durability.

Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

BACKGROUND

Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection.

METHODS

A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement.

RESULT

Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56-0.94; P=0.02; I(2)=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65-1.09; P=0.20; I(2)=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation.

CONCLUSIONS

Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

A Meta-Analysis of Total Arch Replacement With Frozen Elephant Trunk in Acute Type A Aortic Dissection

Objectives:

To assess the safety and efficacy, we performed a meta-analysis of total arch replacement with frozen elephant trunk in exclusive acute type A (neither chronic nor type B) aortic dissection.

Methods:

Databases including MEDLINE and EMBASE were searched through March 2015 using Web-based search engines (PubMed and OVID). Eligible studies were case series of frozen elephant trunk enrolling patients with acute type A (neither chronic nor type B) aortic dissection reporting at least early (in-hospital or 30-day) all-cause mortality. Study-specific estimates were combined in both fixed- and random-effect models.

Results:

Fifteen studies enrolling 1279 patients were identified and included. Pooled analyses demonstrated the cardiopulmonary bypass time of 207.1 (95% confidence interval [CI], 186.1-228.1) minutes, aortic cross-clamp time of 123.3 (95% CI, 113.1-133.5) minutes, selective antegrade cerebral perfusion time of 49.3 (95% CI, 37.6-61.0) minutes, hypothermic circulatory arrest time of 39.0 (95% CI, 30.7-47.2) minutes, early mortality of 9.2% (95% CI, 7.7-11.0%), stroke of 4.8% (95% CI, 2.5-9.0%), spinal cord injury of 3.5% (95% CI, 1.9-6.6%), mid- to long-term (≥1-year) overall mortality of 13.0% (95% CI, 10.4-16.0%), reintervention of 9.6% (95% CI, 5.6-15.8%), and false lumen thrombosis of 96.8% (95% CI, 90.7-98.9%).

Conclusions:

Total arch replacement with frozen elephant trunk provides a safe alternative to that with conventional elephant trunk in patients with acute type A aortic dissection, with acceptable early mortality and morbidity. The rates of mid- to long-term reintervention and false lumen non-thrombosis may be lower in patients undergoing the frozen than conventional elephant trunk procedure.

Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection

OBJECTIVES

The complexity of surgical treatment for acute type A dissection contributes to the variability in patient management. This study was designed to elucidate the contemporary practice preferences of cardiac surgeons regarding different phases of management of acute type A aortic dissection.

METHODS

A 34-item questionnaire was distributed to all Canadian adult cardiac surgeons addressing the preoperative, intraoperative, and postoperative management of acute type A dissection. A total of 100 responses were obtained (82% of active surgeons in Canada). Outcomes were compared between high- and low-volume aortic surgeons.

RESULTS

Seventy-six percent of respondents favored axillary artery cannulation. High-volume surgeons (>150 cases) were more likely to indicate a target lowest nasopharyngeal temperature more than 20 °C (53% vs 25%, P = .02). The majority of surgeons (65%) recommended using selective antegrade cerebral perfusion, with a significantly greater proportion for higher-volume aortic surgeons (P = .03). In addition, high-volume aortic surgeons were more likely to recommend aortic root replacement at smaller diameters (73% vs 55%, P = .02), to recommend more extensive distal aortic resection with routine open hemiarch anastomosis (85% vs 65%, P = .04), and to more commonly perform total arch reconstruction when needed (93% vs 77%, P = .04). In the follow-up period, frequency of serial imaging of the residual aorta was significantly higher for high-volume aortic surgeons (P = .04).

CONCLUSIONS

This study identified some commonalities in practice preferences among Canadian cardiac surgeons for the management of acute type A aortic dissection. However, it also highlighted significant differences in temperature management, cerebral protection strategies, and extent of resection between high-volume and low-volume aortic surgeons.