Clinical outcomes and rates of aortic growth and reoperation after 1-stage repair of extensive chronic thoracic aortic dissection

Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch

OBJECTIVES

Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS).

METHODS

From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2.

RESULTS

Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified.

CONCLUSIONS

The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don't Despair the Repair

BACKGROUND

There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair.

METHODS

From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis.

RESULTS

Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y.

CONCLUSIONS

Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.

Total arch and descending thoracic aortic replacement for massive hemoptysis requiring CPR caused by intrapulmonary penetration of chronic dissecting aortic aneurysm: a case report

BACKGROUND

Intrapulmonary penetration of the thoracic aorta is a rare, life-threatening complication of a chronic dissecting aortic aneurysm. It causes massive hemoptysis requiring prompt intervention to prevent fatal airway bleeding. A surgical approach that enables diverse surgical maneuvers and intraoperative organ protection is crucial.

CASE PRESENTATION

A 62-year-old man, who underwent graft replacement of the ascending aorta for an acute type A aortic dissection 20 months before, developed massive hemoptysis and cardiac arrest. The hemoptysis was secondary to an aortopulmonary fistula from a rapidly expanding dissecting aortic aneurysm. However, a successful return of spontaneous circulation was achieved with cardiopulmonary resuscitation, including establishment of veno-arterial extracorporeal membrane oxygenation. The patient successfully underwent a total arch and descending thoracic aortic replacement. This was achieved by a median sternotomy combined with a left thoracotomy using a straight incision with a rib-cross (SIRC) approach. The patient was uneventfully discharged and remained well for the following 2 years.

CONCLUSIONS

When performing a surgical graft replacement for an aortopulmonary fistula with a thoracic aortic aneurysm, the surgical approach chosen is critical. A surgical procedure using a median sternotomy combined with a left thoracotomy and a SIRC approach can be an effective therapeutic option.

Transsternal and Transpericardial Approach to Descending Thoracic Aorta via Median Sternotomy-An Option for Extensive Aortic Surgery

We describe a technique for approaching the distal descending thoracic aorta via median sternotomy and posterior pericardiotomy, which enabled us to perform the extensive aortic repair. While this approach shared the lesser invasiveness of the frozen elephant trunk procedure with less confinement by anatomic features, the advantage was counterbalanced by the high incidence of spinal cord ischemia. This approach can be an option in highly selected patients who require extensive aortic repair but have factors prohibiting other conventional approaches.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

False Lumen Stent-Grafts for Repair of Postdissection Aortic Aneurysms

PURPOSE

To evaluate the safety and efficacy of false lumen (FL) stent-grafts in the treatment of postdissection aortic aneurysms.

MATERIALS AND METHODS

Eleven patients who underwent endovascular repair using FL stent-grafts from January 2016 to June 2019 were included. Among them, 2 patients had a prior history of type A aortic dissection, whereas 9 had undergone a prior endovascular repair for type B aortic dissection. Computed tomography angiography was performed to evaluate the reintervention and technical success rate, aortic remodeling, and other related aortic complications.

RESULTS

The mean age of patients was 55.6 ± 10.4 years. Technical success was achieved in all patients, and neither early mortality nor paralysis occurred. In total, 8 visceral branch arteries originating from the FL were reconstructed. The true lumen areas at the celiac axis, superior mesenteric artery, renal artery, and abdominal aortic bifurcation were significantly increased from 230.1 mm² to 312.3 mm², 212.1 mm² to 277.5 mm², 209.1 mm² to 291.6 mm², and 214.4 mm² to 300.6 mm², respectively (P < .05). The total diameter of the aorta at the 4 designated levels was stable or had shrunk in all patients. At a mean follow-up of 18.9 ± 7.6 months, 1 patient received re-intervention owing to iliac stent-graft occlusion. No aortic-related mortality occurred.

CONCLUSIONS

FL stent-grafts can safely and effectively treat patients with postdissection aortic aneurysms. This strategy can be used to promote thrombosis of the FL and aortic remodeling. A larger sample and an extended follow-up period are needed to produce more conclusive results.

Frozen elephant trunk and arch endografts for chronic thoracoabdominal aortic dissections

Chronic aortic dissecting aneurysms (TAAD) presenting after acute Stanford type A or B dissection includes both arch and/or thoracoabdominal aortic aneurysms (TAAA). Approximately 60% of patients who survive surgical treatment of acute type A aortic dissections will require another aortic procedure. Similarly, more than 70% of patients with chronic type B aortic dissections will experience false lumen dilation at 5-year follow-up, often requiring intervention. Open or hybrid aortic repairs of complex TAAD involving the arch and the TAAA are very demanding procedures for both patients and clinicians. Open surgery remains the first line therapy in fit patients. Recent development of branched arch devices has offered an alternative option for high-risk patients. Technical challenges associated with the endovascular management of these complex aneurysms include proximal sealing zone often located in the aortic arch or the ascending aorta, narrow true lumen working space, and aortic branch perfusion by either the true or false lumen, or both. Recent studies have reported encouraging results with endovascular treatment of these complex dissecting aneurysms, especially following open ascending aortic repair. The aim of this review was to describe the available strategies for arch repair in the setting of a chronic TAAD and to determine the subset of patients that can benefit from of a totally endovascular approach.