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Silverberg D, Bar-Dayan A, Raskin D, Canani S, Halak M. The jailed coiling technique: An endovascular solution for saccular aneurysms with suboptimal fixation sites. Vascular 2024:17085381241273269. [PMID: 39212140 DOI: 10.1177/17085381241273269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To evaluate the midterm results of patients with saccular aneurysms treated with the jailed coiling technique. METHODS A retrospective review of 17 patients treated with the jailed coiling technique over a 7 year period, between 2018 and 2024 at our institution. Treatment entails placing an endograft across the neck of the saccular aneurysm followed by coiling of the aneurysm through an extraluminal catheter. Debranching procedures of the aortic arch were performed when necessary in order to create a sealing zone of >5 mm. Data collected included demographics, anatomical features of the lesions and sealing zones, indication for intervention, method of treatment and technical success, sac expansion, and reinterventions. RESULTS 17 patients (median age 69, 14 males) were treated for saccular aneurysms with short, suboptimal sealing zones (aortic arch 13, distal thoracic aorta 2, celiac trunk 1, brachiocephalic artery 1). Among the aortic arch aneurysms, six required preoperative debranching procedures of the aortic arch in order to create a short landing zone of 5 mm, making them eligible for the procedure. Technical success was obtained in all patients. One perioperative mortality occurred. Mean follow-up among those treated for arch aneurysms was 32 months (range 1-71 months). One patient who was treated for an aortic arch aneurysm had a persistent endoleak. No sac enlargement was observed. None of the patients required interventions and none experienced aneurysm related mortality. CONCLUSION The jailed coiling technique is a safe and effective method to treat saccular arterial aneurysms with suboptimal, short sealing zones. It can be utilized for saccular aneurysms located within the aortic arch and for aneurysms located in other locations where coiling or stent grafting is not an option. The procedure can be performed with minimal morbidity with a high percentage of success. Long term durability of the repair needs to be determined.
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Affiliation(s)
- Daniel Silverberg
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Israel
| | - Avner Bar-Dayan
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Israel
| | - Daniel Raskin
- The division of diagnostic imaging, The Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv School of Medicine, Tel Aviv University, Israel
| | - Sami Canani
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Israel
| | - Moshe Halak
- The Department of Vascular Surgery, The Chaim Sheba Medical Center, Israel
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Wang X, Ma J, Li C, Yang F, Wang L, Du Z, Li H, Zhu J, Zhang H, Hou X. Does Higher Temperature During Moderate Hypothermic Circulatory Arrest Increase the Risk of Paraplegia in Acute DeBakey I Aortic Dissection Patients? Can J Cardiol 2024:S0828-282X(24)00520-8. [PMID: 38981559 DOI: 10.1016/j.cjca.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/23/2024] [Accepted: 06/28/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND In this study, we sought to assess the safety of high-moderate (24.1-28.0°C) and low-moderate (20.1-24.0°C) systemic hypothermia during circulatory arrest (MHCA) in patients with acute DeBakey I aortic dissection (DeBakey I AAD), particularly concerning spinal cord protection. METHODS From 2009 to 2020, 1759 patients with DeBakey I AAD who underwent frozen elephant trunk and total arch replacement surgery at a tertiary centre were divided into preoperative malperfusion (viscera, spinal cord, or lower extremities) and nonmalperfusion subgroups. The baseline differences were balanced with the use of propensity score matching. Prognoses were compared between those who were subjected to high-MHCA (nasopharyngeal temperature 24.1-28.0°C) and low-MHCA (nasopharyngeal temperature 20.1-24.0°C). RESULTS In the nonmalperfusion subgroup (n = 1389), 469 pairs of matched patients showed lower in-hospital mortality and incidence of acute kidney injury in the high-MHCA group than in the low-MHCA group: in-hospital mortality 7.0% vs 10.2% (P = 0.01); acute kidney injury, 57.1% vs 64.6% (P < 0.01). The duration of mechanical ventilation was shorter in the high-MHCA group than that in the low-MHCA group (P = 0.03). No significant difference in the incidence of paraplegia was observed between the 2 groups. In the malperfusion subgroup (n = 370), 112 pairs of matched patients showed a higher incidence of paraplegia in the high-MHCA group than in the low-MHCA group (15.9% vs 6.5%; P = 0.04). CONCLUSIONS The safety of high-MHCA, a commonly used temperature management strategy during aortic arch surgery, was recognised in most patients with DeBakey I AAD. However, among patients with preoperative distal organ malperfusion, low-MHCA may be more appropriate owing to an increased risk of postoperative paraplegia associated with high-MHCA.
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Affiliation(s)
- Xiaomeng Wang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiawang Ma
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Yang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongtao Du
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiyang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Ito H, Bessho S, Shomura Y, Kato N, Kanemitsu S, Mizumoto T, Hirano K, Maze Y, Tokui T, Takao M. Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02043-9. [PMID: 38822182 DOI: 10.1007/s11748-024-02043-9] [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: 02/09/2024] [Accepted: 05/18/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. METHODS Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0 years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0 months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. RESULTS Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5 years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5 years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. CONCLUSIONS Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.
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Affiliation(s)
- Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Saki Bessho
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yu Shomura
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Shinji Kanemitsu
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Toru Mizumoto
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
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5
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Nienaber S, Yuan X, Price S, Rosendahl U, Nienaber CA. The elephant's Achilles' heel: a case report of acute obstruction of frozen elephant trunk after proximal aortic dissection repair. Eur Heart J Case Rep 2024; 8:ytae186. [PMID: 38690556 PMCID: PMC11060110 DOI: 10.1093/ehjcr/ytae186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
Background The frozen elephant trunk (FET) technique as a hybrid combining surgical and endovascular repair is an emerging concept to treat complex aortic dissection. Early experience showed technical feasibility and promising clinical outcomes. However, unsuspected complications still arise. Case summary A 25-year-old male presented to the emergency department with a 2-day history of chest pain. After exclusion of acute coronary syndrome, a computed tomography angiography (CTA) revealed Type A (DeBakey Type I) aortic dissection. The patient underwent median stenotomy for complete replacement of the ascending aorta, the aortic arch, and FET. Early after rewarming, the patient became unstable due to severe left ventricular dysfunction. Soon veno-arterial extracorporal membrane oxygenation (VA-ECMO) was required for circulatory support. The cause of deterioration remained unclear until repeated CTA showed acute obstruction of the FET. Invasive exploration confirmed a trans-FET gradient of 100 mmHg, successfully managed by repeated balloon inflation with resolution of both obstruction and gradient. The patient recovered completely without any sequela. Discussion While the mechanism of acute obstruction after FET remains subject to speculation, the rescue intervention of ballooning the obliteration on VA-ECMO was life-saving. Intraoperative ultrasound and videoscopic inspection may be instrumental before chest closure to avoid such critical events.
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Affiliation(s)
- Stephan Nienaber
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Xun Yuan
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
| | - Susanna Price
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
| | - Ulrich Rosendahl
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
- Department of Cardiac Surgery, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London, UK
| | - Christoph A Nienaber
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
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Kim CH, Kim TH, Lee H, Kim MS, Heo W, Yoo KJ, Cho BK, Song SW. One-year outcomes of total arch replacement and frozen elephant trunk using the E-vita Open NEO. Eur J Cardiothorac Surg 2024; 65:ezae017. [PMID: 38238991 DOI: 10.1093/ejcts/ezae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/14/2024] [Accepted: 01/13/2024] [Indexed: 03/12/2024] Open
Abstract
OBJECTIVES In this cohort study, we aimed to assess the 1-year clinical outcomes of using the E-vita Open NEO™ hybrid prosthesis for total arch replacement with frozen elephant trunk (FET) to repair extensive aortic pathologies. METHODS We reviewed individuals who underwent thoracic aortic surgery between April 2021 and March 2023 from the Gangnam Severance Aortic Registry. Exclusion criteria included ascending aortic replacement, 1 or 2 partial arch replacement, descending aortic replacement and total arch replacement without an FET. Finally, all consecutive patients who underwent total arch replacement and FET with E-vita Open NEO for aortic arch pathologies between April 2021 and March 2023 were included in this cohort study. The patients were divided into 3 groups based on their pathology: acute aortic dissection, chronic aortic dissection and thoracic aortic aneurysm. The primary end point was in-hospital mortality. The secondary end points during the postoperative period comprised stroke, spinal cord injury and redo sternotomy for bleeding. Additionally, the secondary end points during the follow-up period included the 1-year survival rate, 1-year freedom from all aortic procedures and 1-year freedom from unplanned aortic interventions. RESULTS The study included 167 patients in total: 92 patients (55.1%) with acute aortic dissection, 20 patients (12.0%) with chronic aortic dissection and 55 patients (32.9%) with thoracic aortic aneurysm. The in-hospital mortality was 1.8% (n = 3). Strokes occurred in 1.8% (n = 3) of the patients, spinal cord injury in 1.8% (n = 3) and redo sternotomy for bleeding was performed in 3.0% (n = 5). There were no significant differences between the pathological groups. The median follow-up period (quartile 1-quartile 3) was 198 (37-373) days, with 1-year survival rates of 95.9%. At 1 year, the freedom from all aortic procedures and unplanned aortic interventions were 90.3% and 92.0%, respectively. CONCLUSIONS The 1-year clinical outcomes of total arch replacement with FET using the E-vita Open NEO were favourable. Long-term follow-up is required to evaluate the durability of the FET.
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Affiliation(s)
- Chong Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Myeong Su Kim
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Woon Heo
- Vascular Access Centre, Lifeline Clinic, Busan, Republic of Korea
| | - Kyung-Jong Yoo
- Department of Cardiovascular Surgery, Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bum-Koo Cho
- The Korea Heart Foundation, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
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7
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Rajesh K, Levine D, Murana G, Castagnini S, Bianco E, Childress P, Zhao Y, Kurlansky P, Pacini D, Takayama H. Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality. Eur J Cardiothorac Surg 2024; 65:ezae041. [PMID: 38318956 DOI: 10.1093/ejcts/ezae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. METHODS This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.
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Affiliation(s)
- Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Giacomo Murana
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sabrina Castagnini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo Bianco
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Patra Childress
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
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8
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Di Marco L, Gliozzi G, Votano D, Murana G, Leone A, Cavalli GG, Brillanti G, Pacini D. Reoperations on the ascending aorta and aortic arch: A retrospective series of 453 patients. J Thorac Cardiovasc Surg 2024; 167:897-907.e3. [PMID: 35690473 DOI: 10.1016/j.jtcvs.2022.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 02/22/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality. METHODS Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations. RESULTS The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P > .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P < .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P < .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P < .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P < .01). CONCLUSIONS In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.
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Affiliation(s)
- Luca Di Marco
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy.
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Daniela Votano
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giacomo Murana
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Alessandro Leone
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giulio Giovanni Cavalli
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
| | - Giorgia Brillanti
- Division of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Italy
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9
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Han SM, DiBartolomeo AD, Pyun AJ, Maithel S, Patel S, Fleischman F. Use of Iliac Branch Endoprosthesis to Rescue Inadvertent False Lumen Deployment of the Innominate Branch Stent During Physician-Modified Fenestrated-Branched Aortic Arch Repair. Vasc Endovascular Surg 2024; 58:193-199. [PMID: 37473451 DOI: 10.1177/15385744231191216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
A 70-year-old male with a history of 3 prior median sternotomies and on anticoagulation presented with acute chest and back pain associated with a pseudoaneurysm of the ascending and aortic arch in the setting of residual dissection involving the innominate, proximal right carotid, and subclavian arteries. A physician-modified triple vessel fenestrated-branched arch endograft was deployed. The innominate branch stent was deployed from the right carotid cut down, while the left carotid and left subclavian branch stents were placed from a femoral approach. Postoperatively, the innominate branch was found to be deployed in the false lumen of the dissected native innominate artery, leading to continued pressurization of the pseudoaneurysm. This was rescued by placing a Gore Iliac Branch Endoprosthesis (IBE) into the innominate branch through a temporary conduit sewn to the right carotid artery with a right subclavian branch placed via a brachial artery cut down into the internal iliac gate. The use of IBE allowed branch stent extension past the dissected native vessels. The patient had an uneventful recovery without neurologic complications. At 3-month follow-up, the patient remains well with an excluded pseudoaneurysm, and patent bifurcated innominate, bilateral carotid, and subclavian artery branches. A Gore IBE can be utilized in a dissected innominate artery to create an innominate branch device during fenestrated-branched endovascular arch repair.
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Affiliation(s)
- Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Shelley Maithel
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sanjeet Patel
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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10
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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11
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Murana G, Gliozzi G, Di Marco L, Campanini F, Snaidero S, Nocera C, Rucci P, Barberio G, Leone A, Lovato L, Pacini D. Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience. Eur J Cardiothorac Surg 2024; 65:ezad364. [PMID: 37930039 PMCID: PMC10859176 DOI: 10.1093/ejcts/ezad364] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/24/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVES The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022. METHODS The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022. RESULTS Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22). CONCLUSIONS The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.
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Affiliation(s)
- Giacomo Murana
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Francesco Campanini
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Silvia Snaidero
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Chiara Nocera
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Bologna, Italy
| | - Giuseppe Barberio
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luigi Lovato
- Cardiovascular Radiology Unit, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
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12
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Kiziltepe U, Ince I, Senkal M, Surer S, Duvan I, Ersoy O, Delibalta O, Mavi O, Sahin E. Total aortic arch replacement without deep hypothermic circulatory arrest in type A aortic dissection: Left axillar artery for arterial cannulation. JTCVS Tech 2023; 22:120-131. [PMID: 38152213 PMCID: PMC10750496 DOI: 10.1016/j.xjtc.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). The frozen elephant trunk technique (FET) additionally requires commercial hybrid grafts. Herein we describe a novel modified FET technique without CA using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection. Methods LAxA anastomosis is made first using a homemade debranching graft, and cardiopulmonary bypass is initiated, followed by anastomoses of left common carotid and innominate arteries. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta/root, cardiac reperfusion is started using a root cannula which continues throughout the procedure. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via left subclavian artery. Lower body perfusion is interrupted for 5 to 8 minutes to deploy an endograft to complete a modified FET. Following cannulation of distal arch graft, perfusion of distal aorta is restarted, and all three grafts are incorporated to construct a neo-ascending aorta and arch. Results Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7, and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body CA time was 7.2 ± 2.8 minutes. Conclusions TAR using standard endografts without CA is possible with LAxA cannulation. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies are required with a higher number of patients to evaluate the efficiency of this novel technique.
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Affiliation(s)
- Ugursay Kiziltepe
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ilker Ince
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Melike Senkal
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Suleyman Surer
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ibrahim Duvan
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ozgur Ersoy
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Delibalta
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Osman Mavi
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Elif Sahin
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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13
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Koulouroudias M, Velissarios K, Kokotsakis J, Magouliotis DE, Tsipas P, Arjomandi Rad A, Viviano A, Kourliouros A, Athanasiou T. Sizing the Frozen Elephant Trunk Based on Aortic Pathology and the Importance of Pre-Operative Imaging. J Clin Med 2023; 12:6836. [PMID: 37959302 PMCID: PMC10649248 DOI: 10.3390/jcm12216836] [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: 08/13/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
The frozen elephant trunk is a formidable tool for the aortovascular surgeon. An appreciation of how to size the graft in different pathologies is key in achieving optimal results. Herein, we demonstrate worked examples of how imaging can be used to plan for a frozen elephant trunk and discuss the nuisances and uncertainties of sizing using three index cases: Type A aortic dissection, distal thoracic aortic aneurysm and chronic dissection.
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Affiliation(s)
- Marinos Koulouroudias
- Department of Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB, UK;
| | | | - John Kokotsakis
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Dimitrios E. Magouliotis
- Department of Cardiothoracic Surgery, Larissa General University Hospital, 41334 Larissa, Greece;
| | - Pantelis Tsipas
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Arian Arjomandi Rad
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Alessandro Viviano
- Department of Cardiac Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
| | - Antonios Kourliouros
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, UK
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14
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Porterie J, Hostalrich A, Dagenais F, Marcheix B, Chaufour X, Ricco JB. Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique. J Clin Med 2023; 12:5693. [PMID: 37685761 PMCID: PMC10488597 DOI: 10.3390/jcm12175693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Jean Porterie
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France;
| | - Aurélien Hostalrich
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France; (A.H.); (X.C.)
| | - François Dagenais
- Department of Cardiovascular Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada;
| | - Bertrand Marcheix
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France;
| | - Xavier Chaufour
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France; (A.H.); (X.C.)
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Poitiers, 86000 Poitiers, France;
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15
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Arnold Z, Geisler D, Aschacher T, Winkler B, Lenz V, Crailsheim I, Folkmann S, Harrer M, Moidl R, Grabenwöger M, Weiss G. Long-Term Results with 187 Frozen Elephant Trunk Procedures. J Clin Med 2023; 12:4143. [PMID: 37373836 DOI: 10.3390/jcm12124143] [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: 05/05/2023] [Revised: 05/28/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
The frozen elephant trunk (FET) technique is an established therapeutic option in the treatment of complex aortic diseases. We report our long-term clinical outcomes after FET repair. A total of 187 consecutive patients underwent FET repair at our department between 8/2005 and 3/2023. Indications included acute and chronic aortic dissections and thoracic aneurysms. Endpoints included operative morbidity and mortality, long-term survival, and the need for reinterventions. Operative mortality, spinal cord injury and permanent stroke rates were: 9.6%, 2.7% and 10.2%, respectively. At five years, overall survival was 69.9 ± 3.9% and freedom from aortic-related death was 82.5 ± 3.0%, whereas at ten years, overall survival was 53.0 ± 5.5% and freedom from aortic-related death was 75.8 ± 4.8%. Sixty-one reinterventions on the thoracic aorta were necessary. Freedom from secondary interventions at ten years was 44.7 ± 6.4% overall (63.1 ± 10.0% for acute dissections, 40.8 ± 10.3% for chronic dissections and 28.9 ± 13.1% for aneurysms, respectively). The high reintervention rate for chronic dissections and for aneurysms is related to the pre-existing aortic pathology. Late aortic growth of untreated segments with potentially fatal outcome occurs even after ten years, so careful annual follow-up is mandatory in this patient cohort.
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Affiliation(s)
- Zsuzsanna Arnold
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Daniela Geisler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Thomas Aschacher
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Bernhard Winkler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
- Medical Faculty, Sigmund Freud University, 1020 Vienna, Austria
| | - Verena Lenz
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Ingo Crailsheim
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Sandra Folkmann
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Marieluise Harrer
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Reinhard Moidl
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
- Medical Faculty, Sigmund Freud University, 1020 Vienna, Austria
| | - Gabriel Weiss
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
- Medical Faculty, Sigmund Freud University, 1020 Vienna, Austria
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16
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Wilson King R, Carroll AM, Higa KC, Cleveland JC, Rove JY, Aftab M, Brett Reece T. Frozen Elephant Trunk for Acute Type A Dissection: Is Risk from Procedure or Patient Characteristics? AORTA (STAMFORD, CONN.) 2023; 11:112-115. [PMID: 37619568 PMCID: PMC10449567 DOI: 10.1055/s-0043-1768970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/07/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The initial goal of acute Type A aortic dissection (ATAAD) repair remains to get the patient off the table safely. More extensive repair is being pushed at the index operation with the frozen elephant trunk (FET) operation, but outcomes are suggested to be worse. However, we hypothesize that the risk associated with the FET in ATAAD is from the patient presenting factors rather than the operation itself. METHODS A retrospective review of a single institution prospective database from 2015 to 2021 was performed. Two cohorts were created based on the indication for FET: evidence of radiographic malperfusion (n = 44) or clinical malperfusion (n = 31). Data were analyzed for preoperative characteristics, intraoperative characteristics, and postoperative outcomes. Statistical univariate analysis was performed with chi-square analysis and t-tests with significance determined at an alpha level of 0.05. RESULTS Preoperative characteristics were similar in each group, independent of malperfusion markers. The intraoperative characteristics were similar, except the clinical malperfusion group had more packed red blood cells and cryoprecipitate given. The clinical malperfusion group had longer intensive care unit length of stay (p < 0.001), more postoperative strokes (p < 0.001), more reoperations (p <0.0001), and higher mortality rate (p = 0.0003). CONCLUSION These data suggest that clinical malperfusion increases the risk of major complications and death. However, full arch replacement with FET in the absence of clinical malperfusion does not appear to add risk to the operation for ATAAD. Patients with increased risk of distal degeneration should be considered for more aggressive replacement to avoid subsequent arch replacement.
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Affiliation(s)
- R. Wilson King
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Adam M. Carroll
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Kelly C. Higa
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Joseph C. Cleveland
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Jessica Y. Rove
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Muhammad Aftab
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Thomas Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
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Kozlov B, Panfilov D, Lukinov V. Frozen Elephant Trunk for Aortic Dissection Using Different Hybrid Grafts: Preliminary Results from a Prospective Study. J Pers Med 2023; 13:jpm13050784. [PMID: 37240954 DOI: 10.3390/jpm13050784] [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: 04/05/2023] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The frozen elephant trunk technique has become popular and led to an expansion of indications for surgery. Various hybrid grafts for the frozen elephant trunk are used, sometimes with significantly different features. The objective of this study was to compare early- and mid-term outcomes after the frozen elephant trunk for aortic dissection using different hybrid grafts. METHODS The prospective study included 45 patients with acute/chronic aortic dissections. The patients were randomized into two groups. Group 1 patients (n = 19) were implanted with a hybrid graft E-vita open plus (E-vita OP). Group 2 (n = 26) included patients who received a MedEng graft. The inclusion criteria were type A and type B acute and chronic aortic dissection. The exclusion criteria were as follows: hyperacute aortic dissection (less than 24 h), organ malperfusion, oncology, severe heart failure, stroke, and acute myocardial infarction. The primary endpoint was early- and mid-term mortality. The secondary endpoints were postoperative complications (stroke and spinal cord ischemia, myocardial infarction, respiratory failure, acute renal injury, and re-operation for bleeding). RESULTS The rate of stroke and spinal cord ischemia in the E-vita OP vs. MedEng groups was 11% vs. 4% (p = 0.565) and 11% vs. 0% (p = 0.173), respectively. The respiratory failure rate was comparable in both groups (p > 0.999). Acute kidney injury requiring hemodialysis and the need for re-sternotomy in the MedEng group vs. E-vita OP group was 31% vs. 16% (p = 0.309) and 15% vs. none (p = 0.126), respectively. Early mortality in the MedEng and E-vita OP groups did not differ (8% vs. 0, p = 0.501). The mid-term survival in the analyzed groups was 79% vs. 61%, (p = 0.079), respectively. CONCLUSIONS No statistically significant differences were observed between patients receiving frozen elephant trunk with the hybrid MedEng and E-vita OP grafts in regard to early mortality and morbidity. Mid-term survival was also non-significant between analyzed groups with a trend toward more favorable mortality in the MedEng group.
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Affiliation(s)
- Boris Kozlov
- Cardiology Research Institute-Branch of the Federal State Budgetary Scientific Institution 'Tomsk National Research Medical Center of the Russian Academy of Sciences', 634012 Tomsk, Russia
| | - Dmitri Panfilov
- Cardiology Research Institute-Branch of the Federal State Budgetary Scientific Institution 'Tomsk National Research Medical Center of the Russian Academy of Sciences', 634012 Tomsk, Russia
| | - Vitaliy Lukinov
- Institute of Computational Mathematics and Mathematical Geophysics, Siberian Branch of the Russian Academy of Sciences, 630090 Novosibirsk, Russia
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18
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Hostalrich A, Porterie J, Boisroux T, Marcheix B, Ricco JB, Chaufour X. Outcomes of Secondary Endovascular Aortic Repair After Frozen Elephant Trunk. J Endovasc Ther 2023:15266028231169172. [PMID: 37125426 DOI: 10.1177/15266028231169172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR). METHODS This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter. RESULTS From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2-34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity. CONCLUSIONS In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft. CLINICAL IMPACT In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study.
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Affiliation(s)
- Aurélien Hostalrich
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Porterie
- Department of Cardiovascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Thibaut Boisroux
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Bertrand Marcheix
- Department of Cardiovascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Baptiste Ricco
- Department of Clinical Research, University Hospital of Poitiers, Poitiers, France
| | - Xavier Chaufour
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
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19
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Tish S, Chase JA, Scoville C, Vogel TR, Cheung S, Bath J. A Systematic Review of Contemporary Outcomes from Aortic Arch In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2023; 91:266-274. [PMID: 36642166 DOI: 10.1016/j.avsg.2023.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND In situ laser fenestrated endovascular aortic repair (L-FEVAR) is a novel and creative solution for complex aortic pathologies in the urgent and emergency setting. Outcomes of this technique, however, are poorly reported. We sought to evaluate the efficacy, safety, and outcomes of L-FEVAR in aortic arch pathologies. METHODS A systematic literature review and analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines. A search was conducted using Google, PubMed, and Scopus to identify studies evaluating L-FEVAR. Two independent reviewers determined study inclusion. Case reports and series including < 10 patients were excluded. Reviewers also assessed the methodological quality and extracted data regarding outcomes. A meta-analysis of endoleak event rates was conducted using a fixed-effect model due to small sample size. RESULTS Eight studies met inclusion criteria between 2013 and 2021. Most studies were retrospective (87.5%) with median follow-up duration of 12.5 months (range 10-42). There were 440 patients included (range 15-148), mostly men (64%). Mean age was 61 years (range 53-68). Included patients were all symptomatic with L-FEVAR being technically successful in 93.3% of cases. The main indication for aortic arch intervention was aortic dissection. Single fenestrations occurred most frequently (68%), followed by triple (22%) then double fenestrations (9%). Meta-analysis of 8 studies (n = 440) demonstrated an endoleak event rate of 0.06 (95% confidence interval 0.04-0.09, P < 0.001) with no observed statistically significant heterogeneity of effects (Q = 7.91, P = 0.34). The median operative time was 162 min (range 53-252) with median length of stay of 10 days (range 7-17). Primary branch patency was 96.6%. Secondary patency rate was 97%. Pooled complication rates such as endoleak occurred in 4.8%, stroke in 2.0%, spinal cord ischemia in 0.2%, retrograde dissection in 0.9%, and 30-day death in 2.0%. Access complications occurred in 0.4%. Antiplatelet regimen was poorly reported in the study cohort. CONCLUSIONS In situ laser fenestration is a feasible, safe, and effective approach to treat aortic arch disease in patients who are unsuitable for open or custom-made endovascular means. High technical success and excellent short-term branch patency can be achieved. These single-institution series exhibit promising short-term outcomes. In a similar paradigm to investigational device exemptions studies for custom-made and physician modified endografts, these preliminary data make a persuasive argument for larger long-term multi-institutional prospective study of this promising technique.
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Affiliation(s)
- Shahed Tish
- Department of Surgery, University of Missouri, Columbia, MO
| | - Jo-Ana Chase
- University of Missouri School of Nursing, Columbia, MO
| | - Caryn Scoville
- Health Sciences Library, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Steven Cheung
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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20
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Cui Y, Liu X, Xiong J, Tan Z, Du L, Lin J. Cardiopulmonary bypass for total aortic arch replacement surgery: A review of three techniques. Front Cardiovasc Med 2023; 10:1109401. [PMID: 37063959 PMCID: PMC10098116 DOI: 10.3389/fcvm.2023.1109401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
One treatment for acute type A aortic dissection is to replace the ascending aorta and aortic arch with a graft during circulatory arrest of the lower body, but this is associated with high mortality and morbidity. Maintaining the balance between oxygen supply and demand during circulatory arrest is the key to reducing morbidity and is the primary challenge during body perfusion. The aim of this review is to summarize current knowledge of body perfusion techniques and to predict future development of this field. We present three perfusion techniques based on deep hypothermic circulatory arrest (DHCA): DHCA alone, DHCA with selective cerebral perfusion, and DHCA with total body perfusion. DHCA was first developed to provide a clear surgical field, but it may contribute to stroke in 4%–15% of patients. Antegrade or retrograde cerebral perfusion can provide blood flow for the brain during circulatory arrest, and it is associated with much lower stroke incidence of 3%–9%. Antegrade cerebral perfusion may be better than retrograde perfusion during longer arrest. In theory, blood flow can be provided to all vital organs through total body perfusion, which can be implemented via either arterial or venous systems, or by combining retrograde inferior vena caval perfusion with antegrade cerebral perfusion. However, whether total body perfusion is better than other techniques require further investigation in large, multicenter studies. Current techniques for perfusion during circulatory arrest remain imperfect, and a technique that effectively perfuses the upper and lower body effectively during circulatory arrest is missing. Total body perfusion should be systematically compared against selective cerebral perfusion for improving outcomes after circulatory arrest.
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21
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Kawajiri H, Saran N, Dearani JA, Schaff HV, Daly RC, Viehman JK, King KS, Pochettino A. Whole Body Retrograde Perfusion Combined With Central Aortic Perfusion Strategy in the Repair of Distal Arch Pathology Through a Lateral Thoracotomy. Mayo Clin Proc 2023; 98:432-442. [PMID: 36868750 DOI: 10.1016/j.mayocp.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/29/2022] [Accepted: 08/10/2022] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To compare the results of the hypothermic circulatory arrest (HCA) + retrograde whole-body perfusion (RBP) technique with those of deep hypothermic circulatory arrest (DHCA-only) approach. METHODS Limited data are available on cerebral protection techniques when distal arch repairs are performed through a lateral thoracotomy. In 2012, the RBP technique was introduced as adjunct to HCA during open distal arch repair via thoracotomy. We reviewed the results of the HCA + RBP technique compared with those of the DHCA-only approach. From February 2000 to November 2019, 189 patients (median age, 59 [IQR, 46 to 71] years; 30.7% female) underwent open distal arch repair via lateral thoracotomy to treat aortic aneurysms. The DHCA technique was used in 117 patients (62%, median age 53 [IQR, 41 to 60] years), whereas HCA + RBP was used in 72 patients (38%, median age 65 [IQR, 51 to 74] years). In HCA + RBP patients, cardiopulmonary bypass was interrupted when systemic cooling achieved isoelectric electroencephalogram; once the distal arch had been opened, RBP was then initiated via the venous cannula (flow of 700 to 1000 mL/min, central venous pressure <15 to 20 mm Hg). RESULTS The stroke rate was significantly lower in the HCA + RBP group (3%, n=2) compared with the DHCA-only (12%, n=14) (P=.031), despite longer circulatory arrest times in HCA + RBP compared with the DHCA-only (31 [IQR, 25 to 40] minutes vs 22 [IQR, 17 to 30] minutes, respectively; P<.001). Operative mortality for patients undergoing HCA + RBP was 6.7% (n=4), whereas for those undergoing DHCA-only it was 10.4% (n=12) (P=.410). The 1-, 3-, and 5-year age-adjusted survival rates for the DHCA group are 86%, 81%, and 75%, respectively. The 1-, 3-, and 5-year age-adjusted survival rates for the HCA + RBP group are 88%, 88%, and 76%, respectively. CONCLUSION The addition of RBP to HCA in the treatment of distal open arch repair via a lateral thoracotomy is safe and provides excellent neurological protection.
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Affiliation(s)
- Hidetake Kawajiri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
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22
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Jia B, Luo C, Li C, Ge Y, Zhong Y, Qiao Z, Hu H, Chen S, Zhu J. The Anzhen Risk Scoring System for Acute Type A Aortic Dissection: A Prospective Observational Study Protocol. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023. [DOI: 10.15212/cvia.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Introduction: Acute type A aortic dissection (ATAAD) is a catastrophic disease with fatal outcomes. Malperfusion syndrome (MPS) is a serious complication of ATAAD, with an incidence of 20–40%. Many studies have shown that MPS is the main risk factor for poor ATAAD prognosis. However, a risk scoring system for ATAAD based on MPS is lacking. Here, we designed a risk scoring system for ATAAD to assess mortality through quantitative assessment of relevant organ malperfusion and subsequently develop rational treatment strategies.
Methods and analysis: This was a prospective observational study. Patients’ perioperative clinical data were collected to establish a database of ATAAD (N≥3000) and determine whether these patients had malperfusion complications. The Anzhen risk scoring system was established on the basis of organ malperfusion by using a random forest survival model and a logistics model. The better method was then chosen to establish a revised risk scoring system.
Ethics and dissemination: This study received ethical approval from the Ethics Committees of Beijing Anzhen Hospital, Capital Medical University (KS2019034-1). Patient consent was waived because biological samples were not collected, and no patient rights were violated. Findings will be disseminated at scientific conferences and in peer-reviewed publications.
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Affiliation(s)
- Bo Jia
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Cheng Luo
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Yongliang Zhong
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Haiou Hu
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Suwei Chen
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
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23
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Luthra S, Tsang GM. Concurrent stabilization of "downstream" aorta during acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2023; 165:586-588. [PMID: 34226050 DOI: 10.1016/j.jtcvs.2021.06.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospital NHS Trust, Southampton, United Kingdom; UK Aortic Surgery Group (UKAS), United Kingdom.
| | - Geoffrey M Tsang
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospital NHS Trust, Southampton, United Kingdom; UK Aortic Surgery Group (UKAS), United Kingdom
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24
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Rahman N, Senanayake E, Mascaro J, Situnayake D, Bishay ES, Patel AJ. Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet's disease. J Cardiothorac Surg 2023; 18:22. [PMID: 36635783 PMCID: PMC9838001 DOI: 10.1186/s13019-023-02145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Behcet's disease is a multi-system inflammatory disorder. A small subset of patients with Behcet's develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree. CASE PRESENTATION We present the case of a 44-year-old lady with Behcet's Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung. CONCLUSIONS A multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet's disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.
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Affiliation(s)
- Niloy Rahman
- grid.412563.70000 0004 0376 6589Department of Thoracic Surgery, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Eshan Senanayake
- grid.412563.70000 0004 0376 6589Department of Cardiac Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Jorge Mascaro
- grid.412563.70000 0004 0376 6589Department of Cardiac Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Deva Situnayake
- grid.412918.70000 0004 0399 8742Department of Rheumatology, National Behcet’s Centre for Excellence, Birmingham City Hospital, Birmingham, UK
| | - Ehab S. Bishay
- grid.412563.70000 0004 0376 6589Department of Thoracic Surgery, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Akshay J. Patel
- grid.412563.70000 0004 0376 6589Department of Thoracic Surgery, University Hospitals Birmingham NHS Trust, Birmingham, UK ,grid.6572.60000 0004 1936 7486Institute of Immunology and Immunotherapy, University of Birmingham, Vincent Drive, Edgbaston, B15 2TT UK
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25
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Zhu L, Li X, Lu Q. A systematic review and meta-analysis of thoracic endovascular aortic repair with the proximal landing zone 0. Front Cardiovasc Med 2023; 10:1034354. [PMID: 36910538 PMCID: PMC9998709 DOI: 10.3389/fcvm.2023.1034354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/06/2023] [Indexed: 03/14/2023] Open
Abstract
Background Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However, the safety and surgical outcomes of extending the proximal landing zone into the ascending aorta (zone 0) in selected cases remain unknown. Thus, we performed a systematic review and meta-analysis of zone 0 thoracic endovascular aortic repair (TEVAR) to obtain a deeper understanding of its safety, outcomes, and trends over time. Methods A literature search was performed using PubMed, EMBASE, and Web of Science databases in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines, from January, 1997 to January, 2022. Only studies involving zone 0 TEVAR were included. The retrieved data from the eligible studies included basic study characteristics, 30-day/in-hospital mortality rate, indications, comorbidities, stent grafts, techniques, and complications. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted fixed-effects model. Results Fifty-three studies with 1,013 patients were eligible for analysis. The pooled 30-day/in-hospital mortality rate of zone 0 TEVAR was 7.49%. The rates of post-operative stroke, type Ia endoleak, retrograde type A aortic dissection, and spinal cord ischemia were 8.95, 9.01, 5.72, and 4.12%, respectively. Conclusions Although many novel stent grafts and techniques targeting zone 0 TEVAR are being investigated, a consensus on technique and device selection in zone 0 TEVAR is yet to be established in current practice. Furthermore, the post-operative stroke rate is relatively high, while other complication rates and perioperative death rate are comparable to those of TEVAR for other aortic zones.
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Affiliation(s)
- Longtu Zhu
- Division of Vascular Surgery, Department of General Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoye Li
- Division of Vascular Surgery, Department of General Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qingsheng Lu
- Division of Vascular Surgery, Department of General Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
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26
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Kong X, Ruan P, Yu J, Jiang H, Chu T, Ge J. Innominate artery direct cannulation provides brain protection during total arch replacement for acute type A aortic dissection. J Cardiothorac Surg 2022; 17:165. [PMID: 35733173 PMCID: PMC9219173 DOI: 10.1186/s13019-022-01919-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/18/2022] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to investigate the safety of direct innominate arterial (IA) cannulation using a pediatric arterial cannula to establish selective antegrade cerebral perfusion (ACP) during total arch replacement (TAR) for acute Stanford type A aortic dissection (ATAAD). Methods This retrospective study included patients with ATAAD who underwent TAR with the frozen elephant trunk (FET) technique between October 2020 and November 2021. Patients treated with direct IA cannulation using a pediatric arterial cannula for selective anterograde cerebral perfusion were included in the study. Results Of the 29 patients, 24 (82.8%) were male. The average age was 50.9 ± 9.47 years. Proximal repair included aortic root plasty (27 patients, [93.1%]) and Bentall surgery (2 patients, [6.9%]). Perioperative mortality and stroke rates were 3.4% and 6.9%, respectively. The mean lowest core temperature was 23.8 ± 0.74 °C and the mean ACP time was 25 ± 6.4 min. The aortic cross-clamp and cardiopulmonary bypass times were 141 ± 28 and 202 ± 29 min, respectively. There were no cases of IA injuries. Conclusion Direct IA cannulation using a pediatric arterial cannula is a simple, safe, and effective technique for establishing ACP during TAR with the FET technique for ATAAD and can avoid the potential complications of axillary artery cannulation.
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Affiliation(s)
- Xiang Kong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China.
| | - Peng Ruan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Jiquan Yu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Hui Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Tianshu Chu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Jianjun Ge
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China.
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27
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Berger T, Graap M, Rylski B, Fagu A, Gottardi R, Walter T, Discher P, Hagar MT, Kondov S, Czerny M, Kreibich M. Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection. Front Cardiovasc Med 2022; 9:911548. [PMID: 35734273 PMCID: PMC9207307 DOI: 10.3389/fcvm.2022.911548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Aim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure. Methods One hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed. Results Distal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure. Conclusion The incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
- *Correspondence: Tim Berger,
| | - Miriam Graap
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Muhammad Taha Hagar
- Department for Diagnostic and Interventional Radiology, Faculty of Medicine, Medical Centre-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
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Malvindi PG, Alfonsi J, Berretta P, Cefarelli M, Gatta E, Di Eusanio M. Normothermic frozen elephant trunk: our experience and literature review. Cardiovasc Diagn Ther 2022; 12:262-271. [PMID: 35800357 PMCID: PMC9253169 DOI: 10.21037/cdt-22-73] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/17/2022] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. METHODS A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. KEY CONTENT AND FINDINGS Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. CONCLUSIONS The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Vascular Surgery Department, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Vendramin I, Isola M, Piani D, Onorati F, Salizzoni S, D'Onofrio A, Di Marco L, Gatti G, De Martino M, Faggian G, Rinaldi M, Gerosa G, Pacini D, Pappalardo A, Livi U. Surgical management and outcomes in patients with acute type A aortic dissection and cerebral malperfusion. JTCVS OPEN 2022; 10:22-33. [PMID: 36004262 PMCID: PMC9390217 DOI: 10.1016/j.xjon.2022.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/01/2022] [Indexed: 12/05/2022]
Abstract
Objective The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion. Methods From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses. Results Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (P = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 (P = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 (P = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 (P = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor. Conclusions Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.
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Affiliation(s)
- Igor Vendramin
- Azienda Sanitaria Universitaria Friuli Centrale, Cardiothoracic Department, Udine, Italy
- Address for reprints: Igor Vendramin, MD, Division of Cardiac Surgery, Cardiothoracic Department, P. le S.M. Misericordia 15, Udine, Italy.
| | - Miriam Isola
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Daniela Piani
- Azienda Sanitaria Universitaria Friuli Centrale, Cardiothoracic Department, Udine, Italy
| | | | | | | | - Luca Di Marco
- Azienda Ospedaliera-Università di Bologna, Bologna, Italy
| | - Giuseppe Gatti
- Azienda Sanitaria Universitaria Giuliana Isontina, Trieste, Italy
| | - Maria De Martino
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | | | - Mauro Rinaldi
- Azienda Ospedaliero-Universitaria di Torino, Torino, Italy
| | - Gino Gerosa
- Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Davide Pacini
- Azienda Ospedaliera-Università di Bologna, Bologna, Italy
| | | | - Ugolino Livi
- Azienda Sanitaria Universitaria Friuli Centrale, Cardiothoracic Department, Udine, Italy
- Department of Medical Area (DAME), University of Udine, Udine, Italy
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Sule J, Chua CR, Teo C, Choong A, Sazzad F, Kofidis T, Sorokin V. Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections. SCAND CARDIOVASC J 2022; 56:91-99. [PMID: 35546567 DOI: 10.1080/14017431.2022.2074095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.
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Affiliation(s)
- Jai Sule
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Cher Rui Chua
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Caven Teo
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Choong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Berger T, Kreibich M, Mueller F, Breurer-Kellner L, Rylski B, Kondov S, Schröfel H, Pingpoh C, Beyersdorf F, Siepe M, Czerny M. Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique. Interact Cardiovasc Thorac Surg 2022; 34:865-871. [PMID: 35092274 PMCID: PMC9070457 DOI: 10.1093/icvts/ivac013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique. METHODS Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each's cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke. RESULTS Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20-8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28-19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09-360.84; P = 0.044) as predictors for postoperative stroke. CONCLUSIONS Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Felix Mueller
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Lara Breurer-Kellner
- Department of Neurology, Faculty of Medicine, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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The Role of False Lumen Area Ratio in Late Aortic Events after Acute Type I Aortic Dissection Repair. Ann Thorac Surg 2022; 114:2217-2224. [DOI: 10.1016/j.athoracsur.2022.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/10/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
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Sajiram S, Luthra S, Tsang G. Bespoke Total Aortic Arch Replacement with Frozen Elephant Trunk (FET): A Novel but a Practical Strategy. JTCVS Tech 2022; 14:45-47. [PMID: 35967221 PMCID: PMC9366606 DOI: 10.1016/j.xjtc.2022.04.021] [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: 02/20/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 12/04/2022] Open
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Vendramin I, de Manna ND, Sponga S, Lechiancole A, Sponza M, Auci E, Bortolotti U, Livi U. Early awaking of patients following FET allows early recognition of paraplegia with prospects for complete recovery using prompt spinal drainage. Indian J Thorac Cardiovasc Surg 2022; 38:207-210. [PMID: 35221560 PMCID: PMC8857386 DOI: 10.1007/s12055-021-01288-w] [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: 04/26/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 10/19/2022] Open
Abstract
We report a patient who presented with paraplegia after ascending aorta and arch replacement using the frozen elephant trunk technique. Immediate postoperatively cerebrospinal fluid drainage allowed successful reversal of spinal cord injury. Early awakening of patients following a frozen elephant trunk technique is mandatory because it allows recognition and treatment of this complication by prompt cerebrospinal liquor drainage.
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Affiliation(s)
- Igor Vendramin
- grid.411492.bCardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | - Sandro Sponga
- grid.411492.bCardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Andrea Lechiancole
- grid.411492.bCardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Massimo Sponza
- grid.411492.bDepartment of Radiology, University Hospital of Udine, Udine, Italy
| | - Elisabetta Auci
- grid.411492.bDepartment of Anesthesia, University Hospital of Udine, Udine, Italy
| | - Uberto Bortolotti
- grid.411492.bCardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- grid.411492.bCardiothoracic Department, University Hospital of Udine, Udine, Italy ,grid.5390.f0000 0001 2113 062XDepartment of Medical Area (DAME), University of Udine, Udine, Italy
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Dai L, Qiu J, Zhao R, Cao F, Qiu J, Wang D, Fan S, Xie E, Song J, Yu C. A Novel Sutureless Integrated Stented (SIS) Graft Prosthesis for Type A Aortic Dissection: A Pilot Study for a Prospective, Multicenter Clinical Trial. Front Cardiovasc Med 2022; 8:806104. [PMID: 35211519 PMCID: PMC8860904 DOI: 10.3389/fcvm.2021.806104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022] Open
Abstract
Aims Various kinds of surgical strategies and prostheses have been advocated to improve short-term and long-term outcomes in type A aortic dissection (TAAD). Large-scale repair of the pathological aorta is hard to generalize due to complex procedures. We aimed to investigate the performance, effectiveness and safety of a novel Sutureless Integrated Stented (SIS) graft prosthesis in TAAD patients undergoing total arch replacement (TAR) and frozen elephant trunk (FET) implantation surgery. Methods All patients admitted to Fuwai Hospital were prospectively screened. Urgent or scheduled surgery was arranged for eligible patients. The primary endpoint was operative mortality. Key secondary endpoints included stroke, spinal cord injury, unexpected aortic reoperation, and 1-year survival. Discharged patients were followed up with computed tomography angiography and transthoracic echocardiography at 3 months, 6 months, and 1 year after surgery. Performance, effectiveness and safety analyses were performed in those patients. Results Between August 1 and September 3, 2020, ten TAAD patients were enrolled in this study and successfully implanted with the SIS graft prosthesis. The median (IQR) age was 56.50 (43.75, 66.75) years (range from 31 to 75), and seven patients were male (70.0%). All patients underwent ascending aorta replacement + TAR + FET and additional procedures when necessary. The median (IQR) operation time, cardiopulmonary bypass time and cross clamp time were 270.50 (218.50, 312.50), 110.00 (88.00, 125.75), 69.50 (51.25, 82.75) min, respectively. Of note, the median (IQR) circulatory arrest time was 9.00 (8.00, 9.00) min (range from 4 to 12). The median (IQR) lowest nasopharyngeal temperature was 26.75 (25.98, 27.67) °C. Follow-up was 100% completed. During the 1-year follow-up, no patients died, no severe adverse events occurred, and rate of freedom from aortic reintervention was 100%. Conclusions The SIS graft prosthesis was implanted in a novel sutureless way, which simplified the surgical procedure, shortened the circulatory arrest time and avoided deep hypothermia. The preliminary clinical outcomes and follow-up outcomes demonstrated the effectiveness and safety of this prosthesis. A large-scale trial is being conducted to further assess these findings.
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Affiliation(s)
- Lu Dai
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawei Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Zhao
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fangfang Cao
- Adult Surgical Intensive Care Unit, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - De Wang
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuya Fan
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Enzehua Xie
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian Song
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Cuntao Yu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Cuntao Yu
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Czerny M, Harringer W. Aortenchirurgie 50 Jahre – eine Zeitreise durch das Organ Aorta. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-021-00473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tokunaga C, Kumagai Y, Chubachi F, Hori Y, Takazawa A, Hayashi J, Asakura T, Ishii R, Nakajima H, Yoshitake A. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6531915. [PMID: 35179581 PMCID: PMC9252127 DOI: 10.1093/icvts/ivac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Chiho Tokunaga
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
- Corresponding author. Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, 1397-1, Yamane, Hidaka-shi, Saitama 350-1298, Japan. Tel: +81-42-984-4111; e-mail: (C. Tokunaga)
| | - Yu Kumagai
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Fumiya Chubachi
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Yuto Hori
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Jun Hayashi
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Ryota Ishii
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University, International Medical Center, Saitama, Japan
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6553998. [DOI: 10.1093/ejcts/ezac171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
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Tan SZCP, Bashir M. Prevention versus cure: Is BioGlue priming the optimal strategy against E-Vita NEO graft oozing? J Card Surg 2021; 37:555-560. [PMID: 34907587 DOI: 10.1111/jocs.16179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Since the introduction of the E-Vita Open NEO aortic prosthesis in 2020, several incidences of post-anastomotic oozing from the polyester portion of the graft have emerged. The use of BioGlue to prime E-Vita Open NEO to prevent this has been suggested as a way to mitigate this worrying complication. We investigate the extent of graft oozing in E-Vita Open NEO and evaluate the use of BioGlue in preventing oozing, both experimentally and in terms of potential clinical complications. MATERIALS AND METHODS E-Vita Open NEO (in straight and branched configurations) was implanted in a perfused model. The distal stent graft and side branches were clamped, and the graft was pressurized with blood to 120 mmHg. The volume of blood (ml) oozing from the graft within 60 s was measured. Nonpressurized grafts were coated with BioGlue up to a thickness of 1, 2, and 3 mm, and the volume (mm3 ) of BioGlue required to do so was recorded. RESULTS Within 60 s, 250.0 ml of blood oozed from the grafts tested. 43.694, 87.389, and 174.778 mm3 of BioGlue were required to coat the device with 1, 2, and 3 mm of BioGlue. CONCLUSION Graft oozing from E-Vita Open NEO represents an omnipresent and worrying risk. The use of BioGlue herein is likely associated with several adverse consequences, which are an additional risk on top of that posed by graft oozing. These risks call into question the suitability of E-Vita Open NEO, especially when compared to alternative devices not affected by oozing.
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Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement, Wales, UK
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40
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Kozlov BN, Panfilov DS. False lumen thrombosis after frozen elephant trunk procedure in acute and chronic aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:195-201. [PMID: 34792310 DOI: 10.23736/s0021-9509.21.11800-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The clinical significance of the false lumen (FL) thrombosis after the thoracic aortic surgery consists in the correlation with aortic remodeling. The aim of the study was to analyze the incidence of the FL thrombosis of the thoracoabdominal aorta after the frozen elephant trunk (FET) procedure in acute and chronic aortic dissection. METHODS A total of 57 consecutive patients with type A and B aortic dissection (AD) underwent the FET procedure between March 2012 and December 2020 were included in a retrospective study. All of the patients were divided in two groups: acute (n=18) and chronic (n=39) AD. Early and 2-year outcomes were evaluated in both groups. Computed tomography scans were obtained along the entire aorta for the aortic status assessment. RESULTS There were no statistically significant differences in early mortality and postoperative outcomes in both groups. The 2-year survival rate in acute and chronic AD was 74.7%±10% vs. 71.4%±7% (p=0.573), respectively. In the follow-up, the FL thrombosis rate, changes of the true lumen and total aortic diameters did not differ significantly between the analyzed groups of patients. The freedom from negative aortic remodeling was 62.2%±26% in acute AD versus 76.2%±11% in chronic AD (p=0.853). One (5.6%) and 4 (10.3%) distal aortic re-interventions were performed in acute and chronic AD, respectively. CONCLUSIONS False lumen thrombosis rate after the FET procedure did not differ significantly in acute and chronic AD.
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Affiliation(s)
- Boris N Kozlov
- Cardiovascular department, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian Federation
| | - Dmitri S Panfilov
- Cardiovascular department, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian Federation -
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Gombert A, Ketting S, Rückbeil MV, Hundertmark AK, Barbati M, Keschenau P, Pedersoli F, Schurink GW, Mees B, Kotelis D, Jacobs MJ. Perioperative and long-term outcome after ascending aortic and arch repair with elephant trunk and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2021; 75:824-832. [PMID: 34606958 DOI: 10.1016/j.jvs.2021.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. METHODS This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. RESULTS Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. CONCLUSIONS Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
| | - Shirley Ketting
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcia Viviane Rückbeil
- Department of Medical Statistics, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ann-Kathrin Hundertmark
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mohammad Barbati
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Federico Pedersoli
- Department of Radiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barend Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital Aachen, RWTH Aachen University, Aachen, Germany; Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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42
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Czerny M, Beyersdorf F, Murana G, Pacini D. Excessive oozing through the fabric of the branched Cryolife-Jotec Evita Open NEO hybrid prosthesis. Eur J Cardiothorac Surg 2021; 60:423-424. [PMID: 33729458 DOI: 10.1093/ejcts/ezab058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/24/2021] [Indexed: 11/12/2022] Open
Abstract
We report 3 cases of excessive oozing after aortic arch replacement using the frozen elephant trunk technique through the fabric of the branched Cryolife-Jotec Evita Open NEO hybrid prosthesis. After weaning from cardiopulmonary bypass, protamine administration as well as standard substitution of plasmatic and cellular coagulation adjusted to thrombelastometry, excessive oozing persisted leading to a complicated postoperative course in all 3 patients.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Giacomo Murana
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Abstract
This review discusses the clinical applications of the frozen elephant trunk procedure for patients with acute aortic dissection. Sub-analysis of the multicenter Japanese Frozenix study, J-ORCHESTRA, are presented, and recent reports of frozen elephant trunk usage for acute aortic dissection are discussed.
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Affiliation(s)
- Yutaka Okita
- Takatsuki General Hospital, Kobe University, Japan
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44
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Mehanna M, Elhamami M, Abolkasem A, Ramadan B, Almaghraby A, Mascaro J. Aortic remodelling and false lumen changes after the frozen elephant trunk technique using the thoraflex hybrid stented graft for aortic dissection. Egypt Heart J 2021; 73:74. [PMID: 34436704 PMCID: PMC8390563 DOI: 10.1186/s43044-021-00198-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background Despite the marked improvement in the aortic dissection repair techniques, residual dissected aorta with a patent false lumen remains an issue. So, the aim of our study is to observe the effect of inserting the Thoraflex Hybrid Graft on the aortic diameters in patients with type A aortic dissection involving the arch and descending aorta. Patients with type I aortic dissection who had aortic dissection repair using the Thoraflex Hybrid Graft in University Hospitals Birmingham were studied. Radiological assessment with computed tomography of the aorta was done at the level of the diaphragm to measure the true lumen, false lumen and total aortic diameters. Significance of change of diameters at early post-operative as compared to the pre-operative period was analysed. Results Eight cases were done in the acute setting, while 14 cases were done in the chronic setting. The ratio of true lumen to the total aortic diameter has significantly increased in the follow-up period as compared to the pre-operative period (P = 0.031). Whereas false lumen to total aortic diameter ratio has significantly decreased (P = 0.024). Subgroup analysis revealed that these changes were not significantly altered by whether the dissection was acute or chronic. Conclusions The Thoraflex Hybrid Graft will induce positive aortic remodelling with expansion of true lumen and will diminish the false lumen. But we could not find a significant difference between acute or chronic cases due to small sample size.
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Affiliation(s)
- Mostafa Mehanna
- Department of Cardiac Surgery, University Hospital Birmingham, Birmingham, UK. .,Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Moustafa Elhamami
- Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Abolkasem
- Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Bassem Ramadan
- Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Abdallah Almaghraby
- Cardiology and Angiology Department, Alexandria University, Alexandria, Egypt
| | - Jorge Mascaro
- Department of Cardiac Surgery, University Hospital Birmingham, Birmingham, UK.,University of Birmingham, Birmingham, UK
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45
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Tsagakis K, Osswald A, Weymann A, Demircioglu A, Schmack B, Wendt D, Jakob H, Ruhparwar A. The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique. Eur J Cardiothorac Surg 2021; 61:195-203. [PMID: 34378023 PMCID: PMC8759516 DOI: 10.1093/ejcts/ezab295] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/01/2021] [Accepted: 05/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported. METHODS Between February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0–3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days. RESULTS Preoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4–1.0; P = 0.036). CONCLUSIONS FET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events. Subject collection 120; 161.
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Affiliation(s)
- Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Anja Osswald
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Aydin Demircioglu
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
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Öz T, Prendes CF, Stana J, Konstantinou N, Pichlmaier M, Tsilimparis N. A Case Report: Is the Lack of Sufficient Radial Force Unfreezing the "Frozen Elephant Trunk"? J Endovasc Ther 2021; 28:955-960. [PMID: 34362265 DOI: 10.1177/15266028211031924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The "frozen elephant trunk" is a hybrid technique to treat aortic arch and proximal descending aortic pathologies in a single step. Despite its encouraging early and long-term results, some stent-graft-related adverse events have been reported. Here, we describe a possible treatment option to "re-freeze" the FET in case of loss of landing zone. We report a patient who developed significant kinking of the FET over the course of the first 2 postoperative years. The 1-year follow-up computed tomography angiography (CTA) showed significant kinking and proximal migration of the endograft portion of the FET, resulting in new thrombus formation. Due to kinking and thrombus progression in subsequent CTA follow-ups (2 years and 2½ years) with risk for peripheral embolization, a secondary endovascular repair was indicated. Transfemoral relining of the stent component with a thoracic aortic endovascular repair (Zenith®TX2®30142) stent-graft was performed. In the context of postoperative aneurysm sac shrinkage, the low radial force and lack of longitudinal stiffness of the hybrid graft may lead to proximal migration, thus secondary kinking, emphasizing the importance of an adequate degree of oversizing of the primary graft and an appropriate follow-up. Selection of a suitable graft for a particular pathology concerning the radial force and longitudinal stiffness is furthermore important.
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Affiliation(s)
- Tugce Öz
- Department of Vascular Surgery, Ludwig-Maximilian University Hospital, Munich, Germany
| | - Carlota F Prendes
- Department of Vascular Surgery, Ludwig-Maximilian University Hospital, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilian University Hospital, Munich, Germany
| | - Nikolaos Konstantinou
- Department of Vascular Surgery, Ludwig-Maximilian University Hospital, Munich, Germany
| | | | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilian University Hospital, Munich, Germany
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47
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Koizumi S, Ishigami M, Tsubota H, Koyama T. Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm. Surg Today 2021; 52:324-329. [PMID: 34279707 DOI: 10.1007/s00595-021-02337-y] [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: 01/06/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. METHODS Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). RESULTS The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. CONCLUSIONS FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.
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Affiliation(s)
- Shigeki Koizumi
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Masanosuke Ishigami
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Hideki Tsubota
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan.
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48
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Pichlmaier M, Buech J, Tsilimparis N, Fabry TG, Joskowiak D, Rustum S, Martens A, Hagl C, Peterss S. Routine Stent-Bridging to the Supraaortic Vessels in Aortic Arch Replacement - 10 year-experience. Ann Thorac Surg 2021; 113:1491-1497. [PMID: 34186091 DOI: 10.1016/j.athoracsur.2021.05.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The SAVSTEB technique (Supra-Aortic Vessel anastomosis STEnt Bridging) simplifies the reattachment of the supraaortic vessels in aortic arch surgery; however, follow-up data are limited. The study aimed to investigate the stent-related performance and complications. METHODS Between 02/2009 and 09/2020, 112 patients underwent total arch replacement with a tetrabranched graft and using the SAVSTEB technique. Mean age was 59.3±12.7 years, male gender prevailed. Nineteen percent suffered from acute aortic dissection extending into the supraaortic vessels, 12% showed chronic dissected vessels and 70% showed unaffected vessels. Left subclavian artery, left common carotid artery and innominate artery were bridged in 88%, 75% and 2%, respectively, an aberrant right subclavian artery in 2%. RESULTS Total stent experience was 341 stent-years, stent patency was found in 98%. Technical success was achieved in all but one case. One percent showed major stent thrombosis requiring reintervention. Minor stent thrombosis was found in 2%. No endoleak was found and the number of new onset dissections distally to the stent was 4%. Freedom from stent-related events was estimated 89.1±0.5% at 3 years. Stroke rate was 10% with highest incidence among non-dissected vessels. The vertebral artery was overstented in 15%, 2% were associated radiographically with stroke. CONCLUSIONS SAVSTEB is a comparatively simple, safe and efficacious technique to create the anastomosis between tetrabranched arch grafts and the supra-aortic arteries in the short and intermediate term. Bleeding from the anastomoses, kinking and scar associated stenosis are negligible; however, vertebral overstenting remains a critical technical issue.
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Affiliation(s)
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | | | - Thomas G Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Saad Rustum
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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49
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Berger T, Kreibich M, Mueller F, Rylski B, Kondov S, Schröfel H, Pingpoh C, Beyersdorf F, Siepe M, Czerny M. The frozen elephant trunk technique for aortic dissection is safe after previous aortic repair. Eur J Cardiothorac Surg 2021; 59:130-136. [PMID: 33038224 DOI: 10.1093/ejcts/ezaa288] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/27/2020] [Accepted: 06/27/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The goal of this study was to evaluate outcomes of aortic arch replacement using the frozen elephant trunk (FET) technique after previous proximal and/or distal open or endovascular thoracic aortic repair. METHODS Sixty-three patients [median age: 63 (55-74) years; 65% men] were operated on for acute or chronic aortic dissection after previous proximal and/or distal open or endovascular thoracic aortic repair. Intraoperative details, clinical outcome and follow-up results were evaluated. RESULTS The median time between the index and the FET procedure was 81 (40-113) months. Fifty-eight (92%) patients had already undergone proximal aortic surgery; supracoronary ascending aortic replacement was the most frequent index procedure [n = 25 (40%)]. Distal aortic interventions had been done in 8 (13%) patients including endovascular thoracic aortic repair in 6 patients (10%). In-hospital mortality was 3% (n = 2). Postoperative strokes occurred in 5 patients (8%); of those, 1 stroke was dissection-related (2%). Subsequent aortic reinterventions after the FET procedure had to be done in 33% (n = 21). CONCLUSIONS Outcomes of aortic arch replacement using the FET technique after previous proximal and/or distal open or endovascular thoracic aortic repair are associated with low mortality and morbidity. Still, postoperative stroke remains an issue. After the successful accomplishments, the approach serves as an ideal platform for the secondary surgical or endovascular downstream aortic procedures, which are frequently needed.
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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
| | - Felix Mueller
- 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
| | - Holger Schröfel
- Department of Cardiovascular Surgery, University Heart Centre Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- 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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50
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Liu Y, Liang S, Zhang B, Dun Y, Guo H, Qian X, Yu C, Sun X. Type II hybrid arch repair versus total arch replacement with frozen elephant trunk: a propensity score-matched analysis. Eur J Cardiothorac Surg 2021; 60:297-304. [PMID: 33939801 DOI: 10.1093/ejcts/ezab047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/18/2020] [Accepted: 01/13/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the objective outcomes of type II hybrid arch repair (HAR) and total arch replacement with frozen elephant trunk (TAR with FET). METHODS Data from 528 patients who underwent aortic arch repair from January 2017 to June 2019 were collected, which consisted of 175 type II HAR and 353 TAR with FET. The propensity score-matched analysis identified a subgroup of 90 pairs. Perioperative data and mid-term follow-up results were assessed. RESULTS There was no significant difference in the composite adverse events (type II HAR, 20.6%, 36/175 vs TAR with FET, 17.8%, 63/353, P = 0.450). Multivariable logistic analysis of the 528 patients showed that the procedure type (type II HAR or TAR with FET) was not associated with composite adverse events, 30-day mortality or stroke. The 3-year survival rates were 84.8% in the type II HAR group and 90.1% in the TAR with FET group (P = 0.12). The 3-year reintervention-free rates in the type II HAR and TAR with FET groups were 98.7% and 96.5% (P = 0.22), respectively. After matching, no significant difference was found in the incidence of composite adverse events or the 3-year survival and reintervention-free rates. CONCLUSIONS No significant clinical differences were found in the early and mid-term outcomes of type II HAR and TAR with FET. The long-term outcomes remain to be investigated. Careful patient selection for individualized approaches is the key to taking full advantage of the 2 surgical procedures.
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Affiliation(s)
- Yanxiang Liu
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shenghua Liang
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Zhang
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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