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Mosbahi S, Berezowski M, Bavaria JE, Kelly JJ, Goel N, Jiang F, Yildiz M, Zhao Y, Szeto WY, Desai ND. Long-Term Outcomes of Antegrade Thoracic Stent Grafting During Repair of Acute DeBakey I Dissection. Ann Thorac Surg 2024:S0003-4975(24)00683-0. [PMID: 39182554 DOI: 10.1016/j.athoracsur.2024.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/24/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND We aim to evaluate the impact of antegrade stenting of the distal arch and proximal descending aorta combined with non-total arch procedures in acute type A aortic dissection. METHODS From 2005 to 2022, 733 nonsyndromic patients presented with acute DeBakey type I aortic dissection and underwent non-total arch procedure. Ninety-five patients underwent antegrade stenting and 638 did not. Propensity-score analysis was performed, and 95 optimal pairs were created. Survival was estimated using the Kaplan-Meier method and cumulative incidence of reintervention with death as a competing event was calculated and compared using Gray's method. RESULTS Survival estimates at 10 years after propensity score matching were similar between both groups, 58.9% (95% CI, 46.5%-74.5%) vs 58.4% (95% CI, 48.3%-70.6%) (P = .6) in the non-stented vs stented group. Cumulative incidence of reintervention with competing risk of death at 10 years after propensity matching was 27% (95% CI, 17%-37%) vs 22% (95% CI, 14%-32%) (P = .44), respectively. CONCLUSIONS Antegrade thoracic endovascular aortic repair may be beneficial for remodeling and facilitating future endovascular reinterventions and reduces the occurrence of reintervention for malperfusion.
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Affiliation(s)
- Selim Mosbahi
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiac Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Mikolaj Berezowski
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Goel
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fei Jiang
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Murat Yildiz
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiac Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Yu Zhao
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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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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Cuellar FL, Oberhuber A, Martens S, Rukosujew A, Marchiori E, Ibrahim A. Analysis of Spinal Ischemia after Frozen Elephant Trunk for Acute Aortic Dissection: An Observational, Single-Center Study. Diagnostics (Basel) 2022; 12:2781. [PMID: 36428841 PMCID: PMC9689016 DOI: 10.3390/diagnostics12112781] [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: 10/08/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This observational study aimed to evaluate the perioperative risk factors for spinal cord ischemia (SCI) in patients who underwent aortic repair with the frozen elephant trunk technique (FET) after acute aortic Stanford A dissection. METHODS From May 2015 to April 2019, 31 patients underwent aortic arch replacement with the FET technique, and spinal ischemia was observed in 4 patients. The risk factors for postoperative SCI were analyzed. RESULTS The mean age of patients with acute aortic dissection was 57.1 years, and 29.4% were female. Four patients developed SCI. There were no significant differences in characteristics such as age and body mass index. The female gender was associated with most of the SCI cases in the univariate analysis (75%, p = 0.016). Known perioperative and intraoperative risk factors were not related to postoperative SCI in our study. Patients who developed SCI had increased serum postoperative creatinine levels (p = 0.03). Twenty-four patients showed complete false lumen thrombosis up to zones 3-4, five patients up to zones 5-6 and two patients up to zones 7-9, which correlates with the postoperative development of SCI (p = 0.02). The total number of patent intercostal arteries was significantly reduced postoperatively in SCI patients (p = 0.044). CONCLUSIONS Postoperative acute kidney injury, the reduction in patent intercostal arteries after surgery and the extension of false lumen thrombosis up to and beyond zone 5 may play a significant role in the development of clinically relevant spinal cord injury after FET.
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Affiliation(s)
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Elena Marchiori
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
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Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis. Gen Thorac Cardiovasc Surg 2022; 70:315-328. [PMID: 35218504 DOI: 10.1007/s11748-022-01792-9] [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: 10/06/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD). METHODS A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed. RESULTS A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm. CONCLUSIONS In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.
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Reid G, Mork C, Mujagic E, Berdajs D. Simple endovascular thoracic aortic stenting rescues a wrongly deployed frozen elephant trunk during a modified procedure. J Int Med Res 2021; 49:300060520986710. [PMID: 33535858 PMCID: PMC7869178 DOI: 10.1177/0300060520986710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We report a bail out approach of endovascular thoracic aorta repair following incorrect deployment of a modified frozen elephant trunk stent graft into the false lumen. A 76-year-old patient was admitted to our Emergency Department. A computed tomography angiography scan showed type I DeBakey aortic dissection. An emergency modified frozen elephant trunk procedure was performed. Immediate postoperative computed tomography angiography showed that the distal segment of the stent was deployed in the false lumen, probably through a re-entry tear at the descending thoracic aorta. Emergency endovascular repair of the thoracic aorta, as well as angioplasty of the superior mesenteric artery and left iliac artery, were performed.
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Affiliation(s)
- Gregory Reid
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Constantin Mork
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
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Commentary: The proximal descending aorta is a "cruel mistress" and should not be ignored. J Thorac Cardiovasc Surg 2020; 163:1762-1763. [PMID: 32950238 DOI: 10.1016/j.jtcvs.2020.06.085] [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: 06/16/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022]
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Samy S, Stein LH. Commentary: Proximal aortic dissection repair-when have things gone too far? J Thorac Cardiovasc Surg 2020; 163:1764-1765. [PMID: 32682589 DOI: 10.1016/j.jtcvs.2020.06.045] [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: 06/01/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sanjay Samy
- Division of Cardiothoracic Surgery, Department of Surgery, Albany Medical College, Albany, NY
| | - Louis H Stein
- Division of Cardiothoracic Surgery, Department of Surgery, Albany Medical College, Albany, NY.
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Hobbs R, Si MS. Commentary: Modified frozen elephant trunk. J Thorac Cardiovasc Surg 2020; 163:1763-1764. [PMID: 32712000 DOI: 10.1016/j.jtcvs.2020.05.094] [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: 05/21/2020] [Revised: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Reilly Hobbs
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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