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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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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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Aortic arch replacement with frozen elephant trunk technique - a single-center study. J Cardiothorac Surg 2019; 14:147. [PMID: 31370864 PMCID: PMC6676558 DOI: 10.1186/s13019-019-0969-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/22/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes. METHODS From 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n = 57) or the Vascutek Thoraflex hybrid prosthesis (n = 11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each. RESULTS Early mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p = 0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p = 0.797 and spinal cord injury: 8.8 vs. 5.9%; p = 0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2 ± 73.5 and 148.3 ± 34 min vs. 189.2 ± 47.8 and 116.3 ± 34.5 min; p < 0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p = 0.575. CONCLUSION The FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.
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Gandet T, Seghrouchni A, Ozdemir BA, Captier G, Demaria R, Alric P, Albat B, Canaud L. Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approach. J Vasc Surg 2018; 68:1217-1224. [PMID: 29680298 DOI: 10.1016/j.jvs.2017.08.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach. METHODS The experiments were performed on six cadaveric human heart, ascending aorta, aortic arch, and descending aorta specimens. Fenestration was fashioned in each standard tubular Valiant thoracic stent graft (Valiant Captivia; Medtronic Vascular, Santa Rosa, Calif) to match the anatomy of each specimen. Stent grafts of sufficient length were selected to cover the entire ascending aorta and aortic arch. Stent graft diameters in proximal sealing zones were oversized by 5% to 10%. The length of the fenestration was the distance between the left subclavian artery and the proximal edge of the origin of the brachiocephalic trunk with an additional 10 mm. The diameter of the scallop was that of the brachiocephalic trunk with an additional 5 mm on all sides. The length of the covered portion of the stent graft was the distance between coronary arteries and the proximal edge of the origin of the brachiocephalic trunk. Two lateral radiopaque markers were positioned to delineate the distal and lateral edge of the scallop. Another 3-cm radiopaque marker was sutured onto the sheath to ensure accurate radiologic positioning of the scallop on the outer curve of the aorta. The left ventricle and the thoracic aorta were connected to a benchtop aortic pulsatile flow model. A 5-mm 30-degree lens was introduced through the left subclavian artery to monitor the procedure. The customized stent graft was deployed by a transapical approach under fluoroscopic control. RESULTS Median duration of stent graft modification was 21 minutes (range, 17-40 minutes). All attempts to deploy the homemade proximal scalloped stent graft by a transapical approach were successful. Completion angiography demonstrated patency of the supra-aortic trunks and of the coronary arteries in all cases. Macroscopic evaluation did not identify any deterioration of the customized stent graft. CONCLUSIONS The use of physician-modified stent grafts is feasible for thoracic endovascular aortic repair of type A dissection by a transapical approach in this model.
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Affiliation(s)
- Thomas Gandet
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Anis Seghrouchni
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Guillaume Captier
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Roland Demaria
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Bernard Albat
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Ludovic Canaud
- Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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Verhoye JP, Belhaj Soulami R, Fouquet O, Ruggieri VG, Kaladji A, Tomasi J, Sellin M, Farhat F, Anselmi A. Elective frozen elephant trunk procedure using the E-Vita Open Plus prosthesis in 94 patients: a multicentre French registry. Eur J Cardiothorac Surg 2017; 52:733-739. [DOI: 10.1093/ejcts/ezx159] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 03/17/2017] [Indexed: 11/14/2022] Open
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Endovascular Stent Grafting for Aortic Arch Aneurysm in Aortoiliac Occlusive Disease following Aortic Arch Debranching and Aortobifemoral Reconstruction. Case Rep Med 2017; 2017:6568028. [PMID: 28408933 PMCID: PMC5376402 DOI: 10.1155/2017/6568028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/11/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022] Open
Abstract
Treatment of thoracic aortic aneurysms constitutes high mortality and morbidity rates despite improvements in surgery, anesthesia, and technology. Endovascular stent grafting may be an alternative therapy with lower risks when compared with conventional techniques. However, sometimes the branches of the aortic arch may require transport to the proximal segments prior to successful thoracic aortic endovascular stent grafting. Atherosclerosis is accounted among the etiology of both aneurysms and occlusive diseases that can coexist in the same patient. In these situations stent grafting may even be more complicated. In this report, we present the treatment of a 92-year-old patient with aortic arch aneurysm and proximal descending aortic aneurysm. For successful thoracic endovascular stent grafting, the patient needed an alternative route other than the native femoral and iliac arteries for the deployment of the stent graft. In addition, debranching of left carotid and subclavian arteries from the aortic arch was also required for successful exclusion of the thoracic aneurysm.
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Shrestha M, Kaufeld T, Beckmann E, Fleissner F, Umminger J, Abd Alhadi F, Boethig D, Krueger H, Haverich A, Martens A. Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients. J Thorac Cardiovasc Surg 2016; 152:148-159.e1. [DOI: 10.1016/j.jtcvs.2016.02.077] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 02/09/2016] [Accepted: 02/26/2016] [Indexed: 11/26/2022]
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Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic Arch and Descending Thoracic Aortic Aneurysms: Experience with Stent Grafting for Second-Stage “Elephant Trunk” Repair. Vascular 2016; 13:5-10. [PMID: 15895668 DOI: 10.1258/rsmvasc.13.1.5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage “elephant trunk” repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1–64 months). Twelve patients (five women and seven men) with a mean age of 69 ± 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.
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Affiliation(s)
- Alfio Carroccio
- Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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The elephant trunk is freezing: The Hannover experience. J Thorac Cardiovasc Surg 2015; 149:1286-93. [DOI: 10.1016/j.jtcvs.2015.01.044] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/27/2014] [Accepted: 01/24/2015] [Indexed: 11/19/2022]
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Haverich A. Aortic arch replacement with frozen elephant trunk-when not to use it. Ann Cardiothorac Surg 2013; 2:592-6. [PMID: 24109566 DOI: 10.3978/j.issn.2225-319x.2013.09.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 09/23/2013] [Indexed: 11/14/2022]
Abstract
Current scientific evidence suggests the frozen elephant trunk (FET) technique plays an important role in modern aortic arch repair operations, both for aneurysmal disease and acute aortic dissection. Its use in extended aneurysm is generally therapeutic, aiming for complete exclusion of the diseased descending thoracic aorta. In acute aortic dissection type A, the application of FET is more prophylactic in nature, with the aim of preventing late dilatation of the proximal descending thoracic aorta. This review will present the journey of the elephant trunk from its conception to the current available technology. By tracing the historical evolution of the FET technique and prosthesis development, we explore the challenges and limitations of evidence-based surgical research. We present data from our growing experience in aortic arch reconstruction, the results from our latest 27 patients undergoing the 4-branch FET indicating substantially reduced morbidity and mortality (0%) in this complex patient cohort.
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Affiliation(s)
- Axel Haverich
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Shrestha M, Martens A, Kruger H, Maeding I, Ius F, Fleissner F, Haverich A. Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J Cardiothorac Surg 2013; 45:289-95; discussion 295-6. [DOI: 10.1093/ejcts/ezt359] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Shrestha M, Martens A, Behrendt S, Maeding I, Koigeldiyev N, Haverich A. Is the branched graft technique better than the en bloc technique for total aortic arch replacement? Eur J Cardiothorac Surg 2013; 45:181-6; discussion 186-7. [DOI: 10.1093/ejcts/ezt357] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Shrestha M, Pichlmaier M, Martens A, Hagl C, Khaladj N, Haverich A. Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results†. Eur J Cardiothorac Surg 2012; 43:406-10. [DOI: 10.1093/ejcts/ezs296] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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14
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Endovascular Aortic Arch Repair: Hopes and Certainties. Eur J Vasc Endovasc Surg 2009; 38:255-61. [DOI: 10.1016/j.ejvs.2009.06.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 06/11/2009] [Indexed: 11/22/2022]
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15
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Sakurai K, Usui A, Ueda Y, Akita T, Yoshikawa M, Murayama H, Ishiguchi T, Tajima K. Midterm results for endovascular stent grafts via median sternotomy for distal aortic arch aneurysm. J Artif Organs 2006; 9:149-53. [PMID: 16998699 DOI: 10.1007/s10047-006-0341-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2003] [Accepted: 05/31/2006] [Indexed: 11/27/2022]
Abstract
Dislocation or perigraft leakage is a major problem during the follow-up period for endovascular stent graft (EVG) implantation via median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied for the prevention of these complications. Here, we evaluate the midterm results and the efficacy of anchoring sutures. There were 21 male and 2 female patients enrolled in the study with an average age of 70 years (59-83). Aneurysm types were 21 true aneurysms (13 fusiform, 8 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. Total arch replacement was performed in two patients and aortocoronary bypass grafting was combined in four patients. Anchoring sutures to fix the EVG via median sternotomy were applied for 11 recent patients. The average follow-up period was 44 (22-79) months. There were no operative mortalities, but one case of paraplegia, one of stroke, and two of temporary spinal cord dysfunction. Complications related to EVG via median sternotomy occurred in five patients who had not received anchoring sutures, but the 11 patients with anchoring sutures showed no EVG-related complications. A chronic type B dissection revealed impending rupture due to false lumen infection 1 year after operation and repeat surgery was performed. Stent dislocation occurred in four patients, two of whom required repeat surgery via left thoracotomy due to endoleakage 3 and 4 years after surgery. One died from aneurismal rupture 5 years after surgery. One required emergency graft replacement because of graft perforation 5 years after surgery. The proportion of patients free from EVG-related events at 5 years after surgery was 75%. Anchoring sutures (P = 0.0155) and a large aneurysm of more than 80 mm (P = 0.0190) were predictors of late EVG-related complications. There were five late deaths: two were from stroke, one from rupture, one from cancer, and one from multiple organ failure after repeat surgery. EVG shortens postoperative recovery with relatively lower mortality, but spinal cord injury is a complication occurring with a relatively high rate. Patients with large aneurysms are not good candidates for EVG implantation via median sternotomy Anchoring sutures to fix the EVG to the aortic wall should help prevent EVG-related events and improve the durability of EVG.
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Affiliation(s)
- Koji Sakurai
- Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan.
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Gowda RM, Misra D, Tranbaugh RF, Ohki T, Khan IA. Endovascular stent grafting of descending thoracic aortic aneurysms. Chest 2003; 124:714-9. [PMID: 12907563 DOI: 10.1378/chest.124.2.714] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The treatment of descending thoracic aortic aneurysms using endovascular stents is one of the more recent advances in treatment and is receiving increasing attention as it is a less invasive alternative to open surgical repair. Although the technology is still primitive, significant improvements have lately been made in the design and deployment of the endovascular stent-grafts. Aortic stent-grafts were used initially to exclude abdominal, and later thoracic, aortic true and false aneurysms. These prostheses have been increasingly used to treat aneurysms, dissections, and traumatic ruptures of the descending thoracic aorta with good early and mid-term outcomes. Although the long-term outcome of patients with aneurysms of the descending thoracic aorta after stent graft implantation has not been investigated, continued refinement of the endovascular approaches has decreased the need for conventional open thoracic aortic aneurysm repair, especially in patients who are at a high risk for standard surgery because of advanced age or the presence of comorbid diseases. The placement of endoluminal stent-grafts to exclude the dissected or ruptured site of thoracic aortic aneurysms is a technically feasible and relatively safe procedure. With the rapid development of endovascular approaches, the treatment of the descending thoracic aortic aneurysms might alter even more, but an extended follow-up is necessary to determine the longer term outcome. Historical perspectives, advantages, device considerations, complications, and current perspectives of the endovascular stent grafting of the descending thoracic aortic aneurysms are elaborated on.
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Affiliation(s)
- Ramesh M Gowda
- Division of Cardiology, Beth Israel Medical Center, New York, NY, USA
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Affiliation(s)
- Takao Ohki
- The Department of Surgery, Division of Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Usui A, Ueda Y, Akita T, Takagi Y, Tajima K, Nishikimi N, Ishiguchi T. Mid-term results of an endovascular stent-graft by means of median sternotomy for distal aortic arch aneurysm. Artif Organs 2002; 26:1044-9. [PMID: 12460383 DOI: 10.1046/j.1525-1594.2002.07027.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Migration and perigraft leakage are major problems after endovascular stent graft (EVG) by means of median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied to prevent these problems. We evaluate the mid-term results and the efficacy of anchoring sutures. The operation was performed on 19 men and 2 women with a mean age of 70 years (range, 59-81). The aneurysms were 19 true (12 fusiform, 7 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. EGVs were implanted by way of the aortic arch under retrograde cerebral perfusion in 13 patients and selective cerebral perfusion in 8. Total arch replacement was performed in 2 patients, and aortocoronary bypass grafting in 4. Anchoring sutures to fix the EVG were applied in 9 patients. The average follow-up period was 28 months (range, 2-56). There were no operative mortalities, but 1 paraplegia, 1 stroke, and 2 cases of temporary spinal cord dysfunction occurred. All aneurysms were thrombosed completely after surgery and reduced in diameter (66.9 +/- 17.4 mm to 57.3 +/- 15.7 mm, p < 0.0001). EVG-related complications arose in 4 patients. A chronic Type B dissection revealed impending rupture because of false lumen infection 1 year after operation, and redo surgery was performed. Migration occurred in 3 patients, all with fusiform aneurysms. One of these had a graft kink 1 year later. Another showed aneurysm enlargement with serous pleural effusion 3 years after operation. The third required redo surgery because of perigraft leakage at 3 years after surgery. There were 2 late deaths caused by stroke. There were no EVG-related complications in the 9 cases in which anchoring sutures were applied and in the 7 cases with saccular aneurysms. No spinal cord dysfunction occurred in 8 cases with low-flow antegrade perfusion by way of both axillary arteries while the aorta was opened. Logistic regression analysis showed significant relevance to complications of large aneurysms, greater than 80 mm in diameter. A large aneurysm tends to give rise to complications involving EVG migration. Anchoring sutures of EVG may prevent EVG-related complications.
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Affiliation(s)
- Akihiko Usui
- Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine, Japan.
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Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002; 74:S1821-4; discussion S1825-32. [PMID: 12440674 DOI: 10.1016/s0003-4975(02)04131-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Endovascular stent grafting through a median sternotomy for a distal arch aneurysm (the frozen elephant trunk procedure) is an alternative to synthetic graft replacement. But spinal cord dysfunction can easily occur as a complication after surgery. Although its cause is uncertain, some attempts at prevention have been instituted. We address the mechanism of spinal cord dysfunction and evaluate the efficacy of our preventive measures. METHODS There were 22 men and 2 women with an average age of 71 (59 to 83) years. There were 22 true aneurysms (13 fusiform, nine saccular), one chronic dissection, and one penetrating aortic ulcer. The following strategies for prevention of spinal cord dysfunction were utilized: low flow perfusion through both axillary arteries (n = 10); pigtail catheter guidance (n = 19); use of a shorter graft with anchoring sutures (n = 12); flooding of the operative field with carbon dioxide (n = 7); aortic unclamping (n = 7), and use of ultra-thin woven Dacron grafts (n = 15). RESULTS There was no operative mortality, but cerebrospinal dysfunction complicated four cases (17%): one paraplegia, one stroke along the basilar artery, and two cases of temporary spinal cord dysfunction (paresthesia of the right leg and urinary disturbance). Cerebrospinal dysfunction tended to occur in fusiform aneurysms (31%, p = 0.044). Except when low flow antegrade perfusion through both the axillary arteries was utilized, which resulted in no cases of paraplegia or paraparesis (p = 0.064), the methods used for prevention of cerebrospinal dysfunction appeared to have little efficacy. CONCLUSIONS Cerebrospinal dysfunction is a serious complication of the frozen elephant trunk procedure. Its cause has not been clarified, but it tends to occur in fusiform-type aneurysms. Antegrade perfusion through both axillary arteries while the aorta is open may be helpful in its prevention.
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Affiliation(s)
- Akihiko Usui
- Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine, Japan.
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Bautista-Hernández V, Moya J, Martinell J, Polo ML, Fraile J. Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump. Ann Thorac Surg 2002; 73:956-8. [PMID: 11899209 DOI: 10.1016/s0003-4975(01)03120-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Vascular complications associated with intraaortic balloon pump placement are quite common and predominantly related to femoral or iliac damage. Iatrogenic injury of the thoracic aorta is less usual and often fatal. Surgery for the lesions of the descending thoracic aorta still has a relatively high morbidity and mortality. Endovascular covered stentgraft prostheses have become a less invasive therapeutic approach to lesions of the thoracic aorta, especially in patients with high surgical risk. We describe a case of perforation of the thoracic aorta caused by an intraaortic balloon pump. The injury was confirmed by aortography and successfully repaired by implantation of an endovascular stent-graft via the left common iliac artery.
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Usui A, Ueda Y, Watanabe T, Kawaguchi O, Ohara Y, Takagi Y, Tajima K, Nishikimi N, Ishiguchi T. Comparative clinical study between endovascular stent grafting on open surgery and conventional graft replacement for distal arch aneurysm. J Artif Organs 2001. [DOI: 10.1007/bf02480018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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