National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

Management of Non-A Non-B Aortic Dissection: A Narrative Review

Non-A non-B aortic dissection remains a complex and controversial topic in cardiovascular management, eliciting varied approaches among cardiologists and surgeons. Due to the limited evidence surrounding this condition, existing guidelines are limited in the complexity of their recommendations. While most patients are initially managed medically, invasive treatment becomes necessary in a large proportion of patients. When surgery is considered, the most utilized techniques include the frozen elephant trunk procedure and endovascular repair strategies targeting the arch and descending thoracic aorta. This narrative review aims to synthesize current knowledge and clinical experiences, highlighting the challenges and evolving practices related to non-A non-B dissection management.

Impact of arch disease pathology on outcomes of zone 0 branched thoracic endovascular arch repair

OBJECTIVE

Zone 0 branched thoracic endovascular arch repair (Z0BTEVAR) has emerged as an alternative to open repair for high-risk patients with aortic arch pathology. However, it is unclear how disease characteristics in this population impacts clinical outcomes. The study aimed to compare Z0BTEVAR according to arch disease pathology and to identify potential predictors of postoperative outcomes.

METHODS

From 2011 to 2023, patients who underwent Z0BTEVAR for chronic aortic dissection (C-AD) or for non-aortic dissection (N-AD) etiology at three European centers were included. The primary outcome was a composite of in-hospital mortality and disabling stroke. Multivariable logistic analyses were conducted to identify independent predictors of the outcomes.

RESULTS

Overall, 213 patients underwent Z0BTEVAR, including 111 patients treated for C-AD and 102 patients treated for N-AD. The median age was 72 years old. Overall composite outcome was 10.3%, higher for patients with N-AD compared with patients with C-AD (15.7% vs 5.4%; P = .01). Similarly, patients with N-AD had more postoperative strokes (17.7% vs 4.5%; P < .01). On multivariable analysis, previous type A aortic dissection was protective for the composite outcome (odds ratio, 0.2; 95% confidence interval, 0.1-0.6), whereas degenerative aneurysm with zone 0 or 1 involvement was predictive of postoperative stroke (odds ratio, 3.7; 95% confidence interval, 1.2-11.8). At 4 years, survival for the N-AD group was 71.8% ± 6.6%, and for the C-AD group was 71.5% ± 6.5% (P = .81).

CONCLUSION

Z0BTEVAR could be performed with satisfactory short- and mid-term outcomes for high-risk patients, particularly those with previous dissection. Patient selection is important, and continued effort should be placed on minimizing postoperative stroke.

Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options

OBJECTIVES

The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices.

METHODS

In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article.

RESULTS

Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease.

CONCLUSIONS

It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

Tailored surgical strategies for mini-access open total arch repair

Objective

Open arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence.

Methods

We evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics.

Results

Arch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach.

Conclusions

Based on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.

Assessment of Thoracic Endovascular Aortic Repair Using Relay Proximal Scallop: Results of a French Prospective Multicentre Study

OBJECTIVE

A proximal scallop design allows aortic arch repair without complex endovascular manipulation in the aortic arch. The aim was to assess the safety and efficacy at one year of the Relay proximal scallop stent graft.

METHODS

A prospective multicentre study evaluated consecutive patients treated with the Relay proximal scallop stent graft in 10 French aortic centres. All consecutive patients eligible for elective thoracic endovascular repair with proximal scallop in the 10 participating centres between January 2015 and July 2018 were included. Primary endpoints were 30 day mortality, stroke, and spinal cord ischaemia (SCI) rates. Outcomes including safety and efficacy, technical and clinical success, all cause death, neurological events, vessel patency, and device specific complications were analysed. Survival and survival without severe complications were estimated using Kaplan-Meier estimates.

RESULTS

Ten aortic centres treated 40 patients for thoracic aortic aneurysm (45%), penetrating atherosclerotic aneurysm (30%), and dissection (25%). Half of the procedures (50%) targeted zone 0 of the aortic arch (zone 0 in 17.5% and zones 0/1 in 32.5%), 37.5% targeted zone 2 (35% zone 2 alone; 2.5% zones 1/2), and 15% targeted zone 1 (12.5% zone 1 alone). Median follow up was one year. Thirty day mortality, stroke, and SCI rates were 10%, 5%, and 0% respectively. Primary technical success was 95%. Type Ia, Ib, and III endoleaks rates were 5.4%, 0%, and 0% respectively at one month. The overall mortality rate at one year was 17.5%. Aneurysm expansion was > 5 mm in one case at one year associated with type Ia endoleak (3%). There was no supra-aortic trunk thrombosis, one (2%) graft kink, and no migration.

CONCLUSION

One year outcomes showed that the Relay proximal scallop stent graft is an acceptable answer to thoracic aortic disease to deal with short proximal landing zones.

Emergency and Compassionate Use of a Novel Ascending Endograft for Ascending and Arch Aortic Pathology

PURPOSE

Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta.

MATERIALS AND METHODS

This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta.

RESULTS

Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%).

CONCLUSIONS

Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies.

CLINICAL IMPACT

This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.

Hybrid Approaches for Aortic Disease – Our Experience

BACKGROUND

Despite significant technological advancements in endovascular aortic repair, the aortic arch remains a challenge due to anatomic complexity including arch angulation and morphology as well as the location of brachiocephalic vessels in relation to landing zones. Total endovascular solutions are in development and being studied, in the meantime, hybrid thoracic endovascular aortic repair (TEVAR) is a viable alternative to traditional open total arch replacement.

METHODS

A retrospective case series was performed reviewing outcomes of 71 patients who underwent hybrid TEVAR in the aortic arch over the past 12 years at our facility.

RESULTS

Major morbidity in the first 30 days post procedure was experienced by 3 patients (15.7%) and included one patient with stroke (n = 1), and another who experienced paraplegia and pulmonary complications (n = 1). There was one in-hospital death as a result of respiratory failure in a patient with multiple underlying comorbidities including chronic obstructive pulmonary disease on postoperative day 5 resulting in a 30-day mortality of 5.2%. After a mean follow-up of 30 months, the overall mortality remained 5.2%. Major morbidity occurred in one patient who developed retrograde type A dissection. There was no stenosis of bypass grafts identified on follow-up imaging. Endoleak was identified in 2 patients. One patient experienced persistent retrograde perfusion of the false lumen with interval aneurysmal degeneration which was managed with an Amplatz vascular plug at 120 months following the initial hybrid TEVAR (5.2%).

CONCLUSIONS

Single-stage hybrid TEVAR in the aortic arch is technically feasible with a good mid-term survival and a long-term freedom from reintervention.