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Lu C, Duan W, Li Z, Wang C, Yang P, Liu Y, Zuo J, Hu J. One-year results of the Flowdynamics Dense Mesh Stent for residual dissection after proximal repair of stanford type A or type B aortic dissection: a multicenter, prospective, and randomized study. Int J Surg 2024; 110:4151-4160. [PMID: 38597396 PMCID: PMC11254268 DOI: 10.1097/js9.0000000000001440] [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] [Received: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Negative remodeling of the distal aorta following proximal repair for acute aortic dissection has garnered growing attention. This clinical scenario has spurred the development of techniques and devices. A multicenter, prospective, and randomized controlled study was conducted with the aim of confirming the safety and effectiveness of a newly-designed flowdynamics dense mesh stent for the treatment of residual dissection after proximal repair. METHODS Patients with nonchronic residual dissection affecting visceral branches were prospectively enrolled at three centers and randomly allocated to either the FDMS group or the control group. Primary endpoints encompassed all-cause and aortic-related mortality, while the patency of branch arteries is indeed a key focal metric. Morphological changes (diameter, area, and volume) were analyzed to demonstrate the therapeutic effect. RESULTS One hundred twelve patients were recruited in the clinical trial, and 103 patients completed the 12-month follow-up. The rate of freedom from all-cause and aortic-related death in the FDMS group was 94.64 and 100%, respectively. All visceral branches remained patent. The FDMS group exhibited a substantial expansion in TL and a notable shrinkage in FL at the planes below renal arteries (ΔArea TL : FDMS vs. Control, 0.74±0.46 vs. 0.34±0.66 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.72±1.26 vs. -0.12±0.86 cm, P =0.01) and 5 cm below renal arteries (ΔArea TL : FDMS vs. Control, 1.06±0.75 vs. 0.16±0.63 cm 2 , P <0.001; ΔArea FL : FDMS vs. Control, -0.53±1.43 vs. -0.25±1.00 cm, P =0.27). Meanwhile, the FDMS group demonstrated an increase of 22.55±11.14 cm 3 in TL ( P <0.001) and a corresponding reduction of 21.94±11.77 cm 3 in FL ( P =0.08). CONCLUSIONS This newly-designed FDMS for endovascular repair of residual dissection following the proximal repair is demonstrated to be safe and effective at 12 months.
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Affiliation(s)
- Chen Lu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi Province
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, People’s Republic of China
| | - Chenhao Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Yu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
| | - Jian Zuo
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi Province
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan
- Department of Cardiothoracic Surgery, West China Guang'an Hospital, Sichuan University, Guang’an, Sichuan Province
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Morjan M, Mestres CA, Savic V, Gerçek M, Van Hemelrijck M, Sromicki J, Dzemali O, Reser D. Indications and outcomes of second aortic procedures after acute type A dissection repair. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae076. [PMID: 38688455 DOI: 10.1093/icvts/ivae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/23/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVES Aortic arch or aortic root replacement is not performed in all cases of acute type A aortic dissection (ATAD), and a second aortic procedure will become necessary over time for some patients. Indications and outcomes, of second aortic procedures have not been studied extensively. METHODS Characteristics and in-hospital outcomes of all patients undergoing surgical repair for type A acute aortic dissection were analysed and patients needing second aortic procedure during follow-up were identified. The latter group was divided in 2 subgroups: on-pump includes patients operated on using cardiopulmonary bypass and off-pump without cardiopulmonary bypass. RESULTS A total of 638 patients underwent surgery for ATAD; 8% required a second aortic procedure. The most frequent indication for the second aortic procedure was dehiscence of suture lines (44%), followed by arch dilatation (24%). In-hospital mortality was 12%. Isolated ascending aorta replacement at the first surgery was associated with higher incidence of second aortic procedure (P = 0.006). Most patients in the on-pump group underwent a proximal reoperation (75%), with a mortality rate of 14.2%. In-hospital mortality of patients in the off-pump group was 7.7%. Long-term survival analysis showed no difference between groups (P = 0,526), Off-pump patients have greater likelihood of a second intervention during follow-up (P = 0.004). CONCLUSIONS Extended aortic root surgery and customized aortic arch repair in ATAD could be reasonable to reduce the incidence and mortality of high-risk second aortic procedures.
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Affiliation(s)
- Mohammed Morjan
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
- Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Duesseldorf, Germany
| | - Carlos-A Mestres
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Vedran Savic
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Mustafa Gerçek
- Clinic for Cardiac Surgery and Pediatric Cardiac Surgery, Heart Center Duisburg, Duisburg, Germany
| | | | - Juri Sromicki
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Diana Reser
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
- Herzklinik Hirslanden, Zürich, Switzerland
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Feng Y, Ma XT, Zhang XX, Wajeehullahi A, Chen ZJ, Li SL, Cheng C. Clinical study of reoperation for acute type A aortic dissection. Front Cardiovasc Med 2024; 11:1340687. [PMID: 38495943 PMCID: PMC10940513 DOI: 10.3389/fcvm.2024.1340687] [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: 11/18/2023] [Accepted: 02/05/2024] [Indexed: 03/19/2024] Open
Abstract
Objective The initial operation for type A aortic dissection has limitations, and there may be a need for reoperation in cases such as giant pseudoaneurysm formation and reduced blood supply to the distal vessels. In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience. Method Between June 2018 and December 2022, 62 patients with type A aortic dissection (TAAD) underwent reoperation after previous surgical treatment. Of these, 49 patients (45 males) underwent endovascular aortic repair (EVAR) with a mean age of (49.69 ± 10.21) years (30-75 years), and 13 patients (11 males) underwent thoracoabdominal aortic replacement (TAAR) with a mean age of (41.00 ± 11.18) years (23-66 years). In this study, we retrospectively analyzed the recorded data of 62 patients. In addition, we summarized and analyzed their Computed Tomographic Angiography (CTA) results and perioperative complications. Outcome In the EVAR group, 47 patients (95.92%) were successfully implanted with overlapping stents, and 2 patients died in the perioperative period. Postoperative complications included cerebral infarction (4.08%), acute renal insufficiency (30.61%), pulmonary insufficiency and need for ventilator (6.12%), poor wound healing (2.04%), postoperative reoperation (16.33%), and lower limb ischemia (2.04%). In the TAAR group, 12 patients (92.31%) were successfully revascularized and 1 patient died in the perioperative period. Postoperative complications included cerebral infarction (7.69%), acute kidney injury (46.15%), pulmonary insufficiency and need for ventilator (15.38%), poor wound healing (30.77%) and postoperative reoperation (15.38%). Conclusion According to the results of the study, compared with TAAR, EVAR was less invasive, faster recovery, and offered a better choice for some high-risk and high-age patients with comorbid underlying diseases. However, the rate of revascularization was higher after EVAR than TAAR due to vascular lesions. Compared with the use of ascending aortic replacement + hemi-aortic arch replacement for acute type A aortic dissection in many countries and regions, the use of ascending aortic replacement + aortic arch replacement + elephant trunk stent is more traumatic in China, but facilitates reoperation. For young patients, the choice of treatment should be individualized combining vascular lesions and long-term quality of life.
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Affiliation(s)
- Yi Feng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xian-Tao Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Xue Zhang
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Akilu Wajeehullahi
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zi-Jun Chen
- Department of Cardiothoracic Surgery, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Shi-Liang Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cai Cheng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Vekstein AM, Doberne JW, Weissler EH, Wojnarski CM, Long CA, Williams AR, Plichta RP, Gaca JG, Hughes GC. Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair. J Thorac Cardiovasc Surg 2023; 166:996-1008.e1. [PMID: 35282930 DOI: 10.1016/j.jtcvs.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Ohira S, Malekan R, Kai M, Goldberg JB, Laskowski I, De La Pena C, Mason I, Lansman SL, Spielvogel D. Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don't Despair the Repair. Ann Thorac Surg 2023; 116:43-50. [PMID: 36653324 DOI: 10.1016/j.athoracsur.2022.10.021] [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: 07/14/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair. METHODS From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis. RESULTS Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y. CONCLUSIONS Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York.
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Igor Laskowski
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Ian Mason
- New York Medical College, Valhalla, New York
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
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Kreibich M, Berger T, Rylski B, Siepe M, Czerny M. Frozen Elephant Trunk Procedure and Risk for Distal Stent-Graft-Induced New Entries. AORTA (STAMFORD, CONN.) 2022; 10:178-181. [PMID: 36521810 PMCID: PMC9754859 DOI: 10.1055/s-0042-1756666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The frozen elephant trunk (FET) procedure is known as an effective treatment option for patients with any aortic pathology involving the aortic arch. However, there is growing evidence that many patients often require secondary intended, expected, or unexpected aortic reinterventions during follow-up. In those with underlying aortic dissection pathology, a substantial risk for developing distal stent-graft-induced new entries (dSINEs) has been identified as one cause for secondary aortic reinterventions. dSINE can develop at any time after the FET procedure. Endovascular treatment is generally feasible and safe to close the newly formed entry with low procedural risk. Nevertheless, all patients need continuous follow-up after FET treatment, ideally in a specialized aortic outpatient clinic.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany,Address for correspondence Maximilian Kreibich, MD, MHBA Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital FreiburgHugstetter Street 55, 79106 FreiburgGermany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Hospital Freiburg, Freiburg, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Vogel J, Räber L, Makaloski V. Pseudoaneurysm Repair With a Septal Occluder. Vasc Endovascular Surg 2022; 56:628-630. [PMID: 35466833 PMCID: PMC9248001 DOI: 10.1177/15385744221095922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction New treatment options, like endovascular aortic repair, reduced the mortality rate of patients suffering from complications after an acute type A aortic dissection repair. Nevertheless, initial successful treatment of an aortic dissection does not fully eliminate the risk of later adverse aortic events like anastomotic pseudoaneurysm. Pseudoaneurysm of the anastomosis between the ascending and the arch graft could initiate complications like peripheral embolization, dysphagia or compression of mediastinum organs. Re-operation via re-sternotomy bears enormous morbidity and mortality for these patients. There is a high unmet need for percutaneous therapeutic options to treat pseudoaneurysms. Case Presentation A 59-year-old-man treated 15 years ago for type A aortic dissection, was hospitalized due to intermittent abdominal pain. A detailed examination revealed 2 pseudoaneurysms: 1 symptomatic at the level of the reimplanted celiac trunk and 1 asymptomatic at the anastomosis between the brachiocephalic trunk and the aortic arch graft. Due to multiple co-morbidities and previous operations, the risk for surgery was considered too high. Both pseudoaneurysm were treated percutaneously, the symptomatic 1 with covered stent and the asymptomatic with Amplatzer™ septal-occluder. Discussion We present an alternative percutaneous therapy approach for treatment of pseudoaneurysm using a septal-occluder. A follow-up computed tomography 3 months later showed successfully excluded pseudoaneurysm.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany
- University of Witten/Herdecke, Witten, Germany
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Demal TJ, Bax L, Brickwedel J, Kölbel T, Vettorazzi E, Sitzmann F, Reichenspurner H, Detter C. Outcome of the frozen elephant trunk procedure as a redo operation. Interact Cardiovasc Thorac Surg 2021; 33:85-92. [PMID: 33667306 DOI: 10.1093/icvts/ivab059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/01/2020] [Accepted: 01/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. METHODS One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. RESULTS A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19-35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23-3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. CONCLUSIONS Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.
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Affiliation(s)
- Till Joscha Demal
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Sitzmann
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
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10
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Kuroda Y, Uchida T, Ohba E, Yamashita A, Nakai S, Kobayashi K, Ochiai T, Sadahiro M. Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection. Interact Cardiovasc Thorac Surg 2021; 32:789-791. [PMID: 33479773 DOI: 10.1093/icvts/ivaa339] [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: 09/18/2020] [Revised: 11/26/2020] [Accepted: 12/12/2020] [Indexed: 11/14/2022] Open
Abstract
Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.
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Affiliation(s)
- Yoshinori Kuroda
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tetsuro Uchida
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Eiichi Ohba
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Atsushi Yamashita
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Shingo Nakai
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kimihiro Kobayashi
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomonori Ochiai
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Mitsuaki Sadahiro
- Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan
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11
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Moeller E, Nores M, Stamou SC. Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 7:155-162. [PMID: 32272487 PMCID: PMC7145439 DOI: 10.1055/s-0039-3401810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.
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Affiliation(s)
- Ellie Moeller
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Marcos Nores
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
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12
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Faure EM, El Batti S, Sutter W, Bel A, Julia P, Achouh P, Alsac JM. Stent-assisted balloon dilatation of chronic aortic dissection. J Thorac Cardiovasc Surg 2020; 162:1467-1473. [DOI: 10.1016/j.jtcvs.2020.01.081] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 11/30/2022]
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13
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Kreibich M, Desai ND, Bavaria JE, Szeto WY, Vallabhajosyula P, Itagaki R, Okamura H, Kimura N, Yamaguchi A, Beyersdorf F, Czerny M, Rylski B. Preoperative neurological deficit in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2020; 30:613-619. [DOI: 10.1093/icvts/ivz311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/23/2019] [Accepted: 12/02/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Our goal was to evaluate postoperative outcomes in patients with type A aortic dissection with preoperative neurological deficits independent of shock.
METHODS
Between 2002 and 2017, 150 of 1600 patients, operated on for aortic dissection type A in 3 centres, presented with preoperative new onset neurological deficits. Postoperative outcomes were classified using a modified Rankin Scale (mRS) as ‘no to moderate disability’ (mRS 0–3) or as ‘poor clinical outcome’ (mRS 4–6). Clinical and radiographic data were analysed.
RESULTS
Ninety-three patients (62%) had no to moderate disability and 57 (38%) had a poor clinical outcome. The in-hospital mortality rate was 18% (28 patients). Patients with poor clinical outcomes were significantly older (P = 0.01) and had a significantly higher incidence of hypertension (P = 0.04), history of stroke (P = 0.03) and common carotid artery occlusion (left common carotid artery: P = 0.01; right common carotid artery: P < 0.01). One-third of all patients developed haemodynamic instability (P = 0.27). Cardiopulmonary bypass (P < 0.01) and cross-clamp (P = 0.03) times were significantly longer in patients with poor clinical outcomes. Age (odds ratio 1.041; P = 0.02) and history of stroke (odds ratio 2.651; P = 0.03) were predictive of poor clinical outcome; coma was not. Haemorrhagic transformation occurred in 7 patients without any independent predictors.
CONCLUSIONS
Most patients with preoperative neurological deficit have no to moderate disability postoperatively but commonly develop preoperative haemodynamic instability. This study suggests that an immediate surgical approach may be reasonable in patients with preoperative neurological deficit or coma.
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Affiliation(s)
- Maximilian Kreibich
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryo Itagaki
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama Medical Centre, Saitama, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama Medical Centre, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama Medical Centre, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama Medical Centre, Saitama, Japan
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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14
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Urbanski PP, Zierer A, Irimie V, Lenos A, Bougioukakis P, Zacher M, Diegeler A. Operative and Long-Term Outcomes After Curative Repair of Acute Dissection Involving the Proximal Aorta. Ann Thorac Surg 2019; 108:115-121. [PMID: 30690022 DOI: 10.1016/j.athoracsur.2018.12.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of the study was to evaluate operative and long-term results after acute type A aorta dissection (AAAD) operation, in which complete resection of all dissected aortic segments (curative repair) was achieved. METHODS Among 205 consecutive patients operated on between 2002 and 2014 because of AAAD were 88 patients (42.9%), in whom the dissection did not extend into the downstream aorta. The distal extension of the dissection ended before the origin of the innominate artery in 50 patients of the study cohort (56.8%) or extended throughout the arch, necessitating a total/subtotal arch replacement to achieve a curative distal repair in 38 remaining patients (43.2%). The aortic root was involved in 52 patients (59.1%) and was repaired using valve-sparing repair (31) or replacement with a valve composite graft (21). Combination of root and open arch surgery was reported in 46 patients (52.3%). RESULTS Thirty-day and in-hospital mortalities were 3.4% and 5.7%, respectively. Survival was estimated starting with the operation and was 81.9% ± 4.5% and 56.6% ± 8.7% at 5 and 10 years, respectively. No patient required reoperation on the aortic root and/or distal thoracoabdominal aorta; however 2 cardiac reoperations were unrelated to the primary surgical procedure. Moreover, the freedom of aortic and/or sudden/unknown death was 100%. CONCLUSIONS Curative aortic repair can be achieved in a relevant share of AAAD patients and is mostly limited by the distal extension of dissection. This kind of repair is advisable, whenever possible, because it can provide very low risk of aortic complications and/or reoperations over time.
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Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
| | - Andreas Zierer
- Department of Thoracic and Cardiovascular Surgery, Johannes Kepler University Hospital, Linz, Austria
| | - Vadim Irimie
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Aristidis Lenos
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Petros Bougioukakis
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Michael Zacher
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Anno Diegeler
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
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15
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In Vitro Evaluation of Aortic Stent Graft Deployment Accuracy in the Distal Landing Zone. Eur J Vasc Endovasc Surg 2018; 56:808-816. [DOI: 10.1016/j.ejvs.2018.07.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/26/2018] [Indexed: 11/17/2022]
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16
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Houben IB, Patel HJ. Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear. Semin Thorac Cardiovasc Surg 2018; 31:122-128. [PMID: 30205145 DOI: 10.1053/j.semtcvs.2018.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/31/2018] [Indexed: 11/11/2022]
Abstract
As emergency repair for acute type A aortic dissection is improving, the reintervention rate increases. Over 10% of cases require an aortic reintervention, which should ideally be performed in an early stage to allow for positive aortic remodeling and to prevent limitations by the stiffened aortic flap. These reinterventions remain a surgical challenge and may come with complications. We provide a comprehensive overview of different management strategies and their success in treating aortic adverse remodelling, based on current evidence of the literature. Two meta-analyses and an additional literature search yielded comparable mortality rates between limited repair and extensive repair. Cardiopulmonary bypass time, cross clamping time and cardiac arrest time were significantly shorter in limited repairs. Reintervention rate was generally lower in extensive repair, although not always significant. In conclusion, the early aggressive approach may be useful to lower reintervention rates. However, it has not yet been proven to be more beneficial. It will be imperative to develop a patient-specific early stage prediction model for residual aortic reintervention.
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Affiliation(s)
- Ignas B Houben
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, Michigan.
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17
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Assi R, Bavaria JE, Desai ND. Techniques and outcomes of secondary open repair for chronic dissection after acute repair of type A aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:759-766. [PMID: 29943963 DOI: 10.23736/s0021-9509.18.10646-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite successful repair of acute type A aortic dissection (TAAD), the distal false lumen may remain patent resulting in progressive degeneration of the remaining distal aorta. This can lead to aneurysmal dilatation and risk of rupture. Open distal reoperation to replace the residually dissected thoraco-abdominal aorta may be accomplished with acceptable morbidity and mortality in experienced hands. This can be facilitated when the index operation for acute TAAD is tailored to exclude all primary tears and set the arch and descending aorta for a subsequent open, endovascular or hybrid procedure.
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Affiliation(s)
- Roland Assi
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA -
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18
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Desai ND, Hoedt A, Wang G, Szeto WY, Vallabhajosyula P, Reinke M, Bavaria JE. Simplifying aortic arch surgery: open zone 2 arch with single branched thoracic endovascular aortic repair completion. Ann Cardiothorac Surg 2018; 7:351-356. [PMID: 30155413 DOI: 10.21037/acs.2018.05.08] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Distal aortic complications from acute DeBakey I dissection repair are an important source of late morbidity and mortality. We present an early experience of using a novel single-branched thoracic aortic endograft in conjunction with open techniques to treat acute DeBakey I aortic dissection. Methods The patients in this series include five hyperacute dissections managed with a combined zone 2 partial arch replacement and placement of a zone 2 single subclavian branch endograft. Results There were no perioperative mortalities, strokes, or spinal cord ischemia in any patients at either stage of the procedure. At follow-up imaging, no patients had anterograde flow into the false lumen. All patients experienced false lumen thrombosis in the stented portion of the aorta. Conclusions This combination of open repair techniques and the use of a novel branched endograft resulted in excellent early outcomes in this pioneer series. Further investigation of these techniques in a prospective fashion is warranted.
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Affiliation(s)
- Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Hoedt
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Wang
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mary Reinke
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
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19
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Berezowski M, Morlock J, Beyersdorf F, Jasinski M, Plonek T, Siepe M, Czerny M, Rylski B. Inaccurate aortic stent graft deployment in the distal landing zone: incidence, reasons and consequences†. Eur J Cardiothorac Surg 2017; 53:1158-1164. [DOI: 10.1093/ejcts/ezx379] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/27/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mikolaj Berezowski
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Julia Morlock
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Marek Jasinski
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Plonek
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
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20
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Rylski B, Hahn N, Beyersdorf F, Kondov S, Wolkewitz M, Blanke P, Plonek T, Czerny M, Siepe M. Fate of the dissected aortic arch after ascending replacement in type A aortic dissection†. Eur J Cardiothorac Surg 2017; 51:1127-1134. [DOI: 10.1093/ejcts/ezx062] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/10/2017] [Indexed: 01/16/2023] Open
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21
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Pan XD, Li B, Ma WG, Zheng J, Liu YM, Zhu JM, Huang LJ, Sun LZ. Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection. J Thorac Dis 2017; 9:529-536. [PMID: 28449459 DOI: 10.21037/jtd.2017.03.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with type A dissection, residual dissection and new distal entry tears following the frozen elephant trunk (FET) procedure adversely affect long-term prognosis. Management include open and endovascular repair, while clinical experience is limited. We evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in management of residual intimal tear or distal new entry tear following FET in patients with type A aortic dissection (TAAD). METHODS Between May 2003 and April 2013, we performed FET and total arch replacement for 1,003 patients with TAAD. Among these, 23 patients (2.3%) required TEVAR for distal new entry (n=2) or residual intimal tear (n=21) at a mean of 2.0±1.6 years after FET. Mean age was 50.1±11.5 years. Marfan syndrome was seen in 2 patients (8.7%). RESULTS Procedural success was 100%. The distal landing zone was above the 11th thoracic vertebra (T11) in 86.9% (20/23). Neither death nor any paraplegia or stroke occurred early after TEVAR. Follow-up was complete in 100% averaging 2.8±1.7 years (0.3-6.4). One non-Marfan patient died of distal aortic rupture at 4 months after TEVAR. No late stroke or paraplegia occurred. Survival was 95.7% (95% CI, 72.9-99.4%) at 3 and 5 years, respectively. CTA detected false lumen obliteration by thrombus around the endograft in the descending aorta in 91.3% (21/23) of patients. CONCLUSIONS These early and midterm outcomes show the efficacy of TEVAR in obliterating the residual intimal tear or distal new entry after FET in patients with TAAD. TEVAR may be an alternative approach to distal new entry or residual intimal tear following FET for patients with TAAD.
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Affiliation(s)
- Xu-Dong Pan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Bin Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Lian-Jun Huang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Aortic Disease Center, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
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22
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Rylski B, Czerny M, Südkamp M, Russe M, Siep M, Beyersdorf F. Fenestrated and Branched Aortic Grafts. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:816-22. [PMID: 26667980 DOI: 10.3238/arztebl.2015.0816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/10/2015] [Accepted: 08/10/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Abdominal and thoracic aortic aneurysms are diagnosed in 40 and 10 to 15 out of 100 000 persons per year, respectively. Fenestrated (fEVAR) and branched (bEVAR) stent grafts have been developed for abdominal juxtarenal and thoracoabdominal aneurysms. We discuss the patency and complication rates of fEVAR and bEVAR procedures and compare them with the outcome of open surgery. METHODS This review is based on pertinent publications from 2011 to 2014 that were retrieved by a selective literature search. The clinical outcomes of case series involving a total of more than 1500 patients are presented. The discussion takes account of recommendations contained in the literature and the authors' own experience. RESULTS Open surgery and aortic stent grafting have not been compared in any randomized trial to date. We identified 7 clinical series that included a total of 1270 fEVAR patients and 5 with a total of 408 bEVAR patients. The perioperative mortality after fEVAR procedures was 0-4%. Spinal cord ischemia arose in 1% of cases. The stent patency rate in visceral vessels ranged from 93 to 98%. bEVAR procedures were associated with both higher mortality (4-7%) and more common spinal cord ischemia (4-13%). 5-8% of all patients needed dialysis perioperatively, and the stent patency rate in visceral vessels was 94-97%. Preoperative renal insufficiency was a risk factor for peri-interventional death. Impaired renal function after fEVAR/bEVAR procedures was mainly associated with intermittent lower limb ischemia. CONCLUSION The results of fEVAR/bEVAR procedures in the last 5 years are similar to those of open surgery. The high postoperative rate of spinal cord ischemia remains a serious problem in the endovascular treatment of thoracoabdominal aortic aneurysms. The decision to implant a stent graft by an endovascular approach or to treat surgically should be made on a case-to-case basis in an interdisciplinary vascular conference.
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Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Center for Diagnostic and Therapeutic Radiology, Medical Center-University of Freiburg
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23
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Dell'Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, Del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016. [PMID: 27770195 DOI: 10.1007/s00380-016-0907-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.
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Affiliation(s)
- Angelo M Dell'Aquila
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Francesco Pollari
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, Maria Eleonora Hospital GVM Care and Research, Palermo, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Julia Hillebrand
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany.
| | - Stefan Schneider
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Jan Landwerht
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Giuseppe Nasso
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Renato Gregorini
- Department of Cardiovascular Surgery, Cardiac Surgery Unit, Città di Lecce Hospital GVM Care and Research, Lecce, Italy
| | - Mauro Del Giglio
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Elisa Mikus
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Alberto Albertini
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM Care and Research, Cotignola, Italy
| | - Heinz Deschka
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany
| | - Sven Martens
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, 48159, Muenster, Germany
| | - Alina Gallo
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
| | | | - Giuseppe Speziale
- Department of Cardiovascular Surgery, Anthea Hospital GVM Care and Research, Bari, Italy
| | - Tommaso Regesta
- Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy
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Dell’Aquila AM, Pollari F, Fattouch K, Santarpino G, Hillebrand J, Schneider S, Landwerht J, Nasso G, Gregorini R, del Giglio M, Mikus E, Albertini A, Deschka H, Fischlein T, Martens S, Gallo A, Concistrè G, Speziale G, Regesta T. Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database. Heart Vessels 2016; 32:566-573. [DOI: 10.1007/s00380-016-0907-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/14/2016] [Indexed: 12/25/2022]
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Urbanski PP, Bougioukakis P, Deja MA, Diegeler A, Irimie V, Lenos A, Zembala MO. Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumens. Eur J Cardiothorac Surg 2015; 49:1382-90. [PMID: 26518381 DOI: 10.1093/ejcts/ezv386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/21/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surgical management of chronic aortic dissection is controversial, especially when the dissection extends into the abdominal aorta in which the visceral arteries originate from different lumens and is combined with aortic arch pathology necessitating surgery. The aim of the study was to evaluate the results of open surgery in this complex aortic pathology. METHODS Between June 2002 and 2015, a total of 17 patients (median age 57, range 32-76 years) necessitating complete arch replacement presented complex chronic dissection of the thoraco-abdominal aorta with the visceral arteries originating from different lumens. Fourteen patients (82%) had had previous cardiac surgery, which was performed on the proximal aorta in all but one because of acute type A dissection. Nine patients without considerable dilatation of the descending aorta received aortic arch replacement with distal resection of the dissection membrane, and 8 patients with progressive dilatation of the thoracic aorta underwent aortic arch and descending aorta replacement via clamshell approach. RESULTS No early (defined as 30-day, 90-day and in-hospital period) deaths, strokes or spinal cord injuries occurred. Only 1 patient (6%) presented temporary neurological dysfunctions (delirium, agitation), which resolved completely before discharge, and an injury of the recurrent laryngeal nerve was documented in 2 patients (12%). Temporary dialysis was necessary in 1 case. The follow-up was complete for all patients. All but one patient, who died due to leukaemia 23 months after surgery, were alive at the last follow-up (median duration 33 months, range 2-118 months). No patient needed a reoperation or an intervention on the thoracic and/or abdominal aorta. Moreover, no noticeable progression of the chronic dissection in the downstream aorta was documented in any patient. CONCLUSIONS The results after conventional aortic arch repair with distal resection of the dissection membrane and, if necessary, with replacement of the progressively dilated chronic dissected thoracic aorta can offer excellent results in experienced hands and, therefore, this technique may be considered as a preferable option for surgical treatment of chronic aortic dissection with involvement of the aortic arch and the visceral arteries originating from different lumens.
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Affiliation(s)
| | | | - Marek A Deja
- Cardiovascular Clinic, Medical University of Silesia, Katowice, Poland
| | - Anno Diegeler
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Vadim Irimie
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | | | - Michal O Zembala
- Department of Cardiovascular Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland
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Shrestha M. Re: Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair. Eur J Cardiothorac Surg 2015; 48:264-5. [PMID: 25656403 DOI: 10.1093/ejcts/ezu555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Malakh Shrestha
- Department of Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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