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Martens A, Beckmann E, Kaufeld T, Arar M, Natanov R, Fleissner F, Korte W, Krueger H, Boethig D, Haverich A, Shrestha M. Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft. J Thorac Cardiovasc Surg 2024; 168:477-487.e9. [PMID: 36813586 DOI: 10.1016/j.jtcvs.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 12/06/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. METHODS A total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. RESULTS The incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. CONCLUSIONS Intraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.
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Affiliation(s)
- Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
| | - Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Morsi Arar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wilhelm Korte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Arjomandi Rad A, Ansaripour A, Magouliotis DE, Abbasciano RG, Koulouroudias M, Viviano A, Rosendahl U, Athanasiou T, Kourliouros A. Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk. J Clin Med 2024; 13:4063. [PMID: 39064105 PMCID: PMC11278031 DOI: 10.3390/jcm13144063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The frozen elephant trunk (FET) technique is increasingly utilized for aortic arch replacement in cases of aortic dissections and aneurysms. This rise in usage has led to more patients needing redo aortic surgeries due to progression of existing conditions, FET-related complications, or new valvular/coronary diseases. This article aims to evaluate surgical techniques to minimize risks during these reoperations, including a case study of a complex redo surgery. Methods: A comprehensive examination of surgical strategies was conducted, focusing on preoperative preparation, cannulation site identification, cerebral and cardiac protective measures, and pitfalls to avoid. The importance of adapting to the modified anatomical landscape post-FET is emphasized. A detailed case study of a patient undergoing complex redo FET surgery is included. Results: The article identified key surgical strategies for reoperation in patients with prior FET, highlighting the importance of meticulous preoperative planning and execution. Techniques to minimize risks include detailed imaging for planning, strategic cannulation for optimal perfusion, multidisciplinary approaches as well as careful fail-safe measures. The case study demonstrates the practical application of these strategies in a high-risk scenario. The evidence underscores the necessity for individualized patient management and the development of standardized protocols. Conclusions: The FET technique, while effective for initial aortic arch repairs, often necessitates complex reoperations. Adopting advanced surgical strategies and multidisciplinary planning can significantly mitigate risks associated with these procedures. Future research should focus on refining these techniques and establishing standardized protocols to improve patient outcomes.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Ali Ansaripour
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Dimitrios E. Magouliotis
- Department of Cardiothoracic Surgery, University Hospital of Larissa, School of Medical Sciences, 413 34 Larissa, Greece;
| | - Riccardo G. Abbasciano
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | | | - Alessandro Viviano
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | - Ulrich Rosendahl
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK;
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.V.); (T.A.)
| | - Antonios Kourliouros
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
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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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Morishita A, Katahira S, Hoshino T, Hanzawa K, Tomioka H. Two-stage hybrid surgical repair for aortic arch pathology with a shaggy aorta: a case report. J Cardiothorac Surg 2024; 19:334. [PMID: 38890739 PMCID: PMC11184779 DOI: 10.1186/s13019-024-02841-5] [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: 01/24/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The surgical treatment strategy for aortic arch pathology with a shaggy aorta must be determined on a case-by-case basis because of the risk of catastrophic complications, such as brain infarction and spinal cord injury. CASE PRESENTATION This report describes the surgical case of two saccular aneurysms of the arch and abdominal aorta associated with a shaggy aorta in a 63-year-old man who underwent total arch replacement and secondary thoracic endovascular aortic repair. Considering the risk of embolization during endovascular therapy, graft replacement for the abdominal aortic aneurysm was initially performed. On postoperative day 28, total arch replacement with the conventional elephant trunk was performed using the functional brain isolation technique, which involves manipulating places far from the atherosclerotic burden, such as arterial inflow for cardiopulmonary bypass and unclamping of neck vessels. On postoperative day 7 after total arch replacement, thoracic endovascular aortic repair was performed across the conventional elephant trunk in the nondiseased descending aorta. No postoperative complications, such as cerebrovascular failure, paraplegia, or embolization to abdominal viscera or lower extremities, occurred. The patient remained asymptomatic. CONCLUSIONS The present case suggests that total arch replacement with the conventional elephant trunk and secondary thoracic endovascular aortic repair may be an effective alternative for aortic arch pathology with a shaggy aorta. The strategy for surgical treatment in patients with aortic arch pathologies with a shaggy aorta must be judged on a case-by-case basis, considering patient characteristics, comorbidities, and preoperative evaluation using transesophageal echocardiography and computed tomography angiography, to eliminate potential determinants of intraoperative stroke.
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Affiliation(s)
- Atsushi Morishita
- Department of Cardiovascular Surgery, Numata Neurosurgery Heart-Disease, 8 Sakae-cho, HospitalNumata, 378-0014, Japan.
| | - Seiichiro Katahira
- Division of Health Administration, Hamakawasaki Operation Center, Toshiba Human Asset Service Corporation, Kawasaki, Japan
| | - Takeshi Hoshino
- Department of Anesthesiology, Minami Machida Hospital, Machida, Japan
| | - Kazuhiko Hanzawa
- Department of Advanced Treatment and Prevention for Vascular Disease and Embolism, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hideyuki Tomioka
- Department of Cardiovascular Surgery, Saitama Easten Cardiovascular Hospital, Koshigaya, Japan
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DiBartolomeo AD, Kazerounim K, Fleischman F, Han SM. The Initial Results of Physician-Modified Fenestrated-Branched Endovascular Repairs of the Aortic Arch and Lessons Learned From the First 21 Cases. J Endovasc Ther 2024:15266028241255539. [PMID: 38778636 DOI: 10.1177/15266028241255539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for the aortic arch provides a minimally invasive treatment option for patients who are too high-risk for open repair. Improvements in technique are gained with ongoing experience with these complex repairs. This study aims to describe outcomes of arch PM-FBEVAR and technical lessons. MATERIALS AND METHODS A retrospective review of consecutive patients who underwent PM-FBEVAR with zone 0 proximal sealing at a single institution between January 2019 and July 2023 was performed. Cases completed using initial techniques (early technique) were compared with cases using the current techniques (current technique). Modification technique changed to include a self-orienting spine trigger wire and anatomically specific fenestrations or inner branches in the current group. The primary outcome was in-hospital mortality. Secondary outcomes included technical success and 30 day stroke. RESULTS A total of 21 patients underwent arch PM-FBEVAR, with 7 in the early group and 14 in the current group. Severe comorbidities were present in both groups including chronic obstructive pulmonary disease (COPD) (43% vs 36%), prior open ascending aortic repair (57% vs 43%), and prior stroke (86% vs 21%), respectively. Technical success was the same (86% vs 86%, p=1.0). Fluoroscopy time (56 vs 24 min, p=0.012) and in-hospital death (43% vs 0%, p=0.026) were significantly lower in the current group. A 30 day stroke rate (29% vs 7%, p=0.247) was non-significantly decreased in the current group. All-cause mortality was 100% vs 7% during median follow-up of 8 and 6 months (p<0.001). Three deaths in the early group were related to their aortic arch repair including aortic rupture during endograft advancement and 2 postoperative strokes. CONCLUSION There is a significant learning curve associated with aortic arch PM-FBEVAR. This study suggests that gained experience, use of the spine trigger wire technique, and precise creation of fenestrations or inner branches can lead to a shorter procedure time and lower complications. CLINICAL IMPACT Physician modified fenestrated branched endografting is feasible for the aortic arch. The high rate of stroke and perioperative mortality was reduced with incorporation of self-orienting spine trigger wire and anatomically specific inner branch creation.
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Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Kayvan Kazerounim
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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Kainz FM, Freystaetter K, Nagel F, Wiedemann D, Podesser BK. Circumferent dissection of the ascending aorta resulting in the occlusion of supra-aortic vessels repaired using the frozen elephant trunk technique - a case report. J Cardiothorac Surg 2024; 19:298. [PMID: 38778415 PMCID: PMC11110333 DOI: 10.1186/s13019-024-02765-0] [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: 05/12/2023] [Accepted: 03/30/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Our patient presented with acute back pain and dyspnea, without neurological symptoms. The computed tomography (CT) scan showed a circumferent rupture of the ascending aortic intima which was invaginated in the arch and descending aorta. CASE PRESENTATION A 54-year-old male patient was diagnosed with a Type A aortic dissection. He was immediately transferred to our operation room (OR) from the emergency department of a peripheral hospital. He presented with a circumferential dissection of the ascending aorta originating just distal to the coronary ostia, with the invaginated intimal mass extending through the arch down the descending aorta. In mild hypothermia, the intimal mass was safely extracted and a frozen elephant trunk (FET) procedure was performed. CONCLUSIONS Despite the extensive dissection affecting the ascending aorta and aortic arch, resulting in partially occluded supra-aortic vessels by an intimal mass, the patient remained without neurological symptoms in the pre- and post-operative period and remains well one year post surgery.
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Affiliation(s)
- Frieda-Maria Kainz
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.
| | - Kathrin Freystaetter
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Felix Nagel
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Dominik Wiedemann
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Bruno K Podesser
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
- Division of Cardiosurgery, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
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Papakonstantinou NA, Martinez-Lopez D, Chung JCY. The frozen elephant trunk: seeking a more definitive treatment for acute type A aortic dissection. Eur J Cardiothorac Surg 2024; 65:ezae176. [PMID: 38676575 DOI: 10.1093/ejcts/ezae176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/10/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVES Conventional treatment for type A aortic dissection includes replacement of the ascending aorta with an open distal anastomosis in the hemiarch position. The frozen elephant trunk (FET) is a hybrid technique that extends the repair to the descending thoracic aorta. The goal is to improve resolution of malperfusion syndrome and to induce positive aortic remodelling and reduce the need for reintervention on the downstream aorta. We aim to summarize the data on the short and long-term outcomes of this technique. METHODS A thorough search of the literature was conducted isolating all articles dealing with aortic remodelling after the use of FET in case of type A acute aortic dissection. Keywords 'aortic dissection', 'frozen elephant trunk', 'aortic remodelling' and 'false lumen thrombosis' were used. Data for type B and chronic aortic dissections were excluded. RESULTS FET use favourably influences aortic remodelling. The main advantages lie in the exclusion of distal entry tears in either the aortic arch or descending aorta thus restoring antegrade blood flow in the true lumen and inducing false lumen thrombosis. False lumen thrombosis is not only induced at the level of the stent deployment but also lower in the distal descending aorta. Moreover, it offers an adequate landing zone in the mid-descending aorta for second-stage endovascular or open surgical aortic repair, if needed. CONCLUSIONS FET can be advantageous in the treatment of acute type A aortic dissection dealing with extended aortic pathology.
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Affiliation(s)
- Nikolaos A Papakonstantinou
- 2nd Cardiac Surgery Department, Onassis Cardiac Surgery Center, Athens, Greece
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Daniel Martinez-Lopez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, Canada
- Cardiac Surgery Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Jennifer Chia-Ying Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, Canada
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Coselli JS, Roselli EE, Preventza O, Malaisrie SC, Stewart A, Stelzer P, Takayama H, Chen EP, Estrera AL, Gleason TG, Fischbein MP, Girardi LN, Patel HJ, Bavaria JE, LeMaire SA. Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial. J Thorac Cardiovasc Surg 2024; 167:1680-1692.e2. [PMID: 36253292 DOI: 10.1016/j.jtcvs.2022.08.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta. METHODS For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality. RESULTS In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group. CONCLUSIONS One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Eric E Roselli
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - S Chris Malaisrie
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Allan Stewart
- East Florida Division, HCA Florida Healthcare, Fort Lauderdale, Fla
| | - Paul Stelzer
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, NY
| | - Hiroo Takayama
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Edward P Chen
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas, McGovern Medical Center, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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9
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Nienaber S, Yuan X, Price S, Rosendahl U, Nienaber CA. The elephant's Achilles' heel: a case report of acute obstruction of frozen elephant trunk after proximal aortic dissection repair. Eur Heart J Case Rep 2024; 8:ytae186. [PMID: 38690556 PMCID: PMC11060110 DOI: 10.1093/ehjcr/ytae186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
Background The frozen elephant trunk (FET) technique as a hybrid combining surgical and endovascular repair is an emerging concept to treat complex aortic dissection. Early experience showed technical feasibility and promising clinical outcomes. However, unsuspected complications still arise. Case summary A 25-year-old male presented to the emergency department with a 2-day history of chest pain. After exclusion of acute coronary syndrome, a computed tomography angiography (CTA) revealed Type A (DeBakey Type I) aortic dissection. The patient underwent median stenotomy for complete replacement of the ascending aorta, the aortic arch, and FET. Early after rewarming, the patient became unstable due to severe left ventricular dysfunction. Soon veno-arterial extracorporal membrane oxygenation (VA-ECMO) was required for circulatory support. The cause of deterioration remained unclear until repeated CTA showed acute obstruction of the FET. Invasive exploration confirmed a trans-FET gradient of 100 mmHg, successfully managed by repeated balloon inflation with resolution of both obstruction and gradient. The patient recovered completely without any sequela. Discussion While the mechanism of acute obstruction after FET remains subject to speculation, the rescue intervention of ballooning the obliteration on VA-ECMO was life-saving. Intraoperative ultrasound and videoscopic inspection may be instrumental before chest closure to avoid such critical events.
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Affiliation(s)
- Stephan Nienaber
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Xun Yuan
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
| | - Susanna Price
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
| | - Ulrich Rosendahl
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
- Department of Cardiac Surgery, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London, UK
| | - Christoph A Nienaber
- Department of Cardiology and Aortic Centre, Guy’s and St. Thomas’ Hospitals NHS Trust, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
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Göbel N, Holder S, Hüther F, Anguelov Y, Bail D, Franke U. Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I. Front Cardiovasc Med 2024; 11:1326124. [PMID: 38559669 PMCID: PMC10978760 DOI: 10.3389/fcvm.2024.1326124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Objective The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair. Methods Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention. Results Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77). Conclusion Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.
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Affiliation(s)
- Nora Göbel
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
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11
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Lee KFL, Bhatia I, Chan TLD, Au WKT, Ho KLC. Proximalization of Frozen Elephant Trunk Procedure: Zone 0 or 1 versus Zone 2 or 3 Arch Repair. Thorac Cardiovasc Surg 2024; 72:89-95. [PMID: 36216330 DOI: 10.1055/s-0042-1757631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Total arch replacement with the frozen elephant trunk (FET) procedure has changed the landscape of therapy for aortic arch diseases. The optimal landing zone for a FET is controversial. We sought to share our early and midterm results of the FET procedure as well as compare the clinical outcomes of proximal and distal FET anastomosis. METHODS A total of 100 patients who underwent total arch replacement using the FET technique were identified between November 2014 and August 2021. According to the FET anastomosis over the aortic arch, patients were classified into two groups (zone 0/1 vs. zone 2/3). In-hospital mortality, complications, and midterm outcomes were assessed based on patient characteristics. RESULTS The overall in-hospital mortality was 8%. Major complications occurred in 32% of patients, including spinal cord injury (5%), stroke (7%), and acute kidney injury requiring dialysis (7%). Zone 2/3 FET (odds ratio: 6.491, 95% confidence interval: 1.930-21.835, p = 0.003) was an independent predictor of the composite endpoint of major complications. The rate of complete false lumen thrombosis was comparable (64.3% vs. 71.4%, p = 0.567). All patients, patients with zone 0/1 FET, and patients with zone 2/3 FET had 3-year freedom from aorta-related events of 73.0, 70.2, and 75.0%, respectively. There were no significant differences (log-rank test, p = 0.500). CONCLUSION Compared with zone 2/3, proximalization of FET using zone 0/1 for anastomosis was associated with better early outcomes and comparable rates of midterm aorta-related events. To substantiate its use, more research on this approach is required.
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Affiliation(s)
- Kwok Fai Lucius Lee
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Tai Leung Daniel Chan
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Wing Kuk Timmy Au
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Ka Lai Cally Ho
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
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12
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Elbatarny M, Stevens LM, Dagenais F, Peterson MD, Vervoort D, El-Hamamsy I, Moon M, Al-Atassi T, Chung J, Boodhwani M, Chu MWA, Ouzounian M. Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry. J Thorac Cardiovasc Surg 2024; 167:935-943.e5. [PMID: 37084820 DOI: 10.1016/j.jtcvs.2023.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 03/26/2023] [Accepted: 04/08/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE We compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention. METHODS Nine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed. RESULTS Mean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10). CONCLUSIONS Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.
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Affiliation(s)
- Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Louis-Mathieu Stevens
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal and Research Center, Montreal, Québec, Canada
| | | | - Mark D Peterson
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, NY
| | - Michael Moon
- Department of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Talal Al-Atassi
- Department of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Munir Boodhwani
- Department of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael W A Chu
- Department of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
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13
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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14
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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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15
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Kiziltepe U, Ince I, Senkal M, Surer S, Duvan I, Ersoy O, Delibalta O, Mavi O, Sahin E. Total aortic arch replacement without deep hypothermic circulatory arrest in type A aortic dissection: Left axillar artery for arterial cannulation. JTCVS Tech 2023; 22:120-131. [PMID: 38152213 PMCID: PMC10750496 DOI: 10.1016/j.xjtc.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). The frozen elephant trunk technique (FET) additionally requires commercial hybrid grafts. Herein we describe a novel modified FET technique without CA using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection. Methods LAxA anastomosis is made first using a homemade debranching graft, and cardiopulmonary bypass is initiated, followed by anastomoses of left common carotid and innominate arteries. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta/root, cardiac reperfusion is started using a root cannula which continues throughout the procedure. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via left subclavian artery. Lower body perfusion is interrupted for 5 to 8 minutes to deploy an endograft to complete a modified FET. Following cannulation of distal arch graft, perfusion of distal aorta is restarted, and all three grafts are incorporated to construct a neo-ascending aorta and arch. Results Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7, and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body CA time was 7.2 ± 2.8 minutes. Conclusions TAR using standard endografts without CA is possible with LAxA cannulation. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies are required with a higher number of patients to evaluate the efficiency of this novel technique.
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Affiliation(s)
- Ugursay Kiziltepe
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ilker Ince
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Melike Senkal
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Suleyman Surer
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ibrahim Duvan
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ozgur Ersoy
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Delibalta
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Osman Mavi
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Elif Sahin
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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16
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Trimarchi S, Gleason TG, Brinster DR, Bismuth J, Bossone E, Sundt TM, Montgomery DG, Pai CW, Bissacco D, de Beaufort HWL, Bavaria JE, Mussa F, Bekeredjian R, Schermerhorn M, Pacini D, Myrmel T, Ouzounian M, Korach A, Chen EP, Coselli JS, Eagle KA, Patel HJ. Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection. Eur J Vasc Endovasc Surg 2023; 66:775-782. [PMID: 37201718 DOI: 10.1016/j.ejvs.2023.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/21/2023] [Accepted: 05/11/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection. METHODS From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests. RESULTS Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006). CONCLUSION Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.
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Affiliation(s)
- Santi Trimarchi
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy.
| | - Tom G Gleason
- Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Derek R Brinster
- Department of Cardiac Surgery, Northwell Health, New York City, NY, USA
| | - Jean Bismuth
- DeBakey Heart & Vascular Centre, Methodist Hospital System, Houston, TX, USA
| | - Eduardo Bossone
- Department of Public Health, University "Federico II", Naples, Italy
| | - Thoralf M Sundt
- Thoracic Aortic Centre, Massachusetts General Hospital, Boston, MA, USA
| | | | - Chih-Wen Pai
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
| | - Daniele Bissacco
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy
| | | | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Firas Mussa
- Department of Cardiac Surgery, Northwell Health, New York City, NY, USA
| | | | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Davide Pacini
- Department of Cardiac Surgery, University Hospital S. Orsola, Bologna, Italy
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, Tromsø University Hospital, Tromsø, Norway
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Duke University, Durham, NC, USA
| | - Joseph S Coselli
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Kim A Eagle
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
| | - Himanshu J Patel
- Cardiovascular Centre, University of Michigan, Ann Arbor, MI, USA
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17
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Geragotellis A, Jubouri M, Al-Tawil M, Mohammed I, Bashir M, Hosseini S. The Fate of Conventional Elephant Trunk in the Frozen Elephant Trunk Era. AORTA (STAMFORD, CONN.) 2023; 11:174-190. [PMID: 38754437 PMCID: PMC11219132 DOI: 10.1055/s-0044-1786352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/08/2023] [Indexed: 05/18/2024]
Abstract
Conventional elephant trunk (cET) and frozen elephant trunk (FET) are two distinct approaches to the surgical treatment of thoracic aortic aneurysms and dissections. With the advent and growing uptake of endovascular technologies, FET is becoming increasingly popular for its potential to be performed as a single-stage operation with better aortic remodeling and less risk of graft kinking than the traditional two-stage cET procedure. However, FET has been associated with a higher risk of spinal cord ischemia and its use in patients with connective tissue disorder remains controversial. The current review aimed to reflect on recent evidence surrounding the application of cET and FET to different types of aortic pathology in both acute and elective settings. Another scope of this review was to compare the characteristics of the currently available FET commercial devices on the global market. Our findings highlight that when the pathology is confined to the proximal descending aorta, such as in Dsine, intervention is often single-staged and false lumen (FL) thrombosis is achieved with good effect. FET remains limited by spinal cord injury and applicability in patients with connective tissue disorder, although some groups have started to circumvent associated complications, likely due to growing surgical expertise. Many other aortic diseases do require second-stage intervention, and even in these cases, there appears to be lower in-hospital mortality when using FET over cET. This is possibly due to the higher rate of endovascular completion facilitated by the completed landing zones created during FET. FET is trending toward becoming the universal treatment modality for extending repair to the descending aorta.
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Affiliation(s)
| | | | | | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Department of Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, United Kingdom
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
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18
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Ravishankar R, Singh SA, Giordano V. The Thoraflex hybrid approach using a zone 0 proximal landing site for first-stage elective treatment of a thoracoabdominal aneurysm. J Surg Case Rep 2023; 2023:rjad692. [PMID: 38164212 PMCID: PMC10758244 DOI: 10.1093/jscr/rjad692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
A 67-year-old woman was referred to the cardiothoracic outpatient clinic with a long-standing asymptomatic type 2 thoracoabdominal aneurysm. Her CT aorta showed extensive disease in the distal arch with no safe landing zone for total endovascular aneurysm repair (TEVAR). An acute bend preceding the descending aorta also made using a conventional elephant trunk challenging. A multi-disciplinary team decision was made to perform an aortic arch replacement using a frozen elephant trunk at zone 0. Utilizing a zone 0 approach in an elective case can result in quicker organ perfusion and successful TEVAR if necessary.
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Affiliation(s)
- Ramanish Ravishankar
- Faculty of Public Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Sanjeet Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee Hospital, Agamemnon St, Clydebank, G81 4DY, United Kingdom
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, United Kingdom
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19
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Kanj M, Cosset B, Oliny A, Farhat F. Implantation of ascyrus medical dissection stent, our first-hand experience. J Cardiothorac Surg 2023; 18:340. [PMID: 37993865 PMCID: PMC10664640 DOI: 10.1186/s13019-023-02377-0] [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: 12/22/2022] [Accepted: 09/29/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection is associated with high perioperative morbidity and mortality. Ascyrus Medical Dissection Stent (Cryolife, Kennesaw, USA) is a novel uncovered hybrid stent graft developed to be used as an adjunct to standard surgical approach to promote true lumen expansion and enhance aortic remodeling. METHODS From March 2021 to March 2022, four consecutive patients presented with acute Debakey type I aortic dissection and underwent emergent surgical repair with Tirone David procedure and implantation of Ascyrus Medical Dissection Stent. We reviewed patient's files retrospectively and described the perioperative outcomes. RESULTS All four device implantations were successful. Overall 30-day mortality was 0%. Malperfusion that was present in two patients pre-operatively improved after Ascyrus Medical Dissection Stent implantation. No aortic reinterventions were needed. No aortic injury related to the device was noted. Favourable changes in aortic true lumen and false lumen dimensions were found in most of our patients but the stent was compressed at the isthmus in one patient. CONCLUSION Ascyrus Medical Dissection Stent is a reliable and secure device. However, its benefits remain unclear when it comes to a positive remodeling and seems less likelihood comparable to a frozen elephant trunk. The main reason seems to be an insufficient radial force of the stent.
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Affiliation(s)
- Mouhammad Kanj
- Department of Cardiothoracic Surgery, Faculty of Medical Science, Lebanese University, Beirut, Lebanon
- Department of Cardiovascular Surgery, Louis Pradel Hospital, Lyon, France
| | - Benoit Cosset
- Department of Cardiovascular Surgery, Louis Pradel Hospital, Lyon, France
| | - Alexandre Oliny
- Department of Cardiovascular Surgery, Louis Pradel Hospital, Lyon, France
| | - Fadi Farhat
- Department of Cardiovascular Surgery, Infirmerie Protestante, 1-3 Chemin du Penthod, 69300, Caluire et Cuire, Lyon, France.
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20
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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21
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Koulouroudias M, Velissarios K, Kokotsakis J, Magouliotis DE, Tsipas P, Arjomandi Rad A, Viviano A, Kourliouros A, Athanasiou T. Sizing the Frozen Elephant Trunk Based on Aortic Pathology and the Importance of Pre-Operative Imaging. J Clin Med 2023; 12:6836. [PMID: 37959302 PMCID: PMC10649248 DOI: 10.3390/jcm12216836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
The frozen elephant trunk is a formidable tool for the aortovascular surgeon. An appreciation of how to size the graft in different pathologies is key in achieving optimal results. Herein, we demonstrate worked examples of how imaging can be used to plan for a frozen elephant trunk and discuss the nuisances and uncertainties of sizing using three index cases: Type A aortic dissection, distal thoracic aortic aneurysm and chronic dissection.
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Affiliation(s)
- Marinos Koulouroudias
- Department of Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB, UK;
| | | | - John Kokotsakis
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Dimitrios E. Magouliotis
- Department of Cardiothoracic Surgery, Larissa General University Hospital, 41334 Larissa, Greece;
| | - Pantelis Tsipas
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Arian Arjomandi Rad
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Alessandro Viviano
- Department of Cardiac Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
| | - Antonios Kourliouros
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, UK
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22
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Suzuki R, Akita M, Miyazaki S, Shimano R. Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk. J Cardiothorac Surg 2023; 18:276. [PMID: 37807044 PMCID: PMC10561458 DOI: 10.1186/s13019-023-02403-1] [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: 03/30/2023] [Accepted: 09/30/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Total arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients. METHODS Forty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed. RESULTS The average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%. CONCLUSIONS The assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm. UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry) https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgi Clinical registration number: UMIN000051531.
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Affiliation(s)
- Ryo Suzuki
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan.
| | - Masafumi Akita
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
| | - Suguru Miyazaki
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
| | - Ryo Shimano
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
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23
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Benk J, Berger T, Kondov S, D'Inka M, Bork M, Walter T, Discher P, Rylski B, Czerny M, Kreibich M. Comparative Study of Male and Female Patients Undergoing Frozen Elephant Trunk Total Arch Replacement. J Clin Med 2023; 12:6327. [PMID: 37834975 PMCID: PMC10573986 DOI: 10.3390/jcm12196327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Our aim was to investigate outcomes and long-term survival in male and female patients after frozen elephant trunk (FET) total arch replacement. METHODS Between March 2013 and January 2023, 362 patients underwent aortic arch replacement via the FET technique. We compared patient characteristics and intra- and postoperative data between male and female patients. RESULTS Male patients were significantly younger (p = 0.012) but revealed a higher incidence of coronary artery disease (p = 0.008) and preoperative dialysis (p = 0.017). More male patients presented with type A aortic dissections (p = 0.042) while more female patients had aortic aneurysms (p = 0.025). The aortic root was replaced in significantly more male patients (p = 0.013), resulting in significantly longer cardiopulmonary bypass duration (p < 0.001) and operative times (p < 0.001). There were no statistically significant differences in postoperative outcome parameters including in-hospital mortality (p = 0.346). However, new in-stent thrombus formation was significantly more frequent in female patients (p = 0.002). Age in years (odds ratio (OR): 1.026, p = 0.049), an acute pathology (OR: 1.941, p = 0.031) and preoperative dialyses (OR: 3.499, p = 0.010) were predictive for long-term mortality in our Cox regression model, sex (p = 0.466) was not. There was no statistical difference in overall survival (log rank: p = 0.425). CONCLUSIONS Female patients are older but reveal fewer cardiovascular risk factors; aneurysms are more common in female than male patients. As female patients undergo concomitant surgical procedures less often, their operative times are shorter. While survival and outcomes were similar, female patients suffered from postoperative new in-stent thrombus formation significantly more often.
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Affiliation(s)
- Julia Benk
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Matthias D'Inka
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Magdalena Bork
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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24
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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: 8] [Impact Index Per Article: 8.0] [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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25
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Porterie J, Hostalrich A, Dagenais F, Marcheix B, Chaufour X, Ricco JB. Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique. J Clin Med 2023; 12:5693. [PMID: 37685761 PMCID: PMC10488597 DOI: 10.3390/jcm12175693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
The surgical management of acute and chronic complex diseases involving the aortic arch and the descending thoracic aorta remains challenging. Hybrid procedures associating total open arch replacement and stent-grafting of the proximal descending aorta were developed to allow a potential single-stage treatment, promote remodeling of the downstream aorta, and facilitate a potential second-stage thoracic endovascular aortic repair by providing an ideal landing zone. While these approaches initially used various homemade combinations of available conventional prostheses and stent-grafts, the so-called frozen elephant trunk technique emerged with the development of several custom-made hybrid prostheses. The aim of this study was to review the contemporary outcomes of this technique in the management of complex aortic diseases, with a special focus on procedural planning, organ protection and monitoring, refinements in surgical techniques, and long-term follow-up.
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Affiliation(s)
- Jean Porterie
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France;
| | - Aurélien Hostalrich
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France; (A.H.); (X.C.)
| | - François Dagenais
- Department of Cardiovascular Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada;
| | - Bertrand Marcheix
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France;
| | - Xavier Chaufour
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France; (A.H.); (X.C.)
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, Centre Hospitalier Universitaire de Poitiers, 86000 Poitiers, France;
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26
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Marné E, Guimbretière G, Mougin J, Le Corvec T, Guyomarch B, De Beaufort LM, Buschiazzo A, Roussel JC, Maurel B. Comparison of Short and Midterm Aortic Reinterventions in Acute Type A Aortic Dissection Treated by Frozen Elephant Trunk or Conventional Arch Repair. Ann Vasc Surg 2023; 95:3-13. [PMID: 37169252 DOI: 10.1016/j.avsg.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/07/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Long-term outcomes after acute type A aortic dissection (ATAAD) are related to remodelling of the descending thoracic aorta and aortic reinterventions. We compared the impact of an extensive repair at the index procedure using the Frozen Elephant Trunk (FET) technique, versus a conventional arch repair, on long-term remodelling of the descending thoracic and reintervention related to the aorta. METHODS Consecutive patients who underwent conventional arch repair (conventional group) or FET repair (FET group) for an ATAAD from September 2018 to November 2021 were included. Patients who died before discharge or were lost to follow-up prior to the first appointment were excluded from the analysis. Preoperative and postoperative computed tomography angiography was reconstructed and diameter of the true/false lumen of the remaining aorta was compared up to 1 year. Negative (increased total diameter ≥ 5 mm) aortic remodelling was collected for each computed tomography angiography, as well as aortic reinterventions. Comparison of demographic, anatomical, and perioperative complications data were performed using Wilcoxon test for continuous variables or Chi-square test for categorical covariates. The Kaplan-Meier method estimator was used to assess survival rates. The Log rank test was used to compare survival curves between the 2 groups. RESULTS Thirty nine patients were included, 22 in the conventional group and 17 in the FET group (82% males, mean age 60 ± 12 years). In the FET group, distal anastomosis was performed in zone 0 or 1 for 82% of patients using the simplified delivery technique. Median maximum preoperative descending aortic diameter was larger in the FET group (33 mm [30; 37] vs. 30 mm [28; 32] [P = 0.0172]). At 30 days, the rate of negative remodelling on the descending thoracic aorta was significantly higher in the conventional group (50%) than in the FET group (8%, P = 0.02). At 1 year, Kaplan-Meier analysis shown a freedom from descending aortic negative remodeling of 35.1% (95% confidence interval (CI) 18.7-66.1%) in conventional group and 44.9% (CI 95% 26.1-77.2%) in FET group with no significant difference. However, early negative remodelling was observed for the conventional group. Within a year, freedom from reintervention was observed for 74.4% (95% CI 57.1-97%) of patients in the conventional group and 75.5 (95% CI 57.1-99.7%) of patients in the FET group with no significant difference. CONCLUSIONS Negative evolution of descending aorta remains a challenge after ATAAD. An extensive repair using the FET technique during the index procedure seems to be associated with satisfying short-term remodelling of descending aorta.
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Affiliation(s)
- Eglantine Marné
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France
| | - Guillaume Guimbretière
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France
| | - Justine Mougin
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France
| | - Tom Le Corvec
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France; Université de Nantes, Nantes, France
| | | | - Louis Marie De Beaufort
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France
| | - Antoine Buschiazzo
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France
| | - Jean Christian Roussel
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France; Université de Nantes, Nantes, France
| | - Blandine Maurel
- CHU Nantes, L'institut du thorax, service de chirurgie cardiaque et vasculaire, Nantes, France; Université de Nantes, Nantes, France.
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Christodoulou KC, Karangelis D, Efenti GM, Sdrevanos P, Browning JR, Konstantinou F, Georgakarakos E, Mitropoulos FA, Mikroulis D. Current knowledge and contemporary management of non-A non-B aortic dissections. World J Cardiol 2023; 15:244-252. [PMID: 37274377 PMCID: PMC10237007 DOI: 10.4330/wjc.v15.i5.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/10/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023] Open
Abstract
Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection’s location, extent, the aortic diameter, the associated complications and the patient’s status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.
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Affiliation(s)
- Konstantinos C Christodoulou
- Department of Cardiac Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis 68100, Greece
| | - Dimos Karangelis
- Department of Cardiac Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis 68100, Greece
| | | | | | - Jennifer R Browning
- Department of Cardiac Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis 68100, Greece
| | - Fotis Konstantinou
- Department of Cardiac Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis 68100, Greece
| | - Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis 68100, Greece
| | | | - Dimitrios Mikroulis
- Department of Cardiac Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis 68100, Greece
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28
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Zhu X, Wang J, Chong H, Jiang Y, Fan F, Pan J, Cao H, Xue Y, Wang D, Zhou Q. Analysis of risk factors for postoperative mortality in acute type A aortic dissection patients under different critical levels. Sci Rep 2023; 13:8107. [PMID: 37208480 DOI: 10.1038/s41598-023-35351-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/16/2023] [Indexed: 05/21/2023] Open
Abstract
We built up a risk stratification model to divide acute type A aortic dissection (aTAAD) patients into low- and high-risk groups, further, to evaluate the risk factors for postoperative mortality. A total of 1364 patients from 2010 to 2020 in our center were retrospectively analyzed. More than twenty clinical variables were related with postoperative mortality. The postoperative mortality of the high-risk patients was doubled than the low-risk ones (21.8% vs 10.1%). The increased operation time, combined coronary artery bypass graft, cerebral complications, re-intubation, continuous renal replacement therapy and surgical infection were risk factors of postoperative mortality in low-risk patients. In addition, postoperative lower limbs or visceral malperfusion were risk factors, axillary artery cannulation and moderate hypothermia were protective factors in high-risk patients. A scoring system for quick decision-making is needed to select appropriate surgical strategy in aTAAD patients. For low-risk patients, different surgical treatments can be performed with similar clinical prognosis. Limited arch treatment and appropriate cannulation approach are crucial in high-risk aTAAD patients.
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Affiliation(s)
- Xiyu Zhu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Junxia Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Hoshun Chong
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yi Jiang
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Fudong Fan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Hailong Cao
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Qing Zhou
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China.
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China.
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Celmeta B, Harky A, Miceli A. Editorial: Frozen elephant trunk surgery in aortic dissection. Front Cardiovasc Med 2023; 10:1154375. [PMID: 36970363 PMCID: PMC10036905 DOI: 10.3389/fcvm.2023.1154375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/14/2023] [Indexed: 03/12/2023] Open
Affiliation(s)
- Bleri Celmeta
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Minimally Invasive Cardiac Surgery Unit, Milan, Italy
| | - Amer Harky
- Department of Cardio-Thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Antonio Miceli
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Minimally Invasive Cardiac Surgery Unit, Milan, Italy
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30
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Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
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31
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Dahl TS, Lindblom RPF. Intermediate outcomes following arch reconstruction with frozen elephant trunk, a single centre study. J Cardiothorac Surg 2023; 18:44. [PMID: 36683042 PMCID: PMC9869602 DOI: 10.1186/s13019-023-02140-5] [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: 02/15/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Surgery on the aortic arch and proximal descending thoracic aorta can be lifesaving but is also associated with significant morbidity, ranging from minor infections to severe neurological impairments as well as a substantial risk of mortality. The aim of this study is to clinically assess outcomes, with special regards to neurologic injury, as well as to seek to identify predictors of in-hospital mortality in two patient groups with different underlying aortic pathology, aneurysms and dissections, undergoing arch/descending aortic repair. METHODS 34 patients (17 aneurysms, 17 dissections) underwent surgery involving the arch and/or descending aorta, using the Thoraflex or E-Vita frozen elephant trunk graft. 40% were female. Subgroup analysis of aneurysms compared to dissections were performed. Mean follow-up time was 53.9 months and mean age 63.5 years. RESULTS In-hospital mortality was 18%. Survival was comparable between aneurysms and dissections. Incidence of spinal cord injury was 9% and stroke 9%. 67% suffered any form of neurological affection, when also cognitive afflictions were included. Perioperative reoperation rate was 29% (bleeding 21%, visceral ischemia 6%, infection 2%), the need for postoperative dialysis was 11% and a series of other minor complications such as atrial fibrillation and pleurocentesis were common. CONCLUSION Postoperative dialysis was found to be a predictor of in-hospital mortality, while both dialysis as well as reoperation due to bleeding and/or visceral ischemia increased the risk for overall mortality, irrespective of preoperative diagnosis. Previous or current smoking appeared to be associated with negative outcomes regarding both in-hospital and overall mortality during follow-up. Trial registration Retrospectively enrolled.
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Affiliation(s)
- Therese Schagerholm Dahl
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Rickard P. F. Lindblom
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden ,grid.412354.50000 0001 2351 3333Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, 751 85 Uppsala, Sweden
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32
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Evaluation of Different Cannulation Strategies for Aortic Arch Surgery Using a Cardiovascular Numerical Simulator. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010060. [PMID: 36671632 PMCID: PMC9854437 DOI: 10.3390/bioengineering10010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023]
Abstract
Aortic disease has a significant impact on quality of life. The involvement of the aortic arch requires the preservation of blood supply to the brain during surgery. Deep hypothermic circulatory arrest is an established technique for this purpose, although neurological injury remains high. Additional techniques have been used to reduce risk, although controversy still remains. A three-way cannulation approach, including both carotid arteries and the femoral artery or the ascending aorta, has been used successfully for aortic arch replacement and redo procedures. We developed circuits of the circulation to simulate blood flow during this type of cannulation set up. The CARDIOSIM© cardiovascular simulation platform was used to analyse the effect on haemodynamic and energetic parameters and the benefit derived in terms of organ perfusion pressure and flow. Our simulation approach based on lumped-parameter modelling, pressure-volume analysis and modified time-varying elastance provides a theoretical background to a three-way cannulation strategy for aortic arch surgery with correlation to the observed clinical practice.
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33
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Luc JGY, Preventza O. Optimal Extent of Repair for Acute Type I Aortic Dissection-Frozen Elephant Trunk? How Long and Why? AORTA (STAMFORD, CONN.) 2022; 10:169-174. [PMID: 36521808 PMCID: PMC9754864 DOI: 10.1055/s-0042-1756664] [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
Acute Type A dissection is a life-threatening condition requiring urgent surgical treatment. The operative technique involves repairs of a variety of distal extents of the transverse aortic arch and the downstream aorta. We review the evidence surrounding the extent of repair for acute Type A aortic dissection and describe our approach to this disease.
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Affiliation(s)
- Jessica G. Y. Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas,Address for correspondence Ourania Preventza, MD, MBA Division of Cardiothoracic Surgery, Michael E. DeBakey Department of SurgeryBCM 390, One Baylor Plaza, Baylor College of Medicine, Houston, TX 77030
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34
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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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35
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 397] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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36
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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D'Onofrio A, Lachat M, Mangialardi N, Antonello M, Schelzig H, Chaykovska L, Hill A, Holden A, Lindsay T, Ten Tan K, Orrico M, Ronchey S, Greener GE, Hayes P, Lorenzoni G, Gerosa G, Planer D. Three-year follow-up of aortic arch endovascular stent grafting with the Nexus device: results from a prospective multicentre study. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6885451. [PMID: 36484696 DOI: 10.1093/ejcts/ezac561] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endovascular aortic arch stent grafting with branched devices has shown initial promising results. The aim of this prospective, multicentre study was to evaluate 3-year outcomes of aortic arch stent grafting with NEXUS® Aortic Arch Stent Graft System (Nexus), a single-branch, bi-modular, off-the-shelf aortic arch stent graft system in high-risk patients. METHODS Patients treated with Nexus, either under the feasibility clinical study or as compassionate use procedures in 5 centres, were included in this study. The primary end point was overall survival. The secondary end points included the incidence of procedure-related unplanned intervention, stroke, paraplegia and endoleak. Clinical and radiologic follow-up was performed at each study site at 30 days, 6 months and on a yearly basis thereafter up to 3 years postoperatively. RESULTS We analysed data from a total of 28 patients. The overall median follow-up was 1132 (interquartile range: 809-1537). There were no device or procedure-related deaths between 1 and 3 years. Overall survival at 1 and 3 years was 89% and 71%, respectively. The cumulative incidence of unplanned reintervention at 1 and 3 years was 11% and 29%, respectively. There were no reports of stroke, paraplegia, aneurysm rupture, myocardial infarction or new aortic valve insufficiency. In this study's 1-3 year follow-up period, 1 type Ib (4%), 1 type II (4%) and 2 type III (8%; between Nexus' distal end and Thoracic endovascular aortic repair (TEVAR) extensions) endoleak were detected. CONCLUSIONS Endovascular aortic arch exclusion with the single-branch, off-the-shelf Nexus system provides promising clinical and radiologic results at 3-year follow-up in a high-risk patient cohort.
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Affiliation(s)
- Augusto D'Onofrio
- University of Padova, Department of Cardiac, Thoracic, Vascular Surgery and Public Health, Padova, Italy
| | - Mario Lachat
- Clinic Hirslanden, Aortic and Vascular Center, Zurich, Switzerland
| | - Nicola Mangialardi
- Ospedale San Camillo-Forlanini, Department of Vascular Surgery, Roma, Italy
| | - Michele Antonello
- University of Padova, Department of Cardiac, Thoracic, Vascular Surgery and Public Health, Padova, Italy
| | - Hubert Schelzig
- Universitätsklinik für Gefäß- und Endovaskularchirurgie, Düsseldorf, Germany
| | | | - Andrew Hill
- Auckland Hospital, Department of Interventional Radiology, Auckland, New Zealand
| | - Andrew Holden
- Auckland Hospital, Department of Interventional Radiology, Auckland, New Zealand
| | - Thomas Lindsay
- Toronto General Hospital, University Health Network, Department of Vascular Surgery, Toronto, ON, Canada
| | - Kong Ten Tan
- Toronto General Hospital, University Health Network, Department of Vascular Surgery, Toronto, ON, Canada
| | - Matteo Orrico
- Ospedale San Camillo-Forlanini, Department of Vascular Surgery, Roma, Italy
| | - Sonia Ronchey
- Ospedale San Filippo Neri, Department of Vascular Surgery, Roma, Italy
| | - Gabby Elbaz Greener
- Hadassah-Hebrew University Medical Center, Department of Interventional Cardiology, Jerusalem, Israel
| | - Paul Hayes
- St John's Innovation Centre, Department of Vascular Surgery, Cambridge, UK
| | - Giulia Lorenzoni
- University of Padova, Department of Cardiac, Thoracic, Vascular Surgery and Public Health, Padova, Italy
| | - Gino Gerosa
- University of Padova, Department of Cardiac, Thoracic, Vascular Surgery and Public Health, Padova, Italy
| | - David Planer
- Hadassah-Hebrew University Medical Center, Department of Interventional Cardiology, Jerusalem, Israel
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38
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Goebel N, Holder SA, Huether F, Bail DHL, Franke UFW. Left Subclavian Artery Sacrifice in Acute Aortic Dissection Repair using the Frozen Elephant Trunk. Thorac Cardiovasc Surg 2022; 70:623-629. [PMID: 35038756 DOI: 10.1055/s-0041-1741058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Surgery of acute aortic dissection using the frozen elephant trunk (FET) can be complicated when the origin of the left subclavian artery (LSA) is dissected and sacrifice by ligation is a viable option. However, the LSA is supposed to play a role in neuroprotection as a major collateral. We, therefore, analyzed our results of LSA sacrifice in this cohort. METHODS We identified a total of 84 patients from our prospectively collected database who underwent FET repair of acute aortic dissection between October 2009 and April 2018. LSA was sacrificed in 19 patients (22.6%). Results were analyzed and compared with regard to neurological outcomes. RESULTS New postoperative stroke was seen in two patients (2.4%) and spinal cord injury in three patients (3.6%) overall, none in the LSA-sacrifice group. We observed a temporary neurological deficit in five patients (6.0%) overall, none in the LSA-sacrifice group. None of the patients developed acute ischemia of the left arm. Only two patients (12.5%) came back for carotid-subclavian artery bypass due to exertion-induced weakness of the left arm 3 to 4 months after the initial surgery. In-hospital mortality was 15.5% overall, with no difference between groups. CONCLUSION LSA sacrifice was not associated with elevated postoperative risk of either central or spinal neurological injury. Thus, it can facilitate FET repair of acute aortic dissection in selected cases when the left subclavian origin cannot be preserved. Carotid-subclavian artery bypass became necessary in only a small fraction of these patients and can be performed as a second-stage procedure.
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Affiliation(s)
- Nora Goebel
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Simone A Holder
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Franziska Huether
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Dorothee H L Bail
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Ibrahim A, Motekallemi A, Yahia A, Oberhuber A, Eierhoff T, Martens S, Marchiori E, Rukosujew A. Volume Changes in the Descending Aorta after Frozen Elephant Trunk and Conventional Hemi-Arch Repair after Acute Type A Aortic Dissection. Diagnostics (Basel) 2022; 12:diagnostics12102524. [PMID: 36292213 PMCID: PMC9600756 DOI: 10.3390/diagnostics12102524] [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] [Received: 09/14/2022] [Revised: 09/26/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to compare the mortality rates, re-intervention rates, and volumetric changes in aortas following surgery, in terms of the true lumen and false lumen changes, using conventional hemi-arch repair (CET) and frozen elephant trunk (FET) techniques. During the period from 2015 to 2018, 66 patients underwent surgical treatment for acute aortic dissection (Debakey type 1). Demographic and procedure-related data were evaluated. We measured volumetric change before surgical treatment, at discharge, and at 12- and 24-month time points based on computed tomography angiography. The study cohort was divided into two groups (FET vs. CET). The mean age of the patients was 56.9 ± 9.4 years in the FET group versus 63.6 ± 11 years in the CET group (p = 0.063). The mean follow-up time was 24 ± 6 and 25 ± 5 months for the FET and CET groups, respectively. There were no significant differences between the two groups in terms of the medical histories of the cohorts. The results showed a significant increase in true lumen volume after the FET procedure (within 24 months postoperatively; p = 0.005), and no significant changes in total (p = 0.392) or false lumen (p = 0.659) volumes were noted. After the CET procedure, there were significant increases in total and false lumen volumes (p = 0.013, p = 0.042), while no significant change in true lumen was observed (p = 0.219). The volume increase in true lumen after the FET procedure was higher compared to the CET group at all postoperative time points (at discharge, 12 months, and 24 months) without significant evidence (p = 0.416, p = 0.422, p = 0.268). At two years, the volume increase in false lumen was significantly higher among the CET group compared to the FET group (p = 0.02). The Kaplan–Meier curve analysis showed that patients who underwent the CET procedure underwent significantly more re-interventions due to false lumen expansion of the descending aorta (p = 0.047). Present study results indicate that the true and false lumen changes in the aorta following the FET and CET procedures were different. FET led to a significant increase in true lumen volume, while false lumen volume remained stable; however, after the CET procedure, significant false lumen enlargement was noted at mid-term follow-up time points. The re-intervention rate after CET was higher due to false lumen expansion.
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Affiliation(s)
- Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Correspondence: ; Tel.: +49-251-8345788
| | - Arash Motekallemi
- Department of Cardiothoracic Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Ahmed Yahia
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Thorsten Eierhoff
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Elena Marchiori
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, 48149 Muenster, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, 48149 Muenster, Germany
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Chivasso P, Mastrogiovanni G, Bruno VD, Miele M, Colombino M, Triggiani D, Cafarelli F, Leone R, Rosapepe F, De Martino M, Morena E, Iesu I, Citro R, Masiello P, Iesu S. Systematic total arch replacement with thoraflex hybrid graft in acute type A aortic dissection: A single centre experience. Front Cardiovasc Med 2022; 9:997961. [PMID: 36312248 PMCID: PMC9614841 DOI: 10.3389/fcvm.2022.997961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction In the last two decades, a more aggressive approach has been encouraged to treat patients with acute type A aortic dissection (ATAAD), extending the repair to the aortic arch and proximal descending thoracic aorta with the frozen elephant trunk (FET) implantation. Here, we report our single-centre experience with the FET technique for the systematic treatment of emergency type A aortic dissection. Materials and methods Between December 2017 and January 2022, 69 consecutive patients were admitted with ATAAD; of those, 66 patients (62.9 ± 10.2 years of age, 81.8% men) underwent emergency hybrid aortic arch and FET repair with the multibranched Thoraflex hybrid graft and were enrolled in the study. Primary endpoints were 30 days- and in-hospital mortality. Secondary endpoints were postoperative morbidity and follow-up survival. To better clarify the impact of age on surgical outcomes, we have divided the study population into two groups: group A for patients <70 years of age (47 patients), and group B for patients ≥70 years (19 patients). Time-to-event analysis has been conducted using the Log-rank test and is displayed with Kaplan-Meier curves. A multiple Cox proportional Hazard model was developed to identify predictors of long-term survival with a stepwise backward/forward selection process. Results 30-days- and in-hospital mortality were 10.6 and 13.6%, respectively. Stroke occurred in three (4.5%) patients. Two (3.0%) patients experienced spinal cord ischemia. We did not find any statistically significant difference between the two groups in terms of main post-operative outcomes. The multivariable Cox proportional hazard model showed left ventricular ejection fraction (HR: 0.83, 95% CI: 0.79–0.92, p < 0.01), peripheral vascular disease (HR: 15.8, 95% CI: 3.9–62.9, p < 0.01), coronary malperfusion (HR: 0.10, 95% CI: 0.01–0.77, p =0.03), lower limbs malperfusion (HR: 5.1, 95% CI: 1.10–23.4, p = 0.04), and cardiopulmonary bypass time (HR: 1.02, 95% CI: 1–1.04, p = 0.01) as independent predictors of long term mortality. Conclusions Frozen elephant trunk repair to treat emergency type A aortic dissection appears to be associated with good early and mid-term clinical outcomes even in the elderly.
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Affiliation(s)
- Pierpaolo Chivasso
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy,*Correspondence: Pierpaolo Chivasso ;
| | - Generoso Mastrogiovanni
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Vito Domenico Bruno
- Bristol Medical School, Translational Health Science Department, Bristol, United Kingdom
| | - Mario Miele
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Mario Colombino
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Donato Triggiani
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Cafarelli
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rocco Leone
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Felice Rosapepe
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Matteo De Martino
- Department of Cardiac Anesthesia, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Elvira Morena
- Department of Cardiac Anesthesia, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Ivana Iesu
- Department of Cardiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rodolfo Citro
- Department of Cardiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Paolo Masiello
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Severino Iesu
- Department of Emergency Cardiac Surgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene. Life (Basel) 2022; 12:life12101511. [DOI: 10.3390/life12101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.
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Kayali F, Jubouri M, Tan SZ, Mohammed I, Bashir M. Aortic remodeling in aortic dissection after frozen elephant trunk: overcoming the challenges. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:434-438. [PMID: 35621062 DOI: 10.23736/s0021-9509.22.12385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The introduction of the single-step hybrid frozen elephant trunk (FET) procedure expanded the surgeon's armamentarium in managing aortic dissection (AD). This is evident by the reduction in mortality and complication rates associated with conventional techniques used to repair ADs. Although FET still carries a risk of certain complications, it has been associated with excellent aortic remodeling following the procedure. The main scope of this review is to evaluate aortic remodeling in aortic dissection after FET as well as to highlight the challenges that may arise and ways to overcome them. A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on aortic remodeling in aortic dissection after FET. The FET procedure promotes excellent long-term remodeling, this is seen in the substantial increase in the size of the true lumen along with the decrease in that of the false lumen (FL), in addition to significant FL thrombosis. However, this occurs to a lesser extent more distally at the level of the abdominal aorta. Negative remodeling may present a major challenge to the process of aortic remodeling, nevertheless, this can be overcome with endovascular reintervention which has demonstrated highly favorable results. Additionally, the choice of FET graft, in terms of type and length, seems to influence outcomes. Namely, the Thoraflex™ Hybrid graft can be considered the superior graft on the global market. On the other hand, there seems to be a debate in the literature on the optimal FET graft length. The FET procedure has revolutionized the field of aortovascular surgery and promotes excellent long-term aortic remodeling. Negative remodeling can occur but can also be favorably overcome with endovascular reintervention. Finally, the choice of FET graft may also influence results, thus, should be taken with great care.
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Affiliation(s)
- Fatima Kayali
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK -
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Amin A, Etheridge GM, Amarasekara HS, Green SY, Orozco-Sevilla V, Coselli JS. Aortic arch repair: lessons learned over three decades at Baylor College of Medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:393-405. [PMID: 35621061 DOI: 10.23736/s0021-9509.22.12376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.
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Affiliation(s)
- Arsalan Amin
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Ginger M Etheridge
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Hiruni S Amarasekara
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Susan Y Green
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA -
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
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Kreibich M, Berger T, Siepe M, Czerny M, Rylski B. „Distal stent graft-induced new entries“ nach Frozen-Elephant-Trunk-Operation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00515-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Berger T, Graap M, Rylski B, Fagu A, Gottardi R, Walter T, Discher P, Hagar MT, Kondov S, Czerny M, Kreibich M. Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection. Front Cardiovasc Med 2022; 9:911548. [PMID: 35734273 PMCID: PMC9207307 DOI: 10.3389/fcvm.2022.911548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Aim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure. Methods One hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed. Results Distal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure. Conclusion The incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
- *Correspondence: Tim Berger,
| | - Miriam Graap
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Muhammad Taha Hagar
- Department for Diagnostic and Interventional Radiology, Faculty of Medicine, Medical Centre-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
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Mousavizadeh M, Bashir M, Jubouri M, Tan SZ, Borzeshi EZ, Ilkhani S, Banar S, Nakhaei P, Rezaei Y, Idhrees M, Hosseini S. Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:265-274. [PMID: 35238527 DOI: 10.23736/s0021-9509.22.12292-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET. EVIDENCE ACQUISITION In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET. EVIDENCE SYNTHESIS Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I2=76%) and 12% for renal failure (95% CI 0.09-0.15; I2=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I2=0%) and 6% (95% CI 0.05-0.08; I2=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I2=0%). CONCLUSIONS Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.
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Affiliation(s)
- Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran - .,Vascular and Endovascular Surgery, Health Education, and Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Elahe Z Borzeshi
- School of Public Health and Safety, Department of Epidemiology, Shahid Beheshti University of Medical Sciences Tehran, Iran
| | - Saba Ilkhani
- Department of Surgery and Vascular Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepideh Banar
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Pooria Nakhaei
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Malvindi PG, Alfonsi J, Berretta P, Cefarelli M, Gatta E, Di Eusanio M. Normothermic frozen elephant trunk: our experience and literature review. Cardiovasc Diagn Ther 2022; 12:262-271. [PMID: 35800357 PMCID: PMC9253169 DOI: 10.21037/cdt-22-73] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/17/2022] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. METHODS A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. KEY CONTENT AND FINDINGS Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. CONCLUSIONS The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Vascular Surgery Department, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Wisniewski K, Motekallemi A, Dell'Aquila AM, Oberhuber A, Schaefers JF, Ibrahim A, Martens S, Rukosujew A. Single-Center Experience With the Thoraflex™ Hybrid Prosthesis: Indications, Implantation Technique and Results. Front Cardiovasc Med 2022; 9:924838. [PMID: 35707127 PMCID: PMC9189312 DOI: 10.3389/fcvm.2022.924838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study was to evaluate the early and mid-term results after the frozen elephant trunk (FET) procedure for the treatment of complex arch and proximal descending aortic disease in a single-center institution. Methods From April 2015 to July 2021, 72 patients (25 women, 60.4 ± 10.3 years) underwent Thoraflex™ Hybrid implantation at our institution. The indications were thoracic aortic aneurysm (TAA) (n = 16, 22.2%), post-dissection aneurysm (n = 21, 29.2%), and acute aortic dissection (AAD) (n = 35, 48.6%). Antegrade cerebral perfusion under moderate hypothermia (28°C) was employed in all cases. Eighteen patients (25%) have already been operated due to heart or aortic disease. Results Overall in-hospital mortality was 12.5% (9 patients). Rates of permanent neurological dysfunction and spinal cord injury were 9.7 and 5.5%, respectively. The in-hospital mortality rate among patients operated on AAD, TAA, and post-dissection aneurysm were 8.6, 6.2, and 23.8%, respectively. At a mean follow-up of 26 ± 20 months, mortality was 9.7%. Furthermore, 23 patients (31.9%) required a subsequent procedure in distal aorta: endovascular stentgraft extension in 19 patients (26.4%) and open aortic surgery in 4 patients (5.5%). The mid-term survival of patients with type A aortic dissection was 97%. Conclusions Our experience with the Thoraflex Hybrid prosthesis demonstrates its surgical applicability for different types of aortic pathologies with promising outcomes during early and midterm follow-up. Our technique and perioperative management lead to comparable or even superior neurological outcomes and mortality in urgent cases considering other high-volume centers.
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Affiliation(s)
- Konrad Wisniewski
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
- *Correspondence: Konrad Wisniewski
| | - Arash Motekallemi
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Angelo M. Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Johannes F. Schaefers
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
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Piperata A, d'Ostrevy N, Busuttil O, Avesani M, Modine T, Lorenzoni G, Azzolina D, Labrousse L, Pernot M. Evaluation of the “release and perfuse technique” for aortic arch surgery. J Card Surg 2022; 37:2633-2639. [DOI: 10.1111/jocs.16640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/27/2022] [Accepted: 04/16/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Antonio Piperata
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Nicolas d'Ostrevy
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Olivier Busuttil
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Martina Avesani
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Thomas Modine
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public Health University of Padova Padova Italy
| | - Danila Azzolina
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public Health University of Padova Padova Italy
| | - Louis Labrousse
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
| | - Mathieu Pernot
- Department of Cardiology and Cardio‐Vascular Surgery, Hôpital Cardiologique de Haut‐Lévèque Bordeaux University Hospital Pessac France
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50
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Sule J, Chua CR, Teo C, Choong A, Sazzad F, Kofidis T, Sorokin V. Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections. SCAND CARDIOVASC J 2022; 56:91-99. [PMID: 35546567 DOI: 10.1080/14017431.2022.2074095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.
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Affiliation(s)
- Jai Sule
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Cher Rui Chua
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Caven Teo
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Choong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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