Efficacy of Total Aortic Arch Replacement Combined with Frozen Elephant Trunk in Aortic Reoperation

Background

The aim of this study was to estimate the long-term efficacy of total aortic arch replacement combined with the frozen elephant trunk (TAR+FET) technique for aortic disease following a prior cardiac surgery procedure.

Material/Methods

We performed TAR+FET for 118 patients for major vessel disease following a prior cardiac procedure with median sternotomy incision. All patients were divided into 5 groups: in group A, the prior major procedure was aortic valve replacement (AVR); in group B, the prior major procedure was isolated ascending aorta replacement; in group C, the prior major procedure was aortic root replacement; in group D, the prior major procedure was aortic arch replacement or intervention; and in group E, the prior major procedure was ‘other’ cardiac operative procedure. The long-term follow-up visit results were estimated using the Kaplan-Meier method.

Results

The 30-day mortality rate after the operation was 13.6% (16/118) – 2 died in group A, 1 in group B, 8 in group C, 4 in group D, and 1 in group E. Follow-up visits were completed in 99% of patients. The mean follow-up time was 47.6±36.3 months and 12 patients had died by follow-up, so the total long-term survival rate was 76.3%. One-year survival rates of the 5 groups were 85% (group A), 93.8% (group B), 82.3% (group C), 50% (group D), and 50% (group E), respectively. Five-year survival rates of the 5 groups were 85%, 93.8%, 80.6%, 50%, and 50%, respectively.

Conclusions

The TAR+FET technique is feasible and efficacious for aortic reoperation in patients who previously underwent cardiac surgery since the short-term mortality in patients with recurrent aortic arch disease after cardiac surgery is not high.

What is the effect of laparoscopic colectomy on pattern of colon cancer recurrence? A propensity score and competing risk analysis compared with open colectomy

BACKGROUND

Variability in colon cancer recurrence after laparoscopic colectomy (LAC) remains poorly understood. The aim of our study was to quantify the influence of LAC on colon cancer recurrence patterns.

METHODS

We included 986 patients undergoing curative colectomy at our institution between 1992 and 2008. Kaplan-Meier, multivariable Cox regression, propensity score adjustment, and competing risks modeling were used to evaluate the influence of laparoscopic surgery on the site of colon cancer recurrence, including the following: liver metastasis, lung metastasis, local recurrence, peritoneal dissemination, other, and multiple sites. We estimated the risk factors for each recurrence site.

RESULTS

Laparoscopic surgery was used in 419 (42.5 %) of 986 patients, with an overall median follow-up time of 5.0 years (interquartile range 3.5). The overall 5-year disease-free survival rate was 86.1 % (open surgery 81.8 % vs. laparoscopic surgery 92.0 %; p < 0.001). However, after covariates and propensity score adjustment, laparoscopic surgery was not a significant risk factor for each type of recurrence: liver hazard ratio (HR) 0.93 (95 % CI 0.45-1.89), p = 0.84; lung HR 0.67 (95 % CI 0.26-1.70), p = 0.39; local HR 0.56 (95 % CI 0.12-2.63), p = 0.46; peritoneal HR 2.49 (95 % CI 0.75-8.27), p = 0.14; others HR 0.47 (95 % CI 0.04-5.13), p = 0.53; multiple HR 0.88 (95 % CI 0.25-3.14), p = 0.84. The risk factors for each type of recurrence were variable and characterized by specific clinicopathological features.

CONCLUSION

Our study reveals that LAC and open colectomy demonstrate comparable overall colon cancer recurrence rates and recurrence sites. Specific clinicopathological characteristics may have a stronger influence on colon cancer recurrence site compared with the surgical technique.

Below knee angioplasty in elderly patients: predictors of major adverse clinical outcomes

AIM

To determine predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in elderly patients with below knee atherosclerotic lesions causing intermittent claudication (IC) or critical limb ischaemia (CLI).

MATERIALS AND METHODS

Over 7.5 years, 76 patients (CLI 72%, n = 55) underwent below knee PTA. The composite end-point of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up which was defined as clinical failure, need for subsequent endovascular or surgical revascularization or amputation. Actuarial freedom from MACO was assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression.

RESULTS

IC was improved in 95% at mean 3.4 years (range 0.5-108 months). Successful limb salvage and ulcer healing were seen in 73% with CLI. Most failures were in the CLI group (27% CLI vs. 5% IC), with an amputation rate of 16% for CLI vs. 5% for IC and persistent ulceration in 24% of CLI. Significant independent predictors of MACO were ulceration (hazard ratio 4.02, 95% CI = 1.55-10.38) and family history of atherosclerosis (hazard ratio 2.53, 95% CI = 1.1-5.92).

CONCLUSION

Primary below knee PTA is a feasible therapeutic option in this elderly population. Limb ulceration and family history of atherosclerosis may be independent predictors of adverse outcome.