1
|
Gilani A, Schachner B, Wood E, Khawaja Z, Imielski B. Total aortic arch debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR) in acute non-A non-B aortic dissection. J Cardiothorac Surg 2024; 19:401. [PMID: 38937775 PMCID: PMC11212385 DOI: 10.1186/s13019-024-02917-2] [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: 03/03/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention. CASE PRESENTATION We present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation. CONCLUSIONS This patient's unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.
Collapse
Affiliation(s)
- Aaron Gilani
- Department of Cardiothoracic Surgery, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Winston-Salem, NC, 27157, USA.
| | - Benjamin Schachner
- Department of Cardiothoracic Surgery, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Winston-Salem, NC, 27157, USA
| | - Elizabeth Wood
- Department of Cardiothoracic Surgery, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Winston-Salem, NC, 27157, USA
| | - Zohaib Khawaja
- Department of Cardiothoracic Surgery, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Winston-Salem, NC, 27157, USA
| | - Bartlomiej Imielski
- Department of Cardiothoracic Surgery, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Winston-Salem, NC, 27157, USA
| |
Collapse
|
2
|
Abt BG, Bojko M, Elsayed RS, Han S, Wang A, Vu I, Wishart D, Fleischman F. Branch-first aortic arch replacement strategy decreases perioperative mortality. J Thorac Cardiovasc Surg 2024; 167:2005-2012.e1. [PMID: 37574006 DOI: 10.1016/j.jtcvs.2023.08.012] [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: 02/26/2023] [Revised: 07/21/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement. METHODS We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality. RESULTS A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007). CONCLUSIONS We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.
Collapse
Affiliation(s)
- Brittany G Abt
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif.
| | - Markian Bojko
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Ramsey S Elsayed
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Sukgu Han
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Alan Wang
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Isabelle Vu
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Danielle Wishart
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Fernando Fleischman
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| |
Collapse
|
3
|
Ram E, Lau C, Dimagli A, Chu NQ, Soletti G, Gaudino M, Girardi LN. Short- and long-term results of total arch replacement: Comparison between island and debranching techniques. JTCVS Tech 2023; 20:10-19. [PMID: 37555035 PMCID: PMC10405193 DOI: 10.1016/j.xjtc.2023.05.003] [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: 02/28/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. METHODS The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. RESULTS The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P = .001), had undergone more previous cardiac operations (54.5% vs 27.4%, P < .001), and had more connective tissue disorder (20.3% vs 4.6%, P < .001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P < .001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P < .001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P = .018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P = .486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P = .897). Ten-year survival was 80% (78% vs 80.9%, log-rank P = .356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P = .495). CONCLUSIONS Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.
Collapse
Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Ngoc-Quynh Chu
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| |
Collapse
|
4
|
Liu P, Wen B, Liu C, Xu H, Zhao G, Sun F, Zhang H, Yao X. En Bloc Arch Reconstruction With the Frozen Elephant Trunk Technique for Acute Type a Aortic Dissection. Front Cardiovasc Med 2021; 8:727125. [PMID: 34651025 PMCID: PMC8505743 DOI: 10.3389/fcvm.2021.727125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The study objective was to evaluate the effect of en bloc arch reconstruction with frozen elephant trunk (FET) technique for acute type A aortic dissection. Methods: 41 patients with acute Stanford type A dissection underwent en bloc arch reconstruction combined with FET implantation between April 2018 and August 2020. The mean age of the patients was 46 ± 13 years, and 9 patients were female. One patient had Marfan syndrome. Six patients had pericardial tamponade, 9 had pleural effusion, 5 had transient cerebral ischemic attack, and 3 had chronic kidney disease. Results: The hospital mortality rate was 9.8% (4 patients). 2 (4.9%) patients had stroke, 23 (56.1%) had acute kidney injury, and 5 (12.2%) had renal failure requiring hemodialysis. During follow-up, the rate of complete false lumen thrombosis was 91.6% (33/36) around the FET, 69.4% (25/36) at the diaphragmatic level, and 27.8% (10/36) at the superior mesenteric artery level. The true lumen diameter at the same three levels of the descending aorta increased significantly while the false lumen diameter reduced at the two levels: pulmonary bifurcation and the diaphragm. The 1-, 2-and 3-year actuarial survival rates were 90.2% [95% confidence interval (CI), 81.2–99.2], 84.2% (95% CI, 70.1–98.3) and 70.2% (95% CI, 42.2–98), respectively. Conclusions: In patients with acute type A dissection, en bloc arch reconstruction with FET technique appeared to be feasible and effective with early clinical follow-up results. Future studies including a large sample size and long-term follow-up are required to evaluate the efficacy.
Collapse
Affiliation(s)
- Penghong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bing Wen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huashan Xu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guochang Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hang Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xingxing Yao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
5
|
Saw LJ, Lim‐Cooke M, Woodward B, Othman A, Harky A. The surgical management of acute type A aortic dissection: Current options and future trends. J Card Surg 2020; 35:2286-2296. [DOI: 10.1111/jocs.14733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Li Jing Saw
- School of MedicineUniversity of Liverpool Liverpool UK
| | | | - Beth Woodward
- College of Medical and Dental SciencesUniversity of Birmingham Birmingham UK
| | - Ahmed Othman
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
| | - Amer Harky
- School of MedicineUniversity of Liverpool Liverpool UK
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest Hospital Liverpool UK
| |
Collapse
|
6
|
Abjigitova D, Mokhles MM, Papageorgiou G, Bekkers JA, Bogers AJJC. Outcomes of different aortic arch replacement techniques. J Card Surg 2019; 35:367-374. [PMID: 31816120 PMCID: PMC7003787 DOI: 10.1111/jocs.14386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Consensus on the best treatment for aortic arch pathology is unresolved due to an emerging variety of procedures. We aimed to compare the outcomes of two major techniques for open aortic arch replacement involving the supra‐aortic branches and to identify the risk factors for specific adverse events. Methods Between 1974 and 2017, 172 patients were treated with either the en bloc (island, n = 59; 34.3%) or branched graft technique (n = 113, 65.7%). Most of the patients were treated in an emergent/urgent setting (52.4%). Results Patients who underwent the en bloc procedure had significantly shorter cardiopulmonary bypass (median: 241 vs 271 minutes, P = .041) and aortic cross clamp times (median: 124 vs 168 minutes, P = .005) than patients who underwent the separate graft technique. Overall, the hospital mortality was lower in the en bloc group, 8.5% vs 19.5%, although the difference was not significant (P = .077). No difference was found in the survival between the separate graft and en bloc groups at 1 (77.0 vs 86.3%), 5 (67.7 vs 66.3%) and 10 years (42.4 vs 51.3%), (P = .63). The postoperative stroke rate was comparable between the en bloc and separate graft cohorts (14.3 vs 19.6%, P = .52). Diabetics and those who underwent an elephant trunk procedure were at a higher risk for reintervention. Conclusions The separate graft technique, which is more common today, showed no difference from the en bloc technique with regard to hospital mortality and morbidity. Furthermore, the late survival and reintervention rates were similar after both procedures.
Collapse
Affiliation(s)
- Djamila Abjigitova
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|