Aortic wrapping for a dilated ascending aorta in bicuspid aortic stenosis

Type a aortic dissection after aortic wrapping performed 26 years ago: a case report

BACKGROUND

Aortic wrapping (AW) has been performed as a less invasive alternative to aortoplasty. However, AW can also cause long-term aortic complications. In this report, we present a rare case of a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction after AW.

CASE PRESENTATION

A female patient had undergone urgent aortic valve replacement with a 19-mm mechanical valve to treat infective endocarditis and AW to treat an enlarged ascending aorta 26 years prior. At the age of 71 years, the patient was diagnosed with a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction. We performed graft replacement of the ascending aorta, including complete resection of the wrap. The patient was discharged on postoperative day 10, and there have been no cardiovascular events during her ongoing follow up.

CONCLUSIONS

AW in younger patients can lead to late aortic complications. Careful consideration should be paid when performing AW in young patients, and patients who have previously undergone AW require strict life-long follow-up.

Long Term Results of Reduction Ascending Aortoplasty

The aim of this retrospective study is to show medium-long-term results in terms of cardiac death and aortic events in patients undergoing reduction ascending aortoplasty between 1997 and 2009 in our hospital. The Fine and Grey model for competing risk analysis was performed for time to cardiac death, with non-cardiac death as the competing risk, and time to recurrence of both re-dilation (aortic diameter > 45 mm) and re-operation with overall death as the competing risk. Paired t-test was used to evaluate the change in aortic diameter from the post-operative values to follow-up. The population included 142 patients. The mean pre-operative aortic diameter and the diameter at follow-up were respectively 46.5 ± 5.11 mm vs. 41.4 ± 5.55 mm (p-value < 0.001). At a mean follow-up of 11.6 ± 4.15 years, 11 patients (7.7%) required re-operation on the ascending aorta. At 16 years, the CIF of aortic-related events was 29.4 ± 7.2%; the freedom from cardiac death was 89.2 ± 3.7%. Ten patients (7%) died from cardiac causes but no one was aortic-related. The Fine and Grey analysis did not identify any significant predictors. This procedure is safe but might be justified only in high-risk patients or in those with advanced age/short life expectancy.

Surgical treatment of mild to moderately dilated ascending aorta in bicuspid aortic valve aortopathy: the art of safety and simplicity

Background

Evaluate the safety and efficacy of our modified technique of the extravascular procedure for treating mild to moderately dilated ascending aorta in patients with bicuspid aortic valve (BAV) aortopathy.

Methods

From January 2015 to December 2018,119 consecutive patients with BAV and ascending aorta dilatation (dimension 40 mm~ 45 mm) were diagnosed in our institution. Among these,49 patients received aggressive aortic valve replace (AVR) + ascending aorta wrapped (wrapped group) while the other 70 patients received AVR + ascending aorta replacement (wheat group). All patients clinical and follow up data were collected for 12 months.

Results

Aortic clamping and cardio-pulmonary bypass times were significantly longer in wheat group than wrap group (P < 0.001and 0.021,respectively). The first 24 h drainage in wheat group were much more than wrap group(P = 0.04). Ascending aorta diameter、left ventricular end diameter and ejection fraction were statistically different between pre- and post-operation (p < 0.001) in both groups, but the heart function and complication were no difference during follow up.

Conclusions

External wrapping of the ascending aorta and wheat procedure have good short-term and long-term results in BAV patients with a mild to moderately dilated ascending aorta. The perioperative period results of external wrapping of the ascending aorta for BAV patients were encouraging.

Concomitant Wrapping of a Moderately Dilated Ascending Aorta during Aortic Valve Replacement: Postoperative Remodeling of a Distinctive Aorta

PURPOSE

The long-term outcomes of aortic wrapping in patients with ascending aortic aneurysms, which are rare, but can be fatal, remain poorly understood. This retrospective study analyzed the outcomes of aortic diameter, including aortic root, ascending aorta, and proximal arch diameters, after aortic wrapping during aortic valve replacement surgery.

MATERIALS AND METHODS

Ninety-six patients with ascending aortic dilation of 40-55 mm who underwent aortic wrapping during aortic valve replacement were selected for this study. Aortic diameter was measured at three levels perioperatively and at follow-up (median time of 9.1±4.2 years). A linear mixed-effects model was used to analyze aortic diameter expansion.

RESULTS

Freedom from adverse aortic events (aortic dissection or rupture, reoperation, or sudden death) at 10 years was 97.9%. No significant dilation at the level of the sinuses of Valsalva (0.069 mm/year, p=0.524) or ascending aorta (0.152 mm/year, p=0.124) was observed. Significant dilation occurred at the proximal aortic arch (0.343 mm/year, p=0.006). Subgroup analysis with a multivariable linear mixed model identified initial ascending aortic diameter to be a significant predictor of proximal arch dilation (p=0.032). Receiver operating characteristic curve analysis revealed that the cut-off for the prediction of proximal arch redilation was an initial mid-ascending aortic diameter of 47.0 mm (area under the curve 0.747, 90% confidence interval 0.613-0.881, p=0.023).

CONCLUSION

Aortic wrapping could be considered as a safe and long-term therapeutic option. Redilation of the proximal arch should be carefully observed during long-term follow-up.

Efficacy of ascending aortic banding technique concomitant with type I hybrid aortic arch repair in high-risk patients

Banding of the ascending aorta has been introduced as a less complex procedure to optimize the proximal landing zone of the stent graft in hybrid aortic arch surgery. However, data about the long-term results and effects of this technique are still limited. We aimed to study the efficacy of banding of the ascending aorta in hybrid aortic arch repair. The study included 11 high-risk patients with dilated ascending aorta (wider than 38 mm in diameter) undergoing ascending aortic banding for hybrid arch repair. Clinical outcomes, including technical success, endoleaks, perioperative mortality and morbidity, and sequential remodeling of the ascending aorta were investigated. The average diameter of the ascending aorta had been reduced (p = 0.02) from 42.1 mm (range = 39.0-46.4) to 37.2 mm (range = 35.6-38.6) after banding procedure. The technical success rate was 100.0%. No type I endoleak occurred, but 2 cases of distal stent graft-induced new entry required re-interventions. The 5-year survival and freedom from aortic events rates both were 81.8%. The ascending aortic diameter remained stable and no proximal migration of the stent graft was observed during the study period. The 5-year results validated the durability of this therapeutic modality, especially in high-risk patients.

Wrapping of the ascending aorta revisited-is there any role left for conservative treatment of ascending aortic aneurysm?

Dilatation of the ascending aorta (AA) is a common finding in patients with aortic valve disease. The clinical practice guidelines recommend replacing the AA whenever the diameter exceeds 45 mm. However, no consensus has been reached regarding the approach when the aorta is only moderately dilated. Although the risk in aorta replacement is generally low, it may be higher when associated with other complex surgical procedures or it is carried out in elderly patients or patients with significant comorbidity. This would justify the use of alternative surgical techniques, which reduce surgical risk and guarantee a durable correction of the aortic pathology. Conservative treatment of aneurysms of the AA via wrapping with different synthetic materials has been implemented for many years. The most commonly used technical variant is wrapping the dilated aorta with a vascular prosthesis with a predetermined diameter. When this technique is adequately applied, it immediately reduces the diameter of the AA and, to a lesser degree, the diameter of the aortic root and arch, while at the same time it reinforces the weak aortic wall. These effects lead to a drop-in wall shear stress and in the risk of aortic dissection and rupture, and persist over time. Although the low elasticity of the external support causes significant changes in the histologic structure of the aortic wall, mainly atrophy and alterations typical of a foreign body-induced reaction, this does not seem to involve a higher risk of complications. In some selected patients, this technique may be used in cases other than post-stenotic aortopathy, and also in aortas with a larger diameter.

Recurrence of Aneurysm of the Ascending Aorta after Patch Repair: The Fate of an Aortic Patch

Pseudoaneurysm of the ascending aorta is a rare but life- threatening complication after aortic cannulation and cardiovascular surgery, and it has the potential to rupture. We experienced a rare case of recurrence of aneurysm of the ascending aorta 7 years after patch repair of a small aneurysm at an aortic cannulation site. The repaired aorta had been wrapped with a Teflon felt strip during the previous surgery, and the wrapped aorta had become thin with deterioration of the normal structure of the aortic wall.