Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

Double-branched stent graft and four-stage deployment in total arch repair: safety and feasibility evaluation in porcine models

OBJECTIVES

The primary objective of this research was to evaluate the safety and feasibility of an innovative double-branched stent graft system employing four-stage deployment technology for aortic arch repair in porcine models.

METHODS

The double-branched stent graft system consisted of a proximal polyester artificial blood vessel, the main and double-branched stent grafts and a delivery system. We utilized 12 healthy pigs as experimental animals (6 per group). Postimplantation, samples were collected at 90 and 180 days after the operations. Preoperative and postoperative imaging and intraoperative arterial blood gas analyses were performed. After the pigs were euthanized, the implanted product, surrounding tissue and major organs were collected for pathological analysis.

RESULTS

The technical success rate of the stent graft implants was 100% (12/12). All animals survived to the experimental end point. Perioperative assessments showed intact stent grafts, and imaging features at the end of the follow-up period revealed neither endoleak nor device migration. No major adverse cardiovascular events were observed during the postoperative follow-up period. Pathological examinations confirmed the satisfactory biocompatibility of the stent graft.

CONCLUSIONS

This innovative double-branched stent graft system with four-stage deployment technology was affirmed as a safe and feasible option for aortic arch repair in accordance with our preclinical evaluation with porcine models.

Strategy for acute DeBakey type I aortic dissection considering midterm results: a retrospective cohort study comparing ascending aortic replacement and total arch replacement with frozen elephant trunk technique

BACKGROUND

Acute type A aortic dissection is treated with an emergency procedure that uses ascending aortic replacement (AAR). However, to avoid a residual dissected aorta with a false lumen, total arch replacement (TAR) is required. The frozen elephant trunk (FET) technique is a promising surgical approach that promotes false lumen obliteration in a single step. Therefore, this retrospective single-center study aimed to evaluate the operative outcomes of AAR and TAR with FET.

METHODS

Between 2007 and 2021, 143 patients with acute DeBakey type I aortic dissection underwent a central repair using AAR (n = 95) or TAR with FET (n = 43). All perioperative variables, the duration of all-cause mortality, and aortic events defined as dilatation of the distal aorta > 5 cm, new occurrences of aortic dissection, distal aortic surgery, and distal aortic rupture were recorded. We compared these perioperative variables and mid-term results with an additional focus on distal aortic events.

RESULTS

Patient background data did not differ between the two groups. Perioperative results for the TAR with FET group vs the AAR group showed similar operative times (306 vs 298 min, P = 0.862), but the TAR group had longer cardiopulmonary bypass times (154 vs 179 min, P < 0.001). The freedom from all-cause death for the TAR vs AAR groups using the Kaplan-Meier method was 81.9% vs 85.4% and 78.0% vs 85.4% (P = 0.407) at 1 and 3 years, respectively. Freedom from aorta-related events was 90.6% vs 97.6% and 69.3% vs 87.0% (P = 0.034) at 1 and 3 years, respectively.

CONCLUSIONS

TAR with FET had comparable perioperative results to AAR in acute DeBakey type I aortic dissection and was considered a valuable method to avoid aorta-related events in the midterm.

Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection

BACKGROUND

The management of anastomosis and hemostasis of the dissected aorta remains challenging. This study aims to establish an optimal surgical strategy for type A acute aortic dissection by reviewing single-center data using the turn-up anastomosis technique.

METHODS

Between 2003 and 2015, 264 consecutive patients with type A acute aortic dissection who underwent emergency surgery within 14 days of symptom onset were enrolled.

RESULTS

The mean age of the patients was 67.7 ± 13.4 years, and 129 were males. The operative time and surgical bleeding were 390.9 ± 144.5 min and 2983.8 ± 3026.5 mL, respectively. In-hospital mortality was observed in 25 patients (9.4%), and 3 (1.1%) experienced uncontrolled bleeding (from the aortic root in two patients and coagulopathy due to dabigatran in one patient). Immediate reopening for bleeding was performed in 20 patients, and bleeding from the aortic anastomosis was observed at three proximal and two distal sites. Proximal re-dissection was observed in 18 patients; in all of which, glue was used, although two re-ruptures of the aortic root were observed among those without glue use. The rates of freedom from all-cause death, aortic death, and aortic events at postoperative 5 years were 78.5 ± 2.7%, 86.8 ± 2.1%, and 74.4 ± 2.9%, respectively. When these values were stratified according to the operative extent, no significant differences were observed.

CONCLUSIONS

Turn-up anastomosis facilitates short circulatory arrest, short operative time, and stable hemostasis, with few anastomotic complications during surgery for type A acute aortic dissection.

Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection?

BACKGROUND

Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement.

AIMS

This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase.

RESULTS

TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair.

CONCLUSION

Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.

Total aortic arch replacement in acute type A aortic dissection - a single institutional experience

Aim

Total arch replacement in the presence of acute aortic dissections is one of the most challenging areas of aortic surgery. Data on outcome in the Indian scenario is sparse. The aim of this study was to assess the outcome of arch replacements in a single tertiary care center.

Material and methods

In this single-center experience, 20 patients underwent total arch replacement between 2012 and 2022. Demographic, intraoperative, and postoperative data were abstracted from hospital records. Only patients with acute type A aortic dissection needing an arch repair were included. Patients with hemi-arch repairs, hybrid repairs, and those operated upon due to aneurysmal disease were excluded from the study. Comparison was made between survivors and non-survivors. Temporal trends for the procedure were assessed.

Results

The study included 20 patients who underwent total aortic arch replacement (TAR) during the study period (2012-2022). The mean age was 49.3 ± 12.5 years, and 15 (75%) of the patients were males. Seven (35%) patients were operated within 24 h of symptom onset. Permanent stroke was seen in 1 (5%) patient and temporary neurological dysfunction was observed in 1 (5%) patient. The re-exploration rate was 6 (30%) in the entire cohort and in-hospital mortality was 4 (20%). Follow-up was complete in 18 (90%) of the study population and 14 (87.5%) among survivors. There was one late death in our study which occurred after 46 months of the index operation. The overall mean survival was 76.1 months (95% CI: 49.86-102.43).

Conclusion

TAR can be performed both with acceptable mortality and morbidity in the presence of acute aortic dissections.

Night-time surgery for type a aortic dissection: Immediate or delaying?

OBJECTIVES

This study aims to investigate whether surgery performed during night compared with daytime were associated with an increased risk of operative mortality of type A aortic dissection (TAAD) patients.

METHODS

A total of 2015 TAAD patients who underwent surgical repair were collected from two cardiovascular centers from Jan 2015 to Jan 2021. According to the start time of surgery, patients were divided into daytime group (06:01 a.m. to 06:00 p.m.) and night-time group (06:01 p.m. to 06:00 a.m.), and retrospective analyses were performed between them.

RESULTS

The operative mortality of night-time group (12.2%, 43/352) was dramatically higher than daytime group (6.9%, 115/1663; p = 0.001). There was significant difference between night-time and daytime groups in terms of 30-days mortality (5.8% vs 10.8%; p = 0.001) and in-hospital mortality (3.5% vs 6.0%; p = 0.03). The night-time group had a longer duration of intensive care unit stay (4 vs two; days; p < 0.001) and ventilation support (34 vs 19; hours; p < 0.001), compared with daytime group. The risk factors for operative mortality were night-time surgery (odds ratio [OR], 1.545; p = 0.027), age (odds ratio, 1.152; p < 0.001), total arch replacement (OR, 2.265; p < 0.001) and previous aortic surgery (OR, 2.376; p = 0.003).

CONCLUSION

Night-time surgical repair may be associated with higher operative mortality of patients with TAAD. Nevertheless, it is reasonable to offer emergency surgery at night-time for such patients who were more likely to present disastrous complications with delayed surgical intervention, as outcomes indicate acceptable operative mortality.

Effects of Residual Arch Tears on Late Outcomes After Hemiarch Replacement for DeBakey I Dissection

BACKGROUND

This study evaluated the effect of residual arch tears on late reinterventions and arch dilatation after hemiarch replacement for patients with acute DeBakey type I aortic dissection.

METHODS

Between January 1995 and October 2018, 160 consecutive patients who underwent hemiarch replacement for DeBakey type I dissection were retrospectively enrolled. They were divided into patients with (n = 73) and without (n = 87) residual arch tears. The arch tears group was subdivided into the proximal/middle arch (n = 26) and distal arch (n = 47) groups to evaluate arch growth rates according to the locations of residual arch tears. The endpoints were arch growth rate and late arch and composite events.

RESULTS

The arch diameter increased significantly over time in patients with residual arch tears (1.620 mm/y, P < .001). The increase occurred more rapidly when residual tears occurred at the distal arch than at the proximal/middle arch level (2.101 vs 1.001 mm/y). In the adjusted linear mixed model, residual arch tears or luminal communications at the distal arch level were significant factors associated with increases in the arch diameter over time. The 10-year freedom from late arch and composite event rate was significantly lower for patients with residual arch tears than for those without (82.4% vs 95.5%, P = .001; and 68.0% vs 89.3%, P = .002, respectively).

CONCLUSIONS

Residual arch tears are significant factors associated with late arch dilatation and reinterventions, especially for patients with distal arch tears. Extensive arch replacement during the initial surgery to avoid residual arch tears may improve long-term outcomes.

Distal Aortic Progression After Hemiarch, Zones 1-3 Arch Replacement in Acute Type A Aortic Dissection

BACKGROUND

There is debate regarding aortic arch repair extent for acute type A aortic dissection (ATAAD) patients.

METHODS

From 1996 to 2021, 756 ATAAD patients underwent open arch replacement. The cohort was divided into hemiarch (n = 481), zone 1 (n = 65), zone 2 (n = 148), and zone 3 (n = 62) arch replacement groups. Cross-group comparison of aortic growth was modeled using data from interval postoperative computed tomography or magnetic resonance imaging of the distal aorta.

RESULTS

Demographics were not significantly different except the hemiarch group had more coronary artery disease and less stroke. Intraoperatively, zones 1, 2, and 3 had greater cardiopulmonary bypass, cross-clamp, and hypothermic circulatory arrest times and required more intraoperative blood transfusion than the hemiarch group. Perioperative outcomes were similar among groups except zone 3 had more reoperation for bleeding. Ten-year cumulative incidence of reoperation was hemiarch, 16.7%; zone 1, 16.3%; zone 2, 21.5%; and zone 3, 17.6% (P = .70). Ten-year survival was similar: hemiarch, 66%; zone 1, 60.3%; zone 2, 68.0%); and zone 3 66.1% (P = .20). Aortic arch, descending aorta, and abdominal aorta growth rates were not significantly different among groups over 10 years. In the whole cohort, the growth rate over time for aortic arch was 0.38 mm per year (P < .001), descending aorta 0.84 mm per year (P < .001), and abdominal aorta 0.69 mm per year (P < .001).

CONCLUSIONS

There was no significant difference in long-term survival, distal aorta growth, or reoperation rate for distal aortic aneurysm after hemiarch or zones 1, 2, or 3 arch replacement. Patient-specific arch replacement strategies may be used rather than defaulting to aggressive arch replacement for all ATAAD patients.

Novel Approach to treating a COVID-19 positive patient with a Complex Arch and Descending Aneurysm and Dissection in whom open surgery is prohibitive

Ascending aortic and arch aneurysms are a challenging group of pathologies for surgeons. These typically require a complex open repair, including hypothermic circulatory arrest and carry a high peri-operative risk. Outcomes are best when performed in centers with significant experience and expertise. Many patients, because of co-morbidities, are at a prohibitive risk for these open surgeries. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment of most acute descending thoracic aortic pathologies.[1] However, these require strict anatomic criteria to be successful and are usually confined to the distal arch and descending thoracic aorta. There are no commercially available endovascular devices in the United States to treat this patient population with ascending or proximal arch aneurysms or dissections, especially in an urgent or emergent setting, whose anatomy does not meet criteria for standard TEVAR. We present a novel endovascular approach, including a cerebral protection strategy, to treat a complex arch aneurysm and dissection in a patient who was not a candidate for an open repair.

Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection

To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.

Optimal Extent of Repair for Acute Type I Aortic Dissection-Frozen Elephant Trunk? How Long and Why?

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.

Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data

OBJECTIVES

To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD).

METHODS

We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.

RESULTS

Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025).

CONCLUSION

The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.

Outcomes of hemi- vs. total arch replacement in acute type A aortic dissection: A systematic review and meta-analysis

Background

Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD.

Methods

The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022.

Results

We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70–0.97; P = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; P = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; P = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; P = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia.

Conclusion

In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis.

Systematic review registration:

[INPLASY.COM], identifier [INPLASY202250088].

Aortic remodeling, reintervention, and survival after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection: Midterm results

Objectives

To investigate the midterm results after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection.

Methods

Between October 2014 and April 2021, 196 patients underwent zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. The true lumen area, aortic lumen area, and false lumen status were assessed at four aortic levels, the proximal and distal descending thoracic aorta (level A and level B, respectively), celiac artery branching (level C), and terminal aorta (level D). Aortic remodeling (postoperative area as a percentage of the preoperative area) was classified into 3 groups, positive (true lumen area ≥120% with aortic lumen <120% or true lumen area ≥80% with aortic lumen <80%), minimal (80% ≤ true lumen area and aortic lumen area <120%), and negative remodeling (all other changes).

Results

In-hospital mortality was 13 (6.6%) patients. The overall survival rate was 85.1% at 5 years. The freedom from distal aortic reintervention was 89.9% at 5 years. The prevalence of completely thrombosed or obliterated false lumen at 2 years was 96.8% at level A, 88.4% at level B, 47.2% at level C, and 27.6% at level D. The prevalence of positive aortic remodeling at 2 years was 84.7% at level A, 75.0% at level B, 29.2% at level C, and 16.7% at level D.

Conclusions

Zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection can avoid invasive aortic arch resection and facilitate aortic remodeling of the descending thoracic aorta. The FET effect on aortic remodeling is limited at the aortic level below the FET stent end.

Does deep hypothermic circulatory arrest with versus without retrograde cerebral perfusion affect the outcomes after proximal aortic arch aneurysm and acute type A aortic dissection repair? Different pathologies and cerebral protection techniques with similar results

Hypothermic circulatory arrest is used for proximal and total aortic arch correction in patients with aortic arch aneurysm and acute or chronic type A aortic dissection. Different cerebral perfusion techniques have been proposed for reducing morbidity and mortality rate. The study of Arnaoutakis et al. showed that deep hypothermic circulatory arrest with or without retrograde cerebral perfusion for proximal aortic aneurysm and acute type A aortic dissection correction had similar results with regard to morbidity and mortality rate. In addition, the short circulatory arrest time contributes for favorable outcomes of these patients. Although antegrade cerebral perfusion with hypothermic circulatory is widely used by many cardiac surgeons, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion remains an alternative and safe method for brain protection in patients undergoing proximal aortic arch aneurysm or acute type A aortic dissection repair.

Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease

Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.

Quality of life following surgical repair of acute type A aortic dissection: a systematic review

Background

The outcomes of surgery for acute Stanford Type A aortic dissection (ATAAD) extend beyond mortality and morbidity. The aim of this systematic review was to summarise the literature surrounding health related quality of life (HR-QOL) following ATAAD, compare the outcomes to the standardised population, and to assess the impact of advanced age on HRQOL outcomes following surgery.

Methods

A systematic review of studies after January 2000 was performed to identify HR-QOL in patients following surgery for ATAAD. Electronic searches of three databases were performed and clinical studies extracted by two independent reviewers. Strict inclusion and exclusion criteria were applied. Quality appraisal was conducted utilizing predefined criteria on pilot forms. HR-QOL results were synthesized through a narrative review of included studies.

Results

There was significant attrition in HR-QOL of patients following surgery for ATAAD. Outcomes fared worse when compared to an age adjusted normative population. Of note, elderly patients were physically vulnerable, whereas younger populations may be more mentally vulnerable to postoperative sequalae. The included studies were quite heterogeneous in their study designs, methods, HR-QOL measures reported and follow up time-frames which limited direct comparison between studies.

Conclusion

HR-QOL outcomes are adversely affected when compared to preoperative status and physical health demonstrates significant attrition over time. HR-QOL outcomes are worse off when compared to an age matched general population. In terms of age, advancing age is associated with worse physical component scores but emotional health may fare better than younger patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01875-x.

Visceral and renal malperfusion syndromes in acute aortic dissection type A: the fate of the branch vessel

BACKGROUND

Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections.

METHODS

Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion.

RESULTS

Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion.

CONCLUSIONS

Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.

Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis

OBJECTIVES

Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD).

METHODS

A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed.

RESULTS

A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm.

CONCLUSIONS

In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.

Frozen elephant trunk in acute type A aortic dissections: frontiers and challenges

Acute type A aortic dissection (ATAAD), a surgical emergency, has high mortality and morbidity. More than half of the patients die within 2 weeks and the 30-day mortality is 90%. Frozen elephant trunk in ATAAD addresses the primary and secondary goals - resection of the primary tear in the ascending aorta and promoting remodelling in the downstream aorta. Though the literature supports this fact, in reality these literatures emerge from high-volume centres. But in the "real world" most of the ATAAD are operated on in the low-volume centres. Furthermore, in India, there are unique challenges including the financial burden, transport, emergent availability of the hybrid prosthesis and aortic supercentres.

Extensive Arch Repair with a Novel Two-Branched Stent Graft in Acute Type A Aortic Dissection

Purpose: In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.

Methods: Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).

Results: The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.

Conclusion: Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.

Modified "in situ" arch replacement with an integrative frozen elephant trunk device for acute type A aortic dissection

Background

Total arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified “in situ” arch replacement with an integrative FET device for aTAAD.

Methods

From January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/− or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining “island” arch with the prosthetic vessel and the proximal part of the FET.

Results

MiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.

Conclusions

MiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

OBJECTIVE

The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.

METHODS

From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).

RESULTS

The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).

CONCLUSIONS

Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection

Background

Acute type A aortic dissection with arch involvement is a life-threatening condition, which requires immediate surgical attention. Emergent total arch replacement and root reconstruction is a technically demanding operation with varying outcomes based on surgeon experience. The human factors in total arch replacement in the emergent setting have never been systematically investigated. The ability of surgeons with low volumes to achieve acceptable results in their start-up period is not known.

Methods

From January 2013 to December 2016, patients with acute type A aortic dissection who underwent emergent total arch replacement with three surgeons were enrolled. Basic characteristics, procedural and postoperative outcomes were collected. The time of critical surgical steps and operative mortality were calculated using descriptive statistics and cumulative SUM (CUSUM) analysis.

Results

A total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent emergent total arch replacement. A total of 219 patients (73.0%) had root reinforcement, 295 patients (98.3%) underwent frozen elephant trunk repair. Mean circulatory arrest and cross-clamp times were 29.8±9.8 and 112.3±32.1 min, respectively. The operative mortality was 6.7%, the stroke rate was 4.0%. The mean length of postoperative ICU and hospital stays were 8.4±10.6 and 18.0±12.2 days, respectively. By CUSUM depictions, surgeons appeared to have different learning curves with regards to operative time. By CUSUM failure analysis on operative mortality, two newly appointed surgeons in their start-up period stayed in an acceptable range, while one senior surgeon with higher volumes experienced superior outcomes and better performance.

Conclusions

Although emergent total arch replacement for acute type A dissection is a complex scenario, surgeons well-trained in adult cardiac surgery are able to achieve acceptable results in their start-up period.

Managing acute type A aortic dissections: Is a universal approach feasible?

The goal in the treatment of acute type A aortic dissection (ATAAD) is to resect the primary intimal tear while minimizing associated complications of the disease. This goal can be accomplished by different surgical techniques and operative strategies. The extent of proximal and distal aortic reconstruction and the use of cerebral perfusion adjuncts are highly variable between institutions and within institutions themselves. As operative outcomes for ATAAD have improved considerably over the past decade, the focus has shifted towards extensive aortic reconstruction to minimize aortic reinterventions. However, there remains a distinct difference in how patients with ATAAD are managed in North America when compared with those in East Asia.

Contemporary Surgical Strategies for Acute Type A Aortic Dissection

Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.

Alternatives to the frozen elephant trunk in acute type A aortic dissection

Acute type A aortic dissection remains one of the most challenging condition in cardiothoracic surgery, with a high mortality rate. Various improvements and innovations have happened over the years to better the outcome of this lethal condition. The frozen elephant trunk prosthesis has been developed to negate the long-term complications of acute type A aortic dissection, but at the cost of increased morbidity compared to hemiarch replacement. Although hemiarch and total arch replacement seem have less morbidity than the frozen elephant trunk technique, they do not address the long-term complications of the distal dissected aorta. Few surgeons now suggest hybrid aortic arch repair as a solution for acute type A aortic dissection. The long-term results need to be studied in all procedures before standardizing them. Although multiple strategies are evolving, the short-term goal of acute type A aortic dissection has not changed: to save the patient's life. The surgical strategy has to be tailored according to the patient's condition and the surgeon's experience.

Surgical Outcomes of Type A Aortic Dissection at a Small-Volume Medical Center: Analysis according to the Extent of Surgery

Background

Despite progress in treatment, Stanford type A aortic dissection is still a life-threatening disease. In this study, we analyzed surgical outcomes in patients with Stanford type A aortic dissection according to the extent of surgery at Daegu Catholic University Medical Center.

Methods

We retrospectively analyzed 98 patients with Stanford type A aortic dissection who underwent surgery at our institution between January 2008 and June 2018. Of these patients, 82 underwent limited replacement (hemi-arch or ascending aortic replacement), while 16 patients underwent total arch replacement (TAR). We analyzed in-hospital mortality, postoperative complications, the overall 5-year survival rate, and the 5-year aortic event-free survival rate.

Results

The median follow-up time was 48 months (range, 1–128 months), with a completion rate of 85.7% (n=84). The overall in-hospital mortality rate was 8.2%: 6.1% in the limited replacement group and 18.8% in the TAR group (p=0.120). The overall 5-year survival rate was 78.8% in the limited replacement group and 81.3% in the TAR group (p=0.78). The overall 5-year aortic event-free survival rate was 85.3% in the limited replacement group and 88.9% in the TAR group (p=0.46).

Conclusion

The extent of surgery was not related to the rates of in-hospital mortality, complications, aortic events, or survival. Although this study was conducted at a small-volume center, the in-hospital mortality and 5-year survival rates were satisfactory.

Simplified surgical approach to improve surgical outcomes in the center with a small volume of acute type A aortic dissection surgery

BACKGROUND:

Despite recent advances in surgical techniques and perioperative management, the surgical mortality of acute type A aortic dissection remains high.

OBJECTIVE:

In a hospital with few acute type A aortic dissection operations, we retrospectively investigated whether simplified surgical approach could obtain proper surgical outcomes.

METHODS:

Between October 2007 and December 2016, we performed emergency surgery in 99 patients who had acute type A aortic dissection, including replacement of the hemi-arch in 62 patients (63%) and total arch in 32 patients (32%) and aortic root surgery in 7 patients (7%). Surgical strategy has been simplified over time.

RESULTS:

We performed right axillary artery perfusion in 61 patients (62%) and antegrade cerebral perfusion in 78 patients (79%). During the last 3 years, in-hospital mortality was decreased to 4% (2/47). Preoperative unresolved shock was an independent predictor of hospital death. Although the patients with total arch replacement or aortic root surgery had a mean significantly long cardiopulmonary bypass or circulatory arrest time, in-hospital mortality or neurologic complications was not increased.

CONCLUSIONS:

Simplified surgical approach could provide a reasonable surgical outcome in acute type A aortic dissection surgery in a center with a small volume of acute aortic dissection surgery.

Late outcomes of strategic arch resection in acute type A aortic dissection

OBJECTIVE

To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD).

METHODS

From 1996 to 2017, we compared outcomes of hemiarch (n = 322) versus aggressive arch replacements (zones 2 and 3 arch replacement with implantation of 2-4 arch branches, n = 150) in ATAAD. Indications for aggressive arch were arch aneurysm >4 cm or intimal tear in the aortic arch that was not resectable by hemiarch replacement, or dissection of arch branches with malperfusion.

RESULTS

Patients in the aggressive arch group were significantly younger (mean age: 57 vs 61 years old) and had significantly longer hypothermic circulatory arrest, cardiopulmonary bypass, and aortic crossclamp times. There were no significant differences in perioperative outcomes between hemiarch and aggressive arch groups, including 30-day mortality (5.3% vs 7.3%, P = .38) and postoperative stroke rate (7% vs 7%, P = .96). Over 15 years, Kaplan-Meier survival was similar between hemiarch and aggressive arch groups (log-rank P = .55, 10-year survival 70% vs 72%). Given death as a competing factor, incidence rates of reoperation over 15 years (2.1% vs 2.0% per year, P = 1) and 10-year cumulative incidence of reoperation (14% vs 12%, P = .89) for arch and distal aorta pathology were similar between the 2 groups.

CONCLUSIONS

Both hemiarch and aggressive arch replacement are appropriate approaches for select patients with ATAAD. Aggressive arch replacement should be considered for an arch aneurysm >4 cm or an intimal tear at the arch unable to be resected by hemiarch replacement, or dissection of the arch branches with malperfusion.