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Ghazy A, Chaban R, Pfeiffer P, Probst C, Dohle DS, Treede H, Dorweiler B. Three-Dimensional-Evaluation of Aortic Changes after Frozen Elephant Trunk (FET) in Zone 0 vs. Zone 2 in Acute Type A Aortic Dissection. J Clin Med 2024; 13:2677. [PMID: 38731205 PMCID: PMC11084169 DOI: 10.3390/jcm13092677] [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: 03/27/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: The management of aortic dissection has evolved significantly over the decades, with the frozen elephant trunk (FET) procedure emerging as a key technique for treating complex aortic pathologies. Recent practices involve deploying the FET prosthesis more proximally in the aorta (Zone 0) to reduce complications, leading to questions about its impact on long-term aortic remodeling compared to traditional Zone 2 deployment. Methods: This retrospective analysis utilized 3D segmentation software to assess the volumetric changes in aortic remodeling after acute Type A aortic dissections, comparing FET stent graft deployment in Zone 0 and Zone 2. The study included 27 patients operated on between 2020 and 2022, with volumetric measurements taken from postoperative and 6-month follow-up CT scans. Statistical analyses were performed to evaluate the differences in the aortic true lumen (TL) and the perfused false lumen (PFL) between the two groups. Results: Both Zone 0 and Zone 2 deployments resulted in significant true lumen (TL) increases (Z0 p = 0.001, Z2 p < 0.001) and perfused false lumen (PFL) decreases (Z0 p = 0.02, Z2 p = 0.04), with no significant differences in volumetric changes between the groups (p = 0.7 post op and p = 0.9 after 6 months). The distal anastomosis in Zone 0 did not compromise the aortic remodeling outcomes and was associated with reduced distal ischemia and cerebral perfusion times (p = 0.041). The angle measurements in Zone 0 did not show any significant changes after the 6-month control (p = 0.2). However, in Zone 2, a significant change was detected. (p = 0.022). The part comparison analyses did not indicate significant differences in aortic deviation between the groups (p = 0.62), suggesting comparable effectiveness in aortic remodeling. Conclusions: Performing the distal anastomosis more proximally in Zone 0 offers technical advantages without compromising the effectiveness of aortic remodeling compared to the traditional Zone 2 deployment. This finding supports the continued recommendation of Zone 0 deployment in the management of acute Type A aortic dissections, with ongoing studies being needed to confirm the long-term outcomes and survival benefits.
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Affiliation(s)
- Ahmed Ghazy
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Ryan Chaban
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Philipp Pfeiffer
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Chris Probst
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Daniel-Sebastian Dohle
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University of Mainz, Faculty of Medicine and University Hospital Mainz, 55131 Mainz, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany
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Wilson King R, Carroll AM, Higa KC, Cleveland JC, Rove JY, Aftab M, Brett Reece T. Frozen Elephant Trunk for Acute Type A Dissection: Is Risk from Procedure or Patient Characteristics? AORTA (STAMFORD, CONN.) 2023; 11:112-115. [PMID: 37619568 PMCID: PMC10449567 DOI: 10.1055/s-0043-1768970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/07/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The initial goal of acute Type A aortic dissection (ATAAD) repair remains to get the patient off the table safely. More extensive repair is being pushed at the index operation with the frozen elephant trunk (FET) operation, but outcomes are suggested to be worse. However, we hypothesize that the risk associated with the FET in ATAAD is from the patient presenting factors rather than the operation itself. METHODS A retrospective review of a single institution prospective database from 2015 to 2021 was performed. Two cohorts were created based on the indication for FET: evidence of radiographic malperfusion (n = 44) or clinical malperfusion (n = 31). Data were analyzed for preoperative characteristics, intraoperative characteristics, and postoperative outcomes. Statistical univariate analysis was performed with chi-square analysis and t-tests with significance determined at an alpha level of 0.05. RESULTS Preoperative characteristics were similar in each group, independent of malperfusion markers. The intraoperative characteristics were similar, except the clinical malperfusion group had more packed red blood cells and cryoprecipitate given. The clinical malperfusion group had longer intensive care unit length of stay (p < 0.001), more postoperative strokes (p < 0.001), more reoperations (p <0.0001), and higher mortality rate (p = 0.0003). CONCLUSION These data suggest that clinical malperfusion increases the risk of major complications and death. However, full arch replacement with FET in the absence of clinical malperfusion does not appear to add risk to the operation for ATAAD. Patients with increased risk of distal degeneration should be considered for more aggressive replacement to avoid subsequent arch replacement.
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Affiliation(s)
- R. Wilson King
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Adam M. Carroll
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Kelly C. Higa
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Joseph C. Cleveland
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Jessica Y. Rove
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Muhammad Aftab
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Thomas Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
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Idhrees M, Velayudhan B. Frozen elephant trunk in acute type A aortic dissections: frontiers and challenges. Indian J Thorac Cardiovasc Surg 2022; 38:79-82. [PMID: 35463715 PMCID: PMC8980971 DOI: 10.1007/s12055-021-01315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, 600 026 India
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, 600 026 India
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Czerny M, Beyersdorf F, Murana G, Pacini D. Excessive oozing through the fabric of the branched Cryolife-Jotec Evita Open NEO hybrid prosthesis. Eur J Cardiothorac Surg 2021; 60:423-424. [PMID: 33729458 DOI: 10.1093/ejcts/ezab058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/24/2021] [Indexed: 11/12/2022] Open
Abstract
We report 3 cases of excessive oozing after aortic arch replacement using the frozen elephant trunk technique through the fabric of the branched Cryolife-Jotec Evita Open NEO hybrid prosthesis. After weaning from cardiopulmonary bypass, protamine administration as well as standard substitution of plasmatic and cellular coagulation adjusted to thrombelastometry, excessive oozing persisted leading to a complicated postoperative course in all 3 patients.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Giacomo Murana
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Tan SZCP, Lopuszko A, Munir W, Adams B, Bashir M. Aortic proximalization-Zone 0 versus Zone 2: A concept or true challenge? J Card Surg 2021; 36:3319-3325. [PMID: 34110057 DOI: 10.1111/jocs.15730] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (such as acute type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at aortic Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favor of improved surgical access and clinical outcomes. This review seeks to elucidate whether proximalization of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. METHODS We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. RESULTS Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. CONCLUSION Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review, therefore, recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalization of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.
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Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aleksandra Lopuszko
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Wahaj Munir
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales, Wales, UK
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Choudhury RY, Basharat K, Zahra SA, Tran T, Rimmer L, Harky A, Idhrees M, Bashir M. "Proximalization is Advancement"-Zone 3 Frozen Elephant Trunk vs Zone 2 Frozen Elephant Trunk: A Literature Review. Vasc Endovascular Surg 2021; 55:612-618. [PMID: 33754903 DOI: 10.1177/15385744211002493] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the decades, the Frozen Elephant Trunk (FET) technique has gained immense popularity allowing simplified treatment of complex aortic pathologies. FET is frequently used to treat aortic conditions involving the distal aortic arch and the proximal descending aorta in a single stage. Surgical preference has recently changed from FET procedures being performed at Zone 3 to Zone 2. There are several advantages of Zone 2 FET over Zone 3 FET including reduction in spinal cord injury, visceral ischemia, neurological and cardiovascular sequelae. In addition, Zone 2 FET is a technically less complicated procedure. Literature on the comparison between Zone 3 and Zone 2 FET is scarce and primarily observational and anecdotal. Therefore, further research is warranted in this paradigm to substantiate current surgical treatment options for complex aortic pathologies. In this review, we explore literature surrounding FET and the reasons for the shift in surgical preference from Zone 3 to Zone 2.
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Affiliation(s)
| | - Kamran Basharat
- Department of Medicine, St George's University of London, United Kingdom
| | - Syeda Anum Zahra
- Department of Medicine, St George's University of London, United Kingdom
| | - Tien Tran
- Department of Medicine, St George's University of London, United Kingdom
| | - Lara Rimmer
- General Surgery, 171993Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Faculty of Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic disorders, SIMS Hospital, Chennai
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, 155510Royal Blackburn Teaching Hospital, Blackburn, United Kingdom
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Ho JYK, Bashir M, Teh G, Jakob H, Wong RHL. Launching the E-vita Open Neo amid COVID-Challenges and strategies. J Card Surg 2021; 36:793-795. [PMID: 33554356 PMCID: PMC8014468 DOI: 10.1111/jocs.15197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jacky Y K Ho
- Department of Surgery, Division of Cardiothoracic Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Gloria Teh
- CryoLife, Inc, Asia-Pacific Region, Singapore
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany
| | - Randolph H L Wong
- Department of Surgery, Division of Cardiothoracic Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Velayudhan B, Bashir M, Idhrees M. Left subclavian artery management in frozen elephant trunk: A novel technique. J Card Surg 2020; 36:283-285. [PMID: 33090570 DOI: 10.1111/jocs.15107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/27/2020] [Indexed: 11/30/2022]
Abstract
Proximilization of frozen elephant trunk (FET) necessitates the ligation and reimplantation of the left subclavian artery (LSA), the origin of which is distal and posterior, make rerouting difficult and cumbersome. We describe a rather simple technique for subclavian artery exposure and effective anatomical reconstruction in the mediastinum coupled with hybrid FET utilization for aortic aneurysm in elective and nonelective settings. The division of the sternocleidomastoid coupled with the sandbag behind the left shoulder brings the LSA superficial enabling anastomosis without any difficulty.
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Affiliation(s)
- Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
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Jakob H, Idhrees M, Bashir M. From E-VITA open plus to E-VITA NEO and E-NOVIA. J Card Surg 2020; 36:1814-1817. [PMID: 32949032 DOI: 10.1111/jocs.15044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/05/2020] [Indexed: 11/28/2022]
Abstract
The first clinical implantation of the "Essen I prosthesis" took place in 2005, which was then followed by E-Vita open plus. With further advancements E-Vita Neo and E-Novia was introduced. These devices enable the surgeons to perform frozen elephant trunk in zone 0/1 which eventually reduce the incidence of paraplegia, recurrent laryngeal nerve palsy and proximalization of supraaortic arch vessels. E-vita open plus and successors alleviate frozen elephant trunk operations rendering more stable results in promoting positive remodelling of the distal aorta.
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Affiliation(s)
- Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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