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Coselli JS, Roselli EE, Preventza O, Malaisrie SC, Stewart A, Stelzer P, Takayama H, Chen EP, Estrera AL, Gleason TG, Fischbein MP, Girardi LN, Patel HJ, Bavaria JE, LeMaire SA. Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial. J Thorac Cardiovasc Surg 2024; 167:1680-1692.e2. [PMID: 36253292 DOI: 10.1016/j.jtcvs.2022.08.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta. METHODS For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality. RESULTS In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group. CONCLUSIONS One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Eric E Roselli
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - S Chris Malaisrie
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Allan Stewart
- East Florida Division, HCA Florida Healthcare, Fort Lauderdale, Fla
| | - Paul Stelzer
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, NY
| | - Hiroo Takayama
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Edward P Chen
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas, McGovern Medical Center, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Ibrahim M, Chung JCY, Ascaso M, Hage F, Chu MWA, Boodhwani M, Sheikh AA, Leroux E, Ouzounian M, Peterson MD. In-hospital thromboembolic complications after frozen elephant trunk aortic arch repair. J Thorac Cardiovasc Surg 2024; 167:1217-1226. [PMID: 36137836 DOI: 10.1016/j.jtcvs.2022.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic). METHODS A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed. RESULTS Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P < .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient. CONCLUSIONS Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.
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Affiliation(s)
- Marina Ibrahim
- Division of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Ascaso
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Azmat A Sheikh
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Emilie Leroux
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Shehab M, Wanhainen A, Tegler G, Mani K, Kuzniar M. In situ laser fenestration of the Thoraflex Hybrid frozen elephant trunk for emergent revascularization of the left subclavian artery and laser fenestration for spinal cord perfusion. J Vasc Surg Cases Innov Tech 2024; 10:101426. [PMID: 38375347 PMCID: PMC10875571 DOI: 10.1016/j.jvscit.2024.101426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024] Open
Abstract
In situ laser fenestration (ISLF) has emerged as a promising technique for emergent revascularization of the left subclavian artery in the case of thoracic endovascular aortic repair coverage, presenting excellent technical success rates in most studies. We describe a case of ISLF of the Thoraflex Hybrid frozen elephant trunk device to achieve immediate left subclavian artery revascularization. We demonstrate the feasibility and technical success of using ISLF in this setting, providing a less invasive alternative to conventional surgical revascularization when required.
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Affiliation(s)
- Maysam Shehab
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Gustaf Tegler
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Marek Kuzniar
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Cuko B, Pernot M, Busuttil O, Baudo M, Rosati F, Taymoor S, Modine T, Labrousse L. Frozen elephant trunk technique for aortic arch surgery: the Bordeaux University Hospital experience with Thoraflex hybrid prosthesis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:668-677. [PMID: 37335280 DOI: 10.23736/s0021-9509.23.12706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Aortic arch surgery still represents a challenge, and the frozen elephant trunk (FET) allows a one-step surgery for complex aortic diseases. The aim of the study was to analyze the results of patients undergoing FET procedure for aortic arch surgery at Bordeaux University Hospital. METHODS Patients undergoing FET procedure for multisegmented aortic arch pathologies were analyzed in this single-center retrospective study. Further subgroup analyses were performed according to the degree of urgency of the operation (elective versus emergent surgery) and cerebral protection technique: bilateral selective antegrade cerebral perfusion (B-SACP) versus the unilateral one (U-SACP), regardless of the degree of urgency. RESULTS From August 2018 to August 2022, 77 consecutive patients (64.1±9.9 years, 54 males) were enrolled: 43 (55.8%) for elective surgery and 34 (44.2%) in emergency. Technical success was 100%. 30-day mortality was 15.6% (N.=12, 7% elective vs. 26.5% emergent, P=0.043). Six (7.8%) non-disabling strokes occurred (1.9% B-SACP vs. 20% U-SACP, P=0.021). Median follow-up was 1.11 years (interquartile range, 0.62-2.07). The 1-year overall survival was 81.6±4.45%. The elective group showed a survival trend when compared to the emergency one (P=0.054). However, further examination at landmark analysis elective surgery showed a better survival trend compared to emergency surgery up to 1.78 years (P=0.034), after which significance was lost (P=0.521). CONCLUSIONS Thoraflex hybrid prosthesis for FET technique demonstrated feasibility and satisfactory short-term clinical outcomes, even in emergent settings. In our practice B-SACP seems to offer better protection and less neurological complications compared to U-SACP, nevertheless further analyses are warranted.
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Affiliation(s)
- Besart Cuko
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France -
| | - Mathieu Pernot
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Olivier Busuttil
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Massimo Baudo
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Fabrizio Rosati
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Saud Taymoor
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Thomas Modine
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Louis Labrousse
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
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Geragotellis A, Jubouri M, Al-Tawil M, Mohammed I, Bashir M, Hosseini S. The Fate of Conventional Elephant Trunk in the Frozen Elephant Trunk Era. AORTA (STAMFORD, CONN.) 2023; 11:174-190. [PMID: 38754437 PMCID: PMC11219132 DOI: 10.1055/s-0044-1786352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/08/2023] [Indexed: 05/18/2024]
Abstract
Conventional elephant trunk (cET) and frozen elephant trunk (FET) are two distinct approaches to the surgical treatment of thoracic aortic aneurysms and dissections. With the advent and growing uptake of endovascular technologies, FET is becoming increasingly popular for its potential to be performed as a single-stage operation with better aortic remodeling and less risk of graft kinking than the traditional two-stage cET procedure. However, FET has been associated with a higher risk of spinal cord ischemia and its use in patients with connective tissue disorder remains controversial. The current review aimed to reflect on recent evidence surrounding the application of cET and FET to different types of aortic pathology in both acute and elective settings. Another scope of this review was to compare the characteristics of the currently available FET commercial devices on the global market. Our findings highlight that when the pathology is confined to the proximal descending aorta, such as in Dsine, intervention is often single-staged and false lumen (FL) thrombosis is achieved with good effect. FET remains limited by spinal cord injury and applicability in patients with connective tissue disorder, although some groups have started to circumvent associated complications, likely due to growing surgical expertise. Many other aortic diseases do require second-stage intervention, and even in these cases, there appears to be lower in-hospital mortality when using FET over cET. This is possibly due to the higher rate of endovascular completion facilitated by the completed landing zones created during FET. FET is trending toward becoming the universal treatment modality for extending repair to the descending aorta.
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Affiliation(s)
| | | | | | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Department of Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, United Kingdom
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
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Koulouroudias M, Velissarios K, Kokotsakis J, Magouliotis DE, Tsipas P, Arjomandi Rad A, Viviano A, Kourliouros A, Athanasiou T. Sizing the Frozen Elephant Trunk Based on Aortic Pathology and the Importance of Pre-Operative Imaging. J Clin Med 2023; 12:6836. [PMID: 37959302 PMCID: PMC10649248 DOI: 10.3390/jcm12216836] [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: 08/13/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
The frozen elephant trunk is a formidable tool for the aortovascular surgeon. An appreciation of how to size the graft in different pathologies is key in achieving optimal results. Herein, we demonstrate worked examples of how imaging can be used to plan for a frozen elephant trunk and discuss the nuisances and uncertainties of sizing using three index cases: Type A aortic dissection, distal thoracic aortic aneurysm and chronic dissection.
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Affiliation(s)
- Marinos Koulouroudias
- Department of Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB, UK;
| | | | - John Kokotsakis
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Dimitrios E. Magouliotis
- Department of Cardiothoracic Surgery, Larissa General University Hospital, 41334 Larissa, Greece;
| | - Pantelis Tsipas
- Department of Cardiac Surgery, Evangelismos Hospital, 11527 Athens, Greece; (J.K.); (P.T.)
| | - Arian Arjomandi Rad
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Alessandro Viviano
- Department of Cardiac Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
| | - Antonios Kourliouros
- Department of Cardiac Surgery, Oxford University Hospitals, Oxford OX3 9DU, UK; (A.A.R.); (A.K.)
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London W2 1NY, UK
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Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
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