Early Outcomes of Three Total Arch Replacement Strategies for DeBakey Type I Aortic Dissection

Hybrid total arch replacement via ministernotomy for Stanford type A aortic dissection

Background

Type A aortic dissection (TAAD) is a cardiovascular emergency condition with high mortality rate. Hybrid total aortic arch replacement using endovascular graft for the descending aorta repair results in favorable outcomes and has been recommended as an alternative procedure for the higher-risk category patients. Our institution started applying the upper ministernotomy incision technique for the hybrid procedures back in 2018.

Methods

We collected patients who underwent hybrid total arch replacement (HTAR) via ministernotomy (96) and total arch replacement with frozen elephant trunk (TAR + FET) procedures (99), between 2018 and 2021. The baseline information, intraoperative and postoperative characteristics have been compared. Kaplan-Meier analysis was used for survival evaluation. Cox regression were applied to identify the independent predictor of mortality.

Results

The baseline characteristics between the two patient groups were compared and found similar, except that RBC counts were higher (p = 0.038) and the ascending aorta diameter was smaller (P = 0.019) in the "HTAR" group relative to the "TAR + FET" group. The cardiopulmonary bypass time (P < 0.001), the aortic cross clamp time (P < 0.001), the operation duration (P = .029), ICU (P = 0.037) and postoperative hospital stay (P = 0.002) were shorter in the "HTAR" group. The "HTAR" group exhibited also significantly lower levels of intraoperative transfusion (all <0.001) characteristics than the "TAR + FET" group. The hospital mortality and 1-year mortality revealed similar patterns in both groups.

Conclusion

HTAR via ministernotomy have similar short term prognosis, and also reduced the ICU and postoperative hospital stay. In all, The application of the ministernotomy technique in HTAR was safe and technically feasible and may benefit individual patients as well as hospitals in general.

Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique

The surgical management of acute and chronic complex diseases involving the aortic arch and the descending thoracic aorta remains challenging. Hybrid procedures associating total open arch replacement and stent-grafting of the proximal descending aorta were developed to allow a potential single-stage treatment, promote remodeling of the downstream aorta, and facilitate a potential second-stage thoracic endovascular aortic repair by providing an ideal landing zone. While these approaches initially used various homemade combinations of available conventional prostheses and stent-grafts, the so-called frozen elephant trunk technique emerged with the development of several custom-made hybrid prostheses. The aim of this study was to review the contemporary outcomes of this technique in the management of complex aortic diseases, with a special focus on procedural planning, organ protection and monitoring, refinements in surgical techniques, and long-term follow-up.

Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review

Background and Objective

Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery.

Methods

We conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported.

Key Content and Findings

Most studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure.

Conclusions

There is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.