Thoracoscopic Clipping of Intercostal Artery for Treatment of Type II Endoleak Following Frozen Elephant Trunk Procedure: Case Report

A 38-year-old man with history of Crawford extent I thoracoabdominal aneurysm and chronic type B1,10 aortic dissection underwent a hybrid repair using the frozen elephant trunk technique. The patient was followed up annually, and type II endoleak of the descending thoracic aorta was diagnosed, leading to negative aortic remodeling. The endoleak was managed by performing intercostal artery clipping using minimally invasive thoracoscopic technique under transesophageal echocardiography control. The computed tomography scan showed no endoleak and complete false-lumen thrombosis with positive remodeling in the distal aortic segments.

Preoperative assessment of the technical complexity of minimally invasive aortic root repair

BACKGROUND

The aim of this study was to assess predictors of technical complexity of minimally invasive aortic root repairs (MIARR) performed through J-shaped mini-sternotomies in patients with aortic root aneurysm.

METHODS

This study included 49 patients with aortic root aneurysm who underwent MIARR via an upper median J-shaped mini-sternotomy between January 2017 and April 2020. Preoperative high-resolution computed tomographic images synchronised with electrocardiography were mandatory for inclusion. Predictors of technical complexity were identified, and a scoring system was created. The correlation between technical complexity and intraoperative/postoperative parameters was explored.

RESULTS

There was a significant association between technical complexity and increased procedure time (Spearmen's ρ=-0.45, P=0.001), blood loss (Spearmen's ρ=-0.384, P=0.006), cardiopulmonary bypass time (Spearmen's ρ=-0.301, P=0.035), and postoperative bleeding (Spearmen's ρ=-0.265, P=0.066). The anatomical aorta-sternal relationship (distance of >22.1 mm in the axial plane between the midline of the sternotomy plane and the left coronary), distance between the sternal notch and the aortic valve annulus (>14.5 cm in the sagittal plane), distance between the skin and the left coronary artery (>9.53 cm in the axial plane), obesity (Body Mass Index >30), and-diameter at the brachiocephalic trunk level (>37 mm), were strongly associated with procedural complexity. Overall test accuracy was 75.5%, sensitivity was 73.1%, and specificity 78.3%. Finally, we created an online calculator that surgeons can use to determine the probability of a technically difficult of MIARR based on these factors.

CONCLUSIONS

This novel scoring system can be used to assess the technical complexity of minimally invasive aortic root repairs and to aid in preoperative planning.

A new dissection-specific hybrid stent graft for patients with DeBakey type I aortic dissection

OBJECTIVES

We present our first experience of using a new dissection-specific hybrid stent graft (SG) (the 'Soft Elephant Trunk') in the frozen elephant trunk technique, in patients with non-acute DeBakey type I aortic dissection.

METHODS

Between September 2016 and February 2021, patients with non-acute DeBakey type I aortic dissection underwent the frozen elephant trunk procedure at our centre using 3 SG types: group Z used stiff, distal Z-shaped nitinol SGs (E-Vita, Medtronic); group R used a stiff, ring-shaped nitinol SG (Thoraflex); and group S used a soft, distal dissection-specific SG. Predictors of distal SG-induced new entry were analysed. End points were hospital- and midterm-follow-up results.

RESULTS

The study comprised 109 patients with 46 (42.2%), 22 (20.2%) and 41 (37.6%) patients in groups Z, R and S, respectively. No significant differences were found in early outcomes. Freedom from distal SG-induced new entry was comparable in groups Z, R and S (68.9% vs 92.9% vs 100%, log-rank = 0.14). There was no significant difference in follow-up between the groups. Four-year survival rates were 80.44%, 71.59% and 95.06% in groups Z, R and S, respectively. On multivariable analysis, the presence of connective tissue disorders [hazard ratio (HR) = 5.62, P = 0.11] and SG diameter (HR = 1.37, P = 0.034) were strong predictors of distal SG-induced new entry.

CONCLUSIONS

Dissection-specific hybrid SG with a soft distal end is effective in patients with non-acute DeBakey type I aortic dissection. Compared to non-soft distal SGs, this can reduce the incidence of distal complications. Long-term outcomes are necessary to determine the potential advantages and disadvantages of the new prosthesis.

Single-stage total aortic replacement in patients with mega-aortic syndrome

BACKGROUND

Staged total aortic replacement (TAR) is standard for patients with mega-aortic syndrome (MAS) and severe comorbidities, but a single-stage approach may be better for younger and fit patients. This report described the mid-term results of this approach.

METHODS

We conducted a retrospective medical chart review of all MAS patients in our centre between May 2016 and December 2020 to analyze outcomes of single-stage TAR. Primary endpoints were mortality and major adverse postoperative events; secondary endpoints included aortic re-intervention, all complications, and survival.

RESULTS

Of 47 MAS patients, 13 (27.7%) received single-stage TAR from valve to bifurcation through thoracophrenolumbotomy using circulatory arrest, antegrade cerebral and visceral perfusion. Mean age was 40.1 ± 6.5 years. In-hospital mortality was 15.4%; two patients died on post-operative day (POD) 14 due to fatal stroke and POD 85 due to prosthesis infection. Mean intensive care stay was 7 (15) day, mean hospital stay was 27.5 ± 16.2 day. Stroke occurred in two patients with "shaggy" aortas (one fatal, one transient); paraplegia in one; temporary acute renal failure in two (15.4%), and respiratory failure in 4 (30.8%). There was no aortic re-intervention or further mortality during follow-up.

CONCLUSIONS

Total aortic replacement from valve to bifurcation is a safe approach for younger and fit patients with MAS and provides acceptable midterm outcomes in an experienced centre. Thoracoabdominal incision at fourth intercostal space with retroperitoneal approach of abdominal aorta provides satisfactory exposure for the thoracic aorta and TAA and minimizes surgical trauma in comparison with a combination of two surgical incision.