Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

OBJECTIVE

We compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention.

METHODS

Nine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed.

RESULTS

Mean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10).

CONCLUSIONS

Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.

Hybrid management of type B aortic dissection in a patient with right-sided aortic arch and aberrant left subclavian artery

This report describes a patient with a right-sided aortic arch, aberrant left subclavian artery and Kommerell diverticulum, who presented with aneurysmal degeneration of the aortic root to the descending aorta, in addition to an acute type B2-10 aortic dissection. He underwent hybrid treatment with a valve-sparing aortic root replacement, transverse arch replacement with reattachment of the right subclavian artery, bilateral common carotid arteries, and thoracic endovascular aneurysm repair with left subclavian artery embolization and a left common carotid to subclavian artery bypass.

(s)INE: (soft-graft)-induced new entry tear after elephant trunk procedure

Elephant trunk and frozen elephant trunk are established procedures for the treatment of aortic arch pathologies, such as aneurysm or dissection. The aim of open surgery is to re-expand the true lumen, favouring correct organ perfusion and the thrombosis of the false lumen. Frozen elephant trunk, with its stented endovascular portion, is sometimes associated with a life-threatening complication: the stent graft-induced new entry. In the literature, many studies reported the incidence of such issue after thoracic endovascular prosthesis or frozen elephant trunk, but in our knowledge, there are no case studies about the occurrence of stent graft-induced new entry with the use of soft grafts. For this reason, we decided to report our experience, highlighting how the use of a Dacron graft can cause distal intimal tears. We decided to coin the term soft-graft-induced new entry to indicate the development of an intimal tear induced by the soft prosthesis in the arch and proximal descending aorta.

Diameter change in completely remodelled proximal descending aorta after acute type I dissection repair: implications for estimating the pre-dissection size

 

OBJECTIVES

Pre-dissection diameter of the proximal descending thoracic aorta (p-DTA), if available, would be the reference for determining the size of the stent graft or elephant trunk. Acute type B dissection is known to increase p-DTA diameter by 23% (Rylski factor). This study aimed to investigate the accuracy of estimating post-remodelling diameter of the p-DTA based on the Rylski factor and other post-dissection morphological parameters in acute type I dissection, based on the assumption that the post-remodelling diameter is similar to the pre-dissection diameter.

METHODS

In 60 patients with acute type I dissection showing complete remodelling of the p-DTA false lumen after surgical repair, preoperative and post-remodelling computed tomography scans were reviewed. Parameters, including maximal true lumen diameter (TLDmax) and aortic area-derived diameter divided by the Rylski factor (AoDRylski), were measured at the p-DTA.

RESULTS

After complete remodelling, p-DTA diameter decreased by 4.1 mm (P < 0.001). The equivalent to the Rylski factor was 15%. Both TLDmax and AoDRylski frequently showed ≥2 mm discrepancy from post-remodelling aortic diameter (36.7% and 48.3%, respectively, P = 0.30). When 2 parameters coincided within 2 mm, two-third of their estimations were accurate. AoDRylski was more accurate than TLDmax in patients with a large extent of circumferential dissection, and vice versa with less circumferential dissection (P = 0.027).

CONCLUSIONS

Prediction of post-remodelling aortic diameter relying on a single morphologic parameter carries a substantial risk of overestimation and underestimation. Evaluation based on the extent of circumferential dissection together with the 2 parameters may provide a more reliable estimation.

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome

OBJECTIVE

The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome.

METHODS

We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability.

RESULTS

Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A₁₁, two A₁₀, one A₉) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach.

CONCLUSIONS

A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.

Snare-assisted thoracic endovascular aortic repair for redirection of a false lumen elephant trunk

In recent years, a hybrid approach to the classic two-stage elephant trunk technique has come into favor for treatment of thoracic aortic dissection. During the first stage, inadvertent intraoperative placement of the elephant trunk into the false lumen can occur on rare occasions, resulting in untoward difficulties during the second stage of the procedure. We describe here a snare-assisted technique for endovascular salvage of an elephant trunk that had inadvertently been placed in the false lumen of a chronic aortic dissection.

Perigraft abscess after DeBakey type-1 aortic dissection: a case report

Background

Perigraft abscess is a rare condition which constitutes a small proportion of aortic graft infection (AGI). Early diagnosis is very important for timely intervention and improving the survival rate of patients because of its significant morbidity and mortality.

Case presentation

A 24-year-old young male patient with a history of complicated total arch replacement using elephant trunk technique for acute DeBakey type-1 aortic dissection 6 months before visited our hospital with the chief complaint of persistent fever. Antibiotic treatment in local hospital was ineffective. Echocardiography showed liquid dark area around the aortic graft, and a computerized tomography angiography (CTA) was done for further evaluation of periaortic fluid collection which showed findings to suggest perigraft abscess. The patient underwent surgical debridement of the abscess and was found to have an abscess around the aortic graft which was drained followed by antibiotic treatment. The patient was discharged to his local hospital and recovered well at 2 month follow-up appointment.

Conclusion

This is a very rare case of aortic abscess around the graft that could successfully be managed by graft-conserving surgery, and it emphasizes the significance of early diagnosis of perigraft abscess in patients with aortic dissection surgery.

Endovascular septal fenestration using a radiofrequency wire to salvage inadvertent false lumen deployment of a frozen elephant trunk stent graft

We report a case of a frozen elephant trunk arch repair, where the stent graft was unintentionally placed into the false lumen. Postoperative imaging demonstrated an enlarged false lumen with no thoracic aorta fenestrations that could be traversed to place another thoracic endovascular aortic repair endograft into the true lumen. An atraumatic radiofrequency wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) was used to create a new septal fenestration, enabling thoracic endovascular aortic repair endograft extension into the thoracic true lumen. This novel use of a radiofrequency wire can enable safe and controlled endovascular septal fenestration even in chronic dissections to redirect flow into the true lumen.

Repair of a type B aortic dissection with a re-vascularization of the aberrant right subclavian artery in an adult patient

Background

An aberrant right subclavian artery which arises from the proximal descending aorta may result in aortic dissection. The dissection may occur at either the site of the primary intimal tear or from an aortic branch. These conditions may lead to blood flow limitation and possible aneurysmal degeneration in the future.

Case presentation

We described the clinical presentation and management of a 54-year old patient diagnosed with a rare case of an aberrant right subclavian artery with Stanford Type B aortic dissection. A hybrid surgical approach was successfully performed and the patient had an uneventful recovery.

Conclusion

Even though aortic dissection is often an incidental finding, this case highlighted that in rare situations, it can be associated with an aberrant right subclavian artery. It is important to disseminate this association as it has profound diagnostic and therapeutic implications in safeguarding the clinical outcomes of patients with such condition.

Aortic Cannulation in DeBakey Type I Aortic Dissection Facilitates Subsequent Deployment of a Frozen Elephant Trunk

Arterial cannulation in acute DeBakey type I dissection can be difficult. Moreover, the residual dissected aorta is susceptible to further adverse events in the future. Implanting a stent-graft into the descending aorta during the initial dissection repair ('frozen elephant trunk') has been demonstrated to promote favourable aortic remodelling, mitigating some of these longer-term complications. We describe a technique for cannulation of the ascending aorta in acute dissection that facilitates expeditious antegrade deployment of a frozen elephant trunk.

Dilated cardiomyopathy associated with elephant trunk in Loeys-Dietz syndrome

A 14-year-old boy presented to our institution with a diagnosis of acute type A dissection. He was diagnosed with Loeys-Dietz syndrome and underwent aortic valve sparing repair at the age of 9 years. Emergency total arch repair with elephant trunk (ET) was performed successfully; echocardiogram before discharge showed normal left ventricular function and size. However, he was readmitted 1 month after discharge with significant left ventricular dysfunction and dilatation. The small folded ET caused a pressure gradient between the upper and lower body, which might deteriorate left ventricular function. Urgent balloon arterioplasty was performed to unfold the ET graft, resulting in no improvement of left ventricular function. ET removal and descending aorta replacement with an 18-mm graft was performed eventually. Left ventricular function and brain natriuretic peptide gradually improved after approximately 2 years of follow-up.

Multiple organ embolization with vegetation on an elephant trunk graft

We encountered a rare case of infection in a vascular graft created using the elephant trunk technique. A 65-year-old woman who underwent total arch replacement with the elephant trunk technique was re-admitted with fever. She developed embolization of multiple organs from vegetation attached to the elephant trunk graft which was elucidated by transesophageal echocardiography. Surgery for ruptured jejunal artery aneurysm was performed, and the graft infection healed after long-term antibiotic therapy with the prosthesis left in situ. Graft infection may generate vegetations on an elephant trunk graft. Transesophageal echocardiography is a helpful tool for accurate diagnosis.