Total arch replacement in octogenarians and nonagenarians: A single-center 18-year experience

Predictors of Type 1a Endoleak After Hybrid Thoracic Endovascular Aortic Repair for Aortic Arch Diseases

BACKGROUND

This study analyzed the risk factors for type 1a endoleak after hybrid thoracic endovascular repair (TEVAR) for aortic arch diseases based on preoperative patient characteristics and multidetector computed tomography measurements.

METHODS AND RESULTS

In all, 213 patients who underwent proximal landing zone 1 and 2 hybrid TEVAR for aortic arch pathologies (zone 1, n=82 [38.5%]; zone 2, n=131 [61.5%]; median age 72 years) between May 2008 and February 2020 were enrolled in this study; the median follow-up period was 6.0 years. The rates of type 1a endoleak at 1, 3, 5, and 10 years were 1.4%, 1.4%, 4.1%, and 4.1%, respectively. Multivariate Cox proportional hazard regression analysis revealed that the angle of the aortic arch was a significant risk factor for type 1a endoleak (hazard ratio 1.08; 95% confidence interval 0.85-0.99; P=0.045). The estimated area under the curve in receiver operating characteristic curve analysis was 0.76, and the cut-off value of the aortic arch angle was 95°.

CONCLUSIONS

It is essential to prevent type 1a endoleak, the most severe complication of hybrid TEVAR. The risk factor for type 1a endoleak in this study was a sharper angle of the aortic arch (≤95°). For patients at high risk of type 1a endoleak, it is necessary to consider alternative procedures depending on a patient's surgical risk.

Investigation of risk factors and outcomes of aortic arch aneurysm repair in octogenarians

OBJECTIVE

We reviewed the treatment outcomes for aortic arch aneurysms in elderly patients aged > 80 years, and discussed the risk factors for each technique.

METHODS

Octogenarians who underwent aortic arch aneurysm repair between 2007 and 2021 were included. Fifty-four patients (23 in the total arch replacement [TAR] group and 31 in the thoracic endovascular aortic repair [TEVAR] group) were included in the study. The early- and mid-term outcomes and risk factors for all-cause mortality were examined in each group. To examine timely surgical outcomes, cases of true aneurysms were included, whereas dissected aneurysms and emergency cases due to rupture or other causes were excluded.

RESULTS

No significant differences in 30-day mortality (0% in the TAR group and 5.4% in the TEVAR group) and in-hospital mortality (7.7% in the TAR group and 8.1% in the TEVAR group) were observed between the two groups. The survival rates at 5 years were 82% and 65% in the TAR and TEVAR groups, respectively, without significant difference. The aorta-related averted mortality was 91% and 81% in the TAR and TEVAR groups, respectively, without significant difference. No significant difference in the freedom from aortic events was also observed between the two groups. Previous ischemic heart disease was a significant risk factor for all-cause mortality in the TAR group. No significant risk factors were identified in this group.

CONCLUSION

The choice of procedure was reasonable when considering frailty. Endovascular repair may be a good treatment option for patients with a history of ischemic heart disease.

Outcomes of Total Aortic Arch Replacement in a Canadian Nationwide Registry

BACKGROUND

Accurate benchmarking of outcomes after elective open total arch replacement is important for surgical decision making and for comparisons with emerging endovascular technologies.

METHODS

A multicentre registry of consecutive aortic arch procedures in 9 centres across Canada contained 250 elective total arch replacements from 2010 to 2021. A total of 728 patients undergoing elective hemiarch replacement over the same time period was used as a comparator group. Propensity score matching was used to construct 202 well matched pairs.

RESULTS

Patients undergoing total arch replacement were 63.2 ± 13.6 years old, and 34% were female. These patients were more likely to have connective tissue disorders compared with patients undergoing hemiarch replacement. When under hypothermic circulatory arrest, the total arch group uniformly used antegrade cerebral perfusion with median nadir temperature of 24°C (interquartile range [IQR] 21-25°C), and median duration 33 minutes (IQR 23-51 minutes). Before matching, in-hospital mortality and stroke rates were 5.2% and 10%, respectively, for the total arch group. After matching, the total arch group had in-hospital mortality similar to the hemiarch group (P = 0.58). Rates of stroke were also not statistically different (P = 0.11). The total arch group was more likely to experience delirium, prolonged intubation, increased intensive care unit length of stay, and transfusions.

CONCLUSIONS

Elective total arch replacement is performed with good in-hospital mortality rates that are similar to rates after elective hemiarch repairs. However, total arch replacement was associated with significantly higher rates of other morbidities, including delirium and prolonged intubation.

Factors associated with postsurgical muscle weakness in patients who undergo thoracic aortic surgery: a retrospective cohort study

OBJECTIVE

Aortic surgery is often performed in elderly patients, and these patients have a high risk of postsurgical muscle weakness. To reinforce purposeful postsurgical rehabilitation, we aimed to investigate the factors associated with postsurgical muscle weakness in patients who underwent thoracic aortic surgery.

METHODS

This retrospective cohort study analyzed data of consecutive patients who underwent elective thoracic aortic surgery with cardiopulmonary bypass, and whose knee extensor isometric muscle strength (KEIS) were measured pre- and postoperatively at University Hospital between January 2012 and December 2018. The primary outcome was percent change in KEIS (% change in KEIS). Multivariate linear regression analysis was used to identify independent risk factors for % change in KEIS.

RESULTS

Overall, 218 patients were included. Multivariate linear regression analysis showed that mechanical ventilation time, days from initial sitting to 100 m walking, and the number of exercises in the rehabilitation room were associated with % change in KEIS.

CONCLUSIONS

This study may serve as a reference to stratify patients at risk of postsurgical muscle weakness. The preventive or alternative interventions in patients undergoing thoracic aortic surgery will be assessed in future studies.

Assessment of the Effectiveness of Zone 1-Landing Hybrid TEVAR by Comparing Its Outcomes with Those of Zone 2-Landing Hybrid TEVAR

Background: Hybrid thoracic endovascular aortic repair (TEVAR) without median sternotomy is increasingly being performed in high-risk patients with aortic arch disease. The outcomes of hybrid TEVAR were reported to be worse with a more proximal landing zone. This study aims to clarify the effectiveness of zone 1-landing hybrid TEVAR by comparing the outcomes of zone 2-landing hybrid TEVAR. Methods: From April 2008 to October 2020, 213 patients (zone 1: zone 1-landing hybrid TEVAR, n = 82, 38.5%; zone 2: zone 2-landing hybrid TEVAR, n = 131, 61.5%) were enrolled (median age, 72 years; interquartile range [IQR], 65-78 years), with a median follow-up period of 6.0 years (IQR, 2.8-9.7 years). Results: The mean logistic EuroSCORE was 20.9 ± 14.8%: the logistic EuroSCORE of the zone 1 group (23.3 ± 16.1) was significantly higher than that of the zone 2 group (19.3 ± 12.4%, p = 0.045). The operative time and hospital stay of the zone 1 group were significantly longer than those of the zone 2 group. On the other hand, the in-hospital and late outcomes did not differ significantly between the two groups. There were no significant differences in cumulative survival (66.8% vs. 78.0% at 10 years, Log-rank p = 0.074), aorta-related death-free rates (97.6% vs. 99.2% at 10 years, Log-rank p = 0.312), and aortic event-free rates (81.4% vs. 87.9% at 10 years, Log-rank p = 0.257). Conclusions: Zone 1- and 2-landing hybrid TEVAR outcomes were satisfactory. Despite the high procedural difficulty and surgical risk, the outcomes of zone 1-landing hybrid TEVAR were equal to those of zone 2-landing hybrid TEVAR. If the surgical risk is high, zone 1-landing hybrid TEVAR should not be avoided.

Early and Midterm Outcomes of Type II Hybrid Arch Repair for Complex Aortic Arch Pathology

Background

The hybrid arch repair (HAR) is an appealing surgical option in the management of aortic arch diseases. The aim is to evaluate the short and mid-term outcomes of type II HAR involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment in diverse arch pathologies.

Methods

200 patients with various diffuse aortic pathologies involving the arch were enrolled between 2016 and 2019. Complex arch diseases included acute type A dissection (n = 129, 64.5%), acute type B dissection (n = 16, 8.0%), aortic arch aneurysm (n = 42, 21.0%) and penetrating arch ulcer (n = 13, 6.5%). Mortality, morbidity, survival and re-intervention were analyzed.

Results

The overall 30-day mortality rate was 8.0% (16/200). Stroke was present in 3.5% (7/200) of the general cohort and spinal cord injury was occurred in 3.0% (6/200). Multivariable logistic analysis showed that cardiac malperfusion and CPB time were the risk factors associated with 30-day mortality. The mean follow-up duration was 25.9 months (range 1–57.2 months), and the 3-year survival rate was 83.1%. On Cox regression analysis, age, diabetes, cardiac malperfusion and CPB time predicted short and mid-term overall mortality. A total of 3 patients required reintervention during the follow-up due to the thrombosis of epiaortic artificial vessels (n = 1), anastomotic leak at the site of the proximal ascending aorta (n = 1) and the type I endoleak (n = 1).

Conclusions

Type II HAR was performed with satisfactory early and mid-term outcomes in complex aortic arch pathologies.

Impact of frailty on early and mid-term outcomes of hybrid aortic arch repair

PURPOSE

The purpose of this study was to investigate the impact of frailty on the clinical outcomes of hybrid aortic arch repair with debranching of the supra-aortic arteries.

METHODS

Consecutive patients ≥ 75 years old who underwent hybrid aortic arch repair from January 2010 to December 2019 were retrospectively analyzed. Using the Canadian Study of Health and Aging (CSHA) scale, all patients with a CSHA scale score > 4 were defined as frail. The frail patients (FP) group and the non-frail patients (NFP) group were compared regarding the early and mid-term outcomes of hybrid aortic arch repair.

RESULTS

A total of 84 patients were included. The early postoperative results were not markedly different between the groups, except that the rate of transfer to a rehabilitation hospital was higher in the FP group than in the NFP group. The survival at 5 years was significantly lower in the FP group at 43.0% than in the NFP group at 67.7% (P = 0.015). However, the freedom from aorta-related death was not significantly different between the two groups.

CONCLUSION

Frailty did not affect the short-term outcomes of hybrid aortic arch repair; however, the mid-term outcomes, including the survival, of the frail patients were significantly worse than those of the non-frail patients, mostly because of non-aorta-related causes.

Is total aortic arch replacement with the frozen elephant trunk procedure reasonable in elderly patients?

OBJECTIVES

Total aortic arch replacement is an invasive procedure with significant risks for complications. These risks are even higher in older, multimorbid patients. The current trends in demographic changes in western countries with an ageing population will aggravate this issue. In this study, we present our experience with total aortic arch replacement using the frozen elephant trunk (FET) technique in septuagenarians. We compared the results of septuagenarians with those of younger patients and analysed if there was an improvement in outcome over time.

METHODS

Between August 2001 and March 2020, 225 patients underwent non-urgent FET procedure at our institution. There were 75 patients aged ≥70 years (mean age 74 ± 4) who were assigned to group A, and 150 patients aged <70 years (mean age of 57 ± 11) who were assigned to group B. In groups A and B, the indications for surgery were chronic dissection (21% vs 53%), aortic aneurysm (78% vs 45%) and penetrating atherosclerotic ulcer (1% vs 2%).

RESULTS

The rate for temporary dialysis was significantly higher in group A than in group B (29% vs 13%, P = 0.003), although the majority recovered kidney function. Rates for re-exploration for bleeding and stroke were comparable in both groups. In-hospital mortality was significantly higher in group A than in group B (24% vs 13%, P = 0.037). Logistic regression analysis showed that age >70 years was an independent statistically significant risk factor for in-hospital mortality (odds ratio = 2.513, 95% confidence interval = 1.197-5.278, P-value = 0.015). Follow-up was complete for 100% of patients and comprised a total of 1073 patient-years with a mean follow-up time of 4.8 ± 4.5 years. The 1- and 5-year survival rates were 68% and 49% in group A, and 85% and 71% in group B, respectively (log rank, P < 0.001). Survival did not significantly improve over time.

DISCUSSION

Total aortic arch replacement using the FET technique has a significantly higher risk for perioperative morbidity and mortality in septuagenarians than in younger patients. Long-term survival is significantly impaired in older patients. We recommend thorough patient selection of those who require total aortic arch replacement, and optimization of perioperative management to improve outcomes.

Beating-heart total arch replacement for an octogenarian patient with severe heart failure

Surgical outcomes of total arch replacement (TAR) have improved dramatically over the last decades. However, patients of advanced age and with a severely reduced cardiac function and an extended aortic arch aneurysm may not be candidates for conventional TAR. Endovascular and hybrid treatment for extended aortic aneurysm have demonstrated lower mortality and morbidity, and considered for the advanced age and high-risk patients. But endovascular with total de-branching technique remains challenging with the slightly dilated ascending aorta. Reducing the operation time, cardiac arrest time, and circulatory arrest time should be needed to resolve the problem for the conventional TAR with an advanced age and a severely reduced cardiac function. We herein introduce our surgical technique for the case of an 84-year-old man with a severely reduced cardiac function, who was successfully treated with beating heart TAR with minimization of the operation time, cardiac arrest time, and circulatory arrest time.

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.