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Saeyeldin A, Gryaznov AA, Zafar MA, Wu J, Mukherjee S, Vallabhajosyula P, Ziganshin BA, Elefteriades JA. Interstage mortality in two-stage elephant trunk surgery. J Card Surg 2021; 36:1882-1891. [PMID: 33634489 DOI: 10.1111/jocs.15441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/01/2020] [Accepted: 12/26/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA. METHODS Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long-term, with no plan for near-term utilization). RESULTS In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30-day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. CONCLUSIONS The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two-staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two-Stage approach to the management of extensive TAA.
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Affiliation(s)
- Ayman Saeyeldin
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine, Saint Mary's Hospital, Waterbury, Connecticut, USA.,Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Anton A Gryaznov
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jinlin Wu
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sandip Mukherjee
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA
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Abdelbaky M, Papanikolaou D, Zafar MA, Ellauzi H, Shaikh M, Ziganshin BA, Elefteriades JA. Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair. JTCVS Tech 2021; 6:1-8. [PMID: 34318127 PMCID: PMC8300913 DOI: 10.1016/j.xjtc.2020.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Objective We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair. Methods We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure <10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen. Results The mean patient age was 65.4 ± 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 ± 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFD-related complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Long-term survival was excellent (68.4% at 10 years). Conclusions CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results.
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Affiliation(s)
- Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Hesham Ellauzi
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Maryam Shaikh
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Address for reprints: John A. Elefteriades, MD, PhD (hon), Aortic Institute at Yale-New Haven, Yale University School of Medicine, 789 Howard Ave, Clinic Building CB 317, New Haven, CT 06519.
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