Double-branched stent graft and four-stage deployment in total arch repair: safety and feasibility evaluation in porcine models

OBJECTIVES

The primary objective of this research was to evaluate the safety and feasibility of an innovative double-branched stent graft system employing four-stage deployment technology for aortic arch repair in porcine models.

METHODS

The double-branched stent graft system consisted of a proximal polyester artificial blood vessel, the main and double-branched stent grafts and a delivery system. We utilized 12 healthy pigs as experimental animals (6 per group). Postimplantation, samples were collected at 90 and 180 days after the operations. Preoperative and postoperative imaging and intraoperative arterial blood gas analyses were performed. After the pigs were euthanized, the implanted product, surrounding tissue and major organs were collected for pathological analysis.

RESULTS

The technical success rate of the stent graft implants was 100% (12/12). All animals survived to the experimental end point. Perioperative assessments showed intact stent grafts, and imaging features at the end of the follow-up period revealed neither endoleak nor device migration. No major adverse cardiovascular events were observed during the postoperative follow-up period. Pathological examinations confirmed the satisfactory biocompatibility of the stent graft.

CONCLUSIONS

This innovative double-branched stent graft system with four-stage deployment technology was affirmed as a safe and feasible option for aortic arch repair in accordance with our preclinical evaluation with porcine models.

Perfusion management of arch-clamping technique in total arch replacement with frozen elephant trunk

A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective.

Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis

INTRODUCTION

The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET.

EVIDENCE ACQUISITION

In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET.

EVIDENCE SYNTHESIS

Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I²=76%) and 12% for renal failure (95% CI 0.09-0.15; I²=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I²=0%) and 6% (95% CI 0.05-0.08; I²=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I²=0%).

CONCLUSIONS

Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.

Kinking of Frozen Elephant Trunk Hybrid Prostheses: Incidence, Mechanism, and Management

Introduction

Kinking of the Frozen Elephant Trunk (FET) stent graft is one of the most devastating complications of the FET procedure. It can present post-operatively with reduced arterial pressures in the lower limbs and intermittent claudication. However, it can also be visualized intra-operatively by the surgeons. Unresolved kinking of the stent graft can result in intraluminal thrombus formation and subsequent multi-organ septic emboli.

Aims

The main scope of this review is to collate, summarize and present all the evidence in the literature on kinking of FET stent grafts.

Methods

We carried out a comprehensive literature search on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the incidence, mechanism, and management of FET graft kinking.

Results

Incidence of kinking is variable, ranging from 0% to 8% in the literature, with varying rates associated with each stent graft type. The Thoraflex Hybrid^TM prosthesis seemed to be the most commonly used and superior graft, and out of all the 15 cases of kinking reported in the literature, 5 (33.3%) were associated with just the Frozenix graft which had the highest incidence. There are multiple theories regarding the mechanism of kinking, including the direction of blood flow, the length of the stent grafts used, and the position of the prosthesis in relation to the flexure of the aorta. Multiple reparative management techniques have been suggested in the literature and include total endovascular repair, open repair, balloon dilatation, and deploying a second stent graft.

Conclusion

Graft kinking is one of the most critical complications of the FET technique. Its life-threatening sequelae warrant appropriate follow-up of these patients post-operatively, in addition to time management if kinking is suspected. Given the limited evidence in the literature, future studies should incorporate graft kinking into their outcomes reporting.

Extensive Arch Repair with a Novel Two-Branched Stent Graft in Acute Type A Aortic Dissection

Purpose: In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.

Methods: Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).

Results: The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.

Conclusion: Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.

Hypothermic circulatory arrest time affects neurological outcomes of frozen elephant trunk for acute type A aortic dissection: A systematic review and meta-analysis

BACKGROUND

The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes.

METHODS

A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA).

RESULTS

Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 - 9; I²  = 68.65%), 5% (95% CI 4 - 7; I²  = 63.93%), and 3% (95% CI 2 - 4; I²  = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances.

CONCLUSIONS

It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.

Novel hybrid treatment for extensive aortic arch aneurysms, a case report

BACKGROUND

The treatment for extensive aortic arch aneurysms involving the aortic arch and descending aorta is challenging for most cardiovascular surgeons. The surgical treatment is associated with a very high mortality rate. The optimal treatment has not been defined.

CASE PRESENTATION

A 49-year-old male was hospitalized due to chest and upper back pain. Computed tomography angiography (CTA) demonstrated there was an extensive aortic arch aneurysm extending to the left common carotid artery and descending aorta. A novel single- stage hybrid surgery was performed on the patient through two steps: treatment of the aortic arch through median sternotomy and thoracic endovascular artery repair. The patient recovered uneventfully.

CONCLUSIONS

Our single-stage hybrid repair approach is safe, simple and effective. It provides an alternative treatment for extensive aortic arch aneurysms.

Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization

BACKGROUND AND AIM OF THE STUDY

The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta-analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization.

METHODS

We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR).

RESULTS

A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in-hospital mortality were 7.104 (95% confidence interval [CI], 5.691-8.661; I²  = 78.53%), 3.465 (95% CI, 2.852-4.136; I²  = 15.96), 14.969 (95% CI, 11.361-18.977; I²  = 91.26%), and 8.933 (95% CI, 7.128-10.919; I²  = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36-0.81; p = .003; I²  = 0%).

CONCLUSIONS

The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

Elephant Trunk Stent Fenestration for Acute Type A Aortic Dissection

BACKGROUND

This study investigated the clinical outcomes of elephant trunk stent fenestration in patients with acute type A aortic dissection (ATAAD).

METHODS

From January 2009 to December 2019, 271 ATAAD patients were treated in the Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University. Patients underwent deep hypothermia circulatory arrest with bilateral antegrade cerebral perfusion with total arch replacement and elephant trunk stent fenestration. Patient characteristics, perioperative findings, and follow-up results were analyzed retrospectively.

RESULTS

The average in-hospital mortality rate was 4.1%, the cardiopulmonary bypass time was 160.8 ± 60.4 minutes, the cross-clamp time was 91.1 ± 24.5 minutes, and the circulatory arrest time was 22.8 ± 5.5 minutes. The rate of reoperation for bleeding was 1.5%, and the pericardial mediastinal drainage volume was 312.0 ± 159.2 mL 24 hours after surgery. Follow-up data were available for 95.4% of patients. Endoleaks developed in 2 patients 3 years after surgery. The postoperative survival rate was 93.0% at 1 year, 89.3% at 5 years, and 81.7% at 10 years.

CONCLUSIONS

Elephant trunk stent fenestration can simplify reconstruction of the left subclavian artery in ATAAD patients and reduce surgical difficulty. Because the early postoperative outcomes and long-term results were satisfactory in our sample, this technique should be promoted for some patients with ATAAD.

A New Aortic Arch Inclusion Technique with Frozen Elephant Trunk for Aortic Arch Aneurysm Treatment

Various surgical techniques have been proposed for treating aortic arch aneurysm (AAA); however, the optimal treatment has not been well defined. This study introduces a new aortic arch inclusion technique with frozen elephant trunk (FET) for AAA treatment.A retrospective analysis was performed among 22 patients for AAA surgical treatment between March 2010 and March 2019. Patients were classified into Z1, Z2, and Z3 groups based on the origins of aneurysms. A stent graft with a 10 cm stented graft and 5-9 cm proximal vascular prosthesis was released into the descending thoracic aorta as FET through an incision in the aortic arch. The proximal vascular prosthesis was retracted into the aortic arch, trimmed to expose the orifices of the brachiocephalic vessels, and sutured inside the aortic arch using the inclusion technique. The proximal sealing location of the vascular graft was tailored to cover the origins of aneurysms.There was no 30-day mortality. No patient had postoperative stroke or paraplegia. Complete aneurysm thrombosis was achieved in all patients. One patient died of severe respiratory tract stenosis 3 months postoperatively. All other 21 patients were alive during 53.3 ± 36.5-month follow-up. Computed tomography angiography was obtained in 15 patients during follow-up. Endoleak was observed in one patient, and the other 14 patients were free from aneurysm-related or graft-related complications during follow-up.The aortic arch inclusion technique with FET provides an alternative technique in treating AAA with satisfactory mid-term follow-up results. A larger patient population with long-term follow-up results is warranted.

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Aortic remodeling in acute type A aortic dissection after frozen elephant trunk implantation

Survivors at first intervention after acute type A aortic dissection often necessitate additional interventions to avoid dilation and rupture of the remaining thoraco-abdominal aorta. During the first-stage arch procedure, the attempt to treat the descending thoracic aorta with a stent graft could attenuate this phenomenon and reduce the need for further open or endovascular reinterventions. In this short review article, the frozen elephant trunk technique was tested as influencing factor of aortic remodeling during follow-up analysis. Late results from the identified studies suggested promising rates of false lumen thrombosis of the descending thoracic aorta (78-100%), suggesting that aortic remodeling is highly probable with this approach. However, a longer surveillance of the aortic diameters is still necessary to confirm this initial hypothesis.

The frozen elephant trunk surgery: a systematic review analysis

The frozen elephant trunk might be considered one of the most appreciated innovations during the last decades to treat complex thoracic aortic lesions. Many useful tips have been progressively introduced to standardize the procedures and, nowadays, the improved post-operative outcomes contributed to spread the procedure. The following article will provide a comprehensive review analysis of the Frozen Elephant Trunk (FET) technique, throughout the current available devices, possible surgical indications and primary post-operative complications.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background

Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods

From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results

In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions

Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

Aortic Arch. The Final Frontier in Cardiac Surgery

Aortic arch pathologies such as acute aortic dissection and aneurysmal disease represent surgical challenges. Various emerging techniques and surgical prostheses have expanded the therapeutic armamentarium over the last years with one principal objective; to simplify the operation and reduce the surgical time. Besides the classic elephant trunk which has been regarded as an evolutionary leap in the treatment of extensive thoracic disease, other novel surgical approaches such as the frozen elephant trunk, the thoracic endovascular aortic repair (TEVAR) and the hybrid open branched stent grafts have been introduced. This brief review aims to evaluate the surgical alternatives used in the management of complex aortic arch and proximal descending aorta pathologies with particular consideration given to the contemporary approaches which endorse single stage operation.

Classification and outcomes of extended arch repair for acute Type A aortic dissection: a systematic review and meta-analysis

Objectives

Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation.

Methods

Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated.

Results

Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05).

Conclusions

Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.

Serum D-dimer is a potential predictor for thromboembolism complications in patients with renal biopsy

Renal biopsy has been widely recommended in clinic to determine the histological patterns of kidney disease. To prevent bleeding complications, patients should routinely stop anticoagulants prior to renal biopsy. However, patients with kidney disease are susceptible to thromboembolisms, particularly in those with severe hypoalbuminemia. This study was designed to investigate the application of serum D-dimer as a predictor for thrombotic events after renal biopsy. 400 consecutive native renal biopsies were prospectively included in this 2-month follow-up study. The overall incidence of bleeding and thrombotic complication is 4%, including hematuria or large perinephric hematoma (2.5%, n = 10) and thrombotic complication (1.5%, n = 6). Compared to low serum D-dimer (<2.00 μg/ml), subjects in the group of high serum D-dimer (≥2.00 μg/ml) were more incline to develop thrombotic complications (9.1% versus 0.3%; RR, 30.33; p < 0.001). D-dimer correlated positively with age (r_s = 0.258, P < 0.001). Inverse correlations were found for albumin (r_s = −0.339, P < 0.001). Taken together, patients with high serum D-dimer carry an increased risk of thrombotic complications after renal biopsy. Our findings suggest that serum D-dimer can serve as a potential predictor for thrombotic events in patients with kidney disease. Further cautions should be given to these subjects.

Ascending Aorta and Hemiarch Replacement Combined With Modified Triple-Branched Stent Graft Implantation for Repair of Acute DeBakey Type I Aortic Dissection

BACKGROUND

To simplify extensive repair of acute DeBakey type I aortic dissection, ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation was developed. The descriptions and early results of this technique are reported.

METHODS

From August 2014 to September 2015, 116 patients with acute DeBakey type I aortic dissection underwent ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation. Clinical data of all patients were retrospectively reviewed. Survivors were followed up prospectively by computed tomography angiography.

RESULTS

The cardiopulmonary bypass time was 131.5 ± 10.7 minutes, the aortic cross-clamp time was 50.0 ± 9.9 minutes, and the selective cerebral perfusion and lower body arrest time was 17.2 ± 2.2 minutes. The in-hospital mortality rate was 3.4%. Two patients were lost during follow-up. One patient died of a cerebrovascular accident 2 months after discharge, and another died of chronic renal failure 5 months after discharge. At the 3-month postoperative scans, complete thrombus formation of the false lumen around the implanted modified triple-branched stent graft occurred in all survivors, at the diaphragmatic level in 69.7% patients, and at the superior mesenteric arterial level in 8.3% patients.

CONCLUSIONS

Extensive thoracic aorta repair of acute type I aortic dissection can be performed simply by combining ascending aorta and hemiarch replacement with modified triple-branched stent graft implantation. This technique can reduce the risk and technical difficulty of extensive thoracic aorta repair to levels close to those seen with ascending aorta and hemiarch graft replacement with open distal anastomosis.

A Meta-Analysis of Total Arch Replacement With Frozen Elephant Trunk in Acute Type A Aortic Dissection

Objectives:

To assess the safety and efficacy, we performed a meta-analysis of total arch replacement with frozen elephant trunk in exclusive acute type A (neither chronic nor type B) aortic dissection.

Methods:

Databases including MEDLINE and EMBASE were searched through March 2015 using Web-based search engines (PubMed and OVID). Eligible studies were case series of frozen elephant trunk enrolling patients with acute type A (neither chronic nor type B) aortic dissection reporting at least early (in-hospital or 30-day) all-cause mortality. Study-specific estimates were combined in both fixed- and random-effect models.

Results:

Fifteen studies enrolling 1279 patients were identified and included. Pooled analyses demonstrated the cardiopulmonary bypass time of 207.1 (95% confidence interval [CI], 186.1-228.1) minutes, aortic cross-clamp time of 123.3 (95% CI, 113.1-133.5) minutes, selective antegrade cerebral perfusion time of 49.3 (95% CI, 37.6-61.0) minutes, hypothermic circulatory arrest time of 39.0 (95% CI, 30.7-47.2) minutes, early mortality of 9.2% (95% CI, 7.7-11.0%), stroke of 4.8% (95% CI, 2.5-9.0%), spinal cord injury of 3.5% (95% CI, 1.9-6.6%), mid- to long-term (≥1-year) overall mortality of 13.0% (95% CI, 10.4-16.0%), reintervention of 9.6% (95% CI, 5.6-15.8%), and false lumen thrombosis of 96.8% (95% CI, 90.7-98.9%).

Conclusions:

Total arch replacement with frozen elephant trunk provides a safe alternative to that with conventional elephant trunk in patients with acute type A aortic dissection, with acceptable early mortality and morbidity. The rates of mid- to long-term reintervention and false lumen non-thrombosis may be lower in patients undergoing the frozen than conventional elephant trunk procedure.

Left Subclavian Artery Fenestration: A Novel Treatment Strategy for Acute Type A Aortic Dissection

BACKGROUND

The optimal surgical strategy for the left subclavian artery (LSA) during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection remains a challenge. The objective of the study is to report a novel surgical technique aiming to simplify the revascularization procedure of total aortic arch replacement combined with stented elephant trunk implantation.

METHODS

We retrospectively reviewed the result of 167 patients who underwent total aortic arch replacement combined with stented elephant trunk implantation between January 2000 and December 2012. Of the 167 patients, 51 were selected to undergo the simplified revascularization, which is to fenestrate a stent graft of the descending aorta instead of performing reconstruction of the LSA. Before performing the new LSA revascularization, we had performed the elephant trunk procedure whereby the tubular material completely covered the LSA. The ensuing revascularization was modified by removing a patch of the polyester fabric of the elephant trunk that was located at the origin of the LSA. Both perioperative variables and postoperative outcome of the surgery were assessed.

RESULTS

The indication for adopting the LSA fenestration was under the circumstance of absence of dissection at the origin of the LSA. The nosocomial mortality of the 51 patients was 7.8% (multiorgan failure 2, renal failure 1, infection 1). During a mean follow-up period of 51.3 ± 27.6 months, the survival rate of the 47 patients was 100%, 90.8%, and 70.2% at 1, 5, and 10 years, respectively. No stroke and left limb ischemia were observed. No patients required reintervention because of anastomotic leak between the LSA and the descending aorta during follow-up.

CONCLUSIONS

The LSA fenestration technique during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection is reliable and effective for patients who have no dissection at the LSA. Furthermore, because the simplified surgical procedure largely shortens the time of operation, it effectively improves the patient's prognosis.

Total Aortic Arch Reconstruction With Triple-Branched Stent Graft or Hemiarch Replacement for Acute Debakey Type I Aortic Dissection: Five-Years Experience With 93 Patients

OBJECTIVE

We compared the outcomes of a new triple-branched stent graft reconstruction technique of total aortic arch with those of the conventional strategy of replacing the hemiarch during the surgical treatment of acute Debakey type I aortic dissection over five years.

METHODS

Fifty-two patients with acute Debakey type I aortic dissection underwent ascending aorta replacement combined with triple-branched stent graft reconstruction of the aortic arch from June 2008 to February 2010. Concurrently, 41 cases of Debakey type I aortic dissection underwent ascending aorta replacement combined with hemiarch replacement. Both groups received hypothermic cardiopulmonary bypass and selective cerebral perfusion.

RESULTS

Patient characteristics and in-hospital mortality of the two groups were similar. Postoperative data were not different between the groups. During the five years after surgery, there were no deaths in the stent graft group and three deaths in the hemiarch group. The late reinterventions/events during follow-up in the stent graft group were significantly less than those in the hemiarch group. On postoperative computed tomography, the aortic diameter of both groups was significantly reduced compared to the postoperative aortic diameter. There was no difference in diameter between one month and five years postoperatively in the stent graft group, although in the hemiarch group the diameter was significantly greater at five years than at one month postoperatively.

CONCLUSION

The triple-branched stent graft reconstruction of the aortic arch is an effective and simplified procedure for the treatment of acute Debakey type I aortic dissection.

Outcome of frozen elephant trunk technique for acute type A aortic dissection: as systematic review and meta-analysis

Acute aortic dissections of Stanford type A require emergency surgery repair and present challenges to surgeons. The frozen elephant technique is one of several approaches used to treat aortic arch dissection. The purpose of this meta-analysis was to investigate the clinical effectiveness of the frozen elephant technique for treating acute type A aortic dissection.Medline, Cochrane, Google Scholar, and ClinicalTrials.gov databases were searched up to March 31, 2014, for studies that assessed the use of frozen elephant trunk technique for treating acute type A aortic dissection. The primary outcome was in-hospital mortality. Secondary outcomes included rate of stroke, spinal cord injury, renal failure, and reoperations for bleeding.Eleven studies were included in the analysis that encompassed 881 patients. The mean age ranged from 45.4 to 66.8 years, and the proportion of the population that was male ranged from 45 to 85%. The overall in-hospital mortality rate was 8%. The rate of stroke, spinal cord injury, renal failure, and frequency of reoperations for bleeding were 3, 4, 5, and 5, respectively. Sensitivity analysis indicates that the findings are robust and there was no publication bias.These findings indicate that the frozen elephant techniques does not bring unacceptable mortality or morbidity risk for treating acute type A aortic dissection.

A self-adaptive triple-branched stent graft for arch repair during open type A dissection surgery

OBJECTIVE

To make the open placement of the triple-branched stent graft technique suitable for most patients with acute type A aortic dissection to achieve effective individual total arch repair, we developed a self-adaptive triple-branched stent graft and arch open technique. In this study, we report the clinical experience and outcomes of total arch repair using implantation of this self-adaptive triple-branched stent graft with the aid of the arch open technique.

METHODS

Between December 2012 and July 2014, 105 consecutive patients with acute type A aortic dissection with indications of total arch repair underwent total arch repair using implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Survivors were followed up prospectively by means of computed tomography angiography.

RESULTS

The cardiopulmonary bypass time was 169.37 ± 27.17 minutes, aortic crossclamp time was 60.48 ± 16.72 minutes, and selective cerebral perfusion and lower body arrest time was 28.95 ± 7.23 minutes. The in-hospital mortality was 4.76%. One patient was lost to follow-up. One sudden death of unknown cause occurred 10 months after surgery. On the 3-month postoperative scans, the false lumen closed with complete thrombus formation around the self-adaptive triple-branched stent graft was found in all survivors and at the diaphragmatic level in 71.72% of patients.

CONCLUSIONS

The simple implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique can be used safely in most patients with acute type A aortic dissection for effective individual total arch repair.

A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery

BACKGROUND

The treatment of complex pathologies of the aortic arch and proximal descending aorta represents a significant challenge for cardiac surgeons. Various surgical techniques and prostheses have been implemented over the past several decades, all with varying degrees of success. The introduction of the frozen elephant trunk (FET) technique facilitates one-stage repair of such pathologies. The present systematic review and meta-analysis aims to assess the safety and efficacy of the FET approach in the current literature.

METHODS

Electronic searches were performed using six databases from their inception to July 2013. Relevant studies utilizing the FET technique were identified. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Seventeen studies were identified for inclusion for qualitative and quantitative analyses, all of which were observational reports. Pooled mortality was 8.3%, while stroke and spinal cord injuries were 4.9% and 5.1% respectively. Cardiopulmonary bypass time, myocardial ischemia time, and circulatory arrest time strongly correlated with perioperative mortality in a linear relationship, while moderate correlations between cerebral perfusion time and mortality, and circulatory arrest time and spinal cord injury, were also identified. Five-year survival, reported in five studies, ranged between 63-88%.

CONCLUSIONS

Overall, results of the present systematic review and meta-analysis suggest that the FET procedure can be performed with acceptable mortality and morbidity risks.

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection

BACKGROUND

Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Sun's procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Sun's procedure in patients with AAAD.

METHODS

Clinical data of 398 consecutive AAAD patients undergoing the Sun's procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis.

RESULTS

Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007).

CONCLUSIONS

The Sun's procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Open triple-branched stent graft applied to patient of acute type A aortic dissection with aberrant right subclavian artery

A 57-year-old Chinese male patient presented with Standford type A aortic dissection with an aberrant right subclavian artery (ARSA). At operation, the ascending aorta was replaced by a mono-branch vascular prosthesis with the branch bypassing to the ARSA; the triple-branched stent graft was inserted into the true lumen of the arch and proximal descending aorta (covering the origin of the ARSA) with each sidearm graft being positioned into the aortic branches; and then its proximal end was sutured to mono-branched vascular prosthesis. Follow-up computed tomography angiography showed false lumen of the dissection disappeared with satisfactory position of the triple-branched stent graft.

Open triple-branched stent graft placement for the surgical treatment of acute aortic arch dissection

BACKGROUND

The primary experience of open triple-branched stent graft placement for acute aortic arch dissection was reported.

METHODS

Between January 2011 and October 2011, 13 well-selected patients (mea age, 46±8.2 years; approximate range, 30~58 years) with acute aortic arch dissection underwent open triple-branched stent graft placement for total arch reconstruction. The triple-branched stent graft was a branched 1-piece graft consisting of a self-expandable nitinol stent and polyester vascular graft fabric (Yuhengjia Sci Tech Corp Ltd, Beijing, China). During hypothermic circulatory arrest, through the transverse incision of the ascending aorta, the main graft of the triple-branched stent graft was inserted into the true lumen of the arch and proximal descending aorta, and then each sidearm graft was positioned one by one into the aortic branch. Once the main graft and sidearm grafts were properly positioned, the restraining strings were withdrawn and then the main graft and sidearm grafts were deployed. Enhanced electric beam computed tomography was performed in each patient before discharge to evaluate the postoperative time course of the residual false lumen.

RESULTS

Open triple-branched stent graft placement was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and arrest time were 138.40±47.75 min, 70.60±28.94 min and 28.60±12.48 min, respectively. All patients were discharged from hospital. Their computed tomographic scans postoperatively showed that all stent grafts were fully opened and not kinked, there was no blood flow surrounding the triple-branched stent graft.

CONCLUSION

Open triple-branched stent graft placement is a new effective technique for total arch reconstruction in acute arch dissection.

EACTS day in the new EACTS House

There is no doubt that the European Association for Cardio-Thoracic Surgery is a success story. In 2011, we celebrated the 25th anniversary of this professional organization. In 2012, we will celebrate the 25th anniversary of the European Journal of Cardio-Thoracic Surgery. In addition, two other journals have been initiated, Interactive CardioVascular and Thoracic Surgery and the Multimedia Manual of Cardio-Thoracic Surgery, and all of them can be accessed through CTSnet (www.ctsnet.org). The most recent development was the birth of EACTS House, and it was to celebrate the official opening of EACTS House on 10 February 2011, that we held the second Strategic meeting, 'EACTS in the Future'. On this occasion, the EACTS council and delegates of the EACTS Domains (Domain of Thoracic Disease, Domain of Vascular Disease, Domain of Congenital Cardiac Disease and Domain of Adult Cardiac Disease) came together with representative thoracic and cardio-vascular surgeons from North America, Asia and BRICS countries as well as senior managers from industry in order to decide where to go from there. As a basis for starting the discussions, a sector analysis of the activities of the Department of Cardio-Vascular Surgery at CHUV in Lausanne, Switzerland was performed in order to identify the trends in the activities of our group of surgeons by pulling the consolidated data for the period running from 1 January 1995 to 31 December 2010. Interestingly enough, the most frequent procedures like coronary artery bypass graft and valve repair/replacement did not increase despite a growing programme. In our setting, the compensation came mainly from vascular surgery and mechanical circulatory support. These data have to be put in perspective by the reports provided by the EACTS domain chairs in order to identify the challenges and opportunities for the future development of our specialties.