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Ito H, Bessho S, Shomura Y, Kato N, Kanemitsu S, Mizumoto T, Hirano K, Maze Y, Tokui T, Takao M. Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02043-9. [PMID: 38822182 DOI: 10.1007/s11748-024-02043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/18/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. METHODS Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0 years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0 months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. RESULTS Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5 years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5 years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. CONCLUSIONS Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.
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Affiliation(s)
- Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Saki Bessho
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yu Shomura
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Shinji Kanemitsu
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Toru Mizumoto
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
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Samadzadeh Tabrizi N, Sá MP, Jacquemyn X, Yousef S, Brown JA, Serna-Gallegos D, Sultan I. Central versus peripheral cannulation for acute type A aortic dissection: A meta-analysis of over 14,000 patients. Am J Surg 2024:115780. [PMID: 38825544 DOI: 10.1016/j.amjsurg.2024.115780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/08/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE The optimal cannulation strategy for patients with acute type A aortic dissections (ATAAD) is unclear. METHODS A systematic search was performed to identify all studies comparing aortic and non-aortic cannulation in patients undergoing ATAAD repair. The primary endpoint was overall survival. The secondary endpoints were operative mortality, postoperative stroke, renal failure, renal replacement therapy, paraplegia, and mesenteric ischemia. Pooled meta-analyses with aggregated and reconstructed time-to-event data were performed. RESULTS Twenty-three studies were included (aortic: 3904; non-aortic: 10,719). Ten-year overall survival was 61.1 % and 58.4 % for aortic and non-aortic cannulation, respectively (HR 1.07; 95 % CI 0.92-1.25; p = 0.38). No statistically significant difference was observed for operative mortality (p = 0.10), stroke (p = 0.89), renal failure (p = 0.83), or renal replacement therapy (p = 0.77). CONCLUSION Patients undergoing surgery for ATAAD can undergo aortic cannulation with similar outcomes to those who undergo non-aortic cannulation.
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Affiliation(s)
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
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3
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Göbel N, Holder S, Hüther F, Anguelov Y, Bail D, Franke U. Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I. Front Cardiovasc Med 2024; 11:1326124. [PMID: 38559669 PMCID: PMC10978760 DOI: 10.3389/fcvm.2024.1326124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Objective The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair. Methods Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention. Results Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77). Conclusion Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.
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Affiliation(s)
- Nora Göbel
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
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4
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Han SM, DiBartolomeo AD, Pyun AJ, Maithel S, Patel S, Fleischman F. Use of Iliac Branch Endoprosthesis to Rescue Inadvertent False Lumen Deployment of the Innominate Branch Stent During Physician-Modified Fenestrated-Branched Aortic Arch Repair. Vasc Endovascular Surg 2024; 58:193-199. [PMID: 37473451 DOI: 10.1177/15385744231191216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
A 70-year-old male with a history of 3 prior median sternotomies and on anticoagulation presented with acute chest and back pain associated with a pseudoaneurysm of the ascending and aortic arch in the setting of residual dissection involving the innominate, proximal right carotid, and subclavian arteries. A physician-modified triple vessel fenestrated-branched arch endograft was deployed. The innominate branch stent was deployed from the right carotid cut down, while the left carotid and left subclavian branch stents were placed from a femoral approach. Postoperatively, the innominate branch was found to be deployed in the false lumen of the dissected native innominate artery, leading to continued pressurization of the pseudoaneurysm. This was rescued by placing a Gore Iliac Branch Endoprosthesis (IBE) into the innominate branch through a temporary conduit sewn to the right carotid artery with a right subclavian branch placed via a brachial artery cut down into the internal iliac gate. The use of IBE allowed branch stent extension past the dissected native vessels. The patient had an uneventful recovery without neurologic complications. At 3-month follow-up, the patient remains well with an excluded pseudoaneurysm, and patent bifurcated innominate, bilateral carotid, and subclavian artery branches. A Gore IBE can be utilized in a dissected innominate artery to create an innominate branch device during fenestrated-branched endovascular arch repair.
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Affiliation(s)
- Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Shelley Maithel
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sanjeet Patel
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
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Gao J, Yan J, Duan Y, Yu J, Li W, Luo Z, Yu W, Xie D, Liu Z, Xiong J. Aortic arch branch-prioritized reconstruction for type A aortic dissection surgery. Front Cardiovasc Med 2024; 10:1321700. [PMID: 38348137 PMCID: PMC10859855 DOI: 10.3389/fcvm.2023.1321700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/26/2023] [Indexed: 02/15/2024] Open
Abstract
Background Acute Stanford type A aortic dissection (STAAD) is a fatal condition requiring urgent surgical intervention. Owing to the complexity of the surgical process, various complications, such as neurological disorders, are common. In this study, we prioritized the reconstruction of aortic arch branches during surgery and investigated the association between prioritizing the branches and the postoperative outcomes of patients with STAAD. Methods Ninety-seven patients were included in the observational study and underwent total arch replacement and frozen elephant trunk technique between January 2018 and June 2021. Of these, 35 patients underwent the branch-priority technique, and 62 patients underwent the classic technique. By analyzing the perioperative outcomes, we compared the differences between the two techniques. Results The branch priority group had significantly shorter cardiopulmonary bypass and ventilator times and earlier postoperative wake-up times than the classic group. Additionally, the ICU stay time was shorter, with a significant decrease in neurological complications and 24 h drainage in the branch priority group compared to the classic group. Conclusion The branch priority technique can effectively provide better brain protection, resulting in earlier awakening of patients after surgery, reduced neurological complications, shorter ventilation time and decreased ICU hospitalization time. Therefore, it is recommended for use in aortic dissection surgeries.
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Affiliation(s)
- Jianfeng Gao
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Jie Yan
- Department of Thoracic Surgery, The First People’s Hospital of Nankang District, Ganzhou, China
| | - Yanyu Duan
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Engineering Research Center of Intelligent Acoustic Signals of Jiangxi Province, Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
- Ganzhou Cardiovascular Rare Disease Diagnosis and Treatment Technology Innovation Center, Gannan Medical University, Ganzhou, China
| | - Junjian Yu
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Wentong Li
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zhifang Luo
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Wenbo Yu
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Dilin Xie
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Ziyou Liu
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jianxian Xiong
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
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7
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Patel ST, Gusev MV, Razzouk AJ. Total arch replacement using frozen elephant trunk and repair of bilateral subclavian artery aneurysms in a patient with type 2 Loeys-Dietz syndrome. J Vasc Surg Cases Innov Tech 2023; 9:101292. [PMID: 38106350 PMCID: PMC10725073 DOI: 10.1016/j.jvscit.2023.101292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/24/2023] [Indexed: 12/19/2023] Open
Abstract
Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. Vessel tortuosity and aneurysms throughout the vasculature are unique to LDS. Aortic root enlargement is ubiquitous, with most patients undergoing root replacement at some point in their lifetime. Multiple vascular procedures are required to prolong life expectancy. We describe a staged hybrid approach to a 17-year-old patient with LDS presenting with ascending aorta, arch, and bilateral subclavian artery aneurysms and prominent tortuosity. Transposition of the left vertebral and subclavian arteries onto the common carotid artery was performed. Total aortic arch replacement with frozen elephant trunk extension into the descending thoracic aorta was performed as a second stage. Bilateral subclavian artery aneurysms were excluded with the use of a four-branched graft.
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Affiliation(s)
- Sheela T. Patel
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Maksim V. Gusev
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Anees J. Razzouk
- Department of Cardiothoracic Surgery, Loma Linda University Health, Loma Linda, CA
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8
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Suzuki R, Akita M, Miyazaki S, Shimano R. Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk. J Cardiothorac Surg 2023; 18:276. [PMID: 37807044 PMCID: PMC10561458 DOI: 10.1186/s13019-023-02403-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/30/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Total arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients. METHODS Forty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed. RESULTS The average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%. CONCLUSIONS The assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm. UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry) https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgi Clinical registration number: UMIN000051531.
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Affiliation(s)
- Ryo Suzuki
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan.
| | - Masafumi Akita
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
| | - Suguru Miyazaki
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
| | - Ryo Shimano
- Department of Cardiovascular Surgery, Shinmatsudo Central General Hospital, 1-380 Shinmatsudo, Matsudo, Chiba, 270-0034, Japan
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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10
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Misfeld M, Marin-Cuartas M, Ramirez P, Wehrmann K, Renatus K, Deo SV, Gohmann RF, Haunschild J, Leontyev S, Borger MA, Etz CD. Early Intraluminal Frozen Elephant Trunk Stent Graft Thrombosis After Aortic Arch Surgery. Ann Thorac Surg 2023; 116:450-457. [PMID: 36608753 DOI: 10.1016/j.athoracsur.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Partial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis. METHODS Retrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event. RESULTS A total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3). CONCLUSIONS Early postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis.
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Affiliation(s)
- Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Sydney Medical School, University of Sydney, Australia.
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Paulina Ramirez
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Katharina Wehrmann
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Salil V Deo
- Department of Veterans Affairs, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Robin F Gohmann
- Department of Radiology, Leipzig Heart Center, Leipzig, Germany
| | - Josephina Haunschild
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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The Frozen Elephant Technique Using a Novel Hybrid Prosthesis for Extensive Aortic Arch Disease: A Multicentre Study. Adv Ther 2023; 40:1104-1113. [PMID: 36633731 PMCID: PMC9988725 DOI: 10.1007/s12325-022-02418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The frozen elephant trunk technique (FET) has become routine for aortic arch and descending aortic repair. New hybrid prosthesis models are constantly being developed to increase effectiveness and durability of aortic repair. Recently, concerns were raised regarding increased post-operative bleeding using a new-generation hybrid prosthesis (E-vita® OPEN NEO, CryoLife Inc. JOTEC GmbH, Hechingen, Germany). We report the outcomes of a multi-centre experience of using the E-vita OPEN NEO. METHODS All patients undergoing aortic surgery at five European centres using the E-vita OPEN NEO from 2020 to 2022 were included (n = 22). The primary endpoint was the amount of chest drain fluid after 24 h and re-thoracotomy rate for bleeding. RESULTS Median patient age was 62.5 ± 12.6 years, 50.0% (11/22 patients) were female and 27.3% (6/22) of procedures were re-operative cardiac surgeries. Aortic dissection was present in 54.5% (12/22). The median cardiopulmonary bypass time was 148 min and ischaemia time was 84 min. Mortality at 30 days was 4.5% (1/22) and the stroke rate was 18.2% (4/22). The rate of re-thoracotomy for bleeding was 4.5% (1/22) with a median amount of chest drain fluid within 24 h of 569 (IQR 338-910) ml. There were no device-associated adverse events. CONCLUSIONS Use of this new-generation hybrid prosthesis for FET was safe and effective. Patient follow-up was largely uneventful given the extent of the procedures performed. In particular, bleeding events were uncommon in this cohort of patients comprising many aortic dissections and re-operative procedures. No increase in oozing was observed.
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12
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Li J, Zhou Y, Qin W, Su C, Huang F, Chen X. Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience. Asian Cardiovasc Thorac Ann 2023; 31:8-14. [PMID: 35014890 DOI: 10.1177/02184923211070115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. METHODS Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. RESULTS A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 - 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 - 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 - 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 - 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. CONCLUSIONS Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.
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Affiliation(s)
- Jian Li
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Yueyun Zhou
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Wei Qin
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
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Tan SZCP, Mohammed I, Bashir M. Frozen Elephant Trunk Sizing: A 30,000-Feet Perspective with Thoraflex Hybrid Stent Graft. AORTA (STAMFORD, CONN.) 2022; 10:182-190. [PMID: 36521811 PMCID: PMC9754870 DOI: 10.1055/s-0042-1756667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There is currently no standard, evidence-based approach for sizing the Thoraflex Hybrid prosthesis in frozen elephant trunk surgery. We present regional data on 906 Thoraflex grafts implanted in the United Kingdom between December 2012 and August 2021 to emphasize the heterogeneity in sizing practices and evaluate the impact this may have on clinical outcomes. Highlighting this heterogeneity will help develop an evidence-based approach to prosthesis sizing, thereby aiding decision-making for arch repair.
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Affiliation(s)
- Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India,Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran,Department of Vascular and Endovascular Surgery, Velindre University National Health Service Trust, Health and Education Improvement Wales, Wales, United Kingdom,Address for correspondence Mohamad Bashir, MD, PhD, MRCS Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health and Education Improvement WalesWales CF15 7QQUnited Kingdom
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14
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Park KH. Transsternal and Transpericardial Approach to Descending Thoracic Aorta via Median Sternotomy-An Option for Extensive Aortic Surgery. AORTA (STAMFORD, CONN.) 2022; 10:147-154. [PMID: 36521805 PMCID: PMC9754876 DOI: 10.1055/s-0042-1750413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We describe a technique for approaching the distal descending thoracic aorta via median sternotomy and posterior pericardiotomy, which enabled us to perform the extensive aortic repair. While this approach shared the lesser invasiveness of the frozen elephant trunk procedure with less confinement by anatomic features, the advantage was counterbalanced by the high incidence of spinal cord ischemia. This approach can be an option in highly selected patients who require extensive aortic repair but have factors prohibiting other conventional approaches.
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Affiliation(s)
- Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea,Address for correspondence Kay-Hyun Park, MD, PhD Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine82, Gumiro 173-street Bundang-gu, Seongnam-si 13620Korea
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15
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Iannacone EM, Robinson NB, Rahouma M, Audisio K, Soletti G, Lau C, Gaudino M, Girardi LN. Elephant trunk simplifies thoracoabdominal aortic aneurysm repair without impacting operative risk. J Card Surg 2022; 37:4685-4691. [PMID: 36285541 DOI: 10.1111/jocs.17064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/30/2022] [Accepted: 10/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM An open two-stage elephant trunk (ET) technique may aid in the technical ease of subsequent thoracoabdominal aortic aneurysm (TAAA) repair. We analyze whether the presence of an ET improves outcomes for patients undergoing extent I and II TAAA repair. METHODS From September 1997 to October 2020, 469 patients underwent extent I or II TAAA repair. We compared those with prior ET to those without. Primary outcome was composite major adverse events (MAE) including operative mortality, myocardial infarction, permanent spinal cord injury, cerebrovascular accident, need for tracheostomy, and new need for dialysis. RESULTS Thirty-eight (8.1%) patients had prior ET and 431 (91.9%) did not. There were no differences in baseline characteristics. The no ET group was more likely to undergo urgent or emergent procedures. Composite MAE occurred in 82 (19%) of the no ET group and 5 (15.8%) of the ET group (p = .785). Operative mortality was 5.5% and not significantly different between the groups (p = 1.00). No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus 19 [16-22] min; p ≤ .001 and 42 [32-53] versus 30 [25-39] min; p ≤ .001). CONCLUSIONS Extent I and II TAAA repair after ET can be safely performed in a tertiary referral center with shorter bypass and cross-clamp times. ET eliminates the need for circulatory arrest or clamping a hostile arch.
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Affiliation(s)
- Erin M Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Newell Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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16
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Goebel N, Holder SA, Huether F, Bail DHL, Franke UFW. Left Subclavian Artery Sacrifice in Acute Aortic Dissection Repair using the Frozen Elephant Trunk. Thorac Cardiovasc Surg 2022; 70:623-629. [PMID: 35038756 DOI: 10.1055/s-0041-1741058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Surgery of acute aortic dissection using the frozen elephant trunk (FET) can be complicated when the origin of the left subclavian artery (LSA) is dissected and sacrifice by ligation is a viable option. However, the LSA is supposed to play a role in neuroprotection as a major collateral. We, therefore, analyzed our results of LSA sacrifice in this cohort. METHODS We identified a total of 84 patients from our prospectively collected database who underwent FET repair of acute aortic dissection between October 2009 and April 2018. LSA was sacrificed in 19 patients (22.6%). Results were analyzed and compared with regard to neurological outcomes. RESULTS New postoperative stroke was seen in two patients (2.4%) and spinal cord injury in three patients (3.6%) overall, none in the LSA-sacrifice group. We observed a temporary neurological deficit in five patients (6.0%) overall, none in the LSA-sacrifice group. None of the patients developed acute ischemia of the left arm. Only two patients (12.5%) came back for carotid-subclavian artery bypass due to exertion-induced weakness of the left arm 3 to 4 months after the initial surgery. In-hospital mortality was 15.5% overall, with no difference between groups. CONCLUSION LSA sacrifice was not associated with elevated postoperative risk of either central or spinal neurological injury. Thus, it can facilitate FET repair of acute aortic dissection in selected cases when the left subclavian origin cannot be preserved. Carotid-subclavian artery bypass became necessary in only a small fraction of these patients and can be performed as a second-stage procedure.
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Affiliation(s)
- Nora Goebel
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Simone A Holder
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Franziska Huether
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Dorothee H L Bail
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Moula AI, Romeo JLR, Parise G, Parise O, Maessen JG, Natour E, Bidar E, Gelsomino S. The evolution of arch surgery: Frozen elephant trunk or conventional elephant trunk? Front Cardiovasc Med 2022; 9:999314. [PMID: 36337868 PMCID: PMC9630467 DOI: 10.3389/fcvm.2022.999314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], p = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], p = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.
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Shimada A, Yamamoto T, Dohi S, Yokoyama Y, Endo D, Tabata M. Two-stage aortic surgery for distal aortic arch and descending aorta aneurysms: A case report. Medicine (Baltimore) 2022; 101:e30342. [PMID: 36086696 PMCID: PMC10980456 DOI: 10.1097/md.0000000000030342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Although surgical treatment strategies for patients with extensive thoracic aortic disease involving the aortic arch have improved considerably, the impact of stent graft length and placement site on aortic remodeling at long-term follow-up is not fully understood, and the protection of the Adamkiewicz artery (AKA) using the frozen elephant trunk (FET) method is also unclear. PATIENT CONCERNS The patient was a 69-year-old man with diabetic nephropathy who became increasingly fatigued and started maintenance hemodialysis 6 months prior to admission. At 64 years, he underwent clipping of a right cerebellar artery aneurysm. In addition, a 1.8 cm aneurysm was found in the contralateral extracranial internal carotid artery. He also had an atrial septal defect and moderate aortic regurgitation and was receiving continuous positive airway pressure therapy for sleep apnoea syndrome. DIAGNOSIS He had aneurysms in the aortic arch (4.8 cm in diameter) and descending aorta (6 cm in diameter), which was located at T6-9. Preoperative 3-dimensional computed tomography showed that the (AKA) bifurcated at T10-11. INTERVENTIONS Considering the patient's several comorbidities and frailty, we planned to perform 1-stage extended aortic arch repair using the FET procedure. However, we performed 2-stage aortic surgery to prevent spinal ischemia, anticipating substantial cardiac enlargement and blood pressure instability due to dialysis treatment. Aortic valve replacement, atrial septal defect patch closure, and aortic arch surgery were performed. A 7-cm elephant trunk was inserted in the descending aorta. Postoperatively, the patient continued rehabilitation until his blood pressure stabilized during dialysis therapy. At postoperative week 4, he underwent thoracic endovascular aortic repair for a descending aortic aneurysm. OUTCOMES After surgery, his physical strength decreased; however, he recovered and was discharged 1 month later without any complications. One year after the second operation, he is living a healthy life. LESSONS Extensive aortic arch surgery using the FET procedure is effective for distal aortic arch and descending aortic aneurysms. Nevertheless, in cases in which the position of the AKA is close to the aortic aneurysm and blood pressure control is difficult, a 2-stage procedure and accurate positioning of thoracic endovascular aortic repair are both desirable.
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Affiliation(s)
- Akie Shimada
- Department of Cardiovascular Surgery, Nerima Hospital, Juntendo University, Nerima-ku, Tokyo, Japan
| | - Taira Yamamoto
- Department of Cardiovascular Surgery, Nerima Hospital, Juntendo University, Nerima-ku, Tokyo, Japan
| | - Shizuyuki Dohi
- Department of Cardiovascular Surgery, Nerima Hospital, Juntendo University, Nerima-ku, Tokyo, Japan
| | - Yasutaka Yokoyama
- Department of Cardiovascular Surgery, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Juntendo University, Bunkyo-ku, Tokyo, Japan
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Wang W, Wang Y, Piao H, Zhu Z, Li D, Wang T, Liu K. Ministernotomy approach to aortic arch inclusion and frozen elephant trunk in the treatment of acute Stanford A aortic dissection. Front Cardiovasc Med 2022; 9:944612. [PMID: 36158786 PMCID: PMC9489909 DOI: 10.3389/fcvm.2022.944612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to report our results of ministernotomy approach to Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with frozen elephant trunk (FET) in the treatment in type A aortic dissection (TAAD). We retrospectively analyzed data on 68 Stanford A aortic dissection patients from October 2017 to March 2020. All patients underwent Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermic circulatory arrest combined with ministernotomy approach. 154 TAAD patients between January 2014 and December 2016 underwent complete sternotomy were selected as control group. Clinical characteristics, data during operation, in-hospital and postoperative outcomes of these patients were observed. The mean hypothermic circulatory arrest time in ministernotomy Patients was 39.3 ± 7.9 min, aortic cross-clamp time was 105.9 ± 12.8 min, cardiopulmonary bypass time was 152.8 ± 24.3 min. Three patients died of multiple organ dysfunction syndrome in ministernotomy Patients. Perioperative temporary neurological dysfunction occurred in three (4.41%) patients, and 53 (77.9%) patients did not require any blood product transfusion during and after operation in ministernotomy Patients. Postoperative CT angiography (CTA) examination at 6-32 months showed excellent outcomes except in three (4.41%) cases where arch false lumen patency persisted. The Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermia circulatory arrest simplify the surgical procedure and reduce bleeding, which can be accomplished through minimally invasive approach.
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Mousavizadeh M, Bashir M, Jubouri M, Tan SZ, Borzeshi EZ, Ilkhani S, Banar S, Nakhaei P, Rezaei Y, Idhrees M, Hosseini S. Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:265-274. [PMID: 35238527 DOI: 10.23736/s0021-9509.22.12292-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran - .,Vascular and Endovascular Surgery, Health Education, and Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Elahe Z Borzeshi
- School of Public Health and Safety, Department of Epidemiology, Shahid Beheshti University of Medical Sciences Tehran, Iran
| | - Saba Ilkhani
- Department of Surgery and Vascular Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepideh Banar
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Pooria Nakhaei
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Wisniewski K, Motekallemi A, Dell'Aquila AM, Oberhuber A, Schaefers JF, Ibrahim A, Martens S, Rukosujew A. Single-Center Experience With the Thoraflex™ Hybrid Prosthesis: Indications, Implantation Technique and Results. Front Cardiovasc Med 2022; 9:924838. [PMID: 35707127 PMCID: PMC9189312 DOI: 10.3389/fcvm.2022.924838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study was to evaluate the early and mid-term results after the frozen elephant trunk (FET) procedure for the treatment of complex arch and proximal descending aortic disease in a single-center institution. Methods From April 2015 to July 2021, 72 patients (25 women, 60.4 ± 10.3 years) underwent Thoraflex™ Hybrid implantation at our institution. The indications were thoracic aortic aneurysm (TAA) (n = 16, 22.2%), post-dissection aneurysm (n = 21, 29.2%), and acute aortic dissection (AAD) (n = 35, 48.6%). Antegrade cerebral perfusion under moderate hypothermia (28°C) was employed in all cases. Eighteen patients (25%) have already been operated due to heart or aortic disease. Results Overall in-hospital mortality was 12.5% (9 patients). Rates of permanent neurological dysfunction and spinal cord injury were 9.7 and 5.5%, respectively. The in-hospital mortality rate among patients operated on AAD, TAA, and post-dissection aneurysm were 8.6, 6.2, and 23.8%, respectively. At a mean follow-up of 26 ± 20 months, mortality was 9.7%. Furthermore, 23 patients (31.9%) required a subsequent procedure in distal aorta: endovascular stentgraft extension in 19 patients (26.4%) and open aortic surgery in 4 patients (5.5%). The mid-term survival of patients with type A aortic dissection was 97%. Conclusions Our experience with the Thoraflex Hybrid prosthesis demonstrates its surgical applicability for different types of aortic pathologies with promising outcomes during early and midterm follow-up. Our technique and perioperative management lead to comparable or even superior neurological outcomes and mortality in urgent cases considering other high-volume centers.
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Affiliation(s)
- Konrad Wisniewski
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
- *Correspondence: Konrad Wisniewski
| | - Arash Motekallemi
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Angelo M. Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Johannes F. Schaefers
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
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22
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Aboughdir M, Haq M, Harky A, Field M. Addressing the elephant in the room: Conventional versus frozen elephant trunk in complex aortic surgery. J Card Surg 2022; 37:2408-2409. [PMID: 35538550 DOI: 10.1111/jocs.16593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Maryam Aboughdir
- Department of Medicine, St. George's, University of London, London, UK
| | - Mawiyah Haq
- Department of Medicine, St. George's, University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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23
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Vernice NA, Wingo ME, Walker PB, Demetres M, Stalter LN, Yang Q, de Biasi AR. The great vessel freeze-out: A meta-analysis of conventional versus frozen elephant trunks in aortic arch surgery. J Card Surg 2022; 37:2397-2407. [PMID: 35526122 PMCID: PMC9322650 DOI: 10.1111/jocs.16596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/27/2022] [Indexed: 01/03/2023]
Abstract
Background The optimal treatment strategy for complex aortic arch and proximal descending aortic pathologies remains controversial. Despite the frozen elephant trunk (FET) technique's increasing popularity, its use over the conventional elephant trunk (CET) remains a matter of physician preference and outcomes are varied. Methods This meta‐analysis of available comparative studies of FET versus CET sought to examine differences in survival, reintervention, and adverse events. The following databases were searched from inception—May 2020: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies retrieved were then screened for eligibility against predefined inclusion/exclusion criteria with a protocol registered on Open Science Framework at https://osf.io/hrfze/. Results The search identified 1911 citations, with five studies included. The resultant meta‐analysis included 313 CET and 292 FET cases. FET had lower perioperative mortality (risk ratio [RR]: 0.50, 95% confidence interval [CI]: [0.42; 0.60], p < .001) and improved 1‐year survival compared to CET (hazard ratio: 0.63, 95% CI: [0.42; 0.95], p = .03). There were no significant differences in rates of overall or open reinterventions following FET versus CET, but FET did yield a significantly higher rate of endovascular reintervention (RR: 2.32, 95% CI: [1.17; 4.61], p = .03). No significant differences were observed in the incidences of postoperative stroke, spinal cord injury, or renal failure between groups. Conclusions The FET technique yields superior rates of perioperative and medium‐term survival with no significant increase in overall reinterventions. There was no significant difference in the rate of spinal cord injury between groups, providing further large‐scale evidence that the FET is an acceptable, safe alternative to the CET.
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Affiliation(s)
- Nicholas A Vernice
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Matthew E Wingo
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Paul B Walker
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, New York, USA
| | - Lily N Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Andreas R de Biasi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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24
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“Why is frozen elephant trunk better than classical elephant trunk?”. Indian J Thorac Cardiovasc Surg 2022; 38:70-78. [PMID: 35463719 PMCID: PMC8980990 DOI: 10.1007/s12055-021-01302-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/18/2022] Open
Abstract
The treatment of complex aortic arch disease, in chronic or acute setting, has always represented a fascinating challenge for the heart surgeon also because, often, the involvement of the aortic arch is associated with a simultaneous involvement of the ascending aorta and of the proximal portion of the descending thoracic aorta. In recent years, there have been many surgical and/or endovascular techniques and approaches in a single step or multiple steps proposed with the aim of treating and simplifying these complex conditions. The first procedure available for this purpose was the conventional elephant trunk technique, proposed by the German surgeon Hans Borst, back in 1983. In the following years, the technique has undergone modifications, up to what is nowadays considered its most modern evolution, represented by the frozen elephant trunk which allows managing the proximal descending thoracic aorta using the antegrade release of a self-expandable stent graft. In this review article, we try to analyze the advantages and drawbacks of both techniques from clinical and practical points of view.
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25
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Dai L, Qiu J, Zhao R, Cao F, Qiu J, Wang D, Fan S, Xie E, Song J, Yu C. A Novel Sutureless Integrated Stented (SIS) Graft Prosthesis for Type A Aortic Dissection: A Pilot Study for a Prospective, Multicenter Clinical Trial. Front Cardiovasc Med 2022; 8:806104. [PMID: 35211519 PMCID: PMC8860904 DOI: 10.3389/fcvm.2021.806104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022] Open
Abstract
Aims Various kinds of surgical strategies and prostheses have been advocated to improve short-term and long-term outcomes in type A aortic dissection (TAAD). Large-scale repair of the pathological aorta is hard to generalize due to complex procedures. We aimed to investigate the performance, effectiveness and safety of a novel Sutureless Integrated Stented (SIS) graft prosthesis in TAAD patients undergoing total arch replacement (TAR) and frozen elephant trunk (FET) implantation surgery. Methods All patients admitted to Fuwai Hospital were prospectively screened. Urgent or scheduled surgery was arranged for eligible patients. The primary endpoint was operative mortality. Key secondary endpoints included stroke, spinal cord injury, unexpected aortic reoperation, and 1-year survival. Discharged patients were followed up with computed tomography angiography and transthoracic echocardiography at 3 months, 6 months, and 1 year after surgery. Performance, effectiveness and safety analyses were performed in those patients. Results Between August 1 and September 3, 2020, ten TAAD patients were enrolled in this study and successfully implanted with the SIS graft prosthesis. The median (IQR) age was 56.50 (43.75, 66.75) years (range from 31 to 75), and seven patients were male (70.0%). All patients underwent ascending aorta replacement + TAR + FET and additional procedures when necessary. The median (IQR) operation time, cardiopulmonary bypass time and cross clamp time were 270.50 (218.50, 312.50), 110.00 (88.00, 125.75), 69.50 (51.25, 82.75) min, respectively. Of note, the median (IQR) circulatory arrest time was 9.00 (8.00, 9.00) min (range from 4 to 12). The median (IQR) lowest nasopharyngeal temperature was 26.75 (25.98, 27.67) °C. Follow-up was 100% completed. During the 1-year follow-up, no patients died, no severe adverse events occurred, and rate of freedom from aortic reintervention was 100%. Conclusions The SIS graft prosthesis was implanted in a novel sutureless way, which simplified the surgical procedure, shortened the circulatory arrest time and avoided deep hypothermia. The preliminary clinical outcomes and follow-up outcomes demonstrated the effectiveness and safety of this prosthesis. A large-scale trial is being conducted to further assess these findings.
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Affiliation(s)
- Lu Dai
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawei Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Zhao
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fangfang Cao
- Adult Surgical Intensive Care Unit, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - De Wang
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuya Fan
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Enzehua Xie
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian Song
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Cuntao Yu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Cuntao Yu
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26
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Coselli JS, Frankel WC, Green SY, Amarasekara HS, Zhang Q, Preventza O, LeMaire SA. Staged Repair of Extensive Aneurysms of the Thoracic Aorta by Using the Elephant Trunk Technique. Ann Thorac Surg 2021; 114:1578-1585. [PMID: 34808113 DOI: 10.1016/j.athoracsur.2021.09.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/11/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Staged open repair of extensive aortic aneurysm by using the elephant trunk (ET) technique has facilitated the treatment of aortic aneurysms that affect the entire thoracic aorta. We describe our nearly 3-decade experience with classic ET repairs. METHODS From 1990 through 2021, we performed 363 stage-1 ET repairs to replace the transverse aortic arch in patients with a median age of 65 years [interquartile range: 56-71]. Fifty-six patients (15.4%) presented with acute symptoms, and 182 (50.1%) underwent redo sternotomy. After a median interval of 3.2 months [IQR: 2.0-7.3], 203 (55.9%) patients underwent stage-2 ET completion; few (n=16; 7.9%) had acute symptoms. Stage-2 repairs comprised 162 (80.6%) extent I or II thoracoabdominal aortic replacements. We examined postoperative outcomes including operative mortality, adverse event (a composite end point), survival, and repair failure. RESULTS Operative mortality was 12.4% (45/363) after stage-1 and 10.3% (21/203) after stage-2. The rates of adverse event were 18.5% (67/363) for stage-1 and 18.4% (38/203) for stage-2. Acute symptoms independently predicted operative mortality and adverse event for both stage-1 and stage-2 repairs; additional predictors for stage-2 repairs were older age and extent II repair. Survival was significantly worse for patients who did not receive their stage-2 completion repair than for those who did (p <0.001). CONCLUSIONS Treating extensive aortic aneurysms by using the ET technique for staged repair is associated with substantial morbidity and mortality. Patients who present with acute symptoms are at greater risk of operative mortality and adverse event. Diligent surveillance is needed between stages.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
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Qiu J, Luo X, Wu J, Pan W, Chang Q, Qian X, Sun X, Wei B, Zhang L, Liu S, Jiang W, Yu C. A New Aortic Arch Dissection Classification: The Fuwai Classification. Front Cardiovasc Med 2021; 8:710281. [PMID: 34595220 PMCID: PMC8476803 DOI: 10.3389/fcvm.2021.710281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications. Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are defined as type Ct. The Chi-square test was adopted for the pairwise comparison among the three types. Kaplan-Meier was used for the analysis of long-term survival and survival free of reoperation. Results: In total, 1,063 AcD patients were enrolled from 2010 to 2015: 54 patients were type Cp, 832 were type Ct, and 177 were type Cd. The highest operation proportion of Cp, Ct and Cd were partial arch replacement, total arch replacement, and TEVAR. The surgical mortality in type Ct was higher compared to type Cd (Ct vs. Cd = 9.38 vs. 1.69%, p < 0.01) and type Cp (Ct vs. Cp = 9.38 vs. 1.85%, p = 0.06). There was no difference in surgical mortality of type Cp and Cd (p = 0.93). There were no significant differences in the long-term survival rates (p = 0.38) and free of aorta-related re-operations (p = 0.19). Conclusion: The Fuwai classification is used to distinguish different AcDs. Different AcDs have different surgical mortality and use different operation methods, but they have similar long-term results.
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Affiliation(s)
- Juntao Qiu
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xinjin Luo
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jinlin Wu
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wei Pan
- Department of Anesthesia, Baylor College of Medicine, Texas Heart Institute, Houston, TX, United States
| | - Qian Chang
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Bo Wei
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Liang Zhang
- Department of Cardiovascular Surgery, Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shen Liu
- Department of Cardiovascular Surgery, Peking University International Hospital, Beijing, China
| | - Wenxiang Jiang
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Tsagakis K, Osswald A, Weymann A, Demircioglu A, Schmack B, Wendt D, Jakob H, Ruhparwar A. The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique. Eur J Cardiothorac Surg 2021; 61:195-203. [PMID: 34378023 PMCID: PMC8759516 DOI: 10.1093/ejcts/ezab295] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/01/2021] [Accepted: 05/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported. METHODS Between February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0–3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days. RESULTS Preoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4–1.0; P = 0.036). CONCLUSIONS FET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events. Subject collection 120; 161.
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Affiliation(s)
- Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Anja Osswald
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Aydin Demircioglu
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
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29
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Koizumi S, Ishigami M, Tsubota H, Koyama T. Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm. Surg Today 2021; 52:324-329. [PMID: 34279707 DOI: 10.1007/s00595-021-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. METHODS Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). RESULTS The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. CONCLUSIONS FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.
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Affiliation(s)
- Shigeki Koizumi
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Masanosuke Ishigami
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Hideki Tsubota
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi Chuoku, Kobeshi, Hyogoken, 650-0047, Japan.
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30
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Hage A, Hage F, Dagenais F, Ouzounian M, Chung J, El-Hamamsy I, Peterson MD, Boodhwani M, Bozinovski J, Moon MC, Yamashita M, Chu MWA, Cartier A, Chauvette V, Guo M, White A, Lodewyks C. Frozen Elephant Trunk for Aortic Arch Reconstruction is Associated with Reduced Mortality as Compared to Conventional Techniques. Semin Thorac Cardiovasc Surg 2021; 34:386-392. [PMID: 34089828 DOI: 10.1053/j.semtcvs.2021.03.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 11/11/2022]
Abstract
To examine the perioperative outcomes following aortic arch repair using frozen elephant trunk (FET) vs conventional elephant trunk (ET) techniques. Between 2002 and 2018, 390 patients underwent aortic repair with elephant trunk reconstruction at 9 centers: 172 patients received a FET (mean age: 65+/-13 years, 30% female, 37% aortic dissection) and 218 patients received an ET (mean age: 63+/-13 years, 37% female, 43% aortic dissection). Outcomes of interest included in-hospital mortality; stroke; and spinal cord injury (SCI). In-hospital mortality rate was 11% (n = 43) overall, 9% (n = 15) for FET and 13% (n = 28) for ET. Post-operative stroke occurred in 13% (n = 49) overall, 13% (n = 22) for FET and 12% (n = 27) for ET. The rate of post-operative SCI was 3% (n = 13) overall, 5.0% (n = 9) for FET and 2.0% (n = 4) for ET. When compared to ET, the propensity score analysis confirmed FET to be associated with lower mortality (adjusted risk difference -7.0% (95% CI -13.0 to -1.0), P = 0.02). There was no significant difference in the propensity score-adjusted risk difference for stroke between FET and ET (-0.7%, 95% CI -7.4% to 6.1%, P = 0.85), nor for SCI (3.3%, 95% CI -0.4% to 7.0%, P = 0.085) On multivariable analysis, FET was associated with lower odds of mortality (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and had similar odds of stroke (OR 0.83, 95% CI 0.41-1.70, P = 0.62) and SCI (OR 2.83, 95% CI 0.83-9.60, P = 0.1). FET repair is associated with lower in-hospital mortality as compared to conventional ET, and results in similar risk of stroke and spinal cord injury. Further investigation is warranted.
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Affiliation(s)
- Ali Hage
- Western University, London, Ontario, Canada
| | - Fadi Hage
- Western University, London, Ontario, Canada
| | | | | | | | - Ismail El-Hamamsy
- Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - John Bozinovski
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | | | | | | | | | - Ming Guo
- University of Ottawa, Ottawa, Ontario, Canada
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Jaffar-Karballai M, Tran TT, Oremakinde O, Zafar S, Harky A. Malperfusion in Acute Type A Aortic Dissection: Management Strategies. Vasc Endovascular Surg 2021; 55:721-729. [PMID: 34039116 DOI: 10.1177/15385744211017116] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the decades, it has been well established that malperfusion complicates a number of acute type A aortic dissection (ATAAD) patients. Of the many complications that arise from ATAAD is malperfusion, which is the result of true lumen compression secondary to the dissection, and it is one of the most dangerous complications. Left untreated, malperfusion can eventually compromise circulation to the vascular beds of almost all vital organs. Clinicians must consider the diagnosis of malperfusion promptly following a diagnosis of acute aortic dissection. The outcomes post-surgery for patients with ATAAD with concomitant malperfusion remains poor, despite mortality for aortic surgery improving over time. Optimal management for ATAAD with associated malperfusion has yet to be implemented, further research is warranted to improve the detection and management of this potentially fatal pathology. In this review, we explore the literature surrounding the complications of malperfusion in ATAAD and the various symptom presentations, investigations, and management strategies available.
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Affiliation(s)
- Mona Jaffar-Karballai
- Department of Medicine, St George's University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Tien Thuy Tran
- Department of Medicine, St George's University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Oyinkan Oremakinde
- Department of Medicine, St George's University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Somama Zafar
- Department of Medicine, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool, Heart and Chest Hospital, Liverpool, United Kingdom
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Baciewicz FA. Commentary: Elephant trunk: Straight-up or frozen? J Thorac Cardiovasc Surg 2021; 164:1694-1695. [PMID: 33965226 DOI: 10.1016/j.jtcvs.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Frank A Baciewicz
- Division of Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich.
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Rezaei Y, Bashir M, Mousavizadeh M, Daliri M, Aljadayel HA, Mohammed I, Hosseini S. Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization. J Card Surg 2021; 36:1922-1934. [PMID: 33665866 DOI: 10.1111/jocs.15452] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Daliri
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Abo Aljadayel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Schepens M, Ranschaert W, Vergauwen W, Graulus E, De Vos M. Is the classical elephant trunk better than the frozen elephant trunk? Indian J Thorac Cardiovasc Surg 2021; 38:64-69. [PMID: 35463703 PMCID: PMC8980961 DOI: 10.1007/s12055-020-01131-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/08/2023] Open
Abstract
Aortic diseases located in the ascending aorta, aortic arch or proximal descending aorta often require more than one surgical intervention depending on the type of pathology and its extent as well as future anticipated aortic problems. These obstacles were tackled in 1983 by Hans Borst with the introduction of the classic elephant trunk (cET). This was an outstanding and straightforward procedure. Since then, the cET was very often the first surgical approach for patients with extensive aortic pathology of the ascending aorta and arch extending into the downstream aorta. Thirteen years later, Suto and Kato introduced the frozen elephant trunk (fET) which was later on perfectionized by industry and applied in various ways by many surgical groups worldwide. Comparing the cET with the fET raises a lot of difficulties. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. It would be very short-sighted to close all future discussions about the subject with this statement of the Hannover group made in 2011. Since both techniques and its results cannot be compared statistically due to the heterogeneity of patient groups, the lack of randomization, the difference in type and extent of pathology, the differences in surgical techniques, the learning curve in gaining experience in both techniques, and the lack of reporting standards, no scientific conclusion can be drawn as to which technique is most successful. Comparisons may even be considered futile. It is the purpose of this paper merely to make a descriptive observation of both techniques, to discuss some important elements of interest and to give some constructive and useful criticism.
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Affiliation(s)
- Marc Schepens
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Willem Ranschaert
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Wim Vergauwen
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Eric Graulus
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
| | - Marie De Vos
- Department of Cardiac Surgery, AZ St.Jan, Ruddershove 10, 8000 Brugge, Belgium
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Hynes N, Berguer R, Parodi JC, Acharya Y, Sultan S. Management of complicated aortic dissection: natural history, translational research, simulation, bioconvergence, clinical evidence and literature review. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01473-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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36
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Charchyan ER, Breshenkov DG, Belov YV. [Hybrid aortic repair in patients with type III aortic dissection and concomitant proximal aortic lesion]. Khirurgiia (Mosk) 2020:28-37. [PMID: 33029999 DOI: 10.17116/hirurgia202009128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report our own experience of hybrid treatment using FET technique in patients with type A aortic dissection and concomitant lesion of aortic arch and ascending aorta. MATERIAL AND METHODS There were 90 (28,3%) FET procedures for the period from January 2010 to August 2019. Type B aortic dissection was diagnosed in 19 (45,2%) patients. Type B aortic dissection combined with aortic arch aneurysm occurred in 11 (58%) cases, ascending aorta aneurysm - 15 (79%) cases. Patients underwent total arch and ascending aorta replacement via median sternotomy (upper partial J-shaped sternotomy in 3 cases). Valve-sparing interventions were performed in 58% of cases (aortic root repair - 6 (32%) patients, David procedure - 5 (26%) cases). Intraoperative features, early postoperative morbidity and in-hospital mortality were retrospectively analyzed. In long-term period, distal aortic remodeling, survival rate and incidence of redo interventions were evaluated. RESULTS Mean CPB time was 166±27 min, aortic cross-clamping time - 93±23 min, duration of circulatory arrest - 43±11 min. Neurological complications and paraplegia were absent. In-hospital mortality was absent. Reversible acute renal failure without need for hemodialysis developed in 2 cases (11%). Two patients underwent repeated intervention (TEVAR) due to dSINE and negative aortic remodeling. Annual survival rate was 100%. Freedom from redo aortic surgery was 89,5%. CONCLUSION FET surgery is an adequate alternative treatment for type B aortic dissection combined with lesion of aortic arch and ascending aorta. This approach ensures a one-stage repair in patients with contraindications to TEVAR. Unlike thoracotomy, FET procedure is valuable for simultaneous correction of cardiac and proximal aortic lesion, stabilizing the distal segments of dissected aorta. This is obvious advantage of this technique.
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Affiliation(s)
- E R Charchyan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - D G Breshenkov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - Yu V Belov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
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Liakopoulos OJ, Kroener A, Sabashnikov A, Zeriouh M, Ahmad W, Choi YH, Wahlers T. Single-center experience with the frozen elephant trunk procedure in 111 patients with complex aortic disease. J Thorac Dis 2020; 12:5387-5397. [PMID: 33209372 PMCID: PMC7656366 DOI: 10.21037/jtd-20-1531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The frozen elephant trunk (FET) technique is increasingly used for the treatment of acute and chronic aortic arch disease. This study reports our single center experience with the FET technique in patients with complex aortic disease. Methods Between 2009 and 2019, 111 consecutive patients underwent aortic arch surgery in our institution using the FET technique for acute type A dissection (AAD group; n=75) or non-acute type A dissection (non-AAD group; n=36; 10 patients with chronic type A dissection; 26 patients with aneurysm), respectively. Relevant perioperative data, including 30-day mortality and neurological complications, were retrospectively obtained from our electronic patient’s records, including follow-up (FU) data of outpatient clinical visits and computed tomography (CT). Results Thirty-day mortality in the entire FET cohort was 16.2% (AAD 18.7% vs. non-AAD 11.1%; n=0.414). Severe brain injury was the leading cause of death in AAD patients (12.0% vs. 0% non-AAD; P=0.030). Overall permanent stroke and spinal cord injury was 12.6% and 3.6%. Four patients in the AAD group developed paraplegia and permanent stroke rate was significantly higher in AAD compared to non-AAD patients (17.3% vs. 2.8%; P=0.034). One, 3- and 5-year survival rates were 78.7%±4.0%, 72.2%±4.8%, and 64.3%±6.8% for the total cohort; survival at 1-, 3- and 5-year was 76.7%±5.0%, 71.0%±6.1%, and 64.5%±8.3% for the AAD cohort compared to 83.1%±6.3%, 75.0%±7.9% and 66.7% for non-AAD patients (P=0.579), respectively. Conclusions Our single-center experience confirms good early and mid-term survival after the FET procedure in patients presenting with AAD, CAD and aneurysm. Future efforts should focus on reduction of severe neurological complication.
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Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany.,Department of Cardiac Surgery, Kerckhoff Clinic, Bad Nauheim, Campus Kerckhoff, University of Giessen, Hessen, Germany
| | - Axel Kroener
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany.,Department of Cardiac Surgery, Kerckhoff Clinic, Bad Nauheim, Campus Kerckhoff, University of Giessen, Hessen, Germany.,Department of Vascular Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany.,Department of Cardiac Surgery, Kerckhoff Clinic, Bad Nauheim, Campus Kerckhoff, University of Giessen, Hessen, Germany
| | - Wael Ahmad
- Department of Vascular Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany.,Department of Cardiac Surgery, Kerckhoff Clinic, Bad Nauheim, Campus Kerckhoff, University of Giessen, Hessen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center of the University Hospital of Cologne, Cologne, Germany
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Harky A, Fok M, Bashir M. Which is the Optimal Frozen Elephant Trunk? A Systematic Review and Meta-Analysis of Outcomes in 2161 Patients Undergoing Thoracic Aortic Aneurysm Surgery Using E-vita OPEN PLUS Hybrid Stent Graft versus Thoraflex™ Hybrid Prosthesis. Braz J Cardiovasc Surg 2020; 35:427-436. [PMID: 32864920 PMCID: PMC7454613 DOI: 10.21470/1678-9741-2019-0220] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery. Methods A comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms. Results In total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies. Conclusion Although there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Fok
- Department of Vascular Surgery, Royal Liverpool Hospital, Liverpool, United Kingdom
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Haslingden Rd, Blackburn, United Kingdom
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Qin W, Su C, Li L, Carmichael M, Huang F, Chen X. Is limited aortic resection more justified in elderly patients with type A acute aortic dissection?-insights from single center experience. J Cardiothorac Surg 2020; 15:183. [PMID: 32703274 PMCID: PMC7379362 DOI: 10.1186/s13019-020-01234-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study compared limited aortic repair (ascending, and /or hemi-arch replacement) versus extended-arch repair (ascending, arch and proximal descending aortic replacement) used for patients aged 65 or older, who had type A acute aortic dissection (AAD), analyzing the influence of the extent of aortic repair on outcomes. METHODS From January, 2001 to December, 2015, 103 patients aged 65 or older underwent operation due to type A AAD in Nanjing First Hospital. The cohort was divided into two subgroups according to the surgical approaches, including limited aortic replacement (LAR, n = 41) and total arch replacement + stent elephant trunk implantation (TAR+SET, n = 62). RESULTS There was no significant difference in gender, age, hypertension, diabetes, smoking, PCI history, atrial fibrillation, pericardial effusion, aortic valve insufficiency (≥ moderate), shock situation before operation, and Euro-score II between the two groups except limb malperfusion and tear location. The cross-clamp time, CPB time, intubation time, ICU stay time and hospital time were all significantly less in the LAR group than in the TAR+SET group. A total of 89 patients were discharged home successfully after operation, with a difference of hospital mortality (P = 0.04). The overall survival rates at 5-year follow-up were 82.5 ± 6.0% in LAR group and 75.2 ± 5.6% in TAR+SET group, but with no difference (p = 0.151). The freedom from adverse aortic events at 5-year was 84.3 ± 6.5% in LAR group versus 97.9 ± 2.1% in TAR+SET group, with a statistical difference (p = 0.03). CONCLUSION These findings support limited aortic resection is acceptable for elderly patients with type A AAD if surgical principles allow.
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Affiliation(s)
- Wei Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China
| | - Liangpeng Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China
| | - Michael Carmichael
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China
| | - Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China.
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68# Changle Road, Nanjing, Jiangsu, 210006, P.R. China.
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Yang S, Xue Y, Zhang YC, Gao HQ, Jiang WJ, Li JR, Pan XD, Dong SB, Xu SD, Zheng J, Sun LZ. Sun's total arch replacement and stent elephant trunk with modified branch-first technique for patients with Stanford type A aortic dissection. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:755. [PMID: 32647680 PMCID: PMC7333118 DOI: 10.21037/atm-20-3791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Stanford type A aortic dissection (STAAD) is a critical cardiovascular disease, and surgical procedure is the first-choice treatment. The classical surgical procedure still leads to a high mortality rate and neurological complications. In this study, we introduce a new modified Sun’s procedure and investigate the association between the branch-first technique and the postoperative outcomes of patients with STAAD. Methods A total of 108 consecutive patients with STAAD who underwent arch replacement and stent elephant trunk procedure at Beijing Anzhen Hospital between July, 2017 and November, 2018 were included in the analysis. The patients were divided into two groups: the branch-first group and the classic group. The branch-first group and the classic group comprised 24 patients (22.2%) and 84 patients (77.8%), respectively. Results Patients in the branch-first group had a significantly shorter cardiopulmonary bypass (CPB) duration (172.4±29.9 vs. 194.9±47.4 min; P=0.035), Intensive care unit (ICU) stay [17.0 (14.6–38.2) vs. 42.1 (19.7–87.2) hours; P<0.001], and mechanical ventilation time [15.5 (11.9–40.0) vs. 19.0 (17.0–45.6) hours; P=0.018] than patients in the classic group. The branch-first was associated with a reduction in postoperative neurological complications in all models. Conclusions The benefits of the branch-first technique, including lower CPB duration, better bilateral cerebral perfusion, and higher nasopharyngeal temperature during hypothermic arrest, contributed to a shortened recovery time for patients after surgery.
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Affiliation(s)
- Sheng Yang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Yuan Xue
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - You-Cong Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Hui-Qiang Gao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Wen-Jian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Jian-Rong Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Xu-Dong Pan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Song-Bo Dong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Shang-Dong Xu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Jun Zheng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
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Wang X, Yang F, Zhu J, Liu Y, Sun L, Hou X. Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159:374-387.e4. [DOI: 10.1016/j.jtcvs.2019.01.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/16/2023]
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42
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Matsuzaki Y, Yamasaki T, Hohri Y, Hiramatsu T. Surgical Strategies for Type B Aortic Dissection by Frozen Elephant Trunk. Ann Vasc Dis 2019; 12:473-479. [PMID: 31942204 PMCID: PMC6957904 DOI: 10.3400/avd.oa.19-00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The timing and choice of surgical method for type B aortic dissection, is still a topic of much debate. We performed total arch replacement using frozen elephant trunk (TAR-FET) as a means of preventing distant aortic events, such as retrograde type A aortic dissection (RTAD). We conducted analysis of 142 patients with acute type B dissection who were admitted between January of 2010 and July of 2017. Fifty-five cases required surgical intervention to treat enlargement of the false lumen diameter and ULP formation 2 weeks after the onset of symptoms. 17 TAR-FET were performed with a mean of 42±26 days period from onset to surgery. There were no complications of RTAD or paraplegic, and 90% of patient demonstrated aortic event free survival (5 years) and false lumen reduction ratio of 35%. Based on our analysis, using TAR-FET properly avoids serious complications like RTAD, and is a viable treatment option for type B dissection. (This is a translation of J Jpn Coll Angiol 2018; 58: 151-157.).
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Affiliation(s)
- Yuichi Matsuzaki
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Takuma Yamasaki
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
| | - Takeshi Hiramatsu
- Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital, Kyoto, Kyoto, Japan
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43
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Kari FA, Saravi B, Krause S, Puttfarcken L, Wittmann K, Förster K, Rylski B, Maier S, Göbel U, Siepe M, Czerny M, Beyersdorf F. Spinal ischaemia after thoracic endovascular aortic repair with left subclavian artery sacrifice: is there a critical stent graft length? Eur J Cardiothorac Surg 2019; 53:385-391. [PMID: 28958025 DOI: 10.1093/ejcts/ezx285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/20/2017] [Accepted: 07/05/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Thoracic endovascular aortic repair (TEVAR) is used for treatment of thoracic aortic pathologies, but the covered stent graft can induce spinal ischaemia depending on the length used. The left subclavian artery contributes to spinal cord collateralization and is frequently occluded by the stent graft. Our objective was to investigate the impact of covered stent graft length on the risk of spinal ischaemia in the setting of left subclavian artery sacrifice. METHODS Twenty-six pigs (German country race, mean body weight 36 ± 4 kg) underwent simulated descending aortic TEVAR via left lateral thoracotomy, with left subclavian artery and thoracic segmental artery occlusion in normothermia. Animals were assigned to treatment groups according to simulated stent graft length: TEVAR to T8 (n = 4), TEVAR to T9 (n = 4), TEVAR to T10 (n = 4), TEVAR to T11 (n = 7) and TEVAR to T12 (n = 1) and a sham group (n = 6). End points included spinal cord perfusion pressure, cerebrospinal fluid pressure and spinal cord blood flow using fluorescent microspheres. RESULTS There were no group differences in spinal cord perfusion pressure drop or in spinal cord perfusion pressure regeneration potential at 3 h after the procedure: from a baseline average of 75 mmHg (95% confidence interval 71-83 mmHg) to 73 mmHg (67-75 mmHg) at 3 h in Group T10 versus from a baseline average of 67 mmHg (95% CI 50-81 mmHg) to 65 mmHg (95% confidence interval 48-81 mmHg) in Group T8. There were no differences in the spinal cord blood flow courses over time in the different groups nor was there any difference in cerebrospinal fluid pressure levels and cerebrospinal fluid pressure dynamics between groups. However, we did observe local blood flow distribution to the spinal cord that was inhomogeneous depending on the distance between the simulated stent graft end and the first thoracic anterior radiculomedullary artery. CONCLUSIONS The risk of spinal ischaemia after serial segmental artery occlusion does not depend on the distal extent of the aortic repair alone. Future attempts to allow patient risk stratification for spinal ischaemia need to focus on anterior radiculomedullary artery anatomy together with the extent of planned aortic repair.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Babak Saravi
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karin Wittmann
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Förster
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Anesthesiology and Critical Care, University Medical Center Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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44
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Wang X, Yang F, Wang L, Hou D, Zhu J, Liu Y, Sun L, Hou X. Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery. Can J Cardiol 2019; 35:1483-1490. [PMID: 31587932 DOI: 10.1016/j.cjca.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/22/2019] [Accepted: 07/07/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during aortic arch surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. METHODS From January 2009 to January 2016, 1691 patients who underwent aortic arch surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. RESULTS The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (Pfor interaction< 0.05). The high temperature group had a significant protective effect in the UACP ≤ 40 minutes subgroup (HR, 0.30; 95% CI, 0.12-0.74; P = 0.01) but not in the UACP > 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). CONCLUSIONS This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.
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Affiliation(s)
- Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dengbang Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Bashir M, Harky A, Velayudhan BV. Frozen Elephant Trunk: The Tale of the Tape. Semin Thorac Cardiovasc Surg 2019; 32:855-856. [PMID: 31279914 DOI: 10.1053/j.semtcvs.2019.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 05/24/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamad Bashir
- Department of Emergency Medicine, Macclesfield General Hospital, Macclesfield, United Kingdom.
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Bashi V Velayudhan
- Institute of Cardiac and Advanced Aortic Disorders, SIMS Hospitals, Chennai, India
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46
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Furutachi A, Takamatsu M, Nogami E, Hamada K, Yunoki J, Itoh M, Kamohara K. Early and mid-term outcomes of total arch replacement with the frozen elephant trunk technique for type A acute aortic dissection. Interact Cardiovasc Thorac Surg 2019; 29:753-760. [DOI: 10.1093/icvts/ivz154] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the outcomes of the frozen elephant trunk (FET) technique, using the J Graft FROZENIX for Stanford type A acute aortic dissection, in comparison with the unfrozen elephant trunk technique.
METHODS
Between January 2010 and August 2018, we performed total arch replacement for Stanford type A acute aortic dissection in our hospital. Thirty patients were treated by the elephant trunk procedure (ET group), and 20 patients were treated by the FET procedure (FET group). To evaluate aortic remodelling, we measured the area of the aorta, the true lumen and the false lumen at 12 months of follow-up.
RESULTS
Preoperative characteristics and operation time were not significantly different between the 2 groups. The quantity of blood transfused was much greater in the ET group than in the FET group. Resection or closure of the most proximal entry tear was obtained in 73.3% (22 out of 30 patients) in the ET group and 100% (20 out of 20 patients) in the FET group (P = 0.015). There was no case that had recurrent nerve palsy or paraplegia in the FET group. Stent graft-induced new entry occurred in 3 cases (15.8%) in the FET group. There were no significant differences between the 2 groups in aortic area, true lumen area or false lumen area.
CONCLUSIONS
Total arch replacement with the FET technique in Stanford type A acute aortic dissection carries a risk of distinct complications; however, with thorough advance planning, it should be possible to safely institute this treatment. Further randomization, with a comparison of each technique, is required to provide clear conclusions whether the FET is useful for acute Stanford type A aortic dissection.
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Affiliation(s)
- Akira Furutachi
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masanori Takamatsu
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Eijiro Nogami
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kohei Hamada
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Junji Yunoki
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Manabu Itoh
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Keiji Kamohara
- Department of Cardiovascular Surgery, Nagasaki Kouseikai Hospital, Nagasaki, Japan
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Liakopoulos OJ. Commentary: Spinal cord injury after the frozen elephant trunk procedure: Are we really safe now? J Thorac Cardiovasc Surg 2019; 159:1199-1200. [PMID: 31101345 DOI: 10.1016/j.jtcvs.2019.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany.
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48
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Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery. Ann Thorac Surg 2019; 107:1372-1379. [DOI: 10.1016/j.athoracsur.2018.10.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/25/2018] [Accepted: 10/16/2018] [Indexed: 11/17/2022]
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49
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López Almodóvar LF, Lima Cañadas P, Enríquez Puga A, Narváez Mayorga I, Buendía Miñano JA, Sánchez Casado M, Cañas Cañas A. Single Low-Volume Center Experience with Frozen Elephant Trunk in Acute Type A Aortic Dissections. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 6:125-129. [PMID: 31018235 PMCID: PMC6482024 DOI: 10.1055/s-0039-1677809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute Type A aortic dissection (AAAD) is a surgical emergency. In patients with arch and descending aorta involvement (DeBakey Type I), a total aortic arch replacement with frozen elephant trunk (FET) could favor false lumen thrombosis and improve long-term results. The authors hereby present their experience with this technique in a single low-volume center, to assess whether the technique is feasible to treat such disease. METHODS From January 2011 to December 2016, 43 patients with AAAD were operated on in the authors' institution, which carries out 300 to 350 annual procedures. Among these, 12 patients with an intimal tear in the aortic arch and/or proximal descending aorta received a FET procedure (10 males, age 57 years). Concomitant procedures were aortic valve replacement (42%), Bentall (25%), and aortic valve repair (17%). RESULTS Cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 235 ± 43, 171 ± 33, and 75 ± 20 minutes, respectively. The operative mortality was 16.7% (n = 2). Stroke and re-thoracotomy for bleeding occurred in 8% (n = 1) and 8% (n = 1), respectively. There was no spinal cord injury. Follow-up was 36.1 months. During follow-up, no patients died or required a reoperation on the downstream aorta. CONCLUSION Although all patients were operated on in a low-volume center, the results with FET in AAAD are acceptable. Even though this technique demands high technical skills, it is a promising approach in patients with acute aortic dissection.
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Affiliation(s)
| | - Pedro Lima Cañadas
- Department of Cardiac Surgery, Virgen de la Salud Hospital, Toledo, Spain
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Nishida H, Ota T. Commentary: Ongoing challenges for optimal strategy of aortic arch surgery. J Thorac Cardiovasc Surg 2019; 159:390-391. [PMID: 30902469 DOI: 10.1016/j.jtcvs.2019.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Hidefumi Nishida
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill
| | - Takeyoshi Ota
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill.
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