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Santoro A, Favia N, Valente FBA, Mascia D, Melissano G. Anatomical Feasibility of the "Canaud Technique" for Physician-Modified Thoracic Endovascular Grafts for the Treatment of Aortic Arch Disease. J Endovasc Ther 2024:15266028241258148. [PMID: 38850041 DOI: 10.1177/15266028241258148] [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: 06/09/2024]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR), originally conceived for deployment distal to the left subclavian artery (LSA), has been recently extended to more proximal landing zones. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The aim of this study is to report the proportion of patients with zone 0, 1, and 2 aortic arch lesions that could theoretically be treated with a C-PMEG. MATERIALS AND METHODS Computed tomography angiography (CTA) of all consecutive patient candidates to open, hybrid, or endovascular arch repair from January 2009 to July 2023 at our Institution were analyzed. The assessment of feasibility of C-PEMG was conducted following previously extensively described anatomical criteria. RESULTS During the study period, 209 consecutive patients were candidates for an open, hybrid, or endovascular aortic arch repair. Of them, 164 patients had a preoperative CTA scan eligible for analysis. One hundred twenty-six patients were male (76.8 %), with a mean age of 67 ± 10.8 years. Ninety-four patients (57.3%) were affected by atherosclerotic aneurysms, 48 post-dissecting aneurysms (29.3%) and 22 penetrating aortic ulcers (PAUs) (13.4%). Twenty patients (12.2%) were suitable for double-fenestrated C-PMEG, and 34 patients (20.7%) for single-fenestrated C-PMEG, totaling 32.9% of the entire cohort. The combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, would extend the C-PMEGs feasibility to 69 patients (42.1%). The use of an iliac graft conduit in 3 (1.8%) patients with inadequate ileo-femoral accesses would increase the C-PMEG suitability to 72 patients (43.9%). The main reason for exclusion was excessive ascending aortic diameter in 78 patients (47.6%). CONCLUSIONS The use of C-PMEG was shown to be theoretically feasible in a percentage of patients ranging from 32.9 to 43.9% affected by aortic arch aneurysms, dissections, and PAU. The main reason for exclusion was the dimension of the ascending aorta. The C-PMEG technique is a viable option in aortic arch lesions endovascular treatment. An off-the-shelf device with similar characteristics could also be used in emergency, avoiding the limitations of physician modifications (such as time for back-table procedure, sterility, off-label use). CLINICAL IMPACT Thoracic endovascular aortic repair (TEVAR) has been extended to more proximal landing zones for the treatment of aortic arch aneurysm, dissections, penetrating aortic ulcers. Among total endovascular solutions, the "Canaud technique" for Physician-Modified Thoracic Endovascular Grafts (C-PMEGs) has gained acceptance with good early results. The anatomical feasibility in 164 consecutive patients was 69 patients (42.1%), with the combination of supra-aortic trunks (SAT) bypass or the use of covered stent in IA or left common carotid artery (LCCA) as adjunctive maneuvers, showing that the C-PMEG technique is a viable option in aortic arch lesions endovascular treatment.
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Affiliation(s)
- Annarita Santoro
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Nicola Favia
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | | | - Daniele Mascia
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Germano Melissano
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
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Takei Y, Miyazaki S, Suzuki K, Saito S, Oogaki H, Muraoka Y, Ogasawara T, Tezuka M, Shibasaki I, Fukuda H. Hemodynamic predictors of negative false lumen remodeling after frozen elephant trunk for acute aortic dissection. Gen Thorac Cardiovasc Surg 2024; 72:376-386. [PMID: 37948001 PMCID: PMC11127806 DOI: 10.1007/s11748-023-01984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE We evaluated the blood flow within the downstream aortic false lumen after frozen elephant trunk repair for acute aortic dissection and identified hemodynamic predictors of false lumen expansion and negative false lumen remodeling using four-dimensional flow magnetic resonance imaging. METHODS Thirty-one patients (Stanford type A, n = 28; Stanford type B, n = 3) with patent false lumen who underwent frozen elephant trunk procedures for acute aortic dissection were included in this observational study. Each patient underwent computed tomography during the follow-up period and four-dimensional flow magnetic resonance imaging within 3 postoperative months. The false lumen volumetric expansion rate was calculated using computed tomography data. The direction and the rate of flow in the lower descending aortic false lumen were analyzed. Negative false lumen remodeling was defined as a volumetric increase of > 10% from the baseline volume. RESULTS Negative false lumen remodeling had developed in 6 of the 31 patients during the observation period. Most of the false lumen flows were biphasic during systole. The range between peak and nadir flow rates was associated with the false lumen volumetric expansion rate (β coefficient = 6.77; p < 0.01, R2 = 0.43). CONCLUSIONS The range between peak and nadir flow rates may serve as a hemodynamic predictor of negative false lumen remodeling, enabling further treatment for patients at risk of expansion in the downstream aorta.
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Affiliation(s)
- Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotuga-gun, Tochigi, 321-0293, Japan.
| | | | | | | | - Hayato Oogaki
- Department of Radiology, Dokkyo Medical University Hospital, Mibu-machi, Tochigi, Japan
| | - Yuki Muraoka
- Department of Radiology, Dokkyo Medical University Hospital, Mibu-machi, Tochigi, Japan
| | - Takeshi Ogasawara
- Mathematics and Statistics Section, Department of Fundamental Education, Dokkyo Medical University, Mibu-machi, Tochigi, Japan
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotuga-gun, Tochigi, 321-0293, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotuga-gun, Tochigi, 321-0293, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotuga-gun, Tochigi, 321-0293, Japan
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Comentale G, Pilato E. Safety of del Nido cardioplegia during frozen elephant trunk procedure: A case report of first experience in complex aortic surgery. Perfusion 2024; 39:833-835. [PMID: 36788423 DOI: 10.1177/02676591231157202] [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: 02/16/2023]
Abstract
We report the case of a 74 years-old male who underwent frozen elephant trunk due to a huge aortic arch aneurysm related to a type 1A endoleak after thoracic endovascular aortic repair where cardioplegic arrest was achieved using the Del Nido cardioplegia.
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Affiliation(s)
- Giuseppe Comentale
- Azienda Ospedaliera Universitaria "Federico II", Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
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Lee KFL, Bhatia I, Chan TLD, Au WKT, Ho KLC. Proximalization of Frozen Elephant Trunk Procedure: Zone 0 or 1 versus Zone 2 or 3 Arch Repair. Thorac Cardiovasc Surg 2024; 72:89-95. [PMID: 36216330 DOI: 10.1055/s-0042-1757631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Total arch replacement with the frozen elephant trunk (FET) procedure has changed the landscape of therapy for aortic arch diseases. The optimal landing zone for a FET is controversial. We sought to share our early and midterm results of the FET procedure as well as compare the clinical outcomes of proximal and distal FET anastomosis. METHODS A total of 100 patients who underwent total arch replacement using the FET technique were identified between November 2014 and August 2021. According to the FET anastomosis over the aortic arch, patients were classified into two groups (zone 0/1 vs. zone 2/3). In-hospital mortality, complications, and midterm outcomes were assessed based on patient characteristics. RESULTS The overall in-hospital mortality was 8%. Major complications occurred in 32% of patients, including spinal cord injury (5%), stroke (7%), and acute kidney injury requiring dialysis (7%). Zone 2/3 FET (odds ratio: 6.491, 95% confidence interval: 1.930-21.835, p = 0.003) was an independent predictor of the composite endpoint of major complications. The rate of complete false lumen thrombosis was comparable (64.3% vs. 71.4%, p = 0.567). All patients, patients with zone 0/1 FET, and patients with zone 2/3 FET had 3-year freedom from aorta-related events of 73.0, 70.2, and 75.0%, respectively. There were no significant differences (log-rank test, p = 0.500). CONCLUSION Compared with zone 2/3, proximalization of FET using zone 0/1 for anastomosis was associated with better early outcomes and comparable rates of midterm aorta-related events. To substantiate its use, more research on this approach is required.
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Affiliation(s)
- Kwok Fai Lucius Lee
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Tai Leung Daniel Chan
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Wing Kuk Timmy Au
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Ka Lai Cally Ho
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
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Kim CH, Kim TH, Lee H, Kim MS, Heo W, Yoo KJ, Cho BK, Song SW. One-year outcomes of total arch replacement and frozen elephant trunk using the E-vita Open NEO. Eur J Cardiothorac Surg 2024; 65:ezae017. [PMID: 38238991 DOI: 10.1093/ejcts/ezae017] [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: 09/08/2023] [Revised: 01/14/2024] [Accepted: 01/13/2024] [Indexed: 03/12/2024] Open
Abstract
OBJECTIVES In this cohort study, we aimed to assess the 1-year clinical outcomes of using the E-vita Open NEO™ hybrid prosthesis for total arch replacement with frozen elephant trunk (FET) to repair extensive aortic pathologies. METHODS We reviewed individuals who underwent thoracic aortic surgery between April 2021 and March 2023 from the Gangnam Severance Aortic Registry. Exclusion criteria included ascending aortic replacement, 1 or 2 partial arch replacement, descending aortic replacement and total arch replacement without an FET. Finally, all consecutive patients who underwent total arch replacement and FET with E-vita Open NEO for aortic arch pathologies between April 2021 and March 2023 were included in this cohort study. The patients were divided into 3 groups based on their pathology: acute aortic dissection, chronic aortic dissection and thoracic aortic aneurysm. The primary end point was in-hospital mortality. The secondary end points during the postoperative period comprised stroke, spinal cord injury and redo sternotomy for bleeding. Additionally, the secondary end points during the follow-up period included the 1-year survival rate, 1-year freedom from all aortic procedures and 1-year freedom from unplanned aortic interventions. RESULTS The study included 167 patients in total: 92 patients (55.1%) with acute aortic dissection, 20 patients (12.0%) with chronic aortic dissection and 55 patients (32.9%) with thoracic aortic aneurysm. The in-hospital mortality was 1.8% (n = 3). Strokes occurred in 1.8% (n = 3) of the patients, spinal cord injury in 1.8% (n = 3) and redo sternotomy for bleeding was performed in 3.0% (n = 5). There were no significant differences between the pathological groups. The median follow-up period (quartile 1-quartile 3) was 198 (37-373) days, with 1-year survival rates of 95.9%. At 1 year, the freedom from all aortic procedures and unplanned aortic interventions were 90.3% and 92.0%, respectively. CONCLUSIONS The 1-year clinical outcomes of total arch replacement with FET using the E-vita Open NEO were favourable. Long-term follow-up is required to evaluate the durability of the FET.
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Affiliation(s)
- Chong Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Myeong Su Kim
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Woon Heo
- Vascular Access Centre, Lifeline Clinic, Busan, Republic of Korea
| | - Kyung-Jong Yoo
- Department of Cardiovascular Surgery, Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bum-Koo Cho
- The Korea Heart Foundation, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea
- Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
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Doonan RJ, Senanayake E, Claridge M, Juszczak M, Torella F, Mascaro J, Field M, Adam DJ. Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00192-8. [PMID: 38403183 DOI: 10.1016/j.ejvs.2024.02.032] [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: 06/13/2023] [Revised: 02/08/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. METHODS Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. The primary endpoint was 30 day or in hospital death. The secondary endpoint was midterm survival. Data are presented as median (interquartile range [IQR]). The χ2 or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by calculating the Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered statistically significant. STROBE guidelines were followed. RESULTS A total of 158 patients (72 men; median age 70 years, IQR 64, 75; median distal aortic diameter 58 mm, IQR 46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. The peri-operative mortality rate was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, the distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (IQR 462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without a primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, IQR 60, 75; eight open, one hybrid, 35 endovascular repairs; no deaths) at a median of 256 days (IQR 135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (IQR 85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment. Median follow up was 46 months (IQR 26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%. CONCLUSION TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21%. Distal repair was ultimately indicated in 84% of survivors without a primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve midterm outcomes.
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Affiliation(s)
- Robert-James Doonan
- Division of Vascular Surgery, McGill University Health Centre, Montreal, Canada; Liverpool University Hospitals, Liverpool, UK
| | - Eshan Senanayake
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Maciej Juszczak
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesco Torella
- Liverpool University Hospitals, Liverpool, UK; Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Jorge Mascaro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Field
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Donald J Adam
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024:S0003-4975(24)00077-8. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Murana G, Gliozzi G, Di Marco L, Campanini F, Snaidero S, Nocera C, Rucci P, Barberio G, Leone A, Lovato L, Pacini D. Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience. Eur J Cardiothorac Surg 2024; 65:ezad364. [PMID: 37930039 PMCID: PMC10859176 DOI: 10.1093/ejcts/ezad364] [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: 04/20/2023] [Revised: 10/24/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVES The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022. METHODS The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022. RESULTS Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22). CONCLUSIONS The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.
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Affiliation(s)
- Giacomo Murana
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Francesco Campanini
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Silvia Snaidero
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Chiara Nocera
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Bologna, Italy
| | - Giuseppe Barberio
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luigi Lovato
- Cardiovascular Radiology Unit, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardio-Thoraco-Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, S.Orsola Hospital, University of Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [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: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Motta A, Scarpari C, Borrelli E, Formica F. Multiple Cardiac Diseases Involving the Aortic Arch: Beating Heart Debranching, and Normothermic Arch Replacement: A Case Series. J Clin Med 2024; 13:732. [PMID: 38337426 PMCID: PMC10856784 DOI: 10.3390/jcm13030732] [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: 12/07/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Conventional open surgery is still the gold standard for aortic arch disease, and despite recent developments in optimizing strategies for neuroprotection, distal organ perfusion, and myocardial protection, aortic arch replacement is still associated with high morbidity and mortality rates. (2) Methods: We present our case series of 12 patients undergoing surgical management of multiple cardiac diseases involving the aortic arch. In this single-center study, we report our initial experience over a five-year period (from December 2018 to October 2023) with the use of a "debranching first" technique for the supra-aortic vessels of a beating heart, followed by the cardiac step addressing proximal diseases, and a final distal step treating the aortic arch. This strategy aims to minimize cardiac, cerebral, and peripheral ischemia. (3) Results: Six patients underwent aortic root replacement with either Bentall (n = 4) or valve-sparing aortic root (David procedure) (n = 2). The mean nasopharyngeal temperature was 34 °C and the mean cardiocirculatory arrest was 14.3 min. The early mortality was 8.3% (1 patient); no patient experienced a permanent neurologic event. (4) Conclusions: In patients with complex aortic disease and concomitant cardiac disease, this approach reduces the need for hypothermia and decreases cardiopulmonary bypass time and myocardial arrest time and therefore could represent a valid surgical option, even in high-risk patients.
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Affiliation(s)
- Alessandro Motta
- UO Cardiochirurgia, APSS—Ospedale Santa Chiara, Largo Medaglie d’Oro, 38100 Trento, Italy; (C.S.); (E.B.)
| | - Cristian Scarpari
- UO Cardiochirurgia, APSS—Ospedale Santa Chiara, Largo Medaglie d’Oro, 38100 Trento, Italy; (C.S.); (E.B.)
| | - Ermelinda Borrelli
- UO Cardiochirurgia, APSS—Ospedale Santa Chiara, Largo Medaglie d’Oro, 38100 Trento, Italy; (C.S.); (E.B.)
- UO Cardiochirurgia, Salus Hospital, 42123 Reggio Emilia, Italy
| | - Francesco Formica
- UO Cardiochirurgia, APSS—Ospedale Santa Chiara, Largo Medaglie d’Oro, 38100 Trento, Italy; (C.S.); (E.B.)
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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11
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Kiziltepe U, Ince I, Senkal M, Surer S, Duvan I, Ersoy O, Delibalta O, Mavi O, Sahin E. Total aortic arch replacement without deep hypothermic circulatory arrest in type A aortic dissection: Left axillar artery for arterial cannulation. JTCVS Tech 2023; 22:120-131. [PMID: 38152213 PMCID: PMC10750496 DOI: 10.1016/j.xjtc.2023.08.020] [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: 04/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). The frozen elephant trunk technique (FET) additionally requires commercial hybrid grafts. Herein we describe a novel modified FET technique without CA using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection. Methods LAxA anastomosis is made first using a homemade debranching graft, and cardiopulmonary bypass is initiated, followed by anastomoses of left common carotid and innominate arteries. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta/root, cardiac reperfusion is started using a root cannula which continues throughout the procedure. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via left subclavian artery. Lower body perfusion is interrupted for 5 to 8 minutes to deploy an endograft to complete a modified FET. Following cannulation of distal arch graft, perfusion of distal aorta is restarted, and all three grafts are incorporated to construct a neo-ascending aorta and arch. Results Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7, and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body CA time was 7.2 ± 2.8 minutes. Conclusions TAR using standard endografts without CA is possible with LAxA cannulation. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies are required with a higher number of patients to evaluate the efficiency of this novel technique.
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Affiliation(s)
- Ugursay Kiziltepe
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ilker Ince
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Melike Senkal
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Suleyman Surer
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ibrahim Duvan
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ozgur Ersoy
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Delibalta
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Osman Mavi
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Elif Sahin
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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13
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Panfilov D, Saushkin V, Sazonova S, Kozlov B. Ascending Aortic Surgery for Small Aneurysms in Men and Women. Braz J Cardiovasc Surg 2023; 39:e20220179. [PMID: 37889231 PMCID: PMC10610907 DOI: 10.21470/1678-9741-2022-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/24/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION According to recent data, thoracic aortic surgery has reduced morbidity and mortality including ascending aortic aneurysm treatment; however, women are at increased postoperative risk of adverse outcomes. OBJECTIVE Our aim was to evaluate early and late outcomes in male and female patients who underwent pre-emptive ascending aortic replacement (AAR). METHODS From January 2013 to September 2021, 91 patients (56 [61.5%] men and 35 [38.5%] women) underwent AAR for small (ranged from 5.0 to 5.5 cm) non-syndromic aneurysms. A propensity score-based adjustment of the groups was performed. We compared clinical outcomes between males and females. RESULTS Preoperative normalized aortic diameters were significantly larger in females (2.9 [2.7; 3.2] cm/m2) than in males (2.5 [2.3; 2.6] cm/m2, P<0.001), without differences in absolute values (51 [49; 53] mm vs. 52 [50; 53] mm, P=0.356). There were no significant differences in neurological, cardiac, pulmonary, and renal complications in both groups before and after matching. In-hospital mortality was 1 (1.8%) and 2 (5.7%) (P=0.307) in male and female patients in unmatched groups and 1 (2.9%) and 2 (5.7%) (P=0.553) in matched groups, respectively. Univariate logistic regression analysis revealed that the only risk factor for in-hospital mortality was age (odds ratio 1.117, 95% confidence interval 1.003-1.244; P=0.04). The overall survival rate was 83.5±0.06% in men and 94.3±0.04% in women at 36 months (P=0.404). CONCLUSION Ascending aortic surgery for aneurysms ranged from 5.0 to 5.5 cm seems to have tolerable early and late outcomes in men and women.
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Affiliation(s)
- Dmitri Panfilov
- Cardiovascular Department, Cardiology Research Institute, Tomsk
National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian
Federation
| | - Victor Saushkin
- Cardiac Imaging Department, Cardiology Research Institute, Tomsk
National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian
Federation
| | - Svetlana Sazonova
- Cardiac Imaging Department, Cardiology Research Institute, Tomsk
National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian
Federation
| | - Boris Kozlov
- Cardiovascular Department, Cardiology Research Institute, Tomsk
National Research Medical Center, Russian Academy of Sciences, Tomsk, Russian
Federation
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Sharma VJ, Kanagarajah AR, Seevanayagam S, Kim M, Matalanis G. Branch-first Continuous Perfusion Aortic Arch Replacement: Midterm Results. Ann Thorac Surg 2023; 116:280-286. [PMID: 36152878 DOI: 10.1016/j.athoracsur.2022.09.020] [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: 06/23/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Aortic arch surgery necessitates interruption of perfusion, thus conferring higher morbidity and mortality compared with other aortic surgery. This report describes a branch-first continuous perfusion aortic arch replacement (BF-CPAR) technique that overcomes these shortcomings and describes midterm results with this technique. METHODS This report represents the corresponding author's 15-year experience with BF-CPAR, which involves preliminary mobilization and branch reconstruction before circulatory arrest by using a modified trifurcation graft. Demographic, procedural, and outcome (mortality, reintervention, morbidity, and stroke) were analyzed with Kaplan-Meier and Cox regression. RESULTS Over 15 years (July 2005-February 2021), 155 patients underwent BF-CPAR, at a median age of 66.8 years, 106 (68.3%) on an elective basis and 49 (31.6%) on an emergency basis. There were no aortic deaths after the first postoperative year, thereby resulting in a 1- and 10-year freedom from aortic death constant at 95.6% in patients undergoing elective BF-CPAR and 93.3% in patients undergoing emergency BF-CPAR patients, respectively. Freedom from reintervention on the operated segment at 5 and 9 years was 93.2% and 93.2% in patients undergoing elective cases and 97.1% and 91.4% in emergency cases, respectively. The 10-year freedom from any aortic reintervention was 72.8% in elective patients and 29.2% in emergency patients; there were 38 reinterventions, 76.3% (n = 29/38) done for progression of aneurysmal or dissection disease, of which 79.3% (n = 23/29) were completed endovascularly. Freedom from cerebrovascular-related events at 5 and 10 years was 90.3% and 82.6% in patients undergoing elective BF-CPAR and 75.4% for both time points in patients undergoing emergency BF-CPAR, respectively. CONCLUSIONS BF-CPAR has excellent 10-year results for elective and emergency cases of arch replacement.
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Affiliation(s)
- Varun J Sharma
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia; Department of Cardiac Surgery, Austin Health, Melbourne, Australia; Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia
| | | | - Siven Seevanayagam
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia; Department of Cardiac Surgery, Austin Health, Melbourne, Australia; Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia
| | - Michelle Kim
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia; Department of Cardiac Surgery, Austin Health, Melbourne, Australia; Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia
| | - George Matalanis
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia; Department of Cardiac Surgery, Austin Health, Melbourne, Australia; Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia.
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15
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Brickwedel J, Demal TJ, Detter C. Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review. Cardiovasc Diagn Ther 2023; 13:427-439. [PMID: 37583690 PMCID: PMC10423730 DOI: 10.21037/cdt-22-502] [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: 10/04/2022] [Accepted: 02/15/2023] [Indexed: 08/17/2023]
Abstract
Background and Objective Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery. Methods We conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported. Key Content and Findings Most studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure. Conclusions There is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.
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Affiliation(s)
- Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Till Joscha Demal
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart and Vascular Center Hamburg, Hamburg, Germany
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16
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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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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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18
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Zhao R, Qiu J, Dai L, Song J, Fan S, Cao F, Qiu J, Xu Z, Fan R, Guo Y, Gu T, Jiang X, Li D, Qiao C, Chen Z, Song B, Yu C. Current Surgical Management of Acute Type A Aortic Dissection in China: A Multicenter Registry Study. JACC. ASIA 2022; 2:869-878. [PMID: 36713764 PMCID: PMC9876964 DOI: 10.1016/j.jacasi.2022.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 12/03/2022]
Abstract
Background Many countries and regions have established multicenter registration studies to improve the outcomes of acute type A aortic dissection (ATAAD). Objectives The aims of this study were to report actual preoperative management, surgery type, and early outcomes of surgical treatment for ATAAD in China. Methods This cohort study uses data from the China Registry of Type A Aortic Dissection, a national clinical registry to investigate management of patients with Stanford type A aortic dissection. The data, including surgical management and outcomes of patients with ATAAD, were analyzed from January 2018 to December 2021. Results A total of 1,058 patients with ATAAD were enrolled in this study between January 2018 and December 2021. The mean age of all patients was 51.6 ±11.7 years. The median interval from onset to hospital was 10.65 hours (IQR: 6-24 hours), and the median interval from entering the emergency room to starting operation was 13 hours (IQR: 4.08-28.7 hours). Total arch repair was performed in 938 patients (88.7%), and frozen elephant trunk repair was performed in 800 patients (75.6%). The incidence of early mortality was 7.6%. Conclusions The population of patients with ATAAD in China experienced a longer interval from onset to arrival at the hospital, received more extensive aortic arch repair, and showed a relatively lower early mortality. These findings suggest that there may be a huge survivor bias in patients with ATAAD in China, more efforts should be made to promote prehospital emergency care and preoperative management of Chinese ATAAD patients. (A multicenter registration study of aortic dissection in China; ChiCTR1800015338).
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Affiliation(s)
- Rui Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Dai
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuya Fan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiyun Xu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ruixing Fan
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Tianxiang Gu
- Cardiac Surgery, First Hospital of China Medical University, Shenyang, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Decai Li
- Shandong Provincial Hospital, School of Medicine, Shandong University, Jinan, China
| | - Chenhui Qiao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziying Chen
- Department of Cardiac Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bing Song
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Address for correspondence: Dr Cuntao Yu, Department of Cardiovascular Surgery, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing 100037, China.
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Shalan A, Tenorio ER, Mascaro JG, Juszczak MT, Claridge MW, Melloni A, Bertoglio L, Chiesa R, Oderich GS, Adam DJ. Fenestrated-branched endovascular repair for distal thoraco-abdominal aortic pathology after total aortic arch replacement with frozen elephant trunk. J Vasc Surg 2022; 76:867-874. [PMID: 35697307 DOI: 10.1016/j.jvs.2022.04.035] [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: 01/25/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET). METHODS Interrogation of prospectively-maintained databases from four high volume aortic centres identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. Primary endpoint was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, mid-term survival and freedom from re-intervention. Data are presented as median (IQR). RESULTS 39 patients [21 men; median age, 73 years (67-75)] with degenerative (n=22) and post-dissection TAAAs (n=17) [median diameter 71 mm (61-78)] were identified. Distal FBEVAR was intended in 27 patients [median interval 9.8 months (6.2-16.6)], anticipated in seven and unexpected in five. 31 patients had a two (n=24) or three (n=7) stage distal FBEVAR. Reno-visceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. 30-day mortality was 2.6% [n=1; respiratory failure and spinal cord ischaemia (SCI)]. Six survivors also developed SCI which was associated with complete (n=4), or partial recovery (n=2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7). Eleven patients required 16 late re-interventions. Estimated 3-year survival and freedom from re-intervention were 84±6% and 63±10%, respectively. CONCLUSIONS Distal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Mid-term patient survival is favourable but there remains a high requirement for late re-intervention. FBEVAR represents an acceptable alternative to distal open TAAA repair.
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Affiliation(s)
- Ahmed Shalan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emanuel R Tenorio
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Jorge G Mascaro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Maciej T Juszczak
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin W Claridge
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gustavo S Oderich
- Mayo Clinic, Rochester, Minnesota and The University of Texas Health Sciences Centre at Houston, McGovern Medical School, Houston, Texas, USA
| | - Donald J Adam
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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20
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Berger T, Graap M, Rylski B, Fagu A, Gottardi R, Walter T, Discher P, Hagar MT, Kondov S, Czerny M, Kreibich M. Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection. Front Cardiovasc Med 2022; 9:911548. [PMID: 35734273 PMCID: PMC9207307 DOI: 10.3389/fcvm.2022.911548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Aim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure. Methods One hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed. Results Distal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure. Conclusion The incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
- *Correspondence: Tim Berger,
| | - Miriam Graap
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Muhammad Taha Hagar
- Department for Diagnostic and Interventional Radiology, Faculty of Medicine, Medical Centre-University of Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Hospital Freiburg Heart Centre, University of Freiburg, Freiburg, Germany
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Sule J, Chua CR, Teo C, Choong A, Sazzad F, Kofidis T, Sorokin V. Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections. SCAND CARDIOVASC J 2022; 56:91-99. [PMID: 35546567 DOI: 10.1080/14017431.2022.2074095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.
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Affiliation(s)
- Jai Sule
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Cher Rui Chua
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Caven Teo
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Choong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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22
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Berger T, Kreibich M, Mueller F, Breurer-Kellner L, Rylski B, Kondov S, Schröfel H, Pingpoh C, Beyersdorf F, Siepe M, Czerny M. Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique. Interact Cardiovasc Thorac Surg 2022; 34:865-871. [PMID: 35092274 PMCID: PMC9070457 DOI: 10.1093/icvts/ivac013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique. METHODS Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each's cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke. RESULTS Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20-8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28-19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09-360.84; P = 0.044) as predictors for postoperative stroke. CONCLUSIONS Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Felix Mueller
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Lara Breurer-Kellner
- Department of Neurology, Faculty of Medicine, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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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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24
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NEO E-vita—NEO era! Indian J Thorac Cardiovasc Surg 2022; 38:83-90. [PMID: 35463705 PMCID: PMC8980984 DOI: 10.1007/s12055-021-01303-0] [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: 06/22/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/31/2022] Open
Abstract
AbstractIn this review article, the history of the first commercially available thoracic aortic hybrid graft, the E-vita Open, later modified to the blood-impermeable E-vita Open Plus, is reported from its beginning in 2005 until its newest variation, the E-vita Open NEO, European conformity (CE) marked in 2020. Besides the background of its design and clinical experience in Essen, concomitant evolutionary steps in surgery as well as in strategic approaches like the hybrid operating room concept are displayed, finally leading to a well-rounded surgical package with a device that can be applied in all elective as well as emergency situations with complex arch involving aortic pathologies. With the E-vita Open NEO, now, surgery has been facilitated to convenient anastomosing in any of the arch zones, with the opportunity to use the island technique with a straight graft variation as well as individual head vessel anastomosing with either a trifurcated graft for zone 0 or the branched graft for zone 2 or 3 implantation. With its proven long-term stability, the surgical armamentarium to cope with complex multisegmental thoracic aortic pathologies has been significantly improved.
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25
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6553998. [DOI: 10.1093/ejcts/ezac171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
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Frozen Elephant Trunk in Aortic Arch Disease: Different Devices for Different Pathologies. MEDICINA-LITHUANIA 2021; 57:medicina57101090. [PMID: 34684127 PMCID: PMC8540975 DOI: 10.3390/medicina57101090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/28/2021] [Accepted: 10/09/2021] [Indexed: 11/16/2022]
Abstract
The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in the proximal descending thoracic aorta. In Europe, two hybrid prostheses are available: the E-evita Open Plus hybrid stent graft system provided by JOTEC (Hechingen, Germany) and the ThoraflexTM Hybrid (Vascutek, Inchinnan Scotland). Recommendations for use are extensive pathologies of the arch in case of acute and chronic aortic dissection, degenerative aneurysm and intramural hematoma. The FET approach allows the replacement of the whole arch in one stage with the option of direct treatment of the proximal descending thoracic aorta based on the stent component, creating a safe landing zone for further endovascular treatment more distally. The remarkable feature of this technique is the possibility to perform more proximally (from zone 3 to zone 0) the distal anastomosis in to the arch. This allows for an easier distal anastomosis, reduced hypothermic circulatory arrest time and decreased risk of paraplegia (<5%). Early results are promising and according to the most recent series the rate of developing post-operative renal insufficiency ranges from 3 to 10%, the risk of stroke from 3% to 8% and mortality from 8-15%. The aim of the article will be to provide some knowledge about the use and application of FET procedures in different aortic situations.
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Di Eusanio M, Gatta E. Frozen Elephant Trunk Without Circulatory Arrest in Acute Aortic Dissection. Ann Thorac Surg 2021; 112:e143-e145. [PMID: 33667459 DOI: 10.1016/j.athoracsur.2020.12.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/05/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
Aortic arch repair with frozen elephant trunk is increasingly offered to patients with extensive thoracic aortic disease. Given the magnitude of such a procedure, reported postoperative mortality and morbidity have to be considered adequate but not negligible. To further improve postoperative outcomes we developed a hybrid approach allowing frozen elephant trunk to be performed without hypothermia and circulatory arrest. After an initial experience in patients with chronic aneurysms, we successfully adopted the same approach in a patient with type 1 acute aortic dissection. Transfemoral stent-graft deployment, balloon clamping, and an always antegrade aortic perfusion are key elements of the approach presented here.
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Affiliation(s)
- Marco Di Eusanio
- Cardiac Surgery Department, Lancisi Cardiovascular Center, Ospedali Riuniti, Politechnic University of Marche, Ancona, Italy.
| | - Emanuele Gatta
- Vascular Surgery Department, Ospedali Riuniti, Ancona, Italy
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Grabenwöger M, Mach M, Mächler H, Arnold Z, Pisarik H, Folkmann S, Harrer ML, Geisler D, Moidl R, Winkler B, Bonatti J, Czerny M, Weiss G. Taking the frozen elephant trunk technique to the next level by a stented side branch for a left subclavian artery connection: a feasibility study. Eur J Cardiothorac Surg 2021; 59:1247-1254. [PMID: 33486518 PMCID: PMC8203250 DOI: 10.1093/ejcts/ezaa486] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/20/2020] [Accepted: 11/30/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Our goal was to develop a modified frozen elephant trunk (FET) prosthesis with a stented left subclavian artery (LSA) side branch for LSA connection and to perform preclinical testing in a human cadaver model. METHODS We measured aortic diameters, distance between and diameters of supra-aortic vessels and the distance from the LSA offspring to the level of the left vertebral artery offspring in 70 patients. Based on these measurements, a novel FET prosthesis was developed (Cryolife/Jotec, Hechingen, Germany) featuring a stented side branch for an intrathoracic LSA connection. The feasibility and ease of implantation were tested in 2 human cadaver models at the Anatomical Institute of the Medical University Graz. A covered stent graft (Advanta V12™ by Atrium Medical Corp., Hudson, NH, USA) was used for an LSA extension. RESULTS Accurate deployment of the novel FET prosthesis with anatomical orientation of the stented side branch towards the LSA ostium followed by consecutive stent graft deployment was feasible in both cases. Proximalizing the distal anastomosis level from zone 3 to zone 1 not only diminished the complexity of the procedure but substantially facilitated the completion of the distal anastomosis. A 2.5-cm long extension stent graft was sufficient to seal to the LSA and to maintain left vertebral artery patency in both cases. CONCLUSIONS This initial study in human anatomical bodies could demonstrate the feasibility of implanting a newly designed FET prosthesis. This evolution of the FET technique has the potential to substantially ease total aortic arch replacement by proximalization of the distal anastomosis into zone 1 and by shortening spinal and lower body hypothermic circulatory arrest times via a stented side branch to the LSA. This direct connection enables early restoration of systemic perfusion.
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Affiliation(s)
- Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Sigmund Freud University, Medical Faculty, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria,Corresponding author. Department of Cardiovascular Surgery, Clinic Floridsdorf Vienna, Brünner Strasse 68, 1210 Vienna, Austria. Tel: +43-1-277004308; e-mail: (M. Grabenwöger)
| | - Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Heinrich Mächler
- Department of Cardiac Surgery, Medical University Graz, Graz, Austria
| | - Zsuzsanna Arnold
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Harald Pisarik
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Sandra Folkmann
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Marie-Luise Harrer
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Daniela Geisler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Reinhard Moidl
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Bernhard Winkler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Sigmund Freud University, Medical Faculty, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Johannes Bonatti
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria,Institute of Cardiovascular Research, Karl Landsteiner Society, Austria
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, Faculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Gabriel Weiss
- Sigmund Freud University, Medical Faculty, Vienna, Austria,Department of Vascular Surgery, Clinic Ottakring, Vienna, Austria
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29
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Chabry Y, Porterie J, Gautier CH, Nader J, Chaufour X, Alsac JM, Reix T, Marcheix B, Koskas F, Ruggieri VG, Achouh P, Caus T. The frozen elephant trunk technique in an emergency: THORAFLEX French National Registry offers new insights. Eur J Cardiothorac Surg 2020; 59:ezaa325. [PMID: 33141214 DOI: 10.1093/ejcts/ezaa325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/04/2020] [Accepted: 07/18/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to study the immediate outcome after an emergency frozen elephant trunk procedure with a Thoraflex™ Hybrid prosthesis (THP) in patients included in the EPI-Flex national registry and operated on in 21 French centres. METHODS All patients operated on in France between April 2016 and April 2019 for acute aortic syndromes and who had an frozen elephant trunk procedure with a THP were included in the study. The main end point was in-hospital mortality. The secondary end point was neuromorbidity, including paraplegia. The evolution of the main end point was monitored using a variable life-adjusted display graph with cumulative sum derivatives in order to stop inclusions in case the observed mortality became out of range compared to an expected mortality between 15% and 20%. RESULTS Enrolment ended on the scheduled date and included 109 patients. Most cases (54%) were performed at 3 centres, where more than 10 THP each were implanted (10-26). The observed mortality in the large-volume centres (22%) was comparable to that observed in the low-volume centres (20%). The individually risk-adjusted cumulative sum revealed that observed in-hospital mortality was statistically in line with that predicted by the log EuroSCORE. Analysis of the secondary end point revealed 8% cases of paraplegia, all of which appeared after treatment of the thoracic type A aortic dissection. CONCLUSIONS In France, THP for emergency frozen elephant trunk surgery outside high-volume centres did not result in excessive in-hospital deaths. However, a word of caution must be expressed regarding the prevention of medullar ischaemia even in emergency aortic surgery.
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Affiliation(s)
- Yuthiline Chabry
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Jean Porterie
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Charles-Henri Gautier
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Joseph Nader
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Xavier Chaufour
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Jean Marc Alsac
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Thierry Reix
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
| | - Bertrand Marcheix
- Department of Cardiac and Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Fabien Koskas
- Department of Vascular Surgery, University Hospital Pitié-Salpétrière, APHP, Paris, France
| | - Vito Giovanni Ruggieri
- Department of Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
| | - Paul Achouh
- Department of Cardiac and Vascular Surgery, University Hospital European Hospital Georges-Pompidou, Paris, France
| | - Thierry Caus
- Federation of Heart, Lung and Vessels, University Hospital Amiens-Picardie, Amiens, France
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