1
|
Ibrahim M, Chung JCY, Ascaso M, Hage F, Chu MWA, Boodhwani M, Sheikh AA, Leroux E, Ouzounian M, Peterson MD. In-hospital thromboembolic complications after frozen elephant trunk aortic arch repair. J Thorac Cardiovasc Surg 2024; 167:1217-1226. [PMID: 36137836 DOI: 10.1016/j.jtcvs.2022.08.005] [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: 05/15/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic). METHODS A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed. RESULTS Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P < .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient. CONCLUSIONS Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.
Collapse
Affiliation(s)
- Marina Ibrahim
- Division of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Ascaso
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Azmat A Sheikh
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Emilie Leroux
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Luthra S, Miskolczi S, Velissaris T, De Silva RJ, Luehr M, Kempfert J, Moon MC. Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections. Eur J Cardiothorac Surg 2024; 65:ezae154. [PMID: 38598445 DOI: 10.1093/ejcts/ezae154] [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: 09/03/2023] [Revised: 03/22/2024] [Accepted: 04/08/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. METHODS Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. RESULTS A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. CONCLUSIONS Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.
Collapse
Affiliation(s)
- Suvitesh Luthra
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
- Academic Unit of Human Development and Health, University of Southampton, Southampton, UK
| | - Szabolcs Miskolczi
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
| | - Theodore Velissaris
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton, Southampton, UK
| | - Ravi J De Silva
- Division of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Maximilian Luehr
- Department of Cardio-Thoracic Surgery, Heart Center of the University of Cologne, Cologne, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Michael C Moon
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Alberta, Canada
| |
Collapse
|
3
|
Al-Tawil M, Jubouri M, Tan SZ, Bailey DM, Williams IM, Mariscalco G, Piffaretti G, Chen EP, Velayudhan B, Mohammed I, Bashir M. Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection? Asian Cardiovasc Thorac Ann 2023; 31:596-603. [PMID: 36560846 DOI: 10.1177/02184923221147442] [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: 12/24/2022]
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement. AIMS This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase. RESULTS TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair. CONCLUSION Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.
Collapse
Affiliation(s)
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gabrielle Piffaretti
- Vascular Surgery - Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, DUMC 3442, Durham, NC, USA
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
| |
Collapse
|
4
|
Tan SZCP, Mohammed I, Bashir M. Frozen Elephant Trunk Sizing: A 30,000-Feet Perspective with Thoraflex Hybrid Stent Graft. AORTA (STAMFORD, CONN.) 2022; 10:182-190. [PMID: 36521811 PMCID: PMC9754870 DOI: 10.1055/s-0042-1756667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There is currently no standard, evidence-based approach for sizing the Thoraflex Hybrid prosthesis in frozen elephant trunk surgery. We present regional data on 906 Thoraflex grafts implanted in the United Kingdom between December 2012 and August 2021 to emphasize the heterogeneity in sizing practices and evaluate the impact this may have on clinical outcomes. Highlighting this heterogeneity will help develop an evidence-based approach to prosthesis sizing, thereby aiding decision-making for arch repair.
Collapse
Affiliation(s)
- Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India,Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran,Department of Vascular and Endovascular Surgery, Velindre University National Health Service Trust, Health and Education Improvement Wales, Wales, United Kingdom,Address for correspondence Mohamad Bashir, MD, PhD, MRCS Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health and Education Improvement WalesWales CF15 7QQUnited Kingdom
| |
Collapse
|
5
|
Pathare P, Elbayomi M, Tandler R, Weyand M, Harig F. Successive surgical repair of a progressive aortic dissection in a case of Loeys-Dietz Syndrome. J Card Surg 2022; 37:5634-5638. [PMID: 36403262 DOI: 10.1111/jocs.17221] [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: 08/24/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The Frozen Elephant Trunk technique is a well-established treatment for aortic dissections (Stanford Type A) involving the aortic arch and descending aorta. The Thoraflex™ Hybrid prosthesis (Vascutek Ltd.), consisting of a proximal flexible conduit and a distal self-expanding covered stent, has consistently shown positive results in the treatment of this condition. CASE DESCRIPTION The following is a description of such a staged reconstruction using the Thoraflex™ Hybrid Ante-Flo™ device, performed in a patient previously diagnosed with Loeys-Dietz Syndrome. After clamping the aorta proximally, an incision was taken at the distal end of the stent. Here, the distal end of the new prosthesis was inserted into the true lumen of the descending aorta and the stent was deployed. Following this, a bypass was established via the left atrium, and blood was returned to the lower body using the perfusion arm of the prosthesis with the proximal part of the descending aorta clamped. The collar of the prosthesis was sutured proximally to the aorta near the inlying previous stent. Air was removed via the perfusion arm of the prosthesis, which was then oversewn. DISCUSSION To date, hybrid prostheses have only been used on the proximal aorta in patients with aortic aneurysms and aortic dissections (Stanford Type A). CONCLUSION Using the described technique, it is possible to reconstruct the aortic anatomy using the available prostheses with accuracy and minimal complications.
Collapse
Affiliation(s)
- Presheet Pathare
- Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Mohamed Elbayomi
- Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Rene Tandler
- Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Michael Weyand
- Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Frank Harig
- Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany
| |
Collapse
|
6
|
Mohammed I, Tan SZ, Jubouri M, Shaw M, Bashir M. Institutional practice in sizing of the hybrid prosthesis in frozen elephant trunk surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:406-414. [PMID: 35343661 DOI: 10.23736/s0021-9509.22.12303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The frozen elephant trunk (FET) technique for total arch replacement (TAR) is widely used for repair of aortic arch dissections and aneurysms. Despite its widespread adoption, there are no international or regional guidelines for the sizing of FET prostheses in TAR. We seek to highlight the heterogeneity thereof and pave the way for evidence-based guidelines to advise FET prosthesis sizing in TAR. METHODS An online questionnaire was sent to 22 specialist aortic surgeons from 13 different countries across North America, Europe, Asia, and Australia, inquiring about each surgeon's approach to FET prosthesis sizing. The results were then pooled for frequency analysis. RESULTS All 22 surgeons responded to the questionnaire. Zone 2 is preferred implantation zone for AAD, CAD, and TAA (selected by 72.7%, 72.7%, and 68.2% respectively). The maximal diameter of the true lumen in the DTA is the most common index measurement for AAD and CAD (40.9% and 59.1%, respectively). Stent-graft diameters equal to the index measurement is the most common approach for AAD and CAD (77.3% and 45.5%, respectively) while 59.1% of surgeons oversize the index diameter by 10% for TAA; 100 mm is the preferred length for 50.0%, 27.3%, and 40.9% of surgeons in AAD, CAD, and TAA respectively. CONCLUSIONS There is considerable heterogeneity in sizing practices for FET prostheses internationally, with variable evidence for its impact on clinical outcomes. This issue would be aided by the development of evidence-based guidelines to inform clinical decision making.
Collapse
Affiliation(s)
- Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, York, UK
| | - Matthew Shaw
- Research Unit, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India -
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
| |
Collapse
|
7
|
Tan SZCP, Jubouri M, Mohammed I, Bashir M. What Is the Long-Term Clinical Efficacy of the Thoraflex™ Hybrid Prosthesis for Aortic Arch Repair? Front Cardiovasc Med 2022; 9:842165. [PMID: 35282343 PMCID: PMC8905287 DOI: 10.3389/fcvm.2022.842165] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/03/2022] [Indexed: 01/02/2023] Open
Abstract
Background The widespread adoption of the frozen elephant trunk (FET) technique for total arch reconstruction (TAR) in aortic arch aneurysm and dissection has led to the development of numerous commercial single-piece FET devices, each with its own unique design features. One such device, Thoraflex™ Hybrid (Terumo Aortic, Glasgow, Scotland), has enjoyed widespread use since its introduction. We present and appraisal of its long-term clinical efficacy, based on international data. Materials and Methods Pre-, intra-, and postoperative data associated with Thoraflex™ Hybrid implantations for aortic arch dissection, aneurysm, and penetrating atherosclerotic ulcer (PAU) up to April 2019 was gathered and is presented herein. Follow-up data at discharge, 3-, 6-, 12-, 24-, 36-, 48-, 60-, 72-, and 84- months post-implantation are included. Results Data associated with 931 cases of Thoraflex™ Hybrid implantation are included. Mean age at implantation was 63 ± 12 years. 55% of patients included were male. Aortic dissection accounted for 48% (n = 464) of cases. Mean cardiopulmonary bypass and circulatory arrest durations were 202 +72 and 69 ± 50 min, respectively. 30-day mortality was 0.6% (n = 6), while overall mortality was 14 (1.5%). Freedom from adverse events at 84 months was 95% (n = 869). Postoperative complications included neurological deficit, multi-organ failure, cardiorespiratory compromise, and infection. Discussion Thoraflex™ Hybrid's unique design is advantageous in comparison to market alternatives. Our data is consistent with that reported in literature and suggests Thoraflex™ Hybrid is associated with favourable rates of mortality and morbidity. Conclusion Thoraflex™ Hybrid remains a central player in the aortic arch prosthesis market. Its use it widespread and is associated with favourable design features and clinical outcomes relative to market alternatives.
Collapse
Affiliation(s)
- Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Matti Jubouri
- Hull York Medical School, University of York, York, United Kingdom
| | - Idhrees Mohammed
- Cardiovascular Department, SRM Institute of Medical Science, Institute of Cardiac & Aortic Disorders, SIMS Hospital, Chennai, India
| | - Mohamad Bashir
- Cardiovascular Department, SRM Institute of Medical Science, Institute of Cardiac & Aortic Disorders, SIMS Hospital, Chennai, India.,Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, United Kingdom
| |
Collapse
|
8
|
Beckmann E. Frozen elephant trunk: What can the Salerno experience tell us? J Card Surg 2021; 37:115-116. [PMID: 34661925 DOI: 10.1111/jocs.16088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| |
Collapse
|
9
|
Giambuzzi I, Bonalumi G, Parolari A, Di Mauro M. Commentary: Do not close a door that opens a window! JTCVS Tech 2021; 9:11-12. [PMID: 34647043 PMCID: PMC8501188 DOI: 10.1016/j.xjtc.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/31/2022] Open
Affiliation(s)
- Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy
- Dipartimento Scienze Cliniche e di Comunità, University of Milan, Milan, Italy
| | - Giorgia Bonalumi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy
| | - Alessandro Parolari
- Unit of Cardiac Surgery and Translational Research, IRCCS Policlinico S. Donato, University of Milan, Milan, Italy
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
10
|
Rezaei Y, Bashir M, Mousavizadeh M, Daliri M, Aljadayel HA, Mohammed I, Hosseini S. Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization. J Card Surg 2021; 36:1922-1934. [PMID: 33665866 DOI: 10.1111/jocs.15452] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta-analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization. METHODS We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR). RESULTS A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in-hospital mortality were 7.104 (95% confidence interval [CI], 5.691-8.661; I2 = 78.53%), 3.465 (95% CI, 2.852-4.136; I2 = 15.96), 14.969 (95% CI, 11.361-18.977; I2 = 91.26%), and 8.933 (95% CI, 7.128-10.919; I2 = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36-0.81; p = .003; I2 = 0%). CONCLUSIONS The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.
Collapse
Affiliation(s)
- Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Daliri
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Abo Aljadayel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
11
|
Chauvette V, Ouzounian M, Chung J, Peterson M, Boodhwani M, El-Hamamsy I, Dagenais F, Valdis M, Chu MWA. Review of frozen elephant trunk repair with the Thoraflex Hybrid device. Future Cardiol 2021; 17:1171-1181. [PMID: 33544641 DOI: 10.2217/fca-2020-0152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.
Collapse
Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Division of Cardiac Surgery, Montreal University, Montreal, QC H3T 1J4, Canada
| | - Maral Ouzounian
- Department of Surgery, Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Jennifer Chung
- Department of Surgery, Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Mark Peterson
- Department of Surgery, Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Munir Boodhwani
- Department of Surgery, Division of Cardiac Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - François Dagenais
- Department of Surgery, Division of Cardiac Surgery, Laval University, Quebec, QC G1V 0A6, Canada
| | - Matthew Valdis
- Department of Surgery, Division of Cardiac Surgery, Western University, London, ON N6A 3K7, Canada
| | - Michael W A Chu
- Department of Surgery, Division of Cardiac Surgery, Western University, London, ON N6A 3K7, Canada
| | | |
Collapse
|
12
|
Total arch replacement and frozen elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg 2020; 164:1400-1409.e3. [PMID: 33341270 DOI: 10.1016/j.jtcvs.2020.10.135] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The present study aimed to evaluate the outcomes of total aortic arch replacement with proximalization of distal anastomosis using the frozen elephant trunk technique with the J Graft FROZENIX (Japan Lifeline, Tokyo, Japan) and Gelweave Lupiae (Vascutek Terumo Inc, Scotland, United Kingdom) graft (distal anastomosis performed in zones 1 and 2) in patients with acute Stanford type A acute aortic dissection. METHODS A total of 50 patients underwent total aortic arch replacement using the frozen elephant trunk technique, deploying the J Graft FROZENIX into zone 1 or 2 (zone 1: n = 17, zone 2: n = 33) in combination with the Gelweave Lupiae graft for acute Stanford type A acute aortic dissection. Patient characteristics, intraoperative data, and early and midterm outcomes were analyzed. RESULTS The overall in-hospital mortality rate was 4% (2 patients). The in-hospital mortality rate in patients with visceral malperfusion was 11% (1/9). There were no patients with paraplegia and stent graft-induced new entry. Resection or closure of the most proximal entry tear was achieved in 100% of 42 patients who had postoperative computed tomography. The overall survival was 87.9%, 84.1%, and 84.1% at 1, 2, and 3 years, respectively. However, 1 patient required endovascular extension for the dilatation of the descending thoracic aorta 4 months after the initial surgery. CONCLUSIONS Total aortic arch replacement with the frozen elephant trunk technique (zone 1-2) and Gelweave Lupiae graft was safe and effective in simplifying surgery for acute Stanford type A acute aortic dissection.
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Leone A, Murana G, Coppola G, Berardi M, Botta L, Di Bartolomeo R, Di Marco L, Pacini D. Frozen elephant trunk-the Bologna experience. Ann Cardiothorac Surg 2020; 9:220-222. [PMID: 32551254 DOI: 10.21037/acs.2020.03.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giuditta Coppola
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marianna Berardi
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| |
Collapse
|
15
|
Eldeiry M, Aftab M, Bergeron E, Pal J, Cleveland JC, Fullerton D, Reece TB. The Buffalo Trunk Technique for Aortic Arch Reconstruction. Ann Thorac Surg 2019; 108:680-686. [DOI: 10.1016/j.athoracsur.2019.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/12/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
|
16
|
Aortic arch replacement with frozen elephant trunk technique - a single-center study. J Cardiothorac Surg 2019; 14:147. [PMID: 31370864 PMCID: PMC6676558 DOI: 10.1186/s13019-019-0969-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/22/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes. METHODS From 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n = 57) or the Vascutek Thoraflex hybrid prosthesis (n = 11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each. RESULTS Early mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p = 0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p = 0.797 and spinal cord injury: 8.8 vs. 5.9%; p = 0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2 ± 73.5 and 148.3 ± 34 min vs. 189.2 ± 47.8 and 116.3 ± 34.5 min; p < 0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p = 0.575. CONCLUSION The FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.
Collapse
|
17
|
Chu MW, Losenno KL, Dubois LA, Jones PM, Ouzounian M, Whitlock R, Dagenais F, Boodhwani M, Bhatnagar G, Poostizadeh A, Pozeg Z, Moon M, Kiaii B, Peterson MD. Early Clinical Outcomes of Hybrid Arch Frozen Elephant Trunk Repair With the Thoraflex Hybrid Graft. Ann Thorac Surg 2019; 107:47-53. [DOI: 10.1016/j.athoracsur.2018.07.091] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/27/2018] [Accepted: 07/30/2018] [Indexed: 12/01/2022]
|
18
|
Dashkevich A, Hagl C, Juchem G, Luehr M, Pichlmaier MA. Management of Retrograde False Lumen Perfusion After Hybrid Arch Repair in Acute Aortic Dissection. Ann Thorac Surg 2017; 103:e377-e379. [PMID: 28359505 DOI: 10.1016/j.athoracsur.2016.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022]
Abstract
Patients with acute aortic dissections involving the arch and descending aorta can effectively be treated using the frozen elephant trunk technique. We describe here the novel technique of temporary banding of the descending aorta onto the stent of the hybrid graft in 3 patients who developed unmanageable bleeding from the distal suture line due to retrograde false lumen perfusion and disintegration of the adventitia. Retrograde false lumen perfusion was stopped and therefore bleeding controlled in all patients. Temporal aortic banding represents a novel, feasible, and effective bailout technique for otherwise unmanageable bleeding with fatal outcome in hybrid arch surgery.
Collapse
Affiliation(s)
- Alexey Dashkevich
- Department of Cardiac Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerd Juchem
- Department of Cardiac Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maximilian Luehr
- Department of Cardiac Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | |
Collapse
|
19
|
Frozen versus conventional elephant trunk technique: application in clinical practice. Eur J Cardiothorac Surg 2017; 51:i20-i28. [DOI: 10.1093/ejcts/ezw335] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 08/10/2016] [Indexed: 01/16/2023] Open
|
20
|
Di Marco L, Pacini D, Sposito M, Leone A, Pilato E, Loforte A, Lococo V, Di Bartolomeo R. Single-step surgical procedure for total replacement of the thoracic aorta in a case of Turner syndrome. Int J Cardiol 2015; 199:116-8. [PMID: 26188830 DOI: 10.1016/j.ijcard.2015.06.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/26/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Luca Di Marco
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mirko Sposito
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emanuele Pilato
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonino Loforte
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Valeria Lococo
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
21
|
Szeto WY. Conventional versus frozen elephant trunk for complex aortic arch pathology: What should we be doing now? J Thorac Cardiovasc Surg 2015; 149:1294-5. [DOI: 10.1016/j.jtcvs.2015.02.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 11/17/2022]
|