Systematic total arch replacement with thoraflex hybrid graft in acute type A aortic dissection: A single centre experience

Medium and long-term aortic remodeling following aortic valve replacement combined with anticoagulation for DeBakey I aortic dissection

Background

Total arch replacement with frozen elephant trunk has achieved promising outcomes for DeBakey type I aortic dissection. However, the effects of anticoagulation on the distal false lumen and unfavorable remodeling of the distal aorta after aortic valve replacement remains insufficiently understood. This study aimed to assess the impact of anticoagulation following aortic valve replacement on medium and long-term vascular remodeling outcomes in DeBakey type I aortic dissection.

Methods

We conducted a retrospective analysis of patients who underwent total arch replacement with a frozen elephant trunk for DeBakey Type I aortic dissection from September 2013 to December 2024. Seventy-two patients with preoperative and at least six months postoperative aortic computed tomography angiography images were included and stratified into a valve replacement group (n = 30) and a non-valve replacement group (n = 42). Various parameters of the residual dissected aorta were analyzed at six specific levels to evaluate late aortic remodeling, aortic diameter, and false lumen thrombosis.

Results

The median follow-up period was 17 (interquartile range IQR = 9-27) months. Preoperative characteristics and complications did not significantly differ between the two groups, except for body mass index, blood pressure, and severity of aortic regurgitation. The valve replacement group had longer cardiopulmonary bypass time, aortic cross-clamping time, cardiac arrest time, larger trunk diameter, and higher intraoperative red blood cells transfusion volume compared to the non-valve replacement group. However, there were no statistically significant differences in concomitant procedures, postoperative complications, or length of hospital stay. Regarding postoperative changes in the diameter of aortic lumen and true lumen, there were statistically significant difference in the true lumen on level 1 and the aortic lumen on level 3-5 of the valve replacement group. Additionally, the aortic lumen and true lumen on level 1 and true lumen on level 2 of the non-valve replacement group were statistically difference. There were no significant differences in the rate of aortic remodeling at each level or overall between the two groups. The postoperative false lumen thrombosis rate was higher in the mid-descending thoracic aorta and lower in the distal abdominal aorta.

Conclusions

Anticoagulation following aortic valve replacement for Debakey I aortic dissection has been shown to influence aortic diameter and the false lumen thrombosis rate, but it does not significantly affect the aortic remodeling rate. Overall, anticoagulation appears to be a viable treatment strategy for Debakey I aortic dissection.

Advances and Innovation in Acute Type a Aortic Dissection

The prompt and appropriate management of acute type A aortic dissections is imperative for patient survival. Advances in medical technology have broadened the adjuncts available to treat the spectrum of pathology within this population. The role of medical management prior to surgical intervention and the components of operative management, including cannulation strategies, neuroprotection, and the extent of aortic intervention, have been explored in-depth within the literature. More recent work has identified novel open and endovascular techniques available to treat acute type A dissections. This review aims to summarize the literature, with a particular focus on innovation in cardiac surgery and its role in the care of this high-risk population.

One-year outcomes of total arch replacement and frozen elephant trunk using the E-vita Open NEO

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.

Thoraflex Hybrid Prosthesis (THP): the profile

INTRODUCTION

With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority.

AREAS COVERED

This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted.

EXPERT OPINION

THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.