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Li Q, Li B, Xi S, Li Z, Zhu Z, Jin Z, Yang F, Liu L. Experience with aortic arch inclusion technique using artificial blood vessel for type A aortic dissection: an application study. J Cardiothorac Surg 2024; 19:189. [PMID: 38589942 PMCID: PMC11000396 DOI: 10.1186/s13019-024-02741-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/29/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND This study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD). METHODS We conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular "inclusion" between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The 'inclusion' total aortic arch replacement and stented elephant trunk (SET) surgery were performed. RESULTS Four patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient's false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up. CONCLUSIONS Incorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.
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Affiliation(s)
- Qingfeng Li
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Bin Li
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Shuqiang Xi
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Zhaobin Li
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Zhe Zhu
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Zeyue Jin
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Fan Yang
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China
| | - Lei Liu
- Department of Carvascular Surgery, Hebei Medical University Third Hospital, Shijiazhuang, Hebei Province, China.
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Boldyrev S, Shumkov D, Barbuhatti K, Porkhanov V. Aortic valve resuspension using the Florida sleeve technique with replacement of the aortic arch by stent grafting the thoracic aorta with the hybrid prosthesis E-Vita Open Plus in a patient with DeBakey type I acute aortic dissection. Multimed Man Cardiothorac Surg 2024; 2024. [PMID: 38258652 DOI: 10.1510/mmcts.2023.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Surgery for acute type A aortic dissection is highly challenging, even in expert hands. The goal in such emergency circumstances is primarily to save the patient's life. To minimize the perioperative risk, surgeons often choose surgery involving only supracoronary ascending aortic and hemiarch replacement. However, to achieve a successful repair, the extremely fragile dissected aortic layers must be reconstructed proximally and distally. Most of the surgical procedures for patients with acute type A aortic dissection are supracoronary ascending aortic replacements. Thereby, the Florida sleeve procedure is an attractive alternative for reimplanting the entire aortic root into a Dacron graft. This approach has overcome most of the technical problems associated with composite valve graft or valve-sparing procedures. The frozen elephant trunk procedure is particularly appealing for treating acute type A aortic dissection because of its ability to treat malperfusion by encouraging true lumen expansion and potentially reducing longer-term adverse remodelling within the descending aorta.
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Affiliation(s)
- Sergey Boldyrev
- Department for Adult Cardiac Surgery, S.V. Ochapowski Regional Hospital #1, Krasnodar, Russia
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3
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Mitsuishi A, Hirose N, Okamoto U, Noguchi T, Kawaguchi J, Miura Y. Thoracic endovascular aortic repair for hemolysis 17 years after insertion of classical elephant trunk: a case report. J Cardiothorac Surg 2023; 18:311. [PMID: 37950275 PMCID: PMC10638693 DOI: 10.1186/s13019-023-02415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The classical elephant trunk (ET) technique is a very useful surgical procedure; however, haemolysis in the aorta associated with ET has been previously reported. It normally occurs within several years after the surgery, and it is a rare case of rapidly progressing haemolysis 10 or more years after aortic arch replacement with ET. CASE PRESENTATION A 53-year-old man with a history of Stanford type A aortic dissection (DeBakey type Is), who was treated with total arch aortic replacement and aorto-femoral bypass using a prosthetic graft 17 years ago, developed severe progressive haemolytic anaemia. The ET used for the initial surgery was narrowed, and mechanical haemolysis was suspected. We assumed that progressive mechanical haemolysis occurred because of degeneration of the prosthetic graft. Thoracic endovascular aortic repair was performed, and haemolysis and anaemia were mitigated postoperatively. CONCLUSIONS Haemolysis occurred 17 years after the initial surgery with ET. When haemolysis is suspected in a patient with ET, it must be identified as a cause of haemolysis even if 10 years or more have passed since the ET was inserted. To prevent this complication, attention should be paid to an appropriate ET length and diameter to avoid folding of the ET, particularly when the true cavity diameter is small.
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Affiliation(s)
- Atsuyuki Mitsuishi
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-Shi, Kochi Prefecture, 783-8505, Japan.
| | - Nobuyuki Hirose
- Department of Cardiology, Izumino Hospital, 2-10-53 Azono, Kitamachi, Kochi Prefecture, 781-0011, Japan
| | - Unpei Okamoto
- Department of Cardiovascular Surgery, University Hospital, Kyoto Prefectual Hospital of Medicine, 465, Kajiicho, Kamigyo Ward, Kyoto, 602-8566, Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-Shi, Kochi Prefecture, 783-8505, Japan
| | - Juri Kawaguchi
- Department of Cardiology and Geriatrics, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-Shi, Kochi Prefecture, 783-8505, Japan
| | - Yujiro Miura
- Department of Cardiovascular Surgery, Kochi Medical School Hospital, 185-1, Kohasu, Okohcho, Nankoku-Shi, Kochi Prefecture, 783-8505, Japan
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Kemp U, Zhu A. Can a 'branch-first' approach to aortic arch replacement be safely utilized in Stanford type A acute aortic syndromes? Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad172. [PMID: 37897666 PMCID: PMC10637865 DOI: 10.1093/icvts/ivad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/31/2023] [Accepted: 10/27/2023] [Indexed: 10/30/2023]
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Can a "branch-first" approach to aortic arch replacement be safely utilized in Stanford type A acute aortic syndromes?' Altogether 64 papers were found using the reported searches, of which 10represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All papers included in this BET reported acceptable mortality and/or neurological outcomes in comparison to currently published standards for traditional repair. We conclude that while there is a need for larger series, direct comparison and long-term follow-up, the 'branch-first' approach to aortic arch replacement has been safely performed in several centres in the setting of acute aortic syndromes with results demonstrating acceptable mortality, neurological outcomes and mid-term survival.
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Affiliation(s)
- Ursula Kemp
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Alison Zhu
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, NSW, Australia
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Yoon SY, Seok J, Hong JM. Total aortic arch replacement after wire protrusion of thoracic endovascular aortic repair for aortic dissection: A case report. Trauma Case Rep 2023; 46:100849. [PMID: 37251435 PMCID: PMC10220250 DOI: 10.1016/j.tcr.2023.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 05/31/2023] Open
Affiliation(s)
- Su Young Yoon
- Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Junepill Seok
- Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Jong-Myeon Hong
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, College of Medicine, Chungbuk National University, Cheongju, South Korea
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Tokuda Y, Terazawa S, Yoshizumi T, Ito H, Banno H, Mutsuga M. Hybrid Repair of Extensive Aortic Arch Aneurysms: Outcomes of Isolated Frozen Elephant Trunk Repair and of Elephant Trunk with Second Stage Thoracic Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2023; 66:284-285. [PMID: 37187285 DOI: 10.1016/j.ejvs.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 04/20/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Sachie Terazawa
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomo Yoshizumi
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Department of Vascular Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Sun Y, Wang H, Xu H, Xu X, Wang G, Xu Z. Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery. Asian J Surg 2023; 46:314-320. [PMID: 35443931 DOI: 10.1016/j.asjsur.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/29/2022] [Accepted: 04/01/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Aortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort. METHOD Data were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group. RESULTS 63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955). CONCLUSION Reduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.
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Affiliation(s)
- Yangyong Sun
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China; Department of Cardiothoracic Surgery, Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - He Wang
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hongjie Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiangyang Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Guokun Wang
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Zhiyun Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, China.
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Meinert ÉFRC, Arif R, Karck M. Redo aortic arch replacement through a second transcostal approach for closure of type 1A endoleak after endovascular treatment of type B aortic dissection in Marfan syndrome. Eur J Cardiothorac Surg 2022; 63:6936415. [PMID: 36534925 DOI: 10.1093/ejcts/ezac574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/18/2022] [Indexed: 12/23/2022]
Abstract
A 41-year-old woman with Marfan syndrome suffering from chronic expanding type A dissection of the distal aortic arch and pectus excavatum underwent aortic arch replacement through a left parasternal approach. We demonstrate that this approach is also feasible in complex redo surgery on the aortic arch in selected patients.
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Affiliation(s)
| | - Rawa Arif
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
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9
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Thet MST, Balmforth D, Lopez-Marco A, Ye Oo A. Resternotomy aortic root and arch replacement following previous complex type A aortic dissection requiring endovascular repair for malperfusion. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 36239233 DOI: 10.1510/mmcts.2022.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A redo sternotomy, aortic root, and arch replacement in a patient following previous complex surgical and endovascular type A aortic dissection repair is presented in this video case report. Shortly after having the initial type A aortic dissection repair with replacement of the ascending aorta, the patient developed severe visceral malperfusion due to a compressed distal true lumen and underwent emergency endovascular repair with ascending arch and descending thoracic aorta stents and chimney grafts for the aortic arch vessels as well as fenestration of the intimal flap of the abdominal aorta. Unfortunately, the patient developed permanent paraplegia and progressive symptomatic severe aortic regurgitation. The patient underwent a redo sternotomy, aortic root, and arch replacement with explantation of the ascending stent graft and chimney stent grafts. Antegrade cerebral perfusion was maintained throughout the procedure. The aortic arch was replaced using a Terumo Aortic Plexus multibranched graft distally anastomosed to the endovascular stent graft, and the innominate and left common carotid arteries were reimplanted onto the graft. The aortic root was replaced with a Bioconduit graft, using a modified Cabrol technique to reimplant the left coronary artery. A satisfactory postoperative course and computed tomography imaging highlight the feasibility of this highly complex aortic arch repair with careful preoperative planning.
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Affiliation(s)
- Myat Soe Thet Thet
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Damian Balmforth
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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10
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Lee G, Elbatarny M, Shimamura J, Dagenais F, Peterson MD, Ouzounian M, Chu MWA. Hybrid arch frozen elephant trunk repair for acute type A aortic dissection: Extra-anatomic subclavian reconstruction. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 36227647 DOI: 10.1510/mmcts.2022.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Acute type A aortic dissection is a life-threatening condition that confers significant early perioperative risk but is also associated with late aortic disease progression and the need for reintervention. Recent efforts to improve patient outcomes have focused on improving quality of care and extending treatment in the aortic root and arch to reduce late aortic events. The hybrid arch frozen elephant trunk technique facilitates a more aggressive distal aortic repair that may help mitigate the early and late deleterious effects of persistent false lumen perfusion. However, in the acute and emergency settings, management of the left subclavian artery remains a challenge. We present a step-by-step instructional guide on performing an emergency hybrid arch frozen elephant trunk procedure with emphasis on management of the difficult left subclavian artery. Our case report demonstrates a transthoracic aortoaxillary extra-anatomic bypass of the left axillary artery. We discuss the most important considerations when managing the left subclavian artery in an acute type A aortic dissection. Finally, we detail the benefits and limitations of the transthoracic aortoaxillary extra-anatomic technique and discuss other approaches to left subclavian artery reconstruction.
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Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Junichi Shimamura
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Francois Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Mark D. Peterson
- Division of Cardiac Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
| | - Michael W. A. Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
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Karadzha A, Bogachev-Prokophiev A, Sharifulin R, Ovcharov M, Pivkin A, Afanasyev A. The Bio-Bentall procedure with concomitant hemiarch replacement through a right anterolateral minithoracotomy. Multimed Man Cardiothorac Surg 2022; 2022. [PMID: 35470990 DOI: 10.1510/mmcts.2022.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A right anterior minithoracotomy is a surgical approach that can be an excellent alternative to a median sternotomy. However, for aortic root interventions, the median sternotomy is still the gold standard. Most surgeons are slow to master this method because the visualization is poor and less convenient. These problems can be solved by careful selection of patients and using some technical tricks. The patient is a male with a severe aortic valve lesion and an aneurysm of the ascending aorta involving the proximal arch. We demonstrate step-by- step how to perform a minimally invasive Bio-Bentall procedure with a "hemiarch" replacement through a right anterolateral thoracotomy.
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Affiliation(s)
- Anastasiia Karadzha
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
| | - Alexander Bogachev-Prokophiev
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
| | - Ravil Sharifulin
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
| | - Mikhail Ovcharov
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
| | - Alexey Pivkin
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
| | - Alexander Afanasyev
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center 15, Rechkunovskaya Street, Novosibirsk 630055 Russian Federation
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Pichlmaier M, Tsilimparis N, Hagl C, Peterss S. New anatomical frozen elephant trunk graft for zone 0: endovascular technology reduces invasiveness of open surgery to the max. Eur J Cardiothorac Surg 2021; 61:490-492. [PMID: 34492111 DOI: 10.1093/ejcts/ezab394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
The first-in-man implant of a custom-made branched frozen elephant trunk graft designed for an anastomosis in aortic arch zone 0 is reported. Combining endovascular technology with open surgical techniques has allowed for simplification of the open procedure with substantial reduction in circulatory arrest time and in the extent of the surgical preparations.
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Affiliation(s)
| | | | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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13
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Beckmann E, Martens A, Kaufeld T, Natanov R, Krueger H, Haverich A, Shrestha M. Is total aortic arch replacement with the frozen elephant trunk procedure reasonable in elderly patients? Eur J Cardiothorac Surg 2021; 60:131-137. [PMID: 33582774 DOI: 10.1093/ejcts/ezab063] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Total aortic arch replacement is an invasive procedure with significant risks for complications. These risks are even higher in older, multimorbid patients. The current trends in demographic changes in western countries with an ageing population will aggravate this issue. In this study, we present our experience with total aortic arch replacement using the frozen elephant trunk (FET) technique in septuagenarians. We compared the results of septuagenarians with those of younger patients and analysed if there was an improvement in outcome over time. METHODS Between August 2001 and March 2020, 225 patients underwent non-urgent FET procedure at our institution. There were 75 patients aged ≥70 years (mean age 74 ± 4) who were assigned to group A, and 150 patients aged <70 years (mean age of 57 ± 11) who were assigned to group B. In groups A and B, the indications for surgery were chronic dissection (21% vs 53%), aortic aneurysm (78% vs 45%) and penetrating atherosclerotic ulcer (1% vs 2%). RESULTS The rate for temporary dialysis was significantly higher in group A than in group B (29% vs 13%, P = 0.003), although the majority recovered kidney function. Rates for re-exploration for bleeding and stroke were comparable in both groups. In-hospital mortality was significantly higher in group A than in group B (24% vs 13%, P = 0.037). Logistic regression analysis showed that age >70 years was an independent statistically significant risk factor for in-hospital mortality (odds ratio = 2.513, 95% confidence interval = 1.197-5.278, P-value = 0.015). Follow-up was complete for 100% of patients and comprised a total of 1073 patient-years with a mean follow-up time of 4.8 ± 4.5 years. The 1- and 5-year survival rates were 68% and 49% in group A, and 85% and 71% in group B, respectively (log rank, P < 0.001). Survival did not significantly improve over time. DISCUSSION Total aortic arch replacement using the FET technique has a significantly higher risk for perioperative morbidity and mortality in septuagenarians than in younger patients. Long-term survival is significantly impaired in older patients. We recommend thorough patient selection of those who require total aortic arch replacement, and optimization of perioperative management to improve outcomes.
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Affiliation(s)
- Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krueger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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14
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Pichlmaier M, Buech J, Tsilimparis N, Fabry TG, Joskowiak D, Rustum S, Martens A, Hagl C, Peterss S. Routine Stent-Bridging to the Supraaortic Vessels in Aortic Arch Replacement - 10 year-experience. Ann Thorac Surg 2021; 113:1491-1497. [PMID: 34186091 DOI: 10.1016/j.athoracsur.2021.05.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The SAVSTEB technique (Supra-Aortic Vessel anastomosis STEnt Bridging) simplifies the reattachment of the supraaortic vessels in aortic arch surgery; however, follow-up data are limited. The study aimed to investigate the stent-related performance and complications. METHODS Between 02/2009 and 09/2020, 112 patients underwent total arch replacement with a tetrabranched graft and using the SAVSTEB technique. Mean age was 59.3±12.7 years, male gender prevailed. Nineteen percent suffered from acute aortic dissection extending into the supraaortic vessels, 12% showed chronic dissected vessels and 70% showed unaffected vessels. Left subclavian artery, left common carotid artery and innominate artery were bridged in 88%, 75% and 2%, respectively, an aberrant right subclavian artery in 2%. RESULTS Total stent experience was 341 stent-years, stent patency was found in 98%. Technical success was achieved in all but one case. One percent showed major stent thrombosis requiring reintervention. Minor stent thrombosis was found in 2%. No endoleak was found and the number of new onset dissections distally to the stent was 4%. Freedom from stent-related events was estimated 89.1±0.5% at 3 years. Stroke rate was 10% with highest incidence among non-dissected vessels. The vertebral artery was overstented in 15%, 2% were associated radiographically with stroke. CONCLUSIONS SAVSTEB is a comparatively simple, safe and efficacious technique to create the anastomosis between tetrabranched arch grafts and the supra-aortic arteries in the short and intermediate term. Bleeding from the anastomoses, kinking and scar associated stenosis are negligible; however, vertebral overstenting remains a critical technical issue.
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Affiliation(s)
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | | | - Thomas G Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Saad Rustum
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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15
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Saito Y, Yamamoto H, Fukuda I, Miyata H, Minakawa M, Motomura N. The results of aortic arch replacement using antegrade cerebral perfusion in haemodialysis patients: analysis of the Japan cardiovascular surgery database. Eur J Cardiothorac Surg 2021; 61:162-169. [PMID: 34148088 DOI: 10.1093/ejcts/ezab252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database. METHODS A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014-2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model. RESULTS The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22-8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00-4.10, P = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified. CONCLUSIONS The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality.
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Affiliation(s)
- Yoshiaki Saito
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Ikuo Fukuda
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Masahito Minakawa
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
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16
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Jassar AS. Outcomes after concomitant aortic root and aortic arch replacement: what came first-the root or the arch? Eur J Cardiothorac Surg 2021; 60:631-632. [PMID: 33990835 DOI: 10.1093/ejcts/ezab211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/06/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Arminder S Jassar
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
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17
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Holubec T, Van Linden A, Bodelle B, Walther T. Frozen elephant trunk: minimally invasive implantation of a new trifurcated hybrid aortic prosthesis. Ann Thorac Surg 2021; 112:e321-e323. [PMID: 33662303 DOI: 10.1016/j.athoracsur.2021.02.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/06/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Abstract
Implantation of hybrid prostheses using frozen elephant trunk (FET) technique has become a standard procedure for aortic arch and proximal descending aorta pathologies. New devices have been introduced to reduce the surgical complexity by enabling to perform FET in proximal segments of the aorta. This facilitates use of minimally invasive approach and provides a safe and durable aortic arch repair. We herein report on the first-in-man experience with the new trifurcated FET aortic prosthesis E-vita OPEN NEO using a minimally invasive technique.
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Affiliation(s)
- Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany.
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Boris Bodelle
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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18
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Demal TJ, Bax L, Brickwedel J, Kölbel T, Vettorazzi E, Sitzmann F, Reichenspurner H, Detter C. Outcome of the frozen elephant trunk procedure as a redo operation. Interact Cardiovasc Thorac Surg 2021; 33:85-92. [PMID: 33667306 DOI: 10.1093/icvts/ivab059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/01/2020] [Accepted: 01/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. METHODS One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. RESULTS A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19-35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23-3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. CONCLUSIONS Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.
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Affiliation(s)
- Till Joscha Demal
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Sitzmann
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
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19
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Yamato H, Funaki S, Shimamura K, Kin K, Kuratani T, Sawa Y, Shintani Y. Salvage surgery for stage IVa thymic carcinoma combined with aortic arch resection - case report. J Cardiothorac Surg 2020; 15:305. [PMID: 33028405 PMCID: PMC7542946 DOI: 10.1186/s13019-020-01354-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although complete surgical resection of thymic carcinoma is a prognostic factor, extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality. We report a case of Stage IVa thymic carcinoma successfully resected with a pneumonectomy along with aortic arch replacement after chemotherapy. CASE PRESENTATION A 45-year-old male was diagnosed with thymic carcinoma invasion to the aortic arch and left pulmonary artery. Malignant pericardial effusion was also noted, though disappeared after chemotherapy, thus surgical options were considered. A radical resection procedure including left pneumonectomy, aortic arch replacement with total rerouting of the supra-arch vessels, and right pulmonary artery plication was performed. The postoperative course was uneventful and the patient has been disease-free for 3 years. CONCLUSION Extended salvage surgery might be a valuable option for advanced thymic carcinoma.
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Affiliation(s)
- Hiroyuki Yamato
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiwa Kin
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
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20
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Pei X, Zhu SQ, Long X, Qiu BQ, Lin K, Lu F, Xu JJ, Wu YB. Modified Distal Aortic Arch Occlusion During Aortic Arch Replacement. Heart Lung Circ 2020; 29:e245-e252. [PMID: 32430219 DOI: 10.1016/j.hlc.2020.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 02/12/2020] [Accepted: 03/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Circulatory arrest has been identified as an independent risk factor related to postoperative mortality in patients with Stanford type A aortic dissection. This study described a modified technique for distal aortic arch occlusion that markedly shortened the circulatory arrest time. The early results are encouraging. METHODS From May 2016 to September 2018, 51 patients with Stanford type A aortic dissection underwent the modified procedure for aortic arch replacement. All operations were performed via transitory circulatory arrest by clamping the distal aorta between the left common carotid artery and the left subclavian artery. The in-hospital and follow-up data of the treated patients were investigated. RESULTS Successful repair of the involved vasculature was achieved in all patients. One (1) patient died due to postoperative aspiration and infection, and three patients required continuous renal replacement therapy due to poor preoperative renal function. The remaining patients were successfully discharged. The median average circulatory arrest time was 5.0 (3.0-6.0) minutes. No cases of tracheotomy, delayed closure, secondary thoracotomy, or other complications occurred. During the follow-up period of 2.4-18.6 months, the implanted grafts and stented elephant trunks were all fully open and not kinked. CONCLUSIONS A modified distal aortic arch occlusion can considerably shorten the duration of circulatory arrest. Current experience suggests that this approach can serve as a feasible alternative for patients during aortic arch replacement because of its simplicity and satisfactory clinical effects.
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Affiliation(s)
- Xu Pei
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Shu-Qiang Zhu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Xiang Long
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Bai-Quan Qiu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Kun Lin
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Feng Lu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Jian-Jun Xu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China.
| | - Yong-Bing Wu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China.
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Kuno H, Funaki S, Kimura K, Shimamura K, Kin K, Kuratani T, Sawa Y, Shintani Y. Complete resection of local advanced thymic carcinoma with total aortic arch replacement after chemotherapy: a case report. Surg Case Rep 2019; 5:198. [PMID: 31832805 PMCID: PMC6908541 DOI: 10.1186/s40792-019-0713-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022] Open
Abstract
Background Although complete surgical resection of thymic carcinoma is a prognostic factor, it is not always an option for advanced tumors because of locoregional invasion. Extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality. Case presentation Chest computed tomography (CT) uncovered an abnormal shadow in the mediastinum of a 74-year-old man. An irregularly shaped tumor obstructed the left innominate vein, and invasion of the aortic arch was suspected. A CT-guided percutaneous needle biopsy revealed squamous cell carcinoma of the thymus, which was considered unresectable. The patient underwent chemotherapy elsewhere, then was referred to us for surgical resection. We combined extended surgery with total aortic arch replacement under a cardiopulmonary bypass. Complete resection was achieved, and the patient remains alive without recurrence at 3 years after surgery Conclusion Resection including aortic arch replacement might be an option that can achieve complete resection of local advanced thymic carcinoma.
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Affiliation(s)
- Hidenori Kuno
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Kenji Kimura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiwa Kin
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan.
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Dib B, Seppelt PC, Arif R, Weymann A, Veres G, Schmack B, Beller CJ, Ruhparwar A, Karck M, Kallenbach K. Extensive aortic surgery in acute aortic dissection type A on outcome - insights from 25 years single center experience. J Cardiothorac Surg 2019; 14:187. [PMID: 31694667 PMCID: PMC6836454 DOI: 10.1186/s13019-019-1007-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/20/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND This single center study compares the different surgical techniques used in the treatment of acute aortic dissection type A (AADA) analyzing the influence of the extent of the surgical approach on outcome. METHODS From 1988 to 2012, 407 patients were operated for AADA. The cohort was divided into subgroups according to the surgical approach. These groups were compared with the supracommissural replacement group (SCR; n = 141). Groups included aortic valve sparing techniques (AVS; n = 29), Composite replacement (COMP; n = 119), COMP with total arch replacement (COMP+TAR; n = 27) and SCR with TAR (n = 75). RESULTS Compared to SCR alone, operation (p = 0.005), bypass-, cross-clamp and circulatory arrest times were longer in SCR + TAR (all p < 0.001). Moreover, operation, bypass and cross clamp times were longer in COMP+TAR (p = 0.003, p = 0.002 and p < 0.001 respectively). COMP alone and AVS required longer cross-clamp time, too (p < 0,001 and p = 0.002, respectively). Overall 30-day mortality was 21% with the observed lowest rate after AVS (14%, SCR 18%, COMP 25%) but differences in 30-day mortality were not statistically significant. The estimated 10-year survival was 42%, especially AVS demonstrated a good 10-year survival (69%). David technique was superior to Yacoub technique concerning incidence of redo interventions (p = 0.036). Risk factors for early mortality included age, circulatory arrest, general malperfusion, bypass and operation time. Circulatory arrest per se was revealed as risk factor for long-term survival. CONCLUSIONS Within our single center retrospective study concomitant aortic root repair or aortic arch replacement for AADA demonstrated acceptable early and long-term survival. Circulatory arrest, long bypass and operation times per se might be important risk factors for early mortality. AVS techniques can be performed safely and have good outcomes in acute aortic dissection repair.
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Affiliation(s)
- Bashar Dib
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Gábor Veres
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten J Beller
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, INCCI HaerzZenter, Luxembourg, Luxembourg.
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Tokuda Y, Fujimoto K, Narita Y, Mutsuga M, Terazawa S, Ito H, Matsumura Y, Uchida W, Munakata H, Ashida S, Ono T, Nishi T, Yano D, Ishida S, Kuwabara F, Akita T, Usui A. Spinal cord injury following aortic arch replacement. Surg Today 2020; 50:106-13. [PMID: 31332530 DOI: 10.1007/s00595-019-01853-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Postoperative spinal cord injury is a devastating complication after aortic arch replacement. The purpose of this study was to determine the predictors of this complication. METHODS A group of 254 consecutive patients undergoing aortic arch replacement via median sternotomy, with (n = 78) or without (n = 176) extended replacement of the upper descending aorta, were included in a risk analysis. The frozen elephant trunk technique was used in 46 patients. The patients' atherothrombotic lesions (extensive intimal thickening of > 4 mm) were identified from computed tomography images. RESULTS Complete paraplegia (n = 7) and incomplete paraparesis (n = 4) occurred immediately after the operation (permanent spinal cord injury rate, 1.97%; transient spinal cord injury rate, 2.36%). A multivariable logistic regression analysis identified the use of the frozen elephant trunk technique (odds ratio 36.3), previous repair of thoracoabdominal aorta or descending aorta (odds ratio 29.4), proximal atherothrombotic aorta (odds ratio 9.6), chronic obstructive lung disease (odds ratio 7.1) and old age (odds ratio 1.1) as predictors of spinal cord injury (p < 0.0001, area under curve 0.93). CONCLUSIONS Spinal cord injury occurs with a non-negligible incidence following aortic arch replacement. The full objective assessment of the morphology of the whole aorta and the recognition of the risk factors are mandatory.
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Abstract
Objective We modified the conventional aortic arch replacement procedure to avoid circulation arrest and a prolonged extracorporeal circulation time, especially in cases of acute aortic dissection. We herein present our experience with a modified branch-first approach to acute aortic dissection, with anastomosis of the supra aortic vessels prior to commencing cardiopulmonary bypass. Methods Since 2012, 41 patients (aortic dissection, 36; arch aneurysm, 5) have undergone the modified procedure. Procedurally, the implanted graft was used as a landing zone for second-stage endovascular stent-graft deployment intended to manage the residual descending dissection. Antegrade and retrograde systemic perfusion was instituted during cardioplegic arrest. The brain was actively perfused via the graft throughout the procedure. Results Arch replacement surgery could generally be completed within approximately 4 h. During a 2-year period of aortic dissection or arch aneurysm treatment, only four anastomoses were required during the first stage of operation: two in the aorta, and one each in the innominate and left common carotid arteries. No patient died of surgical causes, and no stent grafts were deployed into the false lumen, a characteristic of procedures using traditionally antegrade deployment. Conclusion We recommend that our procedure for acute aortic dissection be performed in two stages (graft replacement first and stent graft deployment second), particularly for patients underwent preoperative hypotesion. If malperfusion syndrome still exists after graft replacement, stent graft should be deployed in one stage. The arch aneurysm can be treated in one stage because there is no concern about false lumen deployment. Electronic supplementary material The online version of this article (10.1186/s13019-017-0689-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Feng Gao
- Department of Cardiovascular Surgery, Xiangya Haikou Hospital of Middle South University, Haikou Municipal Hospital, Haikou Vascular Disease Research Institute, The No. 43 People Road, Haikou City, 570208, China. .,Department of Cardiovascular Surgery, SuiNing Central Hospital, SuiNing City, China.
| | - Yongjie Ye
- Department of Cardiovascular Surgery, SuiNing Central Hospital, SuiNing City, China
| | - Yongheng Zhang
- Department of Cardiovascular Surgery, SuiNing Central Hospital, SuiNing City, China
| | - Bo Yang
- Department of Cardiovascular Surgery, SuiNing Central Hospital, SuiNing City, China
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25
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Yamanaka K, Shiiya N, Washiyama N, Sato M. Secondary graft-oesophageal fistula after total arch replacement. Interact Cardiovasc Thorac Surg 2017; 25:331-332. [PMID: 28472501 DOI: 10.1093/icvts/ivx112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/07/2017] [Indexed: 11/12/2022] Open
Abstract
Secondary graft-oesophageal fistula is a fatal complication of aortic arch replacement. We report a successful two-stage surgical management of a graft-oesophageal fistula seen in a 68-year-old woman 3 years after total aortic arch replacement. She presented with a prolonged intractable fever without haematemesis. The fistula occurred between the distal aortic anastomosis and oesophagus; the entire graft was surrounded by air. In the first-stage operation, we performed re-replacement of the entire infected graft, oesophagectomy with cervical oesophagostomy, omental transfer and cervical routing of the stomach roll, through an extended left thoracotomy incision with sternal transection. Intravenous antibiotics were administered for 6 weeks; the second-stage cervico-oesophageal anastomosis was performed 57 days later. She was discharged without complications and is doing well 6 months postoperatively.
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Affiliation(s)
- Ken Yamanaka
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Naoki Washiyama
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Masanori Sato
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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Goda M, Suzuki S, Yabu N, Goda M, Machida D, Masuda M. Intermittent distal perfusion shortens hypothermic circulatory arrest time in aortic arch replacement surgery. Gen Thorac Cardiovasc Surg 2017; 65:239-41. [PMID: 27421849 DOI: 10.1007/s11748-016-0690-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
The procedure and efficacy of the intermittent distal perfusion during hypothermic circulatory arrest in total arch replacement was described. During hypothermic circulatory arrest, elephant trunk was fixed inside the descending aorta. Then, the AP Grid Catheter was inserted through the elephant trunk, and blood perfusion at a flow rate of 500 ml/min for 5 min was installed. After the perfusion, distal anastomosis was completed. Clinical results of 23 patients (Group I) with this technique were compared with these of 21 patients without the procedure (Group II). Continuous hypothermic circulatory arrest time was significantly shorter (32.7 vs. 72.7 min; p < 0.05) and postoperative serum creatinine level was significantly lower (1.29 vs. 1.68; p < 0.05) in Group I than Group II. The incidence of abdominal complication was also fewer in Group I. Intermittent distal perfusion shortens hypothermic circulatory arrest time and is protective for the lower body including kidneys.
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Liu KS, Lee CH, Tsai FC, Jhong GH, Hung KC, Liu SJ. Computational Analysis of the Mechanical Behaviors of Hemiarch and Total Arch Replacements. Ann Biomed Eng 2015; 43:2881-91. [PMID: 26014364 DOI: 10.1007/s10439-015-1345-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
Surgery for aortic dissections or aneurysms can be extended into the aortic arch by hemiarch replacement (HAR) or total arch replacement (TAR). Although cardiovascular surgeons have been performing HAR and TAR for decades, the mechanical properties of HAR and TAR are not well understood. This study investigates the mechanical behaviors and stress distributions in HAR and TAR using a hybrid fluid-structure interaction analysis that combines computational fluid dynamics and structural static analysis. Geometrical information on the aortas of 11 subjects was extracted from contrast-enhanced computed tomography (CT) scan data. The CT images were imported into medical image processing software to reconstruct 3D models of the aortas. A 3D finite element model was employed to simulate aortas that receive HAR or TAR. The deformation of the great vessels and the stress distributions at both the vessels and the aortic grafts were calculated. The numerical results revealed that the aortas following TAR exhibited a lower level of stress than those following HAR. Higher stresses may cause arterial wall injury and increase the risk of rupture. Finite element analysis of the aortas and the aortic grafts provides useful information that helps physicians better understand the potential problems that may arise after various surgical procedures.
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Ge YP, Li CN, Chen L, Liu W, Cheng LJ, Liu YM, Zheng J, Ma WG, Zhu JM, Sun LZ. Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection? Heart Lung Circ 2015; 24:1111-7. [PMID: 25981359 DOI: 10.1016/j.hlc.2015.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 03/02/2015] [Accepted: 04/06/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. METHODS Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. RESULTS The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). CONCLUSIONS PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.
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Affiliation(s)
- Yi-Peng Ge
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Cheng-Nan Li
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Lei Chen
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Wei Liu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Li-Jian Cheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Yong-Min Liu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Jun Zheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Wei-Guo Ma
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Jun-Ming Zhu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University.
| | - Li-Zhong Sun
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
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Schneider SRB, Dell'Aquila AM, Akil A, Schlarb D, Panuccio G, Martens S, Rukosujew A. Results of "elephant trunk" total aortic arch replacement using a multi-branched, collared graft prosthesis. Heart Vessels 2014; 31:390-6. [PMID: 25491933 DOI: 10.1007/s00380-014-0612-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/01/2014] [Indexed: 11/25/2022]
Abstract
We report on our experience with a simplified elephant trunk (ET) procedure with a multi-branched prosthesis (Vascutek(®) Siena™ Collared Graft). It consists of a proximal portion (20 cm) with prefabricated side branches, a collar and a distal portion (30 cm). The collar, which can be trimmed into any desired diameter, constitutes the suture portion to the descending aorta. Radiopaque markers in the distal portion indicate the landing zone. Between January 2011 and June 2013, 20 consecutive patients (10 women; mean age, 66 ± 9.3 years) underwent ET procedure, including 6 re-do cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7-29.7 mm). Concomitant procedures included ascending aortic replacement in 16 patients; root replacement in 2; AVR in 2, CABG in 3 and mitral repair in 1 patient. CPB time was 263 ± 94 min; mean duration of ACP was 65 ± 14 min. Two patients died on POD 8 and 78, respectively. Major adverse events included stroke (n = 1), resternotomy for bleeding (n = 2), renal failure requiring temporary dialysis (n = 1) and recurrent nerve paresis (n = 2). After a mean follow-up of 10 ± 8 months, all discharged patients were alive. Seven patients underwent stent-graft implantation of the descending aorta and one patient underwent open descending aortic replacement. The last generation of multi-branched arch prosthesis and especially the Vascutek(®) Siena™ Collared Graft make ET procedure a reasonable treatment option even in patients with acute aortic dissection.
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Affiliation(s)
- Stefan R B Schneider
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
| | - Angelo M Dell'Aquila
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Ali Akil
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Dominik Schlarb
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Guiseppe Panuccio
- Department of Vascular and Endovascular Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Sven Martens
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Andreas Rukosujew
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
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