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Shi R, Zeigler SM, Wooster MD. Endovascular laser fenestration of a frozen elephant trunk stent graft for treatment of chronic cerebral malperfusion. Vascular 2025:17085381251313581. [PMID: 39787277 DOI: 10.1177/17085381251313581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
Abstract
OBJECTIVES Mal-deployment of the thoracic endovascular aortic repair (TEVAR) stent graft during a frozen elephant trunk (FET) procedure for an acute type A aortic dissection (ATAAD) leads to devastating complications. We report a hemiarch replacement with TEVAR stent graft covering the aortic arch vessels salvaged through an endovascular approach. METHODS A 69-year-old man with ATAAD in 2018, status post-hemiarch repair with TEVAR, presented in 2023 with progressive dizziness/syncope and lower extremity hypertension with inability to tolerate anti-hypertensives. A CT scan revealed TEVAR stent graft coverage of the brachiocephalic, left common carotid (LCA), and left subclavian artery (LSA), with retrograde flow into the arch vessels through a false lumen fed by a dissection fenestration at the aortic bifurcation. Given an elevated peri-operative death and stroke risk with an open arch revision, we performed an in situ anterograde laser fenestration of his FET with LCA and LSA stenting via the Culotte technique. RESULTS On 1 year follow-up, the patient's dizziness has resolved, and he has maintained normotension via anti-hypertensives. CONCLUSION Laser fenestration and the Culotte technique can be used to salvage a TEVAR causing coverage of the arch vessels, showing that endovascular techniques can be a safe alternative for rescuing mal-positioned FETs.
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Affiliation(s)
- Richard Shi
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sanford Manning Zeigler
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mathew David Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
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Roselli EE, Vargo PR, Bakaeen F, Koprivanac M, Burns D, Kuramochi Y, Gillinov M. Branched stented anastomosis frozen elephant trunk repair: Early results from a physician-sponsored investigational device exemption study. J Thorac Cardiovasc Surg 2024; 168:746-756. [PMID: 37802330 DOI: 10.1016/j.jtcvs.2023.09.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Multisegment thoracic aortic disease typically requires total aortic arch replacement, affects a heterogenous population, and carries a high risk even at centers of excellence. Risk has been associated with the duration of operation and complexity of repair. A novel branched stented anastomosis frozen elephant trunk repair (B-SAFER) technique has been developed at our center and is currently being studied as a physician-sponsored investigation device exemption (PS-IDE). OBJECTIVE This study aimed to assess the early safety of using this investigational technique to treat the proximal aorta in subjects with aortic disease involving multiple segments. METHODS This prospective, single center, nonrandomized study enrolled patients undergoing B-SAFER for acute aortic syndrome (n = 73), aortic aneurysm with chronic aortic dissection (n = 68), degenerative aortic aneurysm (n = 33), or congenital aortic arch disease (n = 4). Devices are delivered antegrade under hypothermic circulatory arrest, and the arch reconstruction is performed as a single anastomosis single stent (SASS; n = 70), single anastomosis multiple stent (SAMA; n = 68), multiple anastomosis single stent (MASS; n = 21), or multiple anastomosis multiple stent (MAMS; n = 16) reconstruction. The primary safety endpoints were operative mortality, disabling stroke, and paraparesis/paralysis. RESULTS Between May 27, 2021, and December 31, 2022, 178 patients underwent B-SAFER in the configurations and for the indications as described above. The median patient age was 65 years (range, 21 to 85 years), and 52 (29%) were female. The median cardiopulmonary bypass time was 188 minutes (interquartile range [IQR], 155 to 226 minutes), and 97% of the patients underwent repair with antegrade brain perfusion for a median of 46 minutes (IQR, 38 to 61 minutes). Operative mortality occurred in 10 patients (5.6%, including 6 [8.2%] with acute dissection, 2 [2.9%] with chronic dissection, 2 [6.1%] with degenerative aneurysm, and 0 with a congenital disorder), disabling stroke in 5 patients (2.9%), and paraparesis in 1 patient. Other serious complications included respiratory failure (n = 20; 11.4%) and acute kidney injury (n = 18; 10%). Thirty-two patients (18%) had undergone second-stage repairs (28 endovascular and 4 open), with 1 operative mortality after that procedure due to distal rupture. Estimated survival was 95% at 30 days, 88% at 90 days, 84% at 6 months, and 79% at 1 year. One-year survival differed by indication (72% for acute dissection, 91% for chronic dissection, 71% for degenerative aneurysm, and 100% for congenital disorders). CONCLUSIONS The B-SAFER technique for total arch replacement in a complex cohort of patients with various indications for surgery is a safe and reproducible operation, as demonstrated by the early results from a very inclusive PS-IDE study. Further follow-up and analysis will help refine the technique. Novel devices to perform this procedure should be developed.
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Affiliation(s)
- Eric E Roselli
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Patrick R Vargo
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal Bakaeen
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Burns
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Yuki Kuramochi
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Gillinov
- Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Berretta P, Galeazzi M, Malvindi PG, Cefarelli M, Alfonsi J, Bifulco O, Gatta E, Di Eusanio M. Frozen elephant use in type a dissection: fundamentals, innovations, and pitfalls. Expert Rev Med Devices 2024; 21:579-586. [PMID: 38841791 DOI: 10.1080/17434440.2024.2365416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 06/04/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Type A acute aortic dissection (TA-AAD) is a great challenge for aortic surgeons. The establishment of a standardized surgical approach, particularly the determination of whether and when to address the aortic arch and the distal aorta in the same operation as the proximal aorta, is still unclear. AREAS COVERED Frozen elephant trunk (FET) has emerged as a valuable treatment for TA-AAD over the last decade. Here, we discuss the fundamentals and pitfalls of frozen elephant trunk procedures and present the latest innovations. EXPERT OPINION FET has the potential to simplify arch reconstruction in patients with complex arch tears and rupture, optimize perfusion in the distal true lumen for those with a compressed true lumen and malperfusion, address distal reentry tears, and promote false lumen thrombosis and late aortic remodeling. Nevertheless, FET is still associated with non-negligible mortality and morbidity rates. Patient selection, surgical expertise, and postoperative care remain crucial determinants in ensuring successful outcomes. Recent innovations in FET surgery involve the development of techniques to minimize or avoid hypothermic circulatory arrest and new FET devices with different arch branch configurations aiming to facilitate subsequent aortic reinterventions. We believe that both these advancements have the potential to improve patient outcomes.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Pietro G Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Emanuele Gatta
- Vascular Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Egawa A. Transesophageal Echocardiography-Guided Elephant Trunk Procedure for Repair of Descending Thoracic Aorta: A Case Report. Ann Card Anaesth 2024; 27:159-161. [PMID: 38607880 PMCID: PMC11095790 DOI: 10.4103/aca.aca_132_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 04/14/2024] Open
Abstract
ABSTRACT The elephant trunk procedure, an endovascular strategy for retrograde type A acute aortic dissection, is associated with several complications, hemolytic anemia being a rare one. We performed endovascular stent-graft insertion in a patient who developed hemolytic anemia. Transesophageal echocardiography (TEE) detected turbulent jet flow and stenosis position, which was not detected by angiography and intravascular ultrasound (IVUS). This imaging technique proved effective for malperfusion diagnosis and enabled us to confirm its resolution after the endovascular procedure. Intraoperative TEE is a useful adjunct to angiography and IVUS for diagnosis and therapeutic assessment during endovascular repair of a stenosed elephant trunk.
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Affiliation(s)
- Atsushi Egawa
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University School of Medicine, Yakushiji, Shimotsuke, Tochigi, Japan
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Jankovic N, Matkovic M, Bilbija I, Milicevic V, Zlatkovic M, Aleksic N, Cvetic V, Milin-Lazovic J, Putnik S. The Clinical Impact of the Extension of Acute Type A Aortic Surgery on Long-Term Outcomes: Should We Tend to Be Conservative? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:35. [PMID: 38256296 PMCID: PMC10821435 DOI: 10.3390/medicina60010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.
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Affiliation(s)
- Natasa Jankovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Milos Matkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Ilija Bilbija
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Milicevic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Mina Zlatkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Nemanja Aleksic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Cvetic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department for Cardiovascular Radiology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Jelena Milin-Lazovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department of Biostatistics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Svetozar Putnik
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
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Vekstein AM, Doberne JW, Weissler EH, Wojnarski CM, Long CA, Williams AR, Plichta RP, Gaca JG, Hughes GC. Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair. J Thorac Cardiovasc Surg 2023; 166:996-1008.e1. [PMID: 35282930 DOI: 10.1016/j.jtcvs.2022.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Dong Z, Liu H, Kim JB, Gu J, Li M, Li G, Du J, Gu W, Shao Y, Ni B. False lumen-dependent segmental arteries are associated with spinal cord injury in frozen elephant trunk procedure for acute type I aortic dissection. JTCVS OPEN 2023; 15:16-24. [PMID: 37808063 PMCID: PMC10556951 DOI: 10.1016/j.xjon.2023.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/18/2023] [Accepted: 05/02/2023] [Indexed: 10/10/2023]
Abstract
Objective To investigate the association between false lumen (FL) dependency of segmental arteries (SAs) at T9-L3 levels and the risk of spinal cord injury (SCI) following total arch replacement and frozen elephant trunk (FET) implantation in the setting of acute DeBakey type I aortic dissection (AAD). Methods The study involved consecutive patients with AAD who underwent total arch replacement and FET implantation between 2020 and 2022. Primary outcome was postoperative SCI. The inverse probability of treatment weighting (IPTW) method was employed to minimize the impact of no-randomization bias. Antegrade placement of FET was followed by end-to-end anastomosis of a 4-branch arch graft at the proximal landing site of FET. Results A total of 146 patients were included (age, 50.5 ± 11.7 years, 115 male), of whom 35 (24%) had SAs at T9-L3 levels completely dependent on FL (FL-dependency group). There was no significant difference in early (30-day or in-hospital) mortality rates between FL-dependency (14.3%) and FL-independency (18.0%) groups (P = .80), however, the rate of SCI was significantly higher in the FL-Dependency group (34.3% vs 2.7%, P < .001). After adjustments, FL dependency was associated with a significantly increased risk of SCI (odds ratio, 13.1; 95% confidence interval, 4.2-41.0; P < .001), whereas it was not significantly associated with risks of early mortality or other major complications (P = .16-.98). Conclusions FL dependency of SAs at the T9-L3 levels was significantly associated with the development of SCI following FET implantation in AAD, warning against its uses on patients presenting with FL dependency of SAs at critical segments.
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Affiliation(s)
- Zhiqiang Dong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiaxi Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minghui Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junjie Du
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weidong Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Buqing Ni
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome. JTCVS Tech 2022; 17:1-9. [PMID: 36820356 PMCID: PMC9938375 DOI: 10.1016/j.xjtc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/25/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
Objective Emergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called "branched stented anastomosis frozen elephant trunk repair." Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A. Methods We compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration. Results Of 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75 ± 24, 118 ± 47), total operation (313 ± 83, 470 ± 151), and cardiopulmonary bypass (195 ± 46, 277 ± 96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P < .001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery-related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P < .05). Conclusions Extended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.
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Key Words
- AADA, acute aortic dissection type A
- B-SAFER, branched stented anastomosis frozen elephant trunk repair
- CT, computed tomography
- CTAR, conventional total arch replacement
- EAVR, estimated arch vessel reconstruction
- EB-SAFER
- EB-SAFER, extended branched stented anastomosis frozen elephant trunk repair
- FET, frozen elephant trunk
- FFP, fresh-frozen plasma
- HCA, hypothermic circulatory arrest
- LSCA, left subclavian artery
- RBC, red blood cells
- SACP, selective antegrade cerebral perfusion
- SAVSTEB, supra-aortic vessel anastomosis stent bridging
- TAR, total arch replacement
- acute aortic dissection type A
- frozen elephant trunk
- total arch replacement
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He ZY, Yao LP, Wang XK, Chen NY, Zhao JJ, Zhou Q, Yang XF. Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review. World J Clin Cases 2022; 10:8009-8017. [PMID: 36158509 PMCID: PMC9372854 DOI: 10.12998/wjcc.v10.i22.8009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/11/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.
CASE SUMMARY A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.
CONCLUSION Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.
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Affiliation(s)
- Zhi-Yang He
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Lin-Peng Yao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Ke Wang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Nai-Yun Chen
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Jun-Jie Zhao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Qian Zhou
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Feng Yang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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10
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Kayali F, Jubouri M, Tan SZ, Mohammed I, Bashir M. Aortic remodeling in aortic dissection after frozen elephant trunk: overcoming the challenges. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:434-438. [PMID: 35621062 DOI: 10.23736/s0021-9509.22.12385-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The introduction of the single-step hybrid frozen elephant trunk (FET) procedure expanded the surgeon's armamentarium in managing aortic dissection (AD). This is evident by the reduction in mortality and complication rates associated with conventional techniques used to repair ADs. Although FET still carries a risk of certain complications, it has been associated with excellent aortic remodeling following the procedure. The main scope of this review is to evaluate aortic remodeling in aortic dissection after FET as well as to highlight the challenges that may arise and ways to overcome them. A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on aortic remodeling in aortic dissection after FET. The FET procedure promotes excellent long-term remodeling, this is seen in the substantial increase in the size of the true lumen along with the decrease in that of the false lumen (FL), in addition to significant FL thrombosis. However, this occurs to a lesser extent more distally at the level of the abdominal aorta. Negative remodeling may present a major challenge to the process of aortic remodeling, nevertheless, this can be overcome with endovascular reintervention which has demonstrated highly favorable results. Additionally, the choice of FET graft, in terms of type and length, seems to influence outcomes. Namely, the Thoraflex™ Hybrid graft can be considered the superior graft on the global market. On the other hand, there seems to be a debate in the literature on the optimal FET graft length. The FET procedure has revolutionized the field of aortovascular surgery and promotes excellent long-term aortic remodeling. Negative remodeling can occur but can also be favorably overcome with endovascular reintervention. Finally, the choice of FET graft may also influence results, thus, should be taken with great care.
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Affiliation(s)
- Fatima Kayali
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK -
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11
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Amin A, Etheridge GM, Amarasekara HS, Green SY, Orozco-Sevilla V, Coselli JS. Aortic arch repair: lessons learned over three decades at Baylor College of Medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:393-405. [PMID: 35621061 DOI: 10.23736/s0021-9509.22.12376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.
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Affiliation(s)
- Arsalan Amin
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Ginger M Etheridge
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Hiruni S Amarasekara
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Susan Y Green
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA -
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
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12
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“Why is frozen elephant trunk better than classical elephant trunk?”. Indian J Thorac Cardiovasc Surg 2022; 38:70-78. [PMID: 35463719 PMCID: PMC8980990 DOI: 10.1007/s12055-021-01302-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/18/2022] Open
Abstract
The treatment of complex aortic arch disease, in chronic or acute setting, has always represented a fascinating challenge for the heart surgeon also because, often, the involvement of the aortic arch is associated with a simultaneous involvement of the ascending aorta and of the proximal portion of the descending thoracic aorta. In recent years, there have been many surgical and/or endovascular techniques and approaches in a single step or multiple steps proposed with the aim of treating and simplifying these complex conditions. The first procedure available for this purpose was the conventional elephant trunk technique, proposed by the German surgeon Hans Borst, back in 1983. In the following years, the technique has undergone modifications, up to what is nowadays considered its most modern evolution, represented by the frozen elephant trunk which allows managing the proximal descending thoracic aorta using the antegrade release of a self-expandable stent graft. In this review article, we try to analyze the advantages and drawbacks of both techniques from clinical and practical points of view.
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13
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Gambardella I, Girardi LN. Total arch replacement: Technical pearls. JTCVS Tech 2021; 10:8-13. [PMID: 34977695 PMCID: PMC8690326 DOI: 10.1016/j.xjtc.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022] Open
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14
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Wallen T, Carter T, Habertheuer A, Badhwar V, Jacobs JP, Yerokun B, Wallace A, Milewski K, Szeto WY, Bavaria JE, Vallabhajosyula P. National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:21-29. [PMID: 34607380 PMCID: PMC8489998 DOI: 10.1055/s-0041-1724003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement. METHODS The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models. RESULTS A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke (p = 0.91)/cerebrovascular disease (p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002). CONCLUSION TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.
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Affiliation(s)
- Tyler Wallen
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Timothy Carter
- Division of Cardiovascular Surgery, The University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Andreas Habertheuer
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Vinay Badhwar
- Division of Cardiac Surgery, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | | | | | - Karianna Milewski
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, The University of Florida, Gainesville, Florida
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15
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Guo T, Fang Z, Yang G, Zhou Y, Ding N, Peng W, Gong X, He H, Pan X, Chai X. Machine Learning Models for Predicting In-Hospital Mortality in Acute Aortic Dissection Patients. Front Cardiovasc Med 2021; 8:727773. [PMID: 34604356 PMCID: PMC8484712 DOI: 10.3389/fcvm.2021.727773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/24/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Acute aortic dissection is a potentially fatal cardiovascular disorder associated with high mortality. However, current predictive models show a limited ability to efficiently and flexibly detect this mortality risk, and have been unable to discover a relationship between the mortality rate and certain variables. Thus, this study takes an artificial intelligence approach, whereby clinical data-driven machine learning was utilized to predict the in-hospital mortality of acute aortic dissection. Methods: Patients diagnosed with acute aortic dissection between January 2015 to December 2018 were voluntarily enrolled from the Second Xiangya Hospital of Central South University in the study. The diagnosis was defined by magnetic resonance angiography or computed tomography angiography, with an onset time of the symptoms being within 14 days. The analytical variables included demographic characteristics, physical examination, symptoms, clinical condition, laboratory results, and treatment strategies. The machine learning algorithms included logistic regression, decision tree, K nearest neighbor, Gaussian naive bayes, and extreme gradient boost (XGBoost). Evaluation of the predictive performance of the models was mainly achieved using the area under the receiver operating characteristic curve. SHapley Additive exPlanation was also implemented to interpret the final prediction model. Results: A total of 1,344 acute aortic dissection patients were recruited, including 1,071 (79.7%) patients in the survivor group and 273 (20.3%) patients in non-survivor group. The extreme gradient boost model was found to be the most effective model with the greatest area under the receiver operating characteristic curve (0.927, 95% CI: 0.860-0.968). The three most significant aspects of the extreme gradient boost importance matrix plot were treatment, type of acute aortic dissection, and ischemia-modified albumin levels. In the SHapley Additive exPlanation summary plot, medical treatment, type A acute aortic dissection, and higher ischemia-modified albumin level were shown to increase the risk of hospital-based mortality.
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Affiliation(s)
- Tuo Guo
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Zhuo Fang
- College of Information Science and Engineering, Hunan Normal University, Changsha, China
| | - Guifang Yang
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Yang Zhou
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Ning Ding
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Wen Peng
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xun Gong
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Huaping He
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xiaogao Pan
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
| | - Xiangping Chai
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Emergency Medicine and Difficult Diseases Institute, Central South University, Changsha, China.,Trauma Center, Changsha, China
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16
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Beck CJ, Germano E, Artis AS, Kirksey L, Smolock CJ, Lyden SP, Bakaeen FG, Menon V, Roselli EE, Farivar BS. Outcomes and role of peripheral revascularization in type A aortic dissection (TAAD) presenting with acute lower extremity ischemia. J Vasc Surg 2021; 75:495-503.e5. [PMID: 34500026 DOI: 10.1016/j.jvs.2021.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI. METHODS Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis. RESULTS From 2010 to 2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 patients (17%) presented with ALI; 48% (39/81) with isolated ALI, and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular (46%; 11/24), open (33%; 8/24), and hybrid (21%; 5/24) interventions. The major amputation rate was 4% (3/81), and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared with those who did not (log-rank P = .023). Overall survival did not significantly differ between the two groups (log-rank P = .095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared with those with isolated ALI (log-rank P = .0017). Distal extent of dissection flap into zone 11 (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.58-20.2; P = .008) and partial/complete thrombosis of any iliac artery (OR, 3.94; 95% CI, 1.23-12.6; P = .021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR, 8.84; 95% CI, 1.74-44.9; P = .0086) was associated with increased risk of in-hospital mortality. CONCLUSIONS ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.
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Affiliation(s)
- Cassandra J Beck
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emidio Germano
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Behzad S Farivar
- Division of Vascular & Endovascular Surgery, University of Virginia, Charlottesville, Va; Aortic Center, University of Virginia Medical Center, Charlottesville, Va.
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17
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Abstract
This review discusses the clinical applications of the frozen elephant trunk procedure for patients with acute aortic dissection. Sub-analysis of the multicenter Japanese Frozenix study, J-ORCHESTRA, are presented, and recent reports of frozen elephant trunk usage for acute aortic dissection are discussed.
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Affiliation(s)
- Yutaka Okita
- Takatsuki General Hospital, Kobe University, Japan
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18
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Frozen Elephant Trunk Technique in Acute Type A Aortic Dissection: Is It for All? MEDICINA-LITHUANIA 2021; 57:medicina57090894. [PMID: 34577818 PMCID: PMC8467885 DOI: 10.3390/medicina57090894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 02/05/2023]
Abstract
Acute type A aortic dissection (ATAAD) is an indisputable emergency with very poor outcomes without surgical treatment. Although the aortic arch is often involved in the aortic dissection, its optimal management during surgical therapy remains uncertain. A conservative tear-oriented approach has traditionally been adopted, limiting the procedure to the ascending aorta (or hemiarch) replacement. However, dilation of the residual dissected aorta and subsequent rupture may occur, requiring further intervention in the future. In the last two decades, the frozen elephant trunk (FET) technique has become a valid and attractive option to treat aortic disease when the arch and the thoracic aorta are involved, both in elective and in emergency settings. Here, we report a review of the contemporary literature regarding the short- and long-term outcomes of the FET technique in ATAAD repair.
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19
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Li J, Li L, Wang M, Li H, Sun L, Liu Y, Fan R, Zhang Z, Zou C, Zhang H, Gong M. Comparison of Prognosis Between Hybrid Debranching Surgery and Total Open Arch Replacement With Frozen Elephant Trunk for Type A Acute Aortic Syndrome Patients. Front Cardiovasc Med 2021; 8:689507. [PMID: 34386528 PMCID: PMC8353071 DOI: 10.3389/fcvm.2021.689507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background: It is unclear whether the total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery have a difference in the prognosis of patients with type A acute aortic syndrome (AAS). We attempted to compare the short-term and long-term prognosis of total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery in patients with type A acute aortic syndrome (AAS). Methods: From January 2014 to September 2020, a total of 518 patients who underwent TAR with FET surgery and 31 patients who underwent hybrid surgery were included. We analyzed the post-operative mortality and morbidity of complications of the two surgical methods, and we determined 67 patients for subgroup analysis through a 1:2 propensity score match (PSM). We identified risk factors for patient mortality and post-operative neurological complications through multivariate regression analysis. Results: Compared with the TAR with FET group, hybrid surgery could reduce aortic cross-clamp time, reduce intraoperative blood loss and prevent some patients from cardiopulmonary bypass. There was no significant difference in 30-day mortality between the TAR with FET group and the hybrid surgery group (10.6 vs. 9.7%). However, hybrid surgery had increased the incidence of permanent neurological complications in patients (95%CI: 4.7–35.7%, P = 0.001), especially post-operative cerebral infarction (P < 0.001). During the average follow-up period of 31.6 months, there was no significant difference in the 1-year survival rate and 3-year survival rate between the TAR with FET group and the hybrid surgery group (P = 0.811), but hybrid surgery increased the incidence of long-term neurological complications (P < 0.001). In multivariate regression analysis, surgical methods were not a risk factor for post-operative deaths, but hybrid surgery was a risk factor for post-operative neurological complications (P < 0.001). Conclusions: Hybrid surgery is an acceptable treatment for AAS, and its post-operative mortality is similar to FET. But hybrid surgery may increase the risk of permanent neurological complications after surgery, and this risk must be carefully considered when choosing hybrid surgery.
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Affiliation(s)
- Jinzhang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Lei Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Maozhou Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Lizhong Sun
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Zonggang Zhang
- Department of Cardiac Surgery, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chengwei Zou
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
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20
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Reid G, Mork C, Mujagic E, Berdajs D. Simple endovascular thoracic aortic stenting rescues a wrongly deployed frozen elephant trunk during a modified procedure. J Int Med Res 2021; 49:300060520986710. [PMID: 33535858 PMCID: PMC7869178 DOI: 10.1177/0300060520986710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We report a bail out approach of endovascular thoracic aorta repair following incorrect deployment of a modified frozen elephant trunk stent graft into the false lumen. A 76-year-old patient was admitted to our Emergency Department. A computed tomography angiography scan showed type I DeBakey aortic dissection. An emergency modified frozen elephant trunk procedure was performed. Immediate postoperative computed tomography angiography showed that the distal segment of the stent was deployed in the false lumen, probably through a re-entry tear at the descending thoracic aorta. Emergency endovascular repair of the thoracic aorta, as well as angioplasty of the superior mesenteric artery and left iliac artery, were performed.
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Affiliation(s)
- Gregory Reid
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Constantin Mork
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
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21
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Kim KM. Another Tool in the Toolbox. Ann Thorac Surg 2021; 112:754-755. [PMID: 33607047 DOI: 10.1016/j.athoracsur.2021.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Karen M Kim
- Department of Cardiac Surgery, University of Michigan, 1500 E Medical Center Dr, 5164 CVC, SPC 5864, Ann Arbor, MI 48109.
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22
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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: 15] [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.
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Zhang J, Ma W, Chen J, Zhu D, Zhang Y, Kong Y, Zhang J, Zhang W. Distal Remodeling After Operations for Extensive Acute Aortic Dissection. Ann Thorac Surg 2020; 112:83-90. [PMID: 33096070 DOI: 10.1016/j.athoracsur.2020.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 07/19/2020] [Accepted: 08/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood. METHODS From 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n = 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n = 25), and total endovascular repair (n = 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up. RESULTS At 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up. CONCLUSIONS After distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management.
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Affiliation(s)
- Jing Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenrui Ma
- Department of Cardiac Surgery, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinmiao Chen
- Department of Cardiac Surgery, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Zhu
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ye Kong
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Jianfeng Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Song SB, Wu XJ, Sun Y, Cai SH, Hu PY, Qiang HF. A modified frozen elephant trunk technique for acute Stanford type A aortic dissection. J Cardiothorac Surg 2020; 15:322. [PMID: 33087138 PMCID: PMC7579979 DOI: 10.1186/s13019-020-01306-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute Stanford type A aortic dissection is often fatal, with a high mortality rate and requiring emergency intervention. Salvage surgery aims to keep the patient alive by addressing severe aortic regurgitation, tamponade, primary tear, and organ malperfusion and, if possible, prevent the late dissection-related complications in the proximal and downstream aorta. Unfortunately, no optimal standard treatment or technique to treat this disease exists. Total arch replacement with frozen elephant trunk technique plays an important role in treating acute type A aortic dissection. We aim to describe a modified elephant trunk technique and report its short-term outcomes. METHODS From February 2018 to August 2019, 16 patients diagnosed with acute Stanford type A aortic dissection underwent surgery with the modified frozen elephant trunk technique at Xiamen Heart Center (male/female: 9/7; average age: 56.1 ± 7.6 years). All perioperative variables were recorded and analyzed. We measured the diameters of the ascending aorta, aortic arch, and descending aorta on the bifurcation of the pulmonary and abdominal aortas and compared the diameters at admission, before discharge, and 3 months after discharge. RESULTS Fifteen patients (93.8%) had hypertension. The primary tears were located in the lesser curvature of the aortic arch and ascending aorta in 5 (31.3%) and 9 patients (56.3%), respectively, and no entry was found in 2 patients (12.5%). The dissection extended to the iliac artery and distal descending aorta in 14 (87.6%) and 2 patients (12.5%), respectively. The duration of cardiopulmonary bypass (CPB), cross-clamping, and antegrade cerebral perfusion were 215.8 ± 40.5, 140.8 ± 32.3, and 55.1 ± 15.2 min, respectively. Aortic valve repair was performed in 15 patients (93.8%). Bentall procedure was performed in one patient (6.3%). Another patient received coronary artery repair (6.3%). The diameters at all levels were greater on discharge than those on admission, except the aortic arch. After 3 months, the true lumen diameter distal to the frozen elephant trunk increased, indicating false lumen thrombosis and/or aortic remodeling. CONCLUSIONS The modified frozen elephant trunk technique for acute Stanford type A aortic dissection is safe and feasible and could be used for organ malperfusion. Short-term outcomes are encouraging, but long-term outcomes require further investigation.
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Affiliation(s)
- Shi-bo Song
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
| | - Xi-jie Wu
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
| | - Yong Sun
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
| | - Shi-hao Cai
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
| | - Po-yuan Hu
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
| | - Hai-feng Qiang
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen university, XiaMen, 361000 China
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Berdajs DA, Koechlin L, Reid G, Grob F, Gahl B, Schurr U, Reuthebuch O, Eckstein F. Modified frozen elephant trunk procedure as standard approach in acute type A aortic dissection: A propensity-weighted analysis. J Thorac Cardiovasc Surg 2020; 163:1754-1761.e3. [PMID: 32798027 DOI: 10.1016/j.jtcvs.2020.05.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate whether the modified frozen elephant trunk (mFET) procedure provides comparable outcome compared with the standard approach for DeBakey type I aortic dissection. METHODS From November 2008 to December 2018, 262 (mean age 62.7 ± 12.4 years) patients with acute DeBakey type I aortic dissection were included. mFET was performed in 100 (38.2%) patients and isolated ascending aorta and hemiarch replacement (iAoA) were performed in 162 (61.8%). Outcome analyses included in-hospital mortality, stroke rate, incidence of composite cardiovascular events, survival, freedom from aorta-related intervention, as well as freedom from neurologic event. Inverse probability of treatment weighting was applied. RESULTS After inverse probability of treatment weighting, in-hospital mortality was greater in the iAoA group. The incidence of cardiac cause of death, new postoperative renal failure, as well as stroke rate were similar in both groups. The survival at 1 year, 3 years, and 4 years was 84%, 81%, and 77%, respectively, in the iAoA group and 91%, 86%, and 86%, P = .025, respectively, in the mFET group. Cause-specific HR for aortic reoperation 1.03 (confidence interval [CI], 0.43-2.48, P = .95) and neurovascular event 2.72 (CI, 0.62-11.93, P = .19) was similar in 2 groups. Subhazard ratio (sHR) for mortality as competing outcome for aorta-related reintervention sHR of 0.52 (CI, 0.32-0.86, P = .011) and neurologic event sHR of 0.45 (95% CI, 0.26-0.76, P = .003) was significantly lower in mFET. CONCLUSIONS The mFET procedure as surgical treatment modality for DeBakey type I acute aortic dissection may be considered as viable alternative with beneficial mid-term outcome.
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Affiliation(s)
- Denis A Berdajs
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland.
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
| | - Gregory Reid
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
| | - Flurin Grob
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
| | - Ulrich Schurr
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital, Basel, Switzerland
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Ma WG, Chen Y, Zhang W, Li Q, Li JR, Zheng J, Liu YM, Zhu JM, Sun LZ. Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:292-300. [DOI: 10.23736/s0021-9509.20.11293-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Giambuzzi I, Mastroiacovo G, Roberto M, Pirola S, Alamanni F, Cavallotti L, Bonalumi G. Preoperative neurological dysfunctions: what is their meaning in patients presenting with acute type A aortic dissection? Minerva Cardioangiol 2020; 68:511-517. [PMID: 32524808 DOI: 10.23736/s0026-4725.20.05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Type A aortic dissection (AAD) is a life-threatening disease with very high mortality. The gold standard treatment is surgical, as medical treatment has been proven to be ineffective. It is still unclear the role of preoperative neurological dysfunction in the prognosis of the patient. Therefore, the choice of performing surgery in patients with neurological symptoms is still left to the surgeon at the time of the diagnosis. The aim of this study is to make a narrative review of the current literature about the management of patients with neurological symptoms in AAD patients. EVIDENCE ACQUISITION A bibliographical research was performed on PubMed, looking for papers containing the words: "((preoperative neurological symptoms in type a aortic dissection) OR brain injury type A aortic dissection) AND ("2010"[Date - Publication]: "3000"[Date - Publication])". A total of 35 papers were found. EVIDENCE SYNTHESIS A total of 6 papers were chosen to be reviewed. All of them concluded that even patients with severe neurological symptoms (up to comatose state) had a good chance to recover neurological functions after surgery if treated in the first hours from the onset of symptoms. Interestingly, a hemorrhagic stroke was rarely found. CONCLUSIONS Preoperative neurological dysfunction have been long considered a contraindication to surgery. Nevertheless, several authors show neurological and survival good results in patients with preoperative neurological dysfunction. They also stress the importance of surgical timing finding in 5 to 10 hours the surgical time limit to improve neurological dysfunction. A preoperative neurological dysfunction could be considered a strong advice towards surgical intervention. It is time to change and consider prompt surgery not only for survival but also for cerebral protection.
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Affiliation(s)
- Ilaria Giambuzzi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy -
| | | | - Maurizio Roberto
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Sergio Pirola
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | | | - Laura Cavallotti
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Giorgia Bonalumi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
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Okita Y. Frozen elephant trunk with Frozenix prosthesis. Ann Cardiothorac Surg 2020; 9:152-163. [PMID: 32551247 PMCID: PMC7298232 DOI: 10.21037/acs.2020.03.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
This paper presents the clinical applications of the Japanese-made frozen elephant trunk (FET, Frozenix®). The historical aspects of FET development, manufacture and structure of Frozenix, video images of a representative case, and a summary of a multi-centre Japanese Frozenix study, J-ORCHESTRA, are discussed.
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Affiliation(s)
- Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University, Kobe, Hyogo, Japan
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Leone A, Beckmann E, Aandreas M, Di Marco L, Pantaleo A, Reggiani LB, Haverich A, Di Bartolomeo R, Pacini D, Sherestha M. Total aortic arch replacement with frozen elephant trunk technique: Results from two European institutes. J Thorac Cardiovasc Surg 2020; 159:1201-1211. [DOI: 10.1016/j.jtcvs.2019.03.121] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
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Wang X, Yang F, Zhu J, Liu Y, Sun L, Hou X. Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159:374-387.e4. [DOI: 10.1016/j.jtcvs.2019.01.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/16/2023]
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Koechlin L, Kaufmann J, Macius E, Bremerich J, Sommer G, Gahl B, Schurr U, Grapow M, Reuthebuch O, Eckstein F, Berdajs DA. Impact of Modified Frozen Elephant Trunk Procedure on Downstream Aorta Remodeling in Acute Aortic Dissection: CT Scan Follow-Up. World J Surg 2020; 44:1648-1657. [DOI: 10.1007/s00268-020-05374-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Acute type I aortic dissection with or without antegrade stent delivery: Mid-term outcomes. J Thorac Cardiovasc Surg 2019; 158:1273-1281. [DOI: 10.1016/j.jtcvs.2018.11.145] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/28/2018] [Accepted: 11/30/2018] [Indexed: 11/27/2022]
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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: 1.3] [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]
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Ghoreishi M, Sundt TM, Cameron DE, Holmes SD, Roselli EE, Pasrija C, Gammie JS, Patel HJ, Bavaria JE, Svensson LG, Taylor BS. Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database. J Thorac Cardiovasc Surg 2019; 159:2143-2154.e3. [PMID: 31351776 DOI: 10.1016/j.jtcvs.2019.06.016] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 05/18/2019] [Accepted: 06/03/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair. METHODS Acute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated. RESULTS Acute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke. CONCLUSIONS Stroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence.
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Affiliation(s)
- Mehrdad Ghoreishi
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Duke E Cameron
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sari D Holmes
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Eric E Roselli
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chetan Pasrija
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | | | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Lars G Svensson
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley S Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
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Di Marco L, Murana G, Fiorentino M, Amodio C, Mariani C, Leone A, Di Bartolomeo R, Pacini D. The frozen elephant trunk surgery: a systematic review analysis. Indian J Thorac Cardiovasc Surg 2019; 35:118-126. [PMID: 33061076 DOI: 10.1007/s12055-019-00815-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 11/26/2022] Open
Abstract
The frozen elephant trunk might be considered one of the most appreciated innovations during the last decades to treat complex thoracic aortic lesions. Many useful tips have been progressively introduced to standardize the procedures and, nowadays, the improved post-operative outcomes contributed to spread the procedure. The following article will provide a comprehensive review analysis of the Frozen Elephant Trunk (FET) technique, throughout the current available devices, possible surgical indications and primary post-operative complications.
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Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Mariafrancesca Fiorentino
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Ciro Amodio
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Carlo Mariani
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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Akbulut M, Ak A, Arslan Ö, Çekmecelioğlu D, Taş S, Antal Dönmez A, Şişmanoğlu M, Tuncer MA. Early and mid-term results of frozen elephant trunk procedure for acute type A aortic dissection. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:135-142. [PMID: 32082844 PMCID: PMC7021407 DOI: 10.5606/tgkdc.dergisi.2019.16879] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 01/02/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study aims to investigate the early and mid-term results of total thoracic aorta repair with E-vita OPEN PLUS stent graft, which we used to remove the residual false lumen and prevent late-term complications in patients with acute type A aortic dissections. METHODS The study included 41 patients (29 males, 12 females; mean age 51.9±10.4 years; range, 30 to 77 years) who underwent total thoracic aorta repair with frozen elephant trunk stent graft for acute type A aortic dissection between November 2013 and November 2017. The reduction in false lumen size and thrombosis were evaluated by repeated computed tomographyangiography on 10th day and third, sixth, and 12th months. RESULTS Six patients (14.6%) were lost during hospital stay and one patient (2.4%) was lost during the follow-up period. Frozen elephant trunk stent graft"s distal end at descending aorta ended at T6, T7, and T8 levels in 15 (36.6%), 21 (51.2%), and five (12.2%) patients, respectively. The supra-aortic vessels were re-implanted separately in 21 (51.2%) or as island in 20 (48.8%) patients. Transient paraparesis (spinal cord ischemia) was observed in only one patient (2.4%), while permanent neurologic deficit (stroke or coma) was observed in two patients (4.9%). Mean duration of follow-up was 26.5±20.5 months. Computed tomography-angiography at first month showed that false lumen became thrombosed at rates of 93.9% and 54.5% at pulmonary trunk and diaphragmatic level, respectively. CONCLUSION We believe that total arcus repair in acute type A aortic dissection treatment with single-session frozen elephant trunk technique by ensuring early false lumen thrombosis is safe and successful.
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Affiliation(s)
- Mustafa Akbulut
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Adnan Ak
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Özgür Arslan
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Davut Çekmecelioğlu
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Serpil Taş
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Arzu Antal Dönmez
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Mesut Şişmanoğlu
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Altuğ Tuncer
- Department of Cardiovascular Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul, Turkey
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Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques. Asian J Surg 2019; 42:482-487. [DOI: 10.1016/j.asjsur.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022] Open
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Mitsis A, Nienaber CA. Endovascular Treatment of Aortic Diseases. SURGICAL MANAGEMENT OF AORTIC PATHOLOGY 2019:1171-1185. [DOI: 10.1007/978-3-7091-4874-7_82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2024]
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Trimarchi S, de Beaufort HWL, Tolenaar JL, Bavaria JE, Desai ND, Di Eusanio M, Di Bartolomeo R, Peterson MD, Ehrlich M, Evangelista A, Montgomery DG, Myrmel T, Hughes GC, Appoo JJ, De Vincentiis C, Yan TD, Nienaber CA, Isselbacher EM, Deeb GM, Gleason TG, Patel HJ, Sundt TM, Eagle KA. Acute aortic dissections with entry tear in the arch: A report from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2019; 157:66-73. [PMID: 30396735 DOI: 10.1016/j.jtcvs.2018.07.101] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/03/2018] [Accepted: 07/19/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. METHODS Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared. RESULTS The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P < .001), endovascular treatment (3.5% vs 25.0%; P < .001), and medical management (16.2% vs 51.4%; P < .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant. CONCLUSIONS Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.
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Affiliation(s)
- Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy; Department of Scienze Biomediche per la Salute, University of Milan, Milan, Italy.
| | - Hector W L de Beaufort
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Jip L Tolenaar
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Arturo Evangelista
- Department of Cardiology, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Daniel G Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, University of Tromsø, Tromsø, Norway
| | - G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlo De Vincentiis
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Tristan D Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, London, United Kingdom
| | - Eric M Isselbacher
- Thoracic Aortic Center and Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - G Michael Deeb
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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Burke CR, Atluri P. Commentary: To STABILISE or not: Is the additive time of additive benefit? J Thorac Cardiovasc Surg 2018; 157:2166-2167. [PMID: 30448160 DOI: 10.1016/j.jtcvs.2018.10.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Christopher R Burke
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa.
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Di Marco L, Leone A, Murana G, Castelli A, Alfonsi J, Di Bartolomeo R, Pacini D. Acute type A aortic dissection: Rationale and outcomes of extensive repair of the arch and distal aorta. Int J Cardiol 2018; 267:145-149. [PMID: 29880297 DOI: 10.1016/j.ijcard.2018.05.111] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/17/2018] [Accepted: 05/25/2018] [Indexed: 11/18/2022]
Abstract
Type A acute aortic dissection represents one of the most complex and life-threatening disorders of the cardiovascular system. Cardiac tamponade caused by ascending aorta rupture is the most common cause of death. In light of this, emergent surgery with ascending and partial arch replacement represents, in most of cases, the best and the faster therapeutic option. The natural history of aortic dissection, however, teaches us that in most cases there is a distal progression of the aortic disease that often requires further surgical and/or endovascular treatments. In light of this, it can be hypothesized that, by increasing the extent of aortic replacement during the first operation, it may improve the outcome of these patients by reducing the probability of a second surgery or, in selected cases and for appropriate indications, by treating with a single surgical step, the disease. In this short review of the literature, we focalized on the rationale and outcome of an extensive repair of the thoracic aorta.
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Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Castelli
- Cardio-Anesthesiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
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42
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Bashir M, Harky A, Bilal H. Is there a prospect for hybrid aortic arch surgery? Gen Thorac Cardiovasc Surg 2018; 67:132-136. [PMID: 29767819 DOI: 10.1007/s11748-018-0940-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
The surge of endovascular repair of aortic aneurysm in current modern aortic surgery practice has been the key for surgical management of elective cases of thoracic aortic aneurysms. This has paved way for the combined hybrid approach to be amongst the armamentarium for the management of aortic arch disease. The pivotal understanding of the aortic arch natural history coupled with device technology advancement allowed surgeons insight into delivery of hybrid surgery with acceptable morbidity and mortality results. This review article provides current insights into hybrid technique of aortic arch aneurysm repair and the evidences behind its applicability to arch surgery. It is aimed to highlight the challenges encountered for this innovative approach and correlate its challenges to those that are met by the conventional open aortic arch repair.
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Affiliation(s)
- Mohamad Bashir
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
| | - Amer Harky
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,Department of Cardiothoracic Surgery, Northwest Deanery, North West, Liverpool, UK
| | - Haris Bilal
- Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Fukuhara S, Roselli EE. Modified branched reverse frozen elephant trunk repair for failed TEVAR. Ann Cardiothorac Surg 2018; 7:437-442. [PMID: 30155425 DOI: 10.21037/acs.2018.05.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shinichi Fukuhara
- Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Di Bartolomeo R, Murana G, Di Marco L, Alfonsi J, Gliozzi G, Amodio C, Leone A, Pacini D. Is the frozen elephant trunk frozen? Gen Thorac Cardiovasc Surg 2018; 67:111-117. [DOI: 10.1007/s11748-018-0911-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
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Abstract
Aortic diseases include not only the thoracic but also the abdominal part of the aorta. In the etiology cardiovascular risk factors, such as hypertension, smoking and hyperlipoproteinemia play a major role, but more and more genetic diseases with familiar predisposition are being identified. Even large aneurysms remain asymptomatic as long as other organs in the neighborhood are not damaged and no acute aortic event occurs including aortic dissection, intramural hematoma, penetrating aortic ulcer, and traumatic aortic injury. Standardized algorithms allow precise and rapid diagnosis for initiating medicinal therapy or operative and/or endovascular interventions (thoracic/endovascular aortic repair, TEVAR/EVAR) in this emergency situation. Specialized aortic centers are recommended to form localized regional networks.
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Affiliation(s)
- R Erbel
- Institut für Medizinische Informatik, Biometrie und Epidemiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
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Roselli EE, Idrees JJ, Bakaeen FG, Tong MZ, Soltesz EG, Mick S, Johnston DR, Eagleton MJ, Menon V, Svensson LG. Evolution of Simplified Frozen Elephant Trunk Repair for Acute DeBakey Type I Dissection: Midterm Outcomes. Ann Thorac Surg 2018; 105:749-755. [DOI: 10.1016/j.athoracsur.2017.08.037] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/26/2017] [Accepted: 08/21/2017] [Indexed: 11/16/2022]
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Choi C, Pagel PS. Acute Onset of Severe Chest Pain Associated With Strenuous Sexual Activity. J Cardiothorac Vasc Anesth 2018; 32:2620-2622. [PMID: 29571638 DOI: 10.1053/j.jvca.2018.02.025] [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: 02/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Christine Choi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
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48
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Bozso SJ, White A, Nagendran J, Moon MC, Chu MWA. Hybrid aortic arch and frozen elephant trunk reconstruction: bridging the gap between conventional and total endovascular arch repair. Expert Rev Cardiovasc Ther 2018; 16:209-217. [DOI: 10.1080/14779072.2018.1429913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Sabin J. Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Abigail White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Michael C. Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
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Zhou Q, Xue Y, Cao H, Pan J, Wang Q, Fan F, Wang D. Novel arch fenestrated stent graft for acute Stanford Type A aortic dissection with open antegrade implantation. Interact Cardiovasc Thorac Surg 2017; 26:369-375. [PMID: 29161440 DOI: 10.1093/icvts/ivx335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/13/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yunxing Xue
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Qiang Wang
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Fudong Fan
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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50
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Preventza O, Coselli JS, Mayor J, Simpson K, Carillo J, Price MD, Cornwell LD, Omer S, de la Cruz KI, Bakaeen FG, Jobe A. The Stent Is Not to Blame: Lessons Learned With a Simplified US Version of the Frozen Elephant Trunk. Ann Thorac Surg 2017. [DOI: 10.1016/j.athoracsur.2017.03.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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