Management of left subclavian artery in total arch replacement and frozen elephant trunk procedure.
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ABSTRACT:
SUBMITTER: Ho JYK
PROVIDER: S-EPMC8312104 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:We here describe a complex case of a 75-year-old man presenting with contained rupture of an aortic arch aneurysm in the presence of a second thoracic aortic aneurysm. He was managed with emergent total arch replacement with frozen elephant trunk. Another stent-graft was used to achieve hemostasis at the distal anastomosis. He later underwent TEVAR extension to manage his second aneurysm in a staged fashion. This case demonstrates a number of important concepts in the evolving interaction between open and endovascular therapies of the aortic arch, particularly in the emergent setting.
| S-EPMC6472687 | biostudies-literature
Project description:We here describe a complex case of a 75-year-old man presenting with contained rupture of an aortic arch aneurysm in the presence of a second thoracic aortic aneurysm. He was managed with emergent total arch replacement with frozen elephant trunk. Another stent-graft was used to achieve hemostasis at the distal anastomosis. He later underwent TEVAR extension to manage his second aneurysm in a staged fashion. This case demonstrates a number of important concepts in the evolving interaction between open and endovascular therapies of the aortic arch, particularly in the emergent setting.
| S-EPMC6865198 | biostudies-literature
Project description:BackgroundThe frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes.MethodsFrom 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n =?57) or the Vascutek Thoraflex hybrid prosthesis (n =?11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each.ResultsEarly mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p =?0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p =?0.797 and spinal cord injury: 8.8 vs. 5.9%; p =?0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2?±?73.5 and 148.3?± 34?min vs. 189.2?±?47.8 and 116.3?± 34.5?min; p?<? 0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p =?0.575.ConclusionThe FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.
| S-EPMC6676558 | biostudies-literature
Project description:BackgroundTotal arch replacement (TAR) with frozen elephant trunk (FET) was challenging in patients with prior thoracic endovascular aortic repair (TEVAR), for complicated arch pathology and anatomy. In this study, we aimed to present our experiences in TAR with FET after prior TEVAR, and compare the clinical outcomes between the aortic balloon occlusion technique and the conventional technique.MethodsBetween January 2016 and December 2019, 30 patients with prior TEVAR received TAR with FET in our hospital. The aortic balloon occlusion technique was applied in 9 patients, and the conventional technique in 21 patients. The median time interval from TEVAR to reoperation was 9 months (0-168 months). The indications for TAR with FET included retrograde type A aortic dissection, endoleak, arch false aneurysm and new ascending dissection.ResultsThe patients with the balloon occlusion technique had shorter cardiopulmonary bypass time than patients with the conventional technique (151.2±31.3 vs. 183.4±46.8 min, P=0.036). The aortic-clamp time was also shorter in the balloon occlusion group, but without significant difference. The hypothermia circulatory arrest duration was significantly decreased in the balloon occlusion group (5.7±4.1 vs. 21.6±7.5 min, P<0.001). The incidence of major adverse events was 13.3%, and the mortality was 6.7%. No significant differences in the incidence of major adverse events, and the mortality were noted between the two groups. Follow-up was available in 28 survivors. The mean follow-up time was 25.4±13.0 months. No late death, aortic reoperation and complications occurred during follow-up.ConclusionsTAR with FET was a safe and effective procedure in patients with prior TEVAR, with satisfactory early and late outcomes. The aortic balloon occlusion technique could be applied in these patients, and may provide some protective effects.
| S-EPMC7330339 | biostudies-literature
Project description:ObjectivesOur aim was to investigate the occurrence and clinical consequence of postoperative in-stent thrombus formation following the frozen elephant trunk (FET) procedure.MethodsPostoperative computed tomography angiography (CTA) scans of all 304 patients following the FET procedure between 04/2014 and 11/2021 were analysed retrospectively. Thrombus size and location were assessed in multiplanar reconstruction using IMPAX EE (Agfa HealthCare N.V., Morstel, Belgium) software. Patients' characteristics and clinical outcomes were evaluated between patients with and without thrombus formation.ResultsDuring the study period, we detected a new postoperative in-stent thrombus in 19 patients (6%). These patients were significantly older (p = 0.009), predominantly female (p = 0.002) and were more commonly treated for aortic aneurysms (p = 0.001). In 15 patients (79%), the thrombi were located in the distal half of the FET stent-graft. Thrombus size was 18.9 mm (first quartile: 12.1; third quartile: 33.2). Distal embolisation occurred in 4 patients (21%) causing one in-hospital death caused by severe visceral ischaemia. Therapeutic anticoagulation was initiated in all patients. Overstenting with a conventional stent-graft placed within the FET stent-graft was the treatment in 2 patients (11%). Outcomes were comparable both groups. Female sex (p = 0.005; OR: 4.289) and an aortic aneurysm (p = 0.023; OR: 5.198) were identified as significant predictors for thrombus development.ConclusionPostoperative new thrombus formation within the FET stent-graft is a new, rare, but clinically highly relevant event. The embolisation of these thrombi can result in dismal postoperative outcomes. More research is therefore required to better identify patients at risk and improve perioperative treatment.
| S-EPMC9279669 | biostudies-literature
Project description:Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], p = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], p = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.
| S-EPMC9630467 | biostudies-literature
Project description:BackgroundTotal aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study.MethodsThis retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded.ResultsThe 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge.ConclusionsThe ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.
| S-EPMC8425170 | biostudies-literature
Project description: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. Video Abstract Graphical abstract
| S-EPMC9938375 | biostudies-literature
Project description:ObjectivesThe objective of this study was to enhance the efficiency of aortic arch replacement through the development of a novel frozen elephant trunk prosthesis with an endovascular side branch for left subclavian artery (LSA) connection. After successful preclinical testing, the feasibility and safety of implementing this innovative prosthesis in human subjects were investigated.Patients and methodsBetween September 2020 and September 2021, four patients (mean age 67a) with conditions such as penetrating ulcer, non A-non B aortic dissection, and chronic arch aneurysm underwent surgery utilizing the customized device. Surgeries were performed under high moderate hypothermia (27 °C), employing bilateral selective antegrade cerebral perfusion (ASCP) and distal aortic perfusion. Anastomosis of the frozen elephant trunk prosthesis with the aortic arch occurred in zones 1, followed by separate reimplantation of the left common carotid artery and the brachiocephalic artery.ResultsAll patients were discharged in good clinical condition. The mean aortic cross-clamp, antegrade selective cerebral perfusion, and distal aortic perfusion times were 111, 71, and 31 min, respectively. Endovascular extension of the side branch for the left subclavian artery was required in all cases to prevent endoleak formation. One patient received a stent graft extension at the end of the operation, while two others underwent the procedure during their hospital stay. One patient was diagnosed with endoleak at the first follow-up after 3 months, and endoleak sealing was achieved via the brachial artery with an extension stent graft.ConclusionsPreliminary clinical outcomes suggest that the newly designed frozen elephant trunk prosthesis shows promise in simplifying total arch replacement. These initial findings provide a foundation for planned clinical studies to further assess the effectiveness of this modified surgical hybrid graft, with particular attention to the length and diameter of the LSA side arm.
| S-EPMC11341124 | biostudies-literature
Project description:BackgroundEarly identification of postoperative ischemic stroke among patients with acute DeBakey type I aortic dissection (ADIAD) is of great significance to taking timely effective treatment. We aimed to develop and validate a prediction model for postoperative ischemic stroke in ADIAD patients who underwent total arch replacement (TAR) and frozen elephant trunk (FET) under mild hypothermia.MethodsADIAD patients who underwent TAR and FET between January 2017 and April 2023 were enrolled in our study. Preoperative and intraoperative variables were selected using pairwise comparisons, the Least Absolute Shrinkage and Selection Operator (LASSO), and logistic regression to construct a prediction model for postoperative ischemic stroke. The accuracy and calibration of the model were assessed using 1000 bootstrap resamples for internal validation, with the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test. The AUC was also used to evaluate the model's accuracy in the validation cohort.ResultsThe development cohort included 246 patients. The mean [standard deviation (SD)] age of patients in the cohort was 50.7 (11.2) years, 196 (79.7%) were men, and 22 (8.9%) were diagnosed with postoperative ischemic stroke. The validation cohort included 73 patients with a mean (SD) age of 52.5 (11.9) years, 58 (79.5%) were men and 3 (4.1%) were diagnosed with postoperative ischemic stroke. Three variables out of the initial 40 potential predictors were included in the final prediction model: the platelet count [odd ratio (OR), 0.992; 95% confidence interval (CI), 0.983-1.000], the presence of innominate artery dissection (OR, 3.400; 95% CI, 1.027-11.260), and the flow of selective cerebral perfusion (OR, 0.147; 95% CI, 0.046-0.469). The mean AUC in the development cohort was 0.77 (95% CI, 0.68-0.87), and calibration was checked with the Hosmer-Lemeshow test (P = 0.78). In the validation cohort, the AUC was 0.98 (95% CI, 0.94-1.00). A prediction model and a clinical impact curve were developed for practical purposes.ConclusionsIn this study, we have developed a prediction model with competent discriminative ability and calibration. This model can be used for early assessment of the risk of postoperative ischemic stroke in patients with ADIAD following TAR and FET under mild hypothermia.
| S-EPMC10881848 | biostudies-literature