Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection.
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ABSTRACT:
SUBMITTER: Kuroda Y
PROVIDER: S-EPMC8691576 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description: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.
| S-EPMC7579979 | biostudies-literature
Project description:Background: This study was aimed to investigate the incidence, risk factors, and outcomes of patients with postoperative hepatic dysfunction (PHD) after frozen elephant trunk (FET) for type A aortic dissection (TAAD). Method: A retrospective study was performed with 492 patients who underwent FET for TAAD between 2015 and 2019. Independent risk factors for PHD were determined by multivariate mixed-effect logistic analysis with surgeon-specific factor as a random effect. Results: The incidence of PHD was 25.4% (n = 125) in our cohort. Patients with PHD presented higher early mortality (10.4 vs. 1.1%, p < 0.001), rates of acute kidney injury (42.4 vs. 12.8%, p < 0.001), and newly required dialysis (23.2 vs. 3.0%, p < 0.001) compared with those without PHD. Moreover, with the median follow-up period of 41.3 months, the survival curve was worse in patients with PHD compared with no PHD group (log-rank p < 0.001), whereas it was similar after excluding patients who died within 30 days (log-rank p = 0.761). Multivariable analyses suggested that PHD was predicted by preoperative aspartate transferase [odds ratio (OR), 1.057; 95% confidence intervals (CI), 1.036-1.079; p < 0.001], celiac trunk malperfusion (OR, 3.121; 95% CI, 1.008-9.662; p = 0.048), and cardiopulmonary bypass time (OR, 1.014; 95% CI, 1.005-1.023; p = 0.003). Retrograde perfusion (OR, 0.474; 95% CI, 0.268-0.837; p = 0.010) was associated with a reduced risk of PHD. Celiac trunk malperfusion was an independent predictor for PHD but not associated with early mortality and midterm survival. Conclusions: PHD was associated with increased early mortality and morbidity, but not with late death in midterm survival. PHD was predicted by preoperative aspartate transferase, celiac trunk malperfusion, and cardiopulmonary bypass (CPB) time, and retrograde perfusion was associated with a reduced risk of PHD.
| S-EPMC8645859 | biostudies-literature
Project description:ObjectiveTo develop and validate a nomogram model to predict postoperative 30-day mortality in acute type A aortic dissection patients receiving total aortic arch replacement with frozen elephant trunk technique.MethodClinical data on 1,156 consecutive acute type A aortic dissection patients who got total aortic arch replacement using the frozen elephant trunk technique was collected from January 2010 to December 2020. These patients were divided into training and testing cohorts at random with a ratio of 7:3. To predict postoperative 30-day mortality, a nomogram was established in the training set using the logistic regression model. The novel nomogram was then validated in the testing set. The nomogram's calibration and discrimination were evaluated. In addition, we created four machine learning prediction models in the training set. In terms of calibration and discrimination, the nomogram was compared to these machine learning models in testing set.ResultsLeft ventricular end-diastolic diameter <45 mm, estimated glomerular filtration rate <50 ml/min/1.73 m2, persistent abdominal pain, radiological celiac trunk malperfusion, concomitant coronary artery bypass grafting and cardiopulmonary bypass time >4 h were independent predictors of the 30-day mortality. The nomogram based on these 6 predictors manifested satisfying calibration and discrimination. In testing set, the nomogram outperformed the other 4 machine learning models.ConclusionThe novel nomogram is a simple and effective tool to predict 30-day mortality rate for acute type A aortic dissection patients undergoing total aortic arch replacement with frozen elephant trunk technique.
| S-EPMC9226415 | 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) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified "in situ" arch replacement with an integrative FET device for aTAAD.MethodsFrom January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/- or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining "island" arch with the prosthetic vessel and the proximal part of the FET.ResultsMiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.ConclusionsMiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.
| S-EPMC8482334 | biostudies-literature
Project description:OBJECTIVE:This study aimed to evaluate the prevalence of spinal cord injury in total arch replacement with frozen elephant trunk for acute type A aortic dissection using our spinal cord protection technique. METHODS:Between January 2013 and December 2017, 33 patients underwent total arch replacement with frozen elephant trunk for acute type A aortic dissection (mean age 67.9?±?13.3 years). Our spinal cord protection technique involved maintaining extracorporeal circulation through the left subclavian artery in all procedures, using aortic occlusion balloon during distal anastomosis, and inserting frozen elephant trunk above Th 8 with transesophageal echocardiographic guidance. Computed tomography was performed within 1-2 weeks, 12 months, and 36 months postoperatively. We compared the degree of thrombosis of the descending aorta between preoperation and early postoperative period by Fisher's exact test. Moreover, we evaluated postoperative mortality and mobility (including spinal cord injury) at follow-up. RESULTS:The operative mortality within 30 days was 6.1%. Neither paraplegia nor paraparesis was noted. We observed significant thrombosis of the false lumen at the distal arch and aortic valve level of the descending aorta in postoperative early term period (p?<?0.01). At mid-term follow-up (mean 33.9 months), survival probability and 3-year freedom from reoperation rates were 93.9?±?4.1% and 95.0?±?4.9%, respectively. CONCLUSIONS:The frozen elephant trunk technique with our spinal protection strategy provides good postoperative outcomes. Our strategy can maintain spinal cord perfusion without complete ischemia time even during lower body ischemia time. Implementation of our spinal protection strategy will help prevent spinal cord injury and dilated downstream aorta.
| S-EPMC7522075 | biostudies-literature
Project description:The surgical management of acute and chronic complex diseases involving the aortic arch and the descending thoracic aorta remains challenging. Hybrid procedures associating total open arch replacement and stent-grafting of the proximal descending aorta were developed to allow a potential single-stage treatment, promote remodeling of the downstream aorta, and facilitate a potential second-stage thoracic endovascular aortic repair by providing an ideal landing zone. While these approaches initially used various homemade combinations of available conventional prostheses and stent-grafts, the so-called frozen elephant trunk technique emerged with the development of several custom-made hybrid prostheses. The aim of this study was to review the contemporary outcomes of this technique in the management of complex aortic diseases, with a special focus on procedural planning, organ protection and monitoring, refinements in surgical techniques, and long-term follow-up.
| S-EPMC10488597 | biostudies-literature
Project description:ObjectivesTo improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported.MethodsBetween February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0-3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days.ResultsPreoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4-1.0; P = 0.036).ConclusionsFET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events.Subject collection120; 161.
| S-EPMC8759516 | biostudies-literature
Project description:ObjectivesA better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition.MethodsFrom 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups.ResultsAmong weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly.ConclusionsWithout increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.
| S-EPMC10234761 | biostudies-literature
Project description: Not available
| S-EPMC9735389 | biostudies-literature