Survival outcomes of hybrid versus total arch replacement in type A aortic dissection: A meta-analysis of reconstructed individual participant data.

Commentary: The DARTS (Dissected Aorta Repair Through Stent Implantation) trial: Hitting the bull's eye in acute type A aortic dissection?

Modification of Penn Classification and Its Validation for Acute Type A Aortic Dissection

Total fenestrated frozen elephant trunk technique for aortic repair of acute type A aortic dissection

Commentary: Aortic arch repair: Custom made versus one size fits all

Author Reply to Commentary: The Scylla and Charybdis of acute type A aortic dissection: Malperfusion and rupture

Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 h of onset, with the mortality rate is increasing by 1%-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable. This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients. A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE, and Scopus to collate the relevant research evidence. The more aggressive TAR approach for treating ATAAD seems to yield more favorable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique. It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients.

Acute type A aortic dissection repair in octogenarians: Where are the “turn-down” data?

Objectives: There are various treatment strategies for acute type A aortic dissection (ATAAD). In our department, total arch replacement (TAR) using the Frozen Elephant Trunk (FET) is the standard technique for DeBakey type I, which has a patent false lumen, and we assessed the outcomes and postoperative complications. Methods: Of 71 consecutive patients who underwent surgical treatment for ATAAD at our department from October 2020 to May 2023, 42 patients were included, excluding 29 patients whose the descending aorta was thrombosed or not dissected. Results: Age 64±11 years, 30 male patients (71.4%). Preoperatively, cardiac tamponade was observed in 5 cases, malperfusion in 5 cases of head, 2 cases of coronary artery, 3 cases of celiac artery, 3 cases of superior mesenteric artery, 13 cases of renal artery, and 13 cases of lower limbs. The surgical procedures were ascending aortic replacement (AAR) in 6 cases (14.2%), partial arch replacement (PAR) in 2 cases (4.8%), TAR in 5 cases (11.9%), and TAR with FET in 29 cases (69.0%). The mean operation time was 304±70 minutes, the mean cardiopulmonary bypass time 168±45 minutes, the mean cardiac arrest time 100±26 minutes, the mean circulatory arrest time 42±8 minutes, and the mean minimum bladder temperature 26.1±1.4°C. There was no hospital death, and complications included new stroke in 2 patients (4.8%). The residual dissection was AAR5/6 (83.3%), PAR1/2 (50.0%), TAR5/5 (100%), and TAR with FET24/29 (82.8%), of which AAR5/5 (100%), PAR1/1 (100%), TAR2/5 (40.0%), and TAR with FET1/24 (4.2%) had residual dissection in the proximal descending aorta. There were 3 deaths (meningitis, cerebral hemorrhage, gastrointestinal hemorrhage) with a mean follow-up of 8.9±6.7 months. The only additional treatment was preemptive TEVAR in 1 case (2.4%) for residual dissection of proximal descending aorta of TAR with FET. There was no case of stent induced new entry. Conclusions: We consider the early results for ATAAD to be favorable. Furthermore, TAR with FET promotes good thrombosis and remodeling down to the proximal descending level, suggesting that FET may contribute to improved outcomes during follow-up period. Further clinical research on mid-term outcomes is needed.

Commentary: Daytime or nighttime acute type A aortic dissection repair? Does it really matter?

Axillary artery cannulation (AAC) has been widely employed in total arch replacement surgeries using the frozen elephant trunk (FET) technique for acute type A aortic dissection (ATAAD), showing better clinical results than femoral artery cannulation (FAC). Nevertheless, in type II hybrid arch repair (HAR), FAC is crucial for lower body perfusion. Hence, it is unclear whether AAC remains necessary or if AAC represents a more advantageous method for initiating cardiopulmonary bypass. We conducted a study involving patients diagnosed with ATAAD who underwent type II HAR from August 2021 to December 2022. Demographic baseline and intraoperative data were collected, and the postoperative outcomes of patients receiving FAC only were compared with those receiving AAC. There were no significant differences in baseline demographics between patients who underwent FAC alone (n = 46) and those who underwent AAC (n = 39). Patients who underwent AAC showed a lower incidence of transient neurological dysfunction (TND) post-surgery compared to those who underwent FAC (12.8% vs 32.6%, p = .032). There were no significant differences between the groups in terms of postoperative mortality within 30days, permanent neurological dysfunction (PND), length of stay in the intensive care unit (ICU) and postoperative ward, duration of mechanical ventilation, and other complications. Axillary artery cannulation may decrease the incidence of postoperative transient neurological dysfunction (TND) in type II HAR for ATAAD. Nonetheless, studies with larger sample sizes are necessary.

Is Total Arch Replacement Associated With Worse Outcomes During Repair of Acute Type A Aortic Dissection?

Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement. This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches. A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase. TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair. Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.

ObjectivesThe frozen elephant trunk (FET) technique during total arch replacement (TAR) in patients with acute type A aortic dissection (ATAAD) has been shown to promote favorable aortic remodeling. However, few reports have compared the morphological assessments between the conventional elephant trunk (CET) and FET procedures. Here, we investigated whether the FET technique during TAR for the patients with ATAAD could affect aortic remodeling through morphological analysis.MethodsIn total, 464 patients diagnosed with ATAAD underwent emergency ascending aorta or TAR between 2010 and 2023. We retrospectively analyzed the clinical data of 28 patients who underwent TAR and postoperative contrast-enhanced computed tomography. We assigned 28 patients to either the CET group (n = 11) or FET group (n = 17). Patient characteristics, postoperative outcomes, and aortic remodeling analysis were collected.ResultsAortic remodeling analysis showed that the expansion rate of the true lumen (TL) in the descending thoracic aorta was significantly greater in the FET group early and 1 year after surgery. Meanwhile, the shrinkage rate of the false lumen (FL) in the descending thoracic aorta was significantly greater in the FET group early after surgery and tended to be greater in the FET group even 1 year after surgery. Remarkably, the incidence of reintervention of the descending aorta was significantly lower in the FET group.ConclusionsThe FET technique with TAR in patients with ATAAD could improve aortic remodeling through improved TL expansion and preventive FL dilatation in the descending thoracic aorta and reduce the need for surgical reintervention.

Commentary: Open versus clamp-on distal anastomosis techniques in acute type A aortic dissection: The ship has already left the port

Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using the frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation. The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2±10.5 years and 426 were male (82.2%). The mean time from symptomatic onset to surgery was 4.8±3.7 days. Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass (CPB), cross-clamp and selective antegrade cerebral perfusion were 201±50, 112±34, and 26±10 minutes, respectively. Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), re-exploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0±4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, and anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P<0.001) and malperfusion syndrome (binary) (OR 2.291; 95% CI 1.283-6.650; P=0.011) were predictive of operative mortality, while multiple malperfusion predicted late death (hazard ratio, HR 6.815; 95% CI 2.447-18.984; P<0.001). Risk factors for late death and distal reoperation included MFS (HR, 1.824; 95% CI 1.078-3.087; P=0.025) and malperfusion (HR, 1.787; 95% CI 1.042-3.064; P=0.035). In this large series of patients with ATAAD, the FET + TAR technique has achieved favorable early and long-term survival and freedom from reoperation up to 15 years. Marfan syndrome and malperfusion syndrome were risk factors for early and late mortality and distal reoperation. This study adds long-term evidence supporting the use of the FET + TAR technique in patients with ATAAD involving the arch and descending aorta.