Elephant Trunk Procedure Research Articles

Intraoperative platelet transfusion is associated with increased postoperative sternal wound infections among type A aortic dissection patients after total arch replacement.

Blood transfusion and its impact upon clinical outcomes of cardiac surgery have been extensively discussed, especially in the post-aprotinin era. This study compared clinical outcomes and perioperative blood utilisation among acute type A aortic dissection (AAD) patients with or without intraoperative platelet transfusion during total arch replacement, thus intending to investigate prognostic value of platelet transfusion during major aortic surgeries. Acute AAD patients undergoing total arch replacement and stented elephant trunk procedure under hypothermic circulatory arrest with and without intraoperative platelet transfusion at our institute from January 2008 to December 2012 were retrospectively included. Patients were categorised into PLT (n = 74) and non-PLT (n = 85) groups to compare the in-hospital mortality and complications, as well as blood components utilisation. Baseline characteristics and operational features were all comparable between two groups. In PLT group, in-hospital survival was not improved and intraoperative utilisation of red blood cell RBC, fresh frozen plasma (FFP) and cryoprecipitate was not reduced. Postoperative RBC transfusion [2.0(0-4.0) vs 0(0-4.0) U, p = 0.026; 64.9 vs 43.5%, p = 0.007] was significantly increased in PLT group, parallel with the prolonged postoperative hospitalisation time [(24.0 ± 12.7) vs (20.8 ± 10.9) days, p = 0.093] and elevated incidence of sternal wound infections (16.2 vs 5.9%, p = 0.035). Intraoperative platelet transfusion [odds ratio (OR): 3.10, 95% confidence interval (CI): 1.04-9.25, p = 0.043] was identified as independent risk factor of postoperative sternal wound infections by multivariate logistic regression analysis. Intraoperative platelet transfusion did not improve in-hospital prognosis among AAD patients after total arch replacement. The incidence of postoperative sternal wound infections increased among those who received intraoperative platelet transfusion.

Direct distal aortic arch graft cannulation after the elephant trunk procedure: technique for central cannulation during second-stage repair.

Arterial cannulation after the elephant trunk (ET) procedure at the time of second-stage distal repair can be achieved through multiple routes. Common strategies for arterial perfusion at the time of second-stage aortic repair include retrograde perfusion (femoral/iliac vessels), transapical or left subclavian artery cannulation. In the event these cannulation options are not practical or advisable, we offer an alternative approach through cannulation of the distal aortic arch Dacron graft through the left thorax. Advantages include forward distal perfusion, minimal proximal ischaemic time, prevention of thromboembolic events from thrombus attached to the ET and avoidance of malperfusion syndromes.

190 * REDO AFTER ACUTE TYPE A AORTIC DISSECTION: EARLY RESULTS FROM A MULTICENTRE REAL-WORLD EXPERIENCE

Objectives: To provide early results of repetitive surgical procedures after first operation for acute type A aortic dissection (AAD) and to identify risk factors for mortality. Methods: Between May 1998 and January 2014, 117 aortic reoperations after initial operation for AAD (mean time from the first procedure was 3.98 years, range 0.1–20.87) were performed in 110 patients (mean age 59.8 ± 12.6 years) in 7 real-world institutions. Proximal causes for reoperation were aortic root aneurysm in 20, root re-dissection in 17, aortic valve insufficiency in 27 and proximal anastomotic pseudoaneurysm in 26 patients. Distal causes were arch re-dissection in 18, arch dilatation in 15, anastomotic pseudoaneurysm in 25 patients. Results: A total of 74 isolated proximal, 30 isolated distal and 13 combined procedures were performed. There were 23 (19.66%) in-hospital deaths (elective/urgent 11.11%, emergency 66.67%). Causes of death were cardiac in 8, neurological in 3, multiorgan failure in 5, sepsis in 2, bleeding in 3 and lung failure in 2 patients. Multivariate logistic regression analyses revealed that risk factors for mortality were emergency operation (P < 0.0001), previous distal procedure (P = 0.04) and new elephant trunk procedure (P = 0.03). New proximal procedures were not found to be risk factors for early mortality (P = 0.15). Conclusion: This multicentre experience shows that redo surgery after AAD operations remains a challenging procedure especially in emergency settings and after surgery of the distal aorta. Proximal reoperation does not affect mortality; therefore initial aortic root preservation for AAD should not be considered a concern for late reoperations.

Repair of extensive aortic aneurysms: a single-center experience using the elephant trunk technique over 20 years.

We report the early and late outcomes after repair of extensive aortic aneurysms using the 2-stage elephant trunk (ET) technique. Management of aneurysm involving the entire aorta is a significant challenge. Given the anatomical complexity, the staged ET procedure was devised. A paucity of long-term data of outcomes of this approach exists. A single-center retrospective analysis of a prospectively collected database of all patients undergoing repair for extensive aortic aneurysm was performed. Between 1991 and 2013, we repaired 3012 aneurysms of the ascending or thoracoabdominal aorta. Of these, we performed 503 operations in 348 patients using the ET technique. Mean age was 62.4 ± 14.3 years, and 156/346 (45.1%) operations were in women; 288 patients underwent first-stage ET with 157 receiving a complete second-stage repair. Index repair early mortality was 29/317 (9.1%). Completion stage early mortality was 17/186 = 9.1%. Stroke after first-stage ET repair was 10/297 (3.4%) and immediate neurologic deficit after the second-stage ET repair was 6/206 (2.9%). In the 131 patients who did not receive a second-stage repair, 17.8% died in the interval between 31 and 45 days. Extensive aortic aneurysm is a complex problem, but it can be managed safely with a 2-stage open procedure. Those patients who could not complete the completion repair fared poorly. Better predictors for early outcome need to be determined. The use of ET technique remains a valuable approach for repair of extensive aortic aneurysm.

Frozen elephant trunk surgery in acute aortic dissection

Acute aortic dissection is a catastrophic condition, for which emergency surgery is the mainstay of therapy. In approximately 70% of patients who survive surgery, a dissected distal aorta remains, posing a risk of late aneurysmal degeneration, rupture, and malperfusion, and secondary extensive interventions are often required. In order to improve the long-term prognosis, a more extensive intervention, the frozen elephant trunk (FET) procedure, has been introduced. This involves the simultaneous replacement of the aortic arch and antegrade stenting of the descending thoracic aorta (DTA). Although FET is assumed to produce total thoracic aortic remodeling by inducing both coverage of secondary entry tears located in the proximal DTA and obliteration of the false lumen at the proximal DTA, its role in patients with acute dissection remains controversial mostly because of its technical complexity and increased risk of paraplegia. Data available in literature show that, after FET interventions, hospital death, stroke, and spinal cord injury occur in 10.0%, 4.8%, and 4.3% of patients with acute dissection, respectively. Available long-term data are sparse but suggest that aortic remodeling with partial or complete thrombosis of the persistent false lumen can be expected in approximately 90% of cases. The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.

Three-Dimensional Printing for Perioperative Planning of Complex Aortic Arch Surgery

In this study, we show the use of three-dimensional printing models for preoperative planning of surgery for patients with complex aortic arch anomalies. A 70-year-old man with an extensively arteriosclerotic aneurysm reaching from the ascending aorta to the descending aorta was referred to our center for complete aortic arch replacement. We visualized and reconstructed computed tomography data of the patient and fabricated a flexible three-dimensional model of the aortic arch including the aneurysm. This model was very helpful for the preoperative decision making and planning of the frozen elephant trunk procedure owing to the exact and lifelike illustration of the native aortic arch. Three-dimensional models are helpful in preoperative planning and postoperative evaluation of frozen elephant trunk procedures in patients with complex aortic anatomy.

Distortion of a Hybrid Stent Graft Following a Frozen Elephant Trunk Procedure

We describe a case of an acute type A dissection, where technical problems during the frozen elephant trunk technique led to a distortion of the hybrid stent graft with severe stenosis of the thoracic aortic endoprosthesis. Interventional aortoplasty was performed to re-establish flow. This new technique bears some risk of technical failure and therefore should be applied only after careful considerations.

Surgical repair of distal arch psendoaneurysm from ruptured penetrating aortic ulcer with the frozen elephant trunk technique

Ruptured Penetrating Ulcer and aortic arch pseudo-aneurysm is a rare condition but one which carries a high risk of rupture. We report the case of a 74-year-old man with aortic arch pseudo-aneurysm, in which a Frozen Elephant Trunk procedure was successfully performed. There were no postoperative complications at 6 months follow-up. The Computed Tomography Angiogram demonstrated thrombus formation in the pseudo-aneurysm lumen, with no endoleak on the stented part of the descending thoracic aorta and complete patency of all branches of aortic arch. This case demonstrates that the Frozen Elephant Trunk technique may be the treatment of choice when treating such complex aortic arch lesions provided there is no absolute contraindication to radical surgical intervention. However, long-term clinical efficacy and safety have yet to be confirmed.

Commentary on "Multibranched Frozen Elephant Trunk with Left Subclavian Artery Cannulation" by Martinelli, G.L. et al.

Dear Editor: The paper by Martinelli et al. [1] presents a variant of the frozen elephant trunk procedure for repair of pathology in the ascending aorta, aortic arch, and proximal descending aorta. The authors take the approach of performing the distal anastomosis in an extra-anatomic location proximal to the innominate artery. Their other modification involves a side-arm graft to the subclavian artery, which is used initially for perfusion and subsequently for permanent anastomosis to the main graft. This approach is well conceived and offers several potential advantages. First, this technique, like all frozen elephant trunk methods, aims to achieve thrombo-exclusion of the false lumen after introduction of an endoprosthesis into the descending aorta, with the purpose of reducing late aneurysm formation. However, this technique cannot overcome the impact of distal reentries below the bottom of the frozen elephant trunk, which can encourage late dilatation in those segments. Second, transposing the proximal anastomosis to a more proximal extra-anatomic location certainly facilitates the anastomosis, is likely to reduce the circulatory arrest time, and avoids trauma to the recurrent laryngeal nerve. A number of concerns arise regarding this technique, presented in this paper after experience in five patients: The early surgical results (20% mortality) are concerning, with one death and one dialysis-requiring renal failure in this small, early series. Late results are completely unknown. The patency and long-term fate of the multiple long grafts to the great vessels (innominate, left carotid, left subclavian) are entirely unknown. Especially, the patency over long intervals of the subclavian graft traversing the chest wall is entirely unknown. The idea that perfusing the left subclavian artery and, in this way, the left vertebral artery and the anterior spinal artery, is purely anatomical and speculative. There is no physiological or other evidence that this will produce actual benefit to the spinal cord. Since this series is so small, the argument that the authors had no spinal problems is not cogent. Reoperation on patients having had such an operation would be formidable when we look at Figure 2 [1], showing the end anatomic result. Despite the potential theoretical advantages of the proposed approach, strong caution is advised regarding its widespread adoption.

Thoracoabdominal aortic aneurysm repair after frozen elephant trunk procedure

To evaluate the feasibility and the outcomes of second-stage thoracoabdominal (TA) repair after previous frozen elephant trunk (FET) implantation. Between 2005 and 2013, 41 patients underwent open TA aortic repair in our institution. Of these, 9 patients (78% male) underwent second-stage TA repair after previous FET implantation. Feasibility and outcomes were evaluated. The mean interval between FET implantation and second-stage TA repair was 423 days (19-1979 days). Indications for second-stage TA repair were progression in aortic diameter of atherosclerotic aneurysms in the downstream segments in 6 patients, diameter progression in post-dissection aneurysms in 2 patients and giant cell aortitis with aneurysm formation in another patient. There were no in-hospital deaths. The median intensive care unit stay was 3.5 days (range: 1-12 days) and median hospital stay was 22 days (range: 14-132 days). We did not observe symptomatic spinal cord ischaemia or stroke. One patient (11%) developed acute renal failure requiring haemodialysis. Second-stage TA aortic repair after previous frozen elephant implantation is a feasible and effective treatment modality for patients with various pathologies of downstream aortic segments. This approach adds additional value to the conventional elephant trunk technique by providing an excellent landing zone not only for additional stent graft procedures but also for subsequent open TA repair.

Total arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion

To examine the clinical outcomes and impact of using moderate hypothermic circulatory arrest (MHCA) and unilateral selective antegrade cerebral perfusion (uSACP) in the setting of total aortic arch replacement (TOTAL). From 2004 to 2012, 733 patients underwent open arch reconstruction with MHCA and SACP. Of these, 145 (20%) underwent TOTAL. Measured outcomes included death, stroke, temporary neurologic dysfunction (TND), and renal failure. Mean follow-up time was 33 months and ranged from 0 to 95 months. Core temperature at the onset of MHCA was 25.8°C. Cardiopulmonary bypass and myocardial ischemic times were 236 minutes and 181 minutes, respectively. Twenty-three patients (16%) underwent emergency repair of acute type A dissection. Fifty-four cases (37%) were reoperative and 52 (34%) were stage I elephant trunk procedures. Concomitant root replacement was performed in 50 (35%) patients, including 20 David V valve-sparing procedures. Mean duration of circulatory arrest was 55 minutes. Operative mortality was 9.7%. Overall incidence of stroke and TND was 2.8% and 5.6%, respectively. Four patients (2.8%) required postoperative dialysis. Seven-year survival was significantly reduced (P=.04) after repair of type A dissection (83.8%) compared with elective surgery (89.5%). Higher temperature during TOTAL was not found to be a significant risk factor for adverse events. TOTAL using MHCA and uSACP can be accomplished with excellent early and late results. MHCA was not associated with adverse neurologic outcomes or higher operative risk, despite prolonged periods of circulatory arrest.

Acute Type-A aortic dissection with patent false lumen through to the abdominal aorta: effects of a conventional elephant trunk on malperfusion syndromes and narrowed true lumen

Narrowed true lumen and patent false lumen through to the terminal aorta is a high-risk condition for malperfusion syndromes (MS) in acute type-A aortic dissection. It is important to ascertain how the true and false lumens behave after surgery. We retrospectively investigated 45 patients with this pathology. The true lumen sizes at the narrowest levels above and below the superior mesenteric artery were followed by computed tomography after surgery (0-36 months). Thirty-seven MS were seen in 23 patients. Hospital mortality was 8.9%. The narrowed true lumen was not enlarged in the first 6 months with a patent false lumen. The elephant trunk procedure did not improve the true lumen size. An extremely narrowed (≤3 mm) true lumen was associated with a significantly high incidence of MS and mortality. High incidences of MS were observed in this particular pathology. An extremely narrowed true lumen was accompanied by a high incidence of MS and mortality.

Finger-Thumb Technique for Elephant Trunk Retrieval.

In this report we present a brief video illustrating the "Finger-Thumb Technique" that we have used extensively at our institution for elephant trunk retrieval during second stage elephant trunk procedures. Although only safe in experienced hands, this technique is a viable option in the arsenal of a cardiothoracic surgeon, especially in cases when proximally surrounding a massively enlarged aorta is unappealing.

Frozen elephant trunk surgery using the E-vita open plus prosthesis.

Clinical vignette The frozen elephant trunk (FET) procedure is a hybrid therapy available for the treatment of patients with extensive diseases of the thoracic aorta. This approach combines surgical graft replacement of the aortic arch with stent-grafting of the descending thoracic aorta using a covered stent. Different prostheses have been developed for carrying out this surgery, including the commercially available E-vita open plus prosthesis (Jotec Inc., Hechingen, Germany). This hybrid prosthesis is composed of a distal nitinol-covered stent-graft sutured to a proximal woven polyester tube graft (Figure 1). During lower body circulatory arrest and antegrade selective cerebral perfusion (ASCP), the E-vita open plus prosthesis is antegradely deployed into the descending thoracic aorta through the open aorta, while the proximal graft segment is sutured to the distal aortic stump and used to replace the aortic arch. As shown in the video entitled “FET surgery using the E-vita open plus prosthesis”, this manuscript describes our surgical FET approach with ASCP in detail. The video illustrates the surgical treatment of a 75-year-old man who had previously undergone a Bentall procedure and myocardial revascularization for a DeBakey type 1 acute aortic dissection. The patient was admitted to our hospital 4 years later, at which time computer tomography (CT) angiogram showed a pseudo aneurysm at the distal anastomosis measuring 63 mm, and a residual DeBakey type 1 chronic dissection with severe false lumen dilatation at the proximal descending thoracic aorta (61 mm) (Figure 2).

Safety and pitfalls in frozen elephant trunk implantation.

The frozen elephant trunk (FET) procedure, or open stent grafting, is a tool for the combined open and endovascular treatment via a median sternotomy of extensive aortic disease involving both aortic arch and descending thoracic aorta. The technique aims to stabilize the maximum extent of the thoracic aorta in one step, with the goal of either rendering a secondary intervention to the downstream aorta unnecessary or producing an easy landing zone for secondary thoracic endovascular aortic repair (TEVAR) or open surgery. Even though large case series have reported good results, we still have no conclusive evidence as to which patients and what kind of pathologies benefit from this technique. The surgical sequences described for total arch replacement with the FET procedure are just as varied as the associated devices and indications. This article focuses on important perioperative and surgical aspects, as well as potential complications during FET procedures.

Aortic root and total arch replacement with frozen elephant trunk procedure, using a Thoraflex Hybrid Graft.

Aortic root and total arch replacement with frozen elephant trunk procedure, using a Thoraflex Hybrid Graft.

Trade in the hammer for a power driver-perspectives on the frozen elephant trunk repair for aortic arch disease.

Like a power driver for which the bit can be changed for each screw that is turned, improvement of brain protection strategies and the development of hybrid techniques have provided us with the ability to offer tailored repair options for patients with complex thoracic disease involving the arch. Variations of the frozen elephant trunk operation have been the most versatile of the newer hybrid approaches to repair complex thoracic aortic pathology. The frozen elephant trunk procedure includes the use of circulatory arrest in combination with suturing a stentgraft into the arch, and may reduce the risk of stroke and endoleaks. This article describes various methods of performing the frozen elephant trunk procedure with a focus on preoperative considerations including the etiology of disease, the time and urgency of presentation, and the indications to operate.

Mid-term results of elective repair of extensive thoracic aortic pathology by the Evita Open Plus hybrid endoprosthesis only

To describe the early and mid-term clinical and instrumental results of the frozen elephant trunk (FET) procedure using the recent Evita Open Plus hybrid endoprosthesis for elective one-stage treatment of extensive thoracic aortic disease. We reviewed 16 patients undergoing FET for post-dissection aneurysm (50%), true aneurysm (31%) or other aetiologies (19%), through median sternotomy and hypothermic circulatory arrest. An average 14 ± 7.6-month follow-up with regular contrast-enhanced control computed tomography scans was available. Four patients received preliminary carotid-subclavian bypass to improve spinal cord protection. Distal extension through endovascular deployment of stent-grafts into the descending aorta was performed during the same procedure in 3 patients. Concomitant procedures on the ascending aorta/root were done in 25% of cases. There were no cases of operative mortality. Cases of neither cerebral stroke nor postoperative paraplegia were observed. Two cases of transient paraparesis and 1 case of Brown-Séquard syndrome occurred. At follow-up, there were no cases of endoleak or endotension. One patient was reoperated for distal completion (thoracoabdominal aortic replacement). The FET using the Evita Open Plus device is a reliable and versatile treatment for one-step management of extensive disease of the aortic arch and the descending aorta. This strategy should be reserved for patients having limited preoperative comorbidities and good functional status.

Elephant trunk technique for hybrid aortic arch repair

The original elephant trunk technique was developed by Borst in 1983 for the treatment of aortic arch aneurysms. This technique reduced operative risks, but was associated with cumulative mortality rates of 6.9% for the first stage and 7.5% for the second stage. Patients also waited a long time between two major surgical procedures. Only 50.4% of patients underwent the second-stage surgery, and there was a significant interval mortality rate of 10.7%. With the advent of stent-graft techniques, two different hybrid elephant trunk techniques were developed. One technique is first-stage elephant trunk graft placement followed by second-stage endovascular completion. The conventional elephant trunk graft provides a good landing zone for the stent-graft, and endovascular completion is a useful alternative to conventional second-stage surgery. This method has few major complications, and a postoperative paraplegia rate of 1.1%. The other technique is the frozen elephant trunk technique. This technique eliminates the need for subsequent endovascular completion, and is particularly useful for the treatment of acute type A dissection because it can achieve a secure seal. However, it is associated with a higher rate of spinal cord ischemia than other methods such as the original elephant trunk technique. The left subclavian artery (LSA) is often lost when performing a hybrid elephant trunk procedure. Revascularization of the LSA should be performed to prevent arm ischemia and neurological complications such as paraplegia or stroke, although the level of evidence for this recommendation is low.

Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results

The combined disease of the aortic arch and the descending aorta (aneurysms and dissection) remains a surgical challenge. Various approaches have been used to treat this complex pathology. In the two-stage operation, at the first-stage operation, the aortic arch is replaced through a median sternotomy. Later, at the second-stage operation, the descending thoracic aorta is replaced through a lateral thoracotomy. The elephant trunk (ET) technique was introduced by H.G. Borst at our centre in March 1982, greatly simplifying the second-phase operation. We present our 30-year experience. From March 1982 to March 2012, 179 patients (112 males, age 56.4±12.6 years) received an ET procedure for the combined disease of the aortic arch and the descending aorta (91 aneurysms, 88 dissections (47 acute)). Fifty-six of these patients had undergone previous cardiac operations. Concomitant procedures were performed if necessary. The cerebral protection was done either by deep (till 1999) or moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP, after 1999). Cardiopulmonary bypass (CPB) and X-clamp times were 208.5±76.5 min and 123.7±54.8 min, respectively. The intraoperative mortality and 30-day mortality during the first-stage operation were 1.7% (3/179) and 17.3% (31/179, 15 with AADA), respectively. Perioperative stroke was 7.9% (n=14/176). Postoperative recurrent nerve palsy was present in 18.2% (32/176) and paraplegia in 5.6% (10/176). The second-stage completion operation was performed as early as possible. Fifty-seven second-stage completion procedures were performed, either surgically (n=50) or through interventional techniques (n=7). The intraoperative and 30-day mortality after the second-stage completion procedures were 5.2% (3/57) and 7.0% (4/57), respectively. The stroke, recurrent nerve palsy and paraplegia rates were 0, 0 and 7% (4/54), respectively. The ET technique has greatly facilitated the two-stage approach to the surgical treatment of combined diseases of the aortic arch and descending aorta. The initial learning curve, acute dissections, re-do and concomitant procedures partially explain the higher mortality rate. Despite the development of new hybrid techniques, there is still a role for the classical ET in selected patients, particularly in the context of proven long-term results and cost effectiveness.