Elephant Trunk Technique Research Articles

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections.

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Komplike Akut Tip B Aortik Diseksiyonların Tedavisinde Donmuş Fil Hortumu Prosedürü

Introduction: This study aimed to define midterm clinical outcomes and morphological changes of acute complicated type B aortic dissections after the application of frozen elephant trunk technique. Patients and Methods: Data were collected from 143 patients treated with frozen elephant trunk procedure for complex thoracic aortic diseases between May 2012 and October 2018. Twenty-seven patients with acute complicated type B aortic dissection were included in the study. Results: The mean age of the study population was 56.9 ± 9.1 years, and 23 (85.2%)patients were male. Complete false lumen thrombosis in the descending aorta before the distal end of the stent graft was achieved in 88.9% of cases. There was no late mortality observed at a mean follow-up of 50.7 ± 22.5 months. Only one patient died due to multiple organ failure 62 days after the operation. Five patients underwent secondary distal aortic endovascular repair because of stent graft-induced new entry (n= 3) and second-stage treatment for post-dissection aneurysm (n= 2). Conclusion: Aortic arch involvement in acute complicated type B aortic dissections requires more extensive treatment, and frozen elephant trunk procedure serves as an alternative treatment modality.

Early and long-term results of total arch replacement with the frozen elephant trunk technique for acute type A aortic dissection.

We evaluated the operative and long-term outcomes of the frozen elephant trunk (FET) technique for acute type A aortic dissection. This study evaluated 426 consecutive patients who underwent aortic repair for acute type A aortic dissection from June 2007 to December 2018 at our centre. Of these, 139 patients underwent total arch replacement with FET (FET group), and 287 underwent other procedures (no FET group). Ninety-two patients in the FET group were matched to 92 patients in the no FET group by using propensity score matching analysis. Thirty-day mortality and neurological dysfunction were not significantly different between the FET and no FET groups (1.4% vs 2.4%, P = 0.50 and 5.0% vs 6.3%, P = 0.61, respectively). Long-term survival was better in the FET group than in the no FET group (P = 0.008). Freedom from distal thoracic reintervention was similar in the FET and no FET groups (P = 0.74). In the propensity-matched patients, freedom from aortic-related death was better in the FET group than in the no FET group (P = 0.044). Operative outcomes showed no significant difference between the 2 groups. FET contributes to better long-term survival in patients with acute type A aortic dissection.

'Double layer' frozen elephant trunk with balloon endoclamping: a technique to simplify the 2-stage open repair of thoraco-abdominal aortic aneurysms.

Staged replacement of the aortic arch and thoraco-abdominal aorta (TAA) with a frozen elephant trunk followed by TAA repair is a valuable treatment for patients with chronic TAA dissection. However, in patients with an unclampable descending thoracic aorta, the retrieval of the trunk can be problematic and the proximal stent graft-to-graft anastomosis technically challenging. Here we present our 'double layer' frozen elephant trunk technique to treat patients with TAA dissection.

Early and mid-term outcome of frozen elephant trunk using spinal cord protective perfusion strategy for acute type A aortic dissection

ObjectiveThis 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.MethodsBetween 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.ResultsThe 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.ConclusionsThe 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.

Early Results of a Novel Single-Stage Hybrid Aortic Arch Replacement Technique to Reduce Bypass and Circulatory Arrest Duration.

Hybrid repair procedures of the aortic arch have been utilized to reduce surgical risks and apply this therapy to patients who would not traditionally be candidates for open surgical repair. We present a variation on the frozen elephant trunk technique to further reduce cardiopulmonary bypass and circulatory arrest duration. After initiation of cardiopulmonary bypass and during systemic cooling, a wire is advanced from the femoral artery into the aortic arch. In the case of aortic dissection, intravascular ultrasound is used to confirm true lumen placement. Under circulatory arrest, the proximal aortic arch is resected and the wire externalized. Antegrade deployment of a stent graft is performed into the aortic arch and proximal descending aorta. The ascending aortic graft is sewn to the cut end of the aorta, incorporating the stent graft. The graft is cannulated and cardiopulmonary bypass reinitiated. The remainder of the arch replacement is performed during re-warming. Twenty two patients underwent this novel hybrid arch replacement procedure for aortic pseudoaneurysm, aortic dissection, or aneurysm. In comparison to the frozen elephant trunk procedure, where a dacron graft is inserted into the descending aorta, and later fixed with an endograft, this technique allows for immediate distal fixation. In the case of aortic dissection, there is immediate expansion of the true lumen with distal seal, potentially obviating the need for additional procedures. Mean duration of follow up is 12 months (range 1 - 14 months). The mean duration of cardiopulmonary bypass was 109.32 ±3.14 minutes. The mean duration of circulatory arrest was 18.00 ±1.33 minutes at a mean temperature of 23.64 ±0.58 degrees Celsius. There were no mortalities, no permanent disabling strokes, and no renal failure (requiring dialysis). This novel hybrid technique for aortic arch replacement is safe, significantly reduces cardiopulmonary bypass and circulatory arrest times, and is performed readily without need for fluoroscopy. In patients with thoracoabdominal aneurysms, the stent graft can be used as an elephant trunk for further thoracoabdominal aneurysm repair or branched thoracic endovascular aortic repair procedures.

Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years.

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.

Total arch replacement and frozen elephant trunk for aortic dissection in aberrant right subclavian artery.

Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience. From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15-40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft. ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011-1.348; P = 0.034). The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.

The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.

Our goal was to review the surgical treatment of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) in our centre. From January 2014 to April 2018, 22 patients with RTAD after TEVAR were operated on in our centre. The mean age at operation was 52.0 ± 8.0 years old. The median interval between the primary TEVAR procedure and RTAD was 4.6 months (range 0-120 months). The postoperative mortality and morbidity rates were calculated to evaluate the early and long-term results. Twenty patients received total arch replacement with the frozen elephant trunk technique and 2 patients received total arch replacement alone. The mean cardiopulmonary bypass time, aortic cross-clamp time and selective cerebral perfusion time were 172.4 ± 39.3, 100.1 ± 30.3 and 19.7 ± 10.5 min, respectively. The incidence of major adverse events was 18.6% (4/22), including stroke in 1 patient, myocardial dysfunction in 1 patient and renal failure necessitating dialysis in 3 patients. Death within 30 days was 13.6% (3/22 patients). The follow-up data were available for all 19 survivors. The mean follow-up period was 32.2 ± 16.2 months (range 10-62 months). No deaths or aortic-related events occurred during the follow-up period. Total arch replacement with or without the frozen elephant trunk technique was suitable for the management of RTAD after TEVAR, with acceptable early and long-term results.

Follow-up outcomes after the frozen elephant trunk technique in chronic type B dissection

Our goal was to present our experience with a hybrid approach to the frozen elephant trunk (FET) technique for the treatment of patients with chronic type B aortic dissection. Between January 2013 and July 2019, 86 patients underwent the FET procedure at our centre. In 20 patients, the indication was chronic type B aortic dissection with a concomitant proximal aortic lesion. We evaluated the sites of proximal and distal entries, luminal communication and originating visceral branches in the computed tomography scan data. Primary end points were hospital deaths, complications and follow-up survival. Secondary end points included reintervention, thrombosis of the false lumen and aortic remodelling. There were no deaths, neurological complications or paraplegia during hospitalization; however, a few patients (10%) had temporary acute renal failure or required secondary aortic reintervention during the follow-up period. We performed thoracic endovascular aortic repair with stable aortic remodelling during follow-up. The follow-up survival rate was 92.3%, and 87.5% of cases did not require aortic reintervention. The FET technique is an effective method for treating chronic Stanford type B aortic dissection in patients at high risk of retrograde type A aortic dissection, concomitant disease of the proximal aorta and unsuitable anatomy for thoracic endovascular aortic repair, which allows for single-stage radical correction. Compared with thoracic endovascular aortic repair, the FET technique excludes the risk of type Ia endoleak, retrograde type A aortic dissection and possible stent graft migration. This technique provides comparable midterm follow-up outcomes and freedom from reintervention.

The blood protective effect of autologous platelet separation in aortic dissection.

This study aimed to retrospectively analyze the blood protective effect of autologous platelet separation in operations for acute aortic dissection. A total of 130 patients with acute aortic dissection were enrolled into the present study. The average age of these patients was 52.962±10.5061 years old. These patients underwent the modified aortic arch replacement with the elephant trunk technique or endovascular aortic exclusion with covered stent. Among these patients, 68 patients who underwent autologous platelet separation were assigned to the platelet separation group, while the remaining patients were assigned to the control group. All operations were performed under deep hypothermic circulatory arrest. After anesthesia, 1-2 therapeutic doses of autologous platelets were isolated from patients in the platelet separation group, and these platelets were quickly infused back to these patients after heparin was neutralized by protamine at the end of the cardiopulmonary bypass. The preoperative and postoperative indexes in these two groups were compared. There were no statistically significant differences in age, gender, smoking history, drinking history and hypertension history between these two groups. Compared with controls, the transfusion volume of allogeneic platelets in the perioperative period significantly decreased in the platelet separation group (1.919±1.6226 vs. 0.794±1.1789, P < #x003C;< #x200A;0.05), and the use rate of allogeneic platelets also significantly decreased (74.19% vs. 45.59%, P < #x003C;< #x200A;0.05). The intraoperative auto transfusion of platelets significantly reduced the volume of allogeneic platelet transfusion after the operation for aortic dissection, which has a significant blood protective effect.

Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta.

Background Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft. Methods We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta. Results No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3–80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11–25 minutes). Mean follow-up time was 22 months (range, 9–42 months). Conclusions We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without “touching” the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.

Surgery for retrograde dissection and endoleak repair following endovascular repair of type B aortic dissection

This video tutorial presents a case of repair of a delayed-onset retrograde type A dissection after TEVAR with a left carotid-subclavian bypass for acute type B dissection. One of our key challenges was problematic brain and spinal cord protection in a frail patient with distal dissection, and dissection involving an ectasic brachiocephalic trunk extending into the right carotid artery with a significantly increased risk of stroke and paraplegia. We demonstrate the repair of the dissection using the frozen elephant trunk technique and we also present sequential brain and visceral perfusion diagrams.

Usefulness of routine use of bilateral axillary artery perfusion in total arch replacement.

To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes. Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a 'frozen elephant trunk technique'. In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed. The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.

Closing the gap between type A and type B aortic dissections.

Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions.

Impact of the Frozen Elephant Trunk Technique on Total Aortic Arch Replacement

The frozen elephant trunk (FET) technique can facilitate the distal anastomosis of total arch replacement (TAR); therefore, the technique is increasingly being used in TAR cases. However, identifying suitable patients remains controversial. This study analyzes the outcome of TAR using FET and clarifies the indications for using FET. Patients who underwent TAR between January 2008 and December 2018 were enrolled and divided into 2 groups: that is, patients treated with conventional TAR (cTAR group, n=39) and those treated with TAR using FET (TAR-FET group, n=76). Early and late outcomes were compared. The mean operation time was significantly shorter in the TAR-FET group (447.0±82.1min) than in the cTAR group (509.4±123.9min) (P<0.01). Likewise, circulatory arrest time was significantly shorter in the TAR-FET group (29.0±7.8min) than in the cTAR group (64.2±20.2min) (P<0.001). Postoperative renal function tended to be preserved in the TAR-FET group. Recurrent nerve palsy was less frequent in the TAR-FET group (9.2%) compared with the cTAR group (25.6%) (P<0.05). Patients with chronic aortic dissection tended to undergo reintervention more frequently following TAR using the FET technique. The FET technique contributed to save operation and circulatory arrest times during TAR and seemed less invasive in terms of renal function and less-frequent recurrent nerve palsy. Considering posttreatment reintervention, however, care should be taken in its application to chronic aortic dissection.

Early outcome of aortic balloon occlusion during total aortic arch replacement with the frozen elephant trunk technique for aortic dissection.

The aim of this study was to propose and evaluate the new operative technique of aortic balloon occlusion in total aortic arch replacement (TAR) with the frozen elephant trunk that can significantly decrease the time of circulatory arrest and increase the hypothermic cardiopulmonary bypass (CPB) temperature. Between 2010 and 2018, 1335 patients with aortic dissection who underwent TAR with the frozen elephant trunk were included in the study. The newest 80 cases were treated with aortic balloon occlusion. To illustrate the difference with the new procedure, 1255 conventional TAR cases served as the historical control. Femoral and right axillary artery cannulations were used for CPB and antegrade selective cerebral perfusion. Circulatory arrest was implemented at the nasopharyngeal temperature of 28°C with continuous antegrade selective cerebral perfusion. After the stent graft was inserted into the true lumen of the descending aorta, the aortic balloon in a sheath was deployed into the stent graft and positioned at the metal part of the stent graft. When the balloon was inflated with enough saline to compress the stent graft, the sheath was simultaneously pressed by hand to properly fix the balloon and avoid displacement. Then femoral perfusion could be resumed. The aortic balloon occlusion technique was successful in all patients, with the median duration of circulatory arrest being 5 (interquartile range 3-7) min. The 30-day mortality rate was 6.25% (5/80), whereas with the conventional method it was 9.40% (118/1255). The postoperative conscious revival (8.67 vs 11.40 h, P < 0.001) and mechanical ventilation times (19.70 vs 24.45 h, P = 0.02) were significantly shorter. Decreases in postoperative acute kidney injuries (13.75% vs 32.11%, P = 0.001) and liver injuries (8.75% vs 37.61%, P < 0.001) were also observed. The patients were transfused with lesser quantities of red blood cells, plasma and platelets. The aortic balloon occlusion technique is a feasible way to shorten circulatory arrest significantly, to obviate the need for deep hypothermia in TAR with the frozen elephant trunk and to provide favourable protective effects on the central nervous, haematological and visceral systems. With these satisfactory results, this technique deserves further investigation.

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

ObjectiveThe frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality. MethodsWe searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage. ResultsThirty-five studies (total N = 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P < .001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P = .46), stroke 9.3% versus 6.6% (P = .51), and overall adverse events 22.0% versus 16.5% (P = .41). ConclusionsAs the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided.

Association between cardiopulmonary bypass time and 90-day post-operative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study.

The aortic arch replacement and cardiopulmonary bypass (CPB) are both associated with the early mortality after cardiothoracic surgery. This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk (FET) technique with selective ante-grade cerebral perfusion (SACP). We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1, 2017 to December 31, 2018 at Beijing Anzhen Hospital. The baseline characteristics, intra-operative data, and post-operative data were collected. Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day post-operative mortality. The 90-day post-operative mortality was 13.53%. The 78.51% of patients were men. There were 318 (84.35%) type A aortic dissections and 28 (7.43%) aortic aneurysms. Among those, 264 (70.03%) were emergency operations. Median CPB time was 202.0 (176.0, 227.0) min. Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors (hazard ratio: 1.21/10 min increase in CPB time, 95% confidence interval: 1.15-1.27, P < 0.001). Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile (median 236.0 min) was associated with reduced survival rate compared with middle and bottom tertiles (P < 0.001). Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality. CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP. Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Use of the frozen elephant trunk technique for type A intramural hematoma

Use of the frozen elephant trunk technique for type A intramural hematoma