Frozen Elephant Trunk Research Articles

Concomitant aortic root replacement during frozen elephant trunk implantation does not increase perioperative risk.

Our aim was to evaluate the risk of concomitant aortic root replacement during frozen elephant trunk (FET) total arch replacement. Between March 2013 and February 2021, 303 patients underwent aortic arch replacement using the FET technique. Patient characteristics, intra- and postoperative data were compared between patients with (n = 50) and without (n = 253) concomitant aortic root replacement (implantation of a valved conduit or using the reimplantation valve-sparing technique) after propensity score matching. After propensity score matching, there were no statistically significant differences in preoperative characteristics including the underlying pathology. There was no statistically significant difference regarding arterial inflow-cannulation or concomitant cardiac procedures, while cardiopulmonary bypass (P < 0.001) and aortic cross-clamp (P < 0.001) times were significantly longer in the root replacement group. Postoperative outcome was similar between the groups and there were no proximal reoperations in the root replacement group during follow-up. Root replacement was not predictive for mortality (P = 0.133, odds ratio: 0.291) in our Cox regression model. There was no statistically significant difference in overall survival (log rank: P = 0.062). Concomitant FET implantation and aortic root replacement prolongs operative times but does not influence postoperative outcomes or increase operative risk in an experienced high-volume centre. The FET procedure did not appear to be a contraindication for concomitant aortic root replacement even in patients with borderline indications for aortic root replacement.

Elephant trunks use an adaptable prehensile grip

Elephants have long been observed to grip objects with their trunk, but little is known about how they adjust their strategy for different weights. In this study, we challenge a female African elephant at Zoo Atlanta to lift 20–60 kg barbell weights with only its trunk. We measure the trunk’s shape and wrinkle geometry from a frozen elephant trunk at the Smithsonian. We observe several strategies employed to accommodate heavier weights, including accelerating less, orienting the trunk vertically, and wrapping the barbell with a greater trunk length. Mathematical models show that increasing barbell weights are associated with constant trunk tensile force and an increasing barbell-wrapping surface area due to the trunk’s wrinkles. Our findings may inspire the design of more adaptable soft robotic grippers that can improve grip using surface morphology such as wrinkles.

Acute aortic dissection with an aberrant right subclavian artery resulting in rapid false lumen enlargement: a case report

BackgroundAn aberrant right subclavian artery complicated by acute aortic dissection has been reported. Aneurysmal degeneration in the descending aorta adjacent to the Kommerell diverticulum in older patients has also been reported. There are concerns regarding the anatomic and pathological aspects of an aberrant right subclavian artery accompanying the Kommerell diverticulum with respect the surgical strategy for acute aortic dissection.Case presentationWe report the case of a 79-year-old man with an aberrant right subclavian artery who developed acute aortic dissection (DeBakey IIIa) and rapid enlargement of the false lumen with deteriorating dysphagia and back pain. Total arch replacement with the frozen elephant trunk technique was performed. The aberrant right subclavian artery was closed using a stent graft proximally and was ligated distally at the right side of the posterior mediastinum. To prevent injury to the esophagus, the aberrant right subclavian artery was identified by lifting the right side of the thoracic wall using a thoracotomy device for internal thoracic artery harvest to expose the dorsal circumference of the superior vena cava. Additionally, the right subclavian artery was reconstructed using an extra-anatomical bypass.ConclusionsThis surgical strategy could be useful in patients with an aberrant right subclavian artery and the Kommerell diverticulum who require total arch replacement.

Aortic shape variation after frozen elephant trunk procedure predicts aortic events: Principal component analysis study

ObjectiveThe frozen elephant trunk procedure is a well-established technique for the repair of type A ascending aortic dissection and complex aortic arch pathology. The ultimate shape created by the repair may have consequences in long-term complications. The purpose of this study was to apply a machine learning technique to comprehensively describe 3-dimensional aortic shape variations after the frozen elephant trunk procedure and associate these variations with aortic events. MethodsComputed tomography angiography acquired before discharge of patients (n = 93) who underwent the frozen elephant trunk procedure for type A ascending aortic dissection or ascending aortic arch aneurysm was preprocessed to yield patient-specific aortic models and centerlines. Aortic centerlines were subjected to principal component analysis to describe principal components and aortic shape modulators. Patient-specific shape scores were correlated with outcomes defined by composite aortic event, including aortic rupture, aortic root dissection or pseudoaneurysm, new type B dissection, new thoracic or thoracoabdominal pathologies, residual descending aortic dissection with residual false lumen flow, or thoracic endovascular aortic repair complications. ResultsThe first 3 principal components accounted for 36.4%, 26.4%, and 11.6% of aortic shape variance, respectively, and cumulatively for 74.5% of the total shape variation in all patients. The first principal component described variation in arch height-to-length ratio, the second principal component described angle at the isthmus, and the third principal component described variation in anterior-to-posterior arch tilt. Twenty-one aortic events (22.6%) were encountered. The degree of aortic angle at the isthmus described by the second principal component was associated with aortic events in logistic regression (hazard ratio, 0.98; 95% confidence interval, 0.97-0.99; P = .046). ConclusionsThe second principal component, describing angulation at the region of the aortic isthmus, was associated with adverse aortic events. Observed shape variation should be evaluated in the context of aortic biomechanical properties and flow hemodynamics.

Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies.

Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.

First insights into the role of wall shear stress in the development of a distal stent graft induced new entry through computational fluid dynamics simulations.

Distal stent graft induced new entry (dSINE) is an emerging complication after frozen elephant trunk (FET) procedure. The aim of this computational fluid dynamics (CFD) study was to investigate the role of wall shear stress (WSS) after the development of dSINE based on hemodynamic changes. Aortic diameter and WSS of five patients who developed a dSINE after FET procedure were retrospectively analyzed before and after the occurrence of dSINE. Patient-specific 3-dimentional surface models of the aortic lumen were reconstructed from computed tomography angiographic datasets (pre dSINE: n=5, dSINE: n=5) to perform steady-state CFD simulations with laminar blood flow and zero pressure outlet conditions. WSS was calculated at the level of the stent graft (SG), the landing zone of the SG and at a location further distal to the SG, as well as on the outer and inner curvature of the aorta from SG center to its distal end. Post dSINE occurrence, median WSS increased significantly from 0.87 [interquartile range (IQR): 0.83-1.03] to 1.55 (IQR: 1.09-2.70) Pa, (P=0.043) within the SG and from 1.22 (IQR: 0.81-1.44) to 1.76 (IQR: 1.55-3.60) Pa, (P=0.043) at the landing zone of the SG. A non-significant increase from 1.22 (IQR: 0.59-3.50) to 2.58 (IQR: 1.16-3.78) Pa, (P=0.686) further downstream was observed. WSS at the outer curvature of the SG was significantly higher compared to WSS at the inner curvature for dSINE. Adverse hemodynamic conditions in the form of elevated WSS consist inside and at the distal end of the SG as well as at the outer curvature of the aorta, which may contribute to weakening of the aortic wall. These new findings emphasize the relevance and potential of WSS in dSINE for additional adverse events, such as aortic rupture. Further prospective studies are warranted to explore if the combination of clinical parameters with WSS might be useful to decide which patients require an urgent reintervention in terms of a SG extension.

Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome.

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. 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. 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). 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.

Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft

ObjectiveThe frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. MethodsA total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. ResultsThe incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. ConclusionsIntraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet’s disease

BackgroundBehcet’s disease is a multi-system inflammatory disorder. A small subset of patients with Behcet’s develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree.Case presentationWe present the case of a 44-year-old lady with Behcet’s Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung.ConclusionsA multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet’s disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

(s)INE: (soft-graft)-induced new entry tear after elephant trunk procedure

Elephant trunk and frozen elephant trunk are established procedures for the treatment of aortic arch pathologies, such as aneurysm or dissection. The aim of open surgery is to re-expand the true lumen, favouring correct organ perfusion and the thrombosis of the false lumen. Frozen elephant trunk, with its stented endovascular portion, is sometimes associated with a life-threatening complication: the stent graft-induced new entry. In the literature, many studies reported the incidence of such issue after thoracic endovascular prosthesis or frozen elephant trunk, but in our knowledge, there are no case studies about the occurrence of stent graft-induced new entry with the use of soft grafts. For this reason, we decided to report our experience, highlighting how the use of a Dacron graft can cause distal intimal tears. We decided to coin the term soft-graft-induced new entry to indicate the development of an intimal tear induced by the soft prosthesis in the arch and proximal descending aorta.

Early Intraluminal Frozen Elephant Trunk Stent Graft Thrombosis After Aortic Arch Surgery

BackgroundPartial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis. MethodsRetrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event. ResultsA total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3). ConclusionsEarly postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis.

Head-to-head: Zone 2 vs. Zone 3 frozen elephant trunk

Total arch replacement via frozen elephant trunk (FET) is a strategy for managing complex thoracic aortic pathologies involving the arch and descending thoracic aorta (DTA). The FET procedure involves the distal anastomosis of the FET hybrid prosthesis at a chosen aortic arch zone. Though distal anastomosis has been traditionally performed at Zone 3 (Z-3-FET) of the aortic arch, recent practice has seen a significant increase in Zone 2 FET (Z-2-FET). The literature concerning independent Zone 2 and 3 studies and head-to-head comparative studies suggest that Z-2-FET is the superior approach, yielding more favourable results overall, except for aortic remodelling. The improved clinical outcomes achieved with Z-2-FET can be attributed to the shorter operative times, including cardiopulmonary bypass duration, due to the ease and increased surgical site exposure at the aortic arch using this technique. The slightly inferior aortic remodelling observed in Z-2-FET can be explained by the decreased coverage of the DTA distally by the FET stent graft. However, this difference in results can also be attributed to the complexity and severity of the underlying pathology and the surgical approach adopted. The prospect of utilising Zone 0 FET (Z-0-FET) is highly promising, with some studies hinting at its superiority over Z-2-FET. Nevertheless, studies are needed to determine the efficacy of Z-0-FET and directly compare it to Z-2-FET to reach a definitive consensus on the most optimal FET technique. The present literature review aims to provide an overview of major intraoperative and postoperative outcomes achieved with Z-2-FET and Z-3-FET and summarise evidence from studies directly comparing them. Another aim of this narrative review is to explore current literature trends on Z-0-FET uptake.

Surgical Approaches to Single-Stage Extended Aortic Repair from the Ascending to the Distal Descending Aorta.

Single-stage extended replacement from the ascending to the distal descending aorta or beyond is a formidable operation that should be preserved for those who have no other option or those who are physically fit, and should be performed in the experienced centers. Hybrid operations combining open surgical repair with thoracic endovascular aortic repair through a median sternotomy incision are preferable because these operations are less invasive than the extended open aortic repair and the risk of spinal cord ischemia is lower compared with the frozen elephant trunk operation. However, these operations are associated with the inherent demerits of endovascular aneurysm exclusion. When the underlying aortic pathology necessitates extended open aortic repair in a single stage, approaches such as the anterolateral partial sternotomy, straight incision with rib cross, and extended thoracotomy with sternal transection may be useful to provide sufficient exposure for both aortic reconstruction and organ protection, with less surgical stress to the patients.

First in Human Implantation of the Thoracoflo Graft: A New Hybrid Device for Thoraco-Abdominal Aortic Repair

Despite a high rate of success when performed in specialised centres, current techniques for thoraco-abdominal aortic repair are associated with serious complications. The problem of spinal cord ischaemia remains unsolved. The new hybrid graft for thoraco-abdominal aortic repair was developed based on the frozen elephant trunk principle. The device consists of a proximal stent graft for transabdominal retrograde delivery to the descending thoracic aorta, combined with a distal six branched abdominal device for open aortic repair. An additional seventh branch is provided for possible lumbar artery re-implantation. Because the stent graft is implanted via a transabdominal approach, it avoids the need for thoracotomy and extracorporeal circulation. A 56 year old patient with Loeys-Dietz syndrome was placed in a supine position. The aorto-iliac axis was exposed via a midline transperitoneal approach. Following an end to side anastomosis of the iliac branch to the left common iliac artery, the stent graft portion was inserted into the thoracic aorta via the coeliac trunk ostium. After stent implantation and graft de-airing by needle puncture, retrograde blood flow to the abdominal aortic segment, and the lumbar and visceral arteries was established via the end to side iliac anastomosis creating an extra-anatomic bypass. Subsequently, the visceral and renal arteries were anastomosed to the branches. Finally, the aorta was opened and surgical graft attached via the collar. The reconstruction ended with end to end anastomoses of both common iliac arteries to the graft branches. The first and successful implantation of the new Thoracoflo hybrid device via a novel surgical technique is reported, eliminating the need for thoracotomy and extracorporeal circulation for thoraco-abdominal aortic repair.

Research trends and top cited articles on the frozen elephant trunk procedure

ABSTRACT Background: Bibliometric studies can direct academics. There have been many specialties and subspecialties where bibliometric analyses have been published, but our literature search yielded no bibliometric analysis of the frozen elephant trunk (FET) procedure. The primary objective of this study was to identify the most frequently referenced papers on FET procedure research and investigate the research trends. Methods: A dataset of all scientific journals published in the English language was created using the Web of Science (WOS) database. This search was then cross-referenced with a comparable search phrase query of the Scopus Library database in order to locate any publications that could have been overlooked during the first search. Citation counts were used to rank the articles. Also knowledge maps were created using VOSviewer software, and articles and reviews pertaining to the FET procedure in CVDs were taken from the WOS Core Collection. Results: A total of 484 documents on Scopus and 494 documents on WOSpertaining to the FET procedure were included in this study. The leading countries that published most of the research were Germany, Japan, and Italy in both databases. The largest subset of the FET procedure articles was published since 2012. The most cited authors were Karck, Shrestha, and Uchida. The mean Hirsch index of the articles was 40 and 10.47 per article. Conclusion:This study offers information on the traits and standards of the FET procedure literature that has received the most citations, as well as a ranking of the most important sources for this procedure. This work provides as a guide to what constitutes a citeable FET procedure publication by offering the most important references and mostly publishing journals.

Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in 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.

Longitudinal morphological changes of the aorta and the endograft position before and after distal stent graft-induced new entry in aortic dissections.

The aim of this study was to assess the endograft position and aortic geometry changes after thoracic endovascular aortic repair (TEVAR) and frozen elephant trunk (FET) in distal stent-induced new entry (dSINE) patients. In this retrospective cohort study, the baseline demographic and the follow-up data were extracted from the hospital records, and computed tomography scans of dSINE patients after TEVAR or FET between 2011 and 2021 were analysed regarding endograft oversizing, length and migration, taper ratio, aortic diameter at the endograft end, aortic elongation (thoracic inner and outer curvature), wedge apposition angle and tortuosity angle in the distal landing zone. dSINE was found in 22/213 (10%) of TEVAR and 10/31 (32%) of FET patients. The total follow-up time was 45 (27; 59) months. TEVAR was mainly performed with Relay NBS endograft (77%) and FET with Evita open prosthesis (80%). Paraplegia and stroke rates were 3%. dSINE occurred 17 (7; 35) months post-TEVAR and was instantly treated in 18 patients (56%) or followed up for 21 (11; 34) months (n = 14). Migration [+5 mm (1; 11; P < 0.001)], birdbeak angle [+9° (0; 27; P = 0.039)] and aortic diameter +5 mm (1; 11; P < 0.001) increased after dSINE, whereas aortic elongation increased already before [+12 mm (0; 27; P = 0.015)] and peaked after dSINE [+30 mm (9; 38; P < 0.001)]. The aortic elongation was more pronounced in the outer aortic curvature before and after dSINE (before: P = 0.039, after: P = 0.024). Postoperative wedge apposition [17° (12; 20)] increased before dSINE [21° (16; 35; P < 0.001)] and peaked thereafter [31° (21; 40; P < 0.001)]. Aortic elongation may influence the endograft position and provoke TEVAR failure in the distal and proximal landing zones.

Total aortic arch repair between endo and hybrid-the Nexus single-branched endograft.

Minimally invasive zone 0 arch procedures have experienced a great evolution from the total zone 0 debranching techniques towards the total endovascular aortic arch procedures in the last decade. This evolution followed the aim of improved perioperative outcomes for patients with substantial comorbidities, who are not candidates for open aortic arch repair. Nowadays, branched endografts are the main endovascular alternative to the frozen elephant trunk technique. In the case of anatomical suitability, branched endovascular repair of the aortic arch offers an excellent treatment option for patients with severe risk profiles for open surgery [1]. The repair is predominantly based on the custom-made inner branch platforms, with 2 or 3 tunnels located in the main graft, which allow for a safe overlap with the bridging stent grafts to the supra-aortic vessels [2]. From the technical point of view, the Nexus single-branched endograft is different. It is bimodular and consists of a branched arch and an anatomically preshaped ascending aorta module. The branch to the brachiocephalic trunk (BCT) is located at the proximal end of the arch module and allows for precise deployment of the BCT branch from the bifurcation to the BCT origin prior to the complete deployment of the aortic arch and descending aorta portion. The implantation is accomplished by the deployment of the ascending module, which lands distally with its locking latches into the docking sleeve of the arch module.

Risk factors for severe acute kidney injury post complication after total arch replacement combined with frozen elephant trunk, in acute type A aortic dissection.

Total arch replacement with the frozen elephant trunk (TAR + FET) technique is a challenging approach for acute type A aortic dissection (ATAAD). Severe acute kidney injury (AKI) adversely affects the prognosis of hospitalized patients. The study aims to evaluate the incidence and risk factors of severe AKI. We conducted a retrospective cross-sectional study of the records of ATAAD patients following TAR + FET, admitted between January 2013 and December 2018. A multivariate logistic regression model was used to identify predictors of severe postoperative AKI. Severe postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. The whole in-hospital mortality rate was 4.3%. Among 670 patients, major adverse outcomes were present in 169 patients (25.2%), 67 patients (10.0%) required renal replacement therapy (RRT), and 80 (11.9%) developed severe postoperative AKI. In-hospital mortality in the severe AKI group (13.8%) was 4.5 times higher than in the non-severe AKI group (3.1%). Compared with the non-severe AKI patients, the severe AKI patients had a higher incidence of major adverse outcomes (100% vs. 15.1%, P<0.001) and more frequent use of RRT (83.8% vs. 0.0%, P<0.001). Multivariate analysis revealed that severe postoperative AKI was predicted by advanced age [odds ratio (OR) =1.029; 95% confidence interval (CI): 1.002-1.056; P=0.032], lower limb symptoms (OR =4.384; 95% CI: 2.240-8.582; P<0.001), coronary artery involvement (OR =2.478; 95% CI: 1.432-4.288; P=0.001), preoperative postoperative serum creatinine (SCr) (OR =1.008; 95% CI: 1.003-1.013; P=0.001), and prolonged cardiopulmonary bypass (CPB) time (OR =1.011; 95% CI: 1.006-1.015; P<0.001). There was a high incidence of severe AKI and high in-hospital mortality after TAR + FET in ATAAD patients. The risk factors for severe AKI in ATAAD patients undergoing TAR + FET were determined to help identify the high-risk patients and make rational treatment decisions.

The Secret behind Extreme Hypoxia Tolerance: A “Slow-Growth” Thoracoabdominal Aneurysm

A 61-year-old man presented to our institution complaining of back pain. Breathing was comfortable. An arterial blood gas showed extreme hypoxia causing chronic respiratory alkalosis. Further investigations revealed aneurysmal dilatation of the ascending aorta and the Crawford Type II thoracoabdominal aneurysm, with compression of both the left main bronchus and the right pulmonary artery. The patient was managed with a two-stage hybrid surgical approach comprising total arch replacement using the frozen elephant trunk technique followed by endovascular repair.