Hemiarch Repair Research Articles

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Abstract 12550: Overexposed? Evaluating the Need for Serial Surveillance Imaging Following Elective Aortic Hemiarch Replacement

Introduction: The optimal timing for imaging following ascending aortic replacement is unknown. Protocols currently differ based on institution. For the last 3 years, our institution has surveilled patients at 3 months, yearly for 3 years, and at 5 years following the operation. Hypothesis: We hypothesize surveillance CT scans performed at 3 months will identify any pathologies related to the ascending aortic repair that will require re-intervention; additional imaging may be superfluous. Methods: Using our single institution-maintained database, 311 patients who underwent an elective aortic hemiarch repair between February of 2010 and March of 2021 were identified. The timing for and stability of surveillance imaging was reviewed, paying special attention to pathology associated with the repair. Results: Of the 311 patients who underwent elective aortic hemiarch repair, 217 completed surveillance imaging. 187 patients had their initial imaging around 3 months following the operation, 85 patients completed imaging around one year, and 54 patients were imaged 2-8 years post-operatively with some patients undergoing multiple scans during this period. Nine patients required re-intervention; of these 9, four patients demonstrated pathology, on CT scan, associated with the actual ascending arch repair. Two patients developed a pseudoaneurysm (PSA), one at the distal aspect of the repair and one at the left ventricular outflow tract. The other two patients had degeneration of known distal aortic aneurysms. The two PSAs were intervened upon within the first 3 months and the degenerating aneurysms were intervened upon at 1 and 2.5 years post-operatively. Conclusions: These data support surveillance imaging completed at 3 months following ascending aortic replacement is sufficient to identify pathology related to the repair. While other indications may dictate ongoing surveillance, for most patients, the need for further imaging is potentially zero.

Aberrant Subclavian Arteries and Associated Kommerell Diverticulum: Endovascular vs Open Repair

BackgroundVarious surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum. MethodsBetween 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed. ResultsNo mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection. ConclusionsThe treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.

Impact of a multidisciplinary acute aortic dissection program: Improved outcomes with a comprehensive initial surgical repair strategy

ObjectiveAs part of a multidisciplinary aortic dissection (AD) program, a more comprehensive repair strategy for patients with acute type A aortic dissection (ATAAD) and frequent endografting for suitable patients with type B aortic dissection (ATBAD) was adopted in 2015. The aim of this study was to evaluate the impact of these changes. MethodsThis study is a retrospective review of a prospective database containing all patients treated for acute AD between 2003 and 2020. Patients were grouped based on differing repair strategies (pre 2015 vs post 2015). Clinical characteristics, procedural details, and survival data were analyzed. ResultsDuring this time, 323 patients (210 pre, 113 post) were treated for acute AD at our institution. There were 221 patients with ATAAD (149 pre, 72 post) and 102 patients with ATBAD (61 pre, 41 post). The majority (60%) were males, with a mean age of 65.9 ± 15.2 years. There were no differences in cardiovascular risk factors or demographics between the groups. After 2015, fewer patients with ATAAD underwent medical management alone (15% pre vs 4% post; P = .014), and most that underwent surgical intervention had a total arch or aggressive hemiarch repair (27% pre vs 78% post; P < .001). Seventy-four patients (73%) with ATBAD were treated medically, whereas 28 underwent medical management and endografting (23% pre, 34% post; P = .214). For all patients with AD, 30-day mortality was significantly improved (26% pre vs 10% post; P < .001) especially among patients who underwent ATAAD surgery (23% pre vs 9% post; P = .018). Three-year Kaplan-Meier survival estimates showed survival improvement among patients with ATAAD (Log rank P-value = .019); however, this improvement does not extend to type B dissections or the overall cohort. A survival analysis landmarked to 30 days after initial presentation showed no statistical difference in survival from 30 days to 3 years post-presentation. ConclusionsA more comprehensive repair strategy in the management of patients with acute AD resulted in improved overall patient outcomes and significantly decreased 30-day mortality, even though more complex repairs were performed. The long-term impact of the changes made to our program remains to be evaluated.

Initial experience with the new type A arch dissection stent: restoration of supra-aortic vessel perfusion.

The goal of the present study is to investigate changes in supra-aortic vessel perfusion after implantation of the non-covered Ascyrus Medical Dissection Stent (AMDS) for surgical treatment of acute type A aortic dissection. From 2017 to 2020, 16 consecutive patients treated with AMDS and involvement (dissection to total occlusion) of at least 1 supra-aortic vessel were included in the study. Centre-line based computed tomography measurements of true, false and total lumen area using Terarecon software were performed before and after surgery. Changes in the true lumen area were indexed to the entire vessel area. The paired sample t-test was used to assess the significance of the observed differences. Analysis of supra-aortic vessels and the descending aorta showed significant improvement in true lumen perfusion after the AMDS was implanted. The indexed true lumen area increased postoperatively by 72%, 112% and 30% in the innominate, right and left common carotid arteries, respectively. Total occlusions of both common carotid arteries recovered completely after surgical treatment. The proximal- and the mid-descending aorta showed a 78% and 48% improvement of the indexed true lumen area, respectively. Arch repair using AMDS shows promising results in the treatment of acute type A aortic dissection. Quantitative measurements of true and false lumen perfusion demonstrated a significant increase in true lumen area and a 100% regression of totally occluded supra-aortic branches. Further examination in a larger cohort of patients and comparison with isolated hemiarch repair are needed to confirm positive vascular remodelling after an AMDS implant.

Comparative outcomes of total arch versus hemiarch repair in acute DeBakey type I aortic dissection: the impact of 21 years of experience.

With the goal of evaluating the impact of experiences at our centre on comparative outcomes between total arch and hemiarch repairs, we reviewed our 21 years of experience with operations for acute type I aortic dissection. Between 1999 and 2019, a total of 365 patients (177 women; 56.8 ± 12.9 years) with acute type I aortic dissection who had a hemiarch (n = 248) or a total arch replacement (n = 117) were evaluated, and the trends in comparative outcomes were analysed. Over time, deep hypothermic circulatory arrest and retrograde cerebral perfusion were replaced by moderate hypothermia and antegrade cerebral perfusion with the introduction of dedicated aortic surgeons. Overall, operative deaths decreased from 11.0% in time quartile 1 to 2.2% in time quartile 4 (P = 0.090). After adjustment with the use of inverse probability weighting, the total arch group compared with the hemiarch group was at a similar risk of mortality [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.22-2.43; P = 0.71] but at a greater risk of neurological deficit (OR 3.28, 95% CI 1.23-8.98; P = 0.017) in the earlier half period (1999-2009). In the later period (2009-2019), however, both the risks of mortality (OR 0.32, 95% CI 0.03-1.59; P = 0.23) and of neurological injuries (OR 0.42, 95% CI 0.12-1.18; P = 0.13) were comparable between the 2 groups (P for interaction in terms of neurological deficit = 0.007). The multivariable logistic regression model revealed that dedicated aortic surgeons independently contributed to decreased risk of death (OR 0.30, 95% CI 0.09-0.84; P = 0.036). These findings indicate that accumulating institutional experiences, along with resultant improvements in surgical strategies and outcomes, may neutralize the surgical risk gap between total arch and hemiarch repair in acute type I aortic dissection.

Mini-access open arch repair.

BackgroundThe use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty.MethodsThis study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible.ResultsHemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%).ConclusionsMini-access open arch repair is technically feasible and achieved excellent early outcomes.

Late Outcome after Surgery for Type-A Aortic Dissection.

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.

DARTS Trial

DARTS Trial

Minimized perfusion circuit for acute type A aortic dissection surgery.

A minimized perfusion circuit (MPC) may reduce transfusion requirement and inflammatory response. Its use, however, has not been standardized for complicated cardiovascular surgery. We assessed outcomes of surgery for acute type A aortic dissection (ATAAD) performed with a MPC under circulatory arrest. The study involved 706 patients treated surgically for ATAAD (by hemiarch repair [n=571] or total arch repair [n=135]). Total arch repair was performed using selective antegrade cerebral perfusion. Our MPC, a semi-closed bypass system, incorporating a completely closed circuit and a level-sensing reservoir in the venous circuit, was used. Clinical variables, transfusion volume, and outcomes were investigated in patients who underwent hemiarch repair or total arch repair. The overall incidences of shock, organ ischemia, and coagulopathy (prothrombin time-international normalized ratio >1.5) were 26%, 35%, and 8%, respectively. Mean extracorporeal circulation (ECC) time was 149minutes for the hemiarch repair group and 241minutes for the total arch repair group, respectively. No patient required conversion to conventional ECC, and there were no complications related to the use of the MPC. The need for transfusion (98% vs. 91%, P=.017) and median transfusion volume (1970 vs. 1680mL, P=.002) was increased in the total arch repair group. Neither in-hospital mortality (total arch; 12% vs. hemiarch; 7%, P=.11) nor 10-year survival (74.4% vs. 68.4%, P=.79) differed significantly. Outcomes of surgery for ATAAD performed with the MPC were acceptable. The possibility of transfusion and transfusion volume remains high during such surgery, despite the use of the MPC.

Multidimensional Analysis of Descending Aortic Growth After Acute Type A Aortic Dissection

After repair of acute type A aortic dissection, typical geometric variables of conventional aortic surveillance focus on maximum diameter and its rate of growth, potentially missing important geometric changes elsewhere. We determined additional information provided by a semiautomated, 3-dimensional (3D), nonlinear growth model of the descending thoracic aorta after repair of type A aortic dissection. Computed tomographic angiography data were retrospectively collected after hemiarch repair of type A aortic dissection. The descending aorta was systematically reconstructed to generate a 3D model made up of individual segments. The baseline and follow-up diameters were measured semiautomatically for each segment, and the nonlinear interval growth was determined. The fastest growing segment expanded at a rate of 3.8 mm/y (interquartile range, 2.2 to 5.4 mm/y) vs 0.6 mm/y (interquartile range,-0.3 to 1.7 mm/y) when measured at the original site of maximum diameter (P < .01). The maximum baseline diameter was a poor predictor of location with fastest growth (r= 0.10, P > .1). Using the society recommended growth limits, a greater proportion of patients would be considered "at risk" when assessed by our method vs conventional surveillance measures. Our model identifies areas of rapid aortic growth after repair of type A dissection that would likely be missed using current surveillance techniques. The increased precision, resolution, and reproducibility provided by our technique may improve on limitations of current surveillance techniques, provide novel geometric data on aortic remodeling, and contribute to the pursuit of a comprehensive patient-specific approach to aortic risk stratification.

Extended-arch repair for acute type-A aortic dissection: perioperative and mid-term results.

Extended-arch techniques offer the potential to comprehensively treat acute type-A aortic dissection (ATAAD), but add surgical complexity compared to the standard hemiarch technique. This study describes both perioperative and mid-term outcomes following the introduction of an extended-arch technique for ATAAD. Ours is a retrospective single-centre observational study of 95 consecutive patients with ATAAD from 2011 to 2016. The decision to perform extended-arch or hemiarch repair was individualized based on clinical and radiological features. Extended-arch repair was defined as replacement of the ascending aorta and arch with reimplantation of head vessels with or without distal endovascular extension. Clinical follow-up was 100% complete. Cross-sectional double-oblique measurements were performed for aortic remodelling analysis. Extended-arch (n = 28) and hemiarch (n = 67) repair resulted in a in-hospital mortality of 10% (n = 3) and 10%, (n = 7), and permanent neurological deficit rate of 7% and 12%, respectively. At a mean imaging follow-up duration of 2.7 ± 1.5 years, false lumen thrombosis was achieved in 57% and 9% of patients undergoing extended-arch and hemiarch repair, respectively. Rate of growth in the proximal descending aorta was 0.7 ± 2.3 mm/year in the extended-arch group vs 2.7 ± 3.9 mm/year in the hemiarch group. At a mean clinical follow-up time of 3.0 ± 1.6 years, open surgical aortic reoperation was 0% in the extended-arch group and 22% in the hemiarch group. Extended-arch repair of ATAAD can be introduced in the acute setting without increase in perioperative mortality or morbidity. At mid-term follow-up, extended-arch for ATAAD improves aortic remodelling and reduces the need for open surgical reoperation.

Developing skills for thoracic aortic surgery with hypothermic circulatory arrest

ObjectivesTo examine the performance curves of 8 early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) and to analyze the impact of the learning curve on perioperative outcomes. MethodsA total of 1025 consecutive patients who underwent aortic reconstruction with HCA between 2002 and 2017 were analyzed for mortality and 5 other complications (stroke, reoperation for bleeding, dialysis, prolonged ventilation, and sternal wound complications), subdivided into 3 consecutive time periods. This cohort represents the complete inaugural experience of 8 Canadian academic aortic surgeons. A risk-adjusted cumulative sum analysis was used to evaluate the performance curve with respect to predetermined 80% alert and 95% alarm boundary lines. ResultsMean age was 62 ± 13 years, 71% of patients were male, and 24% presented nonelectively. Hemiarch repair was performed in 80% and total arch replacement in 20%. There was a reduction in the incidence of the primary composite outcome over time (P1: 26%, P2: 23%, and P3: 16%; P = .010). Overall in-hospital mortality was 5% and remained stable throughout the 3 periods. Rates of stroke were lower in the late period (P1: 4%, P2: 6%, and P3: 2%; P = .035). Risk-adjusted cumulative sum analysis demonstrated that all surgeons remained within the 95% reassurance boundary throughout their experience, with 6 surgeons performing as expected and 2 performing better than expected. ConclusionsEarly-career surgeons can safely perform operations with HCA from the initiation of their practice. The cumulative sum analysis method is valuable for monitoring competence in aortic surgery and could prove useful in structuring training programs.

Hybrid Off-pump Second-Stage Aortic Arch Repair after Type A Dissection.

Ascending aorta or hemi-arch repair are common in the acute phase of type A dissection. Postdissection aneurysms can develop with antegrade perfusion of the false lumen in the dissected aortic arch and require reoperation. From 2012 to 2018, we reoperated nine patients with postdissection aneurysms using a hybrid technique without cardiopulmonary bypass. The patients had a EuroSCORE II of 13% and a logistic EuroSCORE I of 45% and were not candidates for frozen elephant trunk surgery. The median interval since the acute ascending repair was 184 (92; 528) days. All patients were treated by median resternotomy, ascending to carotid bypass on a partially clamped ascending graft, and transfemoral endovascular repair with a Relay NBS (nonbare stent) or conformable Gore C-TAG stent graft. Technical success was achieved in all cases. Mean follow-up was 405 (220; 672) days. There was no disabling stroke, endoleak, paraplegia, in-hospital, or late mortality. In all patients, the false lumen was completely thrombosed at the aortic arch level with a median aneurysm shrinkage of 13 mm in the distal arch. There was no bird beak or stent graft migration. Distal stent-induced new entry was observed in one case. Reinterventions were not necessary due to diameter stability. Complete debranching with transfemoral thoracic endovascular aneurysm repair showed encouraging results in patients with relevant comorbidities. The used stent grafts performed well in the mid-term follow-up period with no endoleaks or migration.

Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest

Background: Antegrade cerebral perfusion (ACP) is the standard neuroprotection method in aortic surgery. Visceral ischemia during this modality brings out some controversies. We aimed to investigate the level of oxidative stress at the lower part of body during ACP.Methods: Thirty consecutive patients underwent elective ascending aorta and hemiarch repair with ACP (without distal perfusion) were enrolled to study. The patients were enrolled into two groups which were based on 50th percentile of ACP duration (15 patients in each group). Blood samples from inferior vena cava at the end of ACP were collected to assess oxidative stress with biochemical parameters such as lactate, advanced oxidative protein products (AOPP) and thiol levels. Clinical follow-up parameters regarding to visceral and spinal cord ischemia were recorded. There were no clinical complications at both groups.Results: Mean ACP duration for the study group was found to be 15 min (10–28 min). Lactate, AOPP, and thiol levels were found to be similar between two groups. Furthermore, correlation analysis revealed only low level of correlation between ACP duration and lactate levels. Renal and liver function tests were found to be similar between groups.Conclusions: Immediate parameters (such as lactate, AOPP, and thiol) that show alterations in response to oxidative stress were not affected by the duration of ACP. Therefore, ACP without distal perfusion may not be harmful when conducted for short duration.

Innominate Versus Axillary Artery Cannulation for the Hemiarch Repair

BackgroundInnominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing selective antegrade cerebral perfusion during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide less resistance to high flow during bypass and selective antegrade cerebral perfusion. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss. MethodsThis was a single-center retrospective analysis of 206 patients who underwent hemiarch replacement between 2009 and 2017. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary and innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp time, circulatory arrest (CA) time, postoperative transfusions, intensive care unit length of stay, development of any neurological complications, end-organ failure, and mortality. Subgroup analysis was performed for elective and emergent cases. ResultsAxillary and innominate artery cannulation accounted for 37% (n = 77) and 67% (n = 129) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of renal disease in the axillary group (16% versus 6%, P = 0.05). More emergent cases were performed in the axillary group (61% versus 17%, P < 0.001). Innominate cases had shorter CPB times (189 versus 150 min, P < 0.001) and CA (22.5 versus 11 min, P < 0.001) times overall. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference in operative times. Less transfusions were given in the innominate group including units of red blood cells (2 [0-6] versus 0 [0-2], P < 0.001), units of platelets (2 [1-3] versus 1 [0-2], P = 0.001), and units of plasma (6 [2-9] versus 2 [0-4], P < 0.001). A similar trend was observed in the elective subgroup. No difference in transfusions was observed in the emergent subgroup. There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups. ConclusionsAlternate cannulation strategies for open arch anastomoses are evolving with a trend toward using the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection.

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD. In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up. The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients. Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Intimal relayering technique: Yet another operation for acute aortic dissection

Abstract We herein describe a new technique that aims to address some limitations of standard hemiarch aortic replacement in acute type A aortic dissection repair. This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair while providing an elephant trunk configuration for future interventions.

Intimal re-layering technique for type A acute aortic dissection-reconstructing the intimal layer continuity to induce remodeling of the false channel.

Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

Aortic arch repair under moderate hypothermic circulatory arrest with or without antegrade cerebral perfusion based on the extent of repair.

For aortic-arch repair, moderate hypothermic circulatory arrest (HCA) have shown favorable outcomes over conventional deep HCA when coupled with antegrade cerebral perfusion (ACP); however, recent studies have shown that ACP may not be essential when circulatory arrest time is less than 30 minutes. This study aims to evaluate the stratified arch repair strategy of moderate HCA with or without ACP based on the extent of procedure. Consecutive 138 patients (63 female; mean age, 60.2±15.7 years) undergoing open arch repair due to acute aortic syndrome (n=69) or chronic aneurysm (n=69) from January 2012 through April 2017 were enrolled in this study. Stratified neuroprotective strategy was employed according to the extent of repair: hemi-arch repair (n=93) was performed under moderated HCA alone and total-arch repair (n=45) under moderate HCA combined with unilateral ACP. Median total circulatory arrest and total procedural times were 8.0 minutes [interquartile range (IQR), 6.0-10.0] and 233.0 minutes (IQR, 196.0-290.0 minutes), respectively in the hemi-arch group, and 25.0 minutes (IQR, 12.0-33.0 minutes) and 349.0 minutes (IQR, 276.0-406.0 minutes), respectively in the total-arch group. Early mortality occurred in 2 patients (1.4%) who underwent hemi-arch repair for acute aortic dissection. There was no permanent neurological injury, but 2 cases (1.4%) of temporary neurologic deficit in the hemi-arch group. Other complications included re-exploration for bleeding in 6 (4.3%), postoperative extracorporeal life support in 5 (3.6%) and new-dialysis in 6 (4.3%). Stratified cerebral perfusion strategy using moderate hypothermia for aortic-arch surgery based on the extent of arch repair showed satisfactory safety and reasonable efficiency.