Repair Of Acute DeBakey Type Research Articles

Commentator Discussion: A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the Prospective, Single Arm, Multi-center Clinical Investigation to Evaluate the Safety and Effectiveness of AMDS in the Treatment of acute DeBakey Type I Dissection trial

Commentator Discussion: A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the Prospective, Single Arm, Multi-center Clinical Investigation to Evaluate the Safety and Effectiveness of AMDS in the Treatment of acute DeBakey Type I Dissection trial

A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial

BackgroundOutcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion. MethodsPERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. ResultsClinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. ConclusionsEarly results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion.

Deployment of a novel hybrid stent for open repair of acute DeBakey type I aortic dissection with malperfusion

Deployment of a novel hybrid stent for open repair of acute DeBakey type I aortic dissection with malperfusion

Pursuit of the Changes of the Descending Aortic False Lumen after Surgical Repair of Acute DeBakey Type 1 Aortic Dissection

Pursuit of the Changes of the Descending Aortic False Lumen after Surgical Repair of Acute DeBakey Type 1 Aortic Dissection

Concomitant distal bare-metal stenting for residual true lumen stenosis in a frozen elephant trunk technique for acute type A aortic dissection.

For acute type A aortic dissection (TAAD), we have performed aortic arch repair using a frozen elephant trunk (FET) since 20141 and observed that aortic remodeling was limited at the level below the FET stent end postoperatively.2 For acute type B aortic dissection (TBAD), the PETTICOAT (provisional extension to induce complete attachment) technique has been an option to reopen the residual true lumen (TL) collapse after thoracic endovascular aortic repair (TEVAR).3 Similarly, proximal stent grafting with distal bare-metal stenting in a 2-staged manner has been reported in repair of acute DeBakey type I aortic dissection.

Postoperative Maximal Aortic Diameter is a Significant Predictor of Dilation of the Residual Dissected Aorta after Aortic Replacement for Acute Debakey Type I Aortic Dissection

This study investigated the impact of aortic diameter on late aortic dilation of the residual dissected aorta after tear-oriented aortic replacement for acute DeBakey type I aortic dissection. Of 133 patients who underwent aortic replacement for acute DeBakey type I/II aortic dissection between 2008 and 2019, 45 patients with a residual dissected aorta after surgery for acute DeBakey type I aortic dissection and who underwent computed tomography at predischarge and after 1 year were retrospectively assessed. The aortic diameter and false lumen area were measured at 3 levels: the maximal aortic site, seventh thoracic vertebra, and celiac axis. Multivariable Cox regression analysis was employed to identify the predictors of late aortic dilation, defined as an aortic growth rate of ≥5 mm/year or a maximal aortic diameter of ≥55 mm. During a median follow-up of 75 [range: 13-152] months, 6 patients (5 men; mean age: 57 ± 14 years) experienced aortic dilation. All 6 patients had the maximal aortic diameter between the distal aortic arch and seventh thoracic vertebra level at the last computed tomography. Multivariable Cox regression analysis showed that the predischarge maximal aortic diameter was an independent determinant of late aortic dilation (hazard ratio: 2.28/mm, 95% confidence interval: 1.10-5.86). Predischarge maximal aortic diameter is a significant predictor of late aortic dilation in patients with a residual dissected aorta after tear-oriented surgical repair of acute DeBakey type I aortic dissection.

DARTS Trial

DARTS Trial

Acute type I aortic dissection with or without antegrade stent delivery: Mid-term outcomes

ObjectiveWe determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. MethodsOutcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. ResultsThe stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P = .41), persistent stroke (6.3% vs 5.3%, P = .75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P = .059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P = .66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P = .18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P = .0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P = .13). Stented patients also had fewer subsequent procedures (P = .25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P = .015 for overall survival). ConclusionsIn the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients.

Evolution of Simplified Frozen Elephant Trunk Repair for Acute DeBakey Type I Dissection: Midterm Outcomes

A modified technique for frozen elephant trunk (FET) repair of acute DeBakey type I dissection has evolved. Procedural modifications are described and midterm outcomes evaluated. From 2009 to 2016, 72 patients with DeBakey type I dissection underwent emergency simplified FET. Mean age was 59 ± 15 years. Presentation included malperfusion (n= 22, 31%), rupture (n= 12, 16%), and aortic insufficiency (n= 42, 58%). Concomitant procedures included valve replacement (n= 9), root replacement (n= 11; valve sparing n= 6), cusp repair (n= 11), and valve resuspension (n= 21). The first 39 were treated by modifying an early generation stent graft. The next 16 received newer modified stent grafts, and the latest 17 underwent branched single anastomosis technique with left subclavian stent grafting. Operative mortality was 4.2% (n= 3 of 72). Two presented comatose without recovering, the other died from coagulopathy complications. Morbidity included stroke (n= 3, 4.2%), spinal injury (n= 3, 4.2%; 1 permanent), tracheostomy (n= 7, 9.7%), and renal failure (n= 2, 2.8%). Median follow-up was 28 ± 25 months. Survival was 92% at 6 months, 92% at 1 year, 89% at 3 years, and 80% at 5 years. Among 69 survivors, follow-up imaging was available in 63 (91%). Of these, 58 (92%) patients thrombosed the treated false lumen, with shrinkage in 37(54%) patients from 42 ± 8 mm to 37 ± 7 mm. Ten patients underwent 14 late reinterventions for growth and incomplete thrombosis (7 endo extension, 4 left subclavian embolization, 1 bypass, 2 false lumen embolization). Freedom from reintervention was 93% at 6 months, 87% at 1 year, 77% at 3 years, and 72% at 5 years. Simplified FET for treating acute DeBakey type I dissection has evolved and remained safe. It promotes aortic remodeling, and simplifies management of chronic aortic complications.

Ascending Aorta and Hemiarch Replacement Combined With Modified Triple-Branched Stent Graft Implantation for Repair of Acute DeBakey Type I Aortic Dissection

To simplify extensive repair of acute DeBakey type I aortic dissection, ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation was developed. The descriptions and early results of this technique are reported. From August 2014 to September 2015, 116 patients with acute DeBakey type I aortic dissection underwent ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation. Clinical data of all patients were retrospectively reviewed. Survivors were followed up prospectively by computed tomography angiography. The cardiopulmonary bypass time was 131.5 ± 10.7 minutes, the aortic cross-clamp time was 50.0 ± 9.9 minutes, and the selective cerebral perfusion and lower body arrest time was 17.2 ± 2.2 minutes. The in-hospital mortality rate was 3.4%. Two patients were lost during follow-up. One patient died of a cerebrovascular accident 2 months after discharge, and another died of chronic renal failure 5 months after discharge. At the 3-month postoperative scans, complete thrombus formation of the false lumen around the implanted modified triple-branched stent graft occurred in all survivors, at the diaphragmatic level in 69.7% patients, and at the superior mesenteric arterial level in 8.3% patients. Extensive thoracic aorta repair of acute type I aortic dissection can be performed simply by combining ascending aorta and hemiarch replacement with modified triple-branched stent graft implantation. This technique can reduce the risk and technical difficulty of extensive thoracic aorta repair to levels close to those seen with ascending aorta and hemiarch graft replacement with open distal anastomosis.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required.

Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate

Previously, we showed that antegrade stent grafting of the descending thoracic aorta during DeBakey type I dissection repair improves distal aortic remodeling. We assessed midterm outcomes of this reconstructive strategy compared with standard open repair. DeBakey type I dissections (non-Marfan, nontotal arch cases only) from 2005 to 2012 were retrospectively reviewed. One hundred eighty patients underwent standard open repair (standard group), and 62 patients underwent open repair plus stenting (stented group). Open repair entailed ascending aorta plus transverse hemiarch reconstruction under circulatory arrest, with variable aortic root work. Data was prospectively maintained. Preoperative parameters were similar. Patients in the stented group had longer circulatory arrest time and higher utility of antegrade cerebral perfusion (P<.001). In-hospital/30-day mortality (10% vs 14%; P=.51), stroke (5% vs 8%; P=.6), and paraplegia (0% vs 1%; P=1) were similar in the stented versus standard groups. Mean follow-up was 2.7 ± 2.3 and 2.2 ± 2.1 years. Actuarial survival in stented versus standard groups at 1 and 7 years was 86% versus 81% and 76% versus 60% (P=.5). Thoracic aorta false lumen obliteration was improved in the stented group (82% vs 39%; P<.001), along with improved freedom from open distal aortic reoperation rate (98% vs 90% at 6 years, P=.1). Endovascular distal aortic reintervention rate was higher in the stented group (18% vs 3%; P=.008), with zero mortality. Antegrade stent graft deployment during acute DeBakey type I dissection repair is safe method to promote distal aortic remodeling without increasing postoperative or midterm mortality. This technique provides increased freedom from open distal aortic reoperations compared with standard open repair.

Effects of intermittent lower body perfusion on end-organ function during repair of acute DeBakey type I aortic dissection under moderate hypothermic circulatory arrest

To avoid deep hypothermia-related side effects, moderate hypothermic circulatory arrest (HCA) is commonly employed during aortic arch repair, thereby jeopardizing end-organ protection. We sought to analyse the effect of intermittent lower body perfusion (ILBP) on end-organ function during repair of acute DeBakey type I aortic dissection (AIAD). Between May 2008 and May 2011, 107 patients underwent surgical repair for AIAD. All operations were performed with selective cerebral perfusion (SCP) under either moderate HCA only (n = 57) or moderate HCA with ILBP (n = 50). Adverse outcomes, including operative mortality, permanent neurological deficit, temporary neurological deficit, renal failure requiring dialysis and hepatic dysfunction, were compared between the two groups. The mean body temperature at the initiation of SCP was 28.7 ± 1.9 °C. Overall operative mortality occurred in 6 (5.6%) patients. The incidences of permanent neurological deficit and temporary neurological deficit were 1.9 and 4.7%, respectively. None of the 9 (8.4%) patients who suffered postoperative renal failure requiring dialysis received ILBP. The laboratory data showed significantly lower levels of hepatic and kidney enzymes in the ILBP group (P < 0.05). Significantly lower levels of hepatic and kidney enzymes indicate more effective end-organ protection with the use of ILBP. Our data suggest that ILBP provides more effective end-organ protection during repair of aortic arch under moderate HCA.

Ascending, Total Arch, and Descending Thoracic Aortic Repair for Acute DeBakey Type I Aortic Dissection Without Circulatory Arrest

Complications may arise from the residual dissected arch and descending thoracic aorta after conventional ascending and hemiarch repair of acute DeBakey type I aortic dissection. To mitigate these complications, a total arch and elephant trunk procedure has been advocated. This case demonstrates a less invasive hybrid technique, performed in a single-stage fashion through a sternotomy without circulatory arrest or deep hypothermia, to achieve the benefits of the total arch and elephant trunk operation.

Adjunctive Retrograde Thoracic Stent Grafting During Repair of Acute Debakey Type I Dissection Prevents Development of Thoracoabdominal Aortic Aneurysms

Wednesday 10 August – Scientific Session 9/1130–1145 Evolution in the Techniques andOutcomes of Aortic Arch Surgery: A 22 Year Single Centre Experience Reece A. Davies 2,4,∗, Deborah Black2, Richmond W. Jeremy2,3, Paul G. Bannon1,2,4, Matthew S. Bayfield1,4, P. Nicholas Hendel 1,2,4, Clifford F. Hughes1,2,4, Michael K. Wilson1,4, Michael P. Vallely 1,2,4 1 Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia 2 Faculty of Medicine, The University of Sydney, Australia 3 Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia 4 The Baird Institute for Heart and Lung Surgical Research, Sydney, Australia Introduction: Aortic arch replacement is a complicated and high risk procedure used mainly in the treatment of aneurysms and dissections of the aortic arch. There have been many advances over recent years [1,2]. Published mortality rates in modern series vary between 6 and 16% [1,3]. We review the changes in our unit’s techniques and outcomes and attempt to identify predictors of an adverse outcome over the past 22 years. Methods: Data were collated from databases and medical records for all patients who underwent aortic arch replacement surgery from January 1989 toDecember 2010. T ( t t m

Effects of Early Anticoagulation on the Degree of Thrombosis After Repair of Acute DeBakey Type I Aortic Dissection

The degree of false lumen thrombosis after surgical repair of acute DeBakey type I aortic dissection can predict long-term outcomes. However, there are currently no evidence-based recommendations for anticoagulation. We analyzed the effect of early anticoagulation on the residual false lumen and long-term outcomes. This was a retrospective observational study of 136 patients with acute DeBakey type I aortic dissection who underwent surgical repair between 1997 and 2007. We assessed the effect of early anticoagulation on the degree of thrombosis of the false lumen, segmental growth rates, repeat distal procedures, and long-term survival. Among the 136 patients who underwent operations, imaging data in 103 were sufficient for analyzing the degree of thrombosis of the false lumen. Of those, 56 (54%) received anticoagulation therapy immediately postoperatively. The early-anticoagulation group had a higher proportion of completely patent false lumens and lower partial thrombosis than the no-anticoagulation group. Mean segmental aortic growth rate was significantly lower in the early-anticoagulation group than in the no-anticoagulation group (2.9 ± 1.3 and 4.5 ± 2.8 mm/year, p = 0.0184). Overall survival and aorta-related repeat procedure-free survival were significantly better with early anticoagulation than with no anticoagulation (p < 0.05). Early anticoagulation after surgical repair of acute DeBakey type I aortic dissection might have a favorable effect on the onset or extension of thrombosis, aortic growth rate, the need for repeat distal procedures, overall survival, and thrombosis-related complications during long-term follow-up.

Effects of partial thrombosis on distal aorta after repair of acute DeBakey type I aortic dissection

Prognostic implications of partial thrombosis of the residual aorta after repair of acute DeBakey type I aortic dissection have not been elucidated. We sought to analyze the impact of partial thrombosis on segmental growth rates, distal aortic reprocedures, and long-term survival. A total of 118 consecutive patients (55% were male; mean age, 60 years) with acute DeBakey type I aortic dissection underwent surgical repair (1997-2007). The hospital mortality rate was 17.8%. Survivors underwent serial computed tomography scans. Segment-specific average rates of enlargement were analyzed. Distal reprocedures and patient survival were examined. Sixty-six patients had imaging data sufficient for growth rate calculations. The median diameters within 2 weeks after repair were as follows: aortic arch, 3.5 cm; descending aorta, 3.6 cm; and abdominal aorta, 2.4 cm. Subsequent growth rates were artic arch, 0.34 mm/y, descending aorta, 0.51 mm/y, and abdominal aorta, 0.35 mm/y. Partial thrombosis of the residual aorta predicted greater growth in the distal aorta (P = .005). There were 13 distal aortic reprocedures (5 reoperations, 8 stent graft insertions) for 10 years, and reprocedure-free survival was 66%. Partial thrombosis (P = .002) predicted greater risk of aorta-related reprocedures. Cox analysis revealed that estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) (P = .030), reintubation (P = .002), and partial thrombosis (P = .023) were independent predictors for poor survival. Partial thrombosis of the false lumen after repair of acute DeBakey type I aortic dissection, compared with complete patency or complete thrombosis, is a significant independent predictor of aortic enlargement, aorta-related reprocedures, and poor long-term survival.

Axillary artery cannulation in acute ascending aortic dissections

Background. Standard cannulation of the femoral artery in preparation for repair of a dissection involving the ascending aorta carries a high risk of malperfusion. Arterial perfusion through the right axillary artery is more likely to perfuse the true lumen and should be advantageous in acute dissections involving the ascending aorta.Methods. Thirteen patients underwent repair of acute ascending aortic dissections and were perfused through the right axillary artery. All had deep hypothermic circulatory arrest.Results. There was one mild intraoperative cerebrovascular accident with complete recovery and one operative death secondary to low cardiac output. There were no intraoperative problems with perfusion through the axillary artery, and there were no postoperative problems or complications involving the axillary artery, axillary vein, or brachial plexus.Conclusions. Arterial perfusion through the right axillary artery is a safe and effective means of more reliably perfusing the true lumen. In this regard, it may be superior to femoral artery perfusion and could lead to improved outcomes with repair of acute deBakey type I and II aortic dissections.