Results Of Total Arch Replacement Research Articles

Short- and long-term results of total arch replacement for acute type I aortic dissection in comparison to hemiarch replacement: a 10-year follow-up analysis

Abstract Background Optimal management of the arch in cases of acute type-A aortic dissection (ATAAD) involving the aortic arch (DeBakey type I) is still controversial. Extended total arch replacement (TAR) to address re-entries increases the complexity of surgery and may be associated with worse short-term outcome. We aimed in this study to compare short- and long-term outcomes of TAR compared to hemiarch replacement. Methods We retrospectively analyzed data of patients operated for ATAAD in our center. The study was approved by the ethics committee. We used Student’s t-test or Mann-Whitney U test to compare continuous variables. We performed univariate Chi-square and multivariate logistic regression analysis. Log-rank test was used to compare long-term mortality between the two groups. In addition, hazard ratio (HR) with 95% confidence interval (CI) was reported. Results Between July 2007 and November 2021, 396 patients underwent surgery for ATAAD in our center. Among them, 326 (82%) presented with DeBakey type I dissection and were included in further analyses. TAR was performed in 103 (32%) patients, while hemiarch in 221 (68%) patients. Patients who received TAR were significantly younger (59.2±12.3 vs 64.0±13.5 years), had more frequently peripheral arterial disease (24% vs 15%, p=0.065), and presented more frequently preoperatively with neurological deficits (32% vs 18%, p=0.046). Patients in the TAR group received more aortic repair/replacement (29% vs 17%, p=0.018). New permanent postoperative neurological deficits (stroke or paraplegia) occurred in 10% of the TAR group and in 15% of the hemiarch group (p=0.463). Mortality at 30 days was higher in the TAR group but the difference was not statistically significant (27% vs 20%, p=0.198). In the multivariate analyses TAR was not an independent predictor for 30-day mortality (OR: 1.71, 0.91-3.19, p=0.092) or post operative neurological complications (OR: 0.66, 0.28-1.55, p=0.337). The estimated 10-year survival for patients with TAR was 56% compared to 63% for the hemiarch group (Logrank=0.450). In the multivariate Cox regression analysis, TAR was not an independent predictor for long-term survival (adjusted HR: 1.24, 0.79-1.94, p=0.348). Conclusions Total arch replacement was not an independent predictor for postoperative neurological complications, short-, or long-term mortality. Putting a potential surgeon bias aside, our results suggest that the fear of TAR may be overestimated.

Short- and long-term results of total arch replacement: Comparison between island and debranching techniques.

The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching)or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P=.001), had undergone more previous cardiac operations (54.5% vs 27.4%, P<.001), and had more connective tissue disorder (20.3% vs 4.6%, P<.001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10minutes, P<.001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37minutes, P<.001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P=.018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P=.486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P=.897). Ten-year survival was 80% (78% vs 80.9%, log-rank P=.356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P=.495). Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

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

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

Early results of total arch replacement under partial sternotomy.

Partial sternotomy with limited skin incision has been utilized for cardiac surgery. We, therefore, started to apply the partial sternotomy for total arch replacement since 2013 in selected cases. The aim of this study reported the results of our early experiences. Between July 2013 and December 2015, we retrospectively reviewed 15 cases (median age 72, range 67-84, 15 male) who underwent total arch replacement thorough partial sternotomy. All procedures were performed under hypothermic circulatory arrest with selective cerebral perfusion. Median skin incision was 9cm (range 7-15cm, 5.3% of height) and partial sternotomy consisted of 14 upper and 1 lower partial sternotomy (L shape 8 and T shape 7 cases). Median operation time, cardiopulmonary bypass time, ischemic heart time, selective cerebral perfusion time and hypothermic circulatory arrest time were 485 [360-770], 223 [1174-270], 146 [100-163], 154 [116-189], and 69 [45-90] minutes, respectively. Median duration of mechanical ventilator dependent time was 12h [5-38]. Median length of ICU stay and hospital stay were 3 [1-7], and 18 [13-76] days, respectively. Thirty days and in-hospital mortality were 0% without any neurological complications. There are two aorta-related reoperation due to graft inducing hemolytic anemia and no aorta-related death during follow-up (median 954, range 702-1462 days). The early results of total arch replacement through partial sternotomy were satisfactory. The partial sternotomy could be a good option for total arch replacement in selected patients.

Editorial Comment: The Borst elephant trunk technique is not lethal!

The paper by Kondoh et al. [1] describes the results of total arch replacement with a long elephant trunk ending at the level of T6–T8. This technical modification simultaneously differs to, and matches, the classic Borst technique, or a variations of, in a number of ways. What are the similarities? First, the portion of the prosthesis, the trunk, extending into the descending aorta is non-stented and free floating. The length of the trunk is longer than in the classic elephant trunk technique, where it is generally limited to only 5–10 cm (although it has always been a matter of debate as to what the ideal trunk length should be). What are the differences? The proximal anastomosis of the elephant trunk is now located in the distal ascending aorta at the origin of the innominate artery leaving the arch untouched and even unopened. This makes it possible to arrest body circulation only for a brief time period (25 min). The distal end of the elephant trunk is located at the level of T6–T8. Kondoh’s technique also differs from the frozen elephant trunk technique in that the trunk diameter is undersized rather than oversized and, of course, non-stented. In dissection patients it is introduced in the true lumen and the false lumen is not obliterated anymore as in the frozen elephant trunk technique. The fixation of the trunk is also located more proximally. The body arrest temperatures (25°C) are lower than contemporary series, which have described their results with the frozen elephant trunk. Antegrade selective cerebral perfusion is used as in every total arch replacement perfusing both axillary arteries and the left common carotid artery to protect the brain. What could be the advantages of this new technique? The body arrest time is short, all anastomoses can be reached easily, making it obvious that no patient required a re-exploration for bleeding. In-hospital mortality (9 of 127, 7%) is acceptable but not extremely low. What could be the disadvantages? There are still 3.2% spinal cord injuries which is comparable with the frozen elephant trunk but substantially higher than in the classic elephant trunk technique. In-hospital mortality of the second stage is rather high (2 of 12, 16%). As in thoracic endografting, it is understandable that the longer the graft, the higher the risk of paraplegia. During follow-up, there are a high number of aorto-enteric fistulizations, a well-known and almost lethal complication after the frozen elephant trunk but something that has almost never been described after the classic elephant trunk. It is important to stress that, despite the undersizing of the diameter of the graft, the authors found a thromboexclusion in the majority (86%) of the patients treated. This number is even higher than in the frozen elephant trunk. Apparently aortic arch aneurysms extending into the descending thoracic aorta for various lengths, but not below the diaphragm, can nowadays be treated surgically by a multitude of different alternatives. Roughly speaking, one can prefer a one-step approach to a two-step procedure. Of course, the one-step approach offers the advantage of solving the problem in one operation and is theoretically devoted with a morbidity and mortality that is limited to this single procedure. The two-step approach offers the advantage that the repair can be extended below the diaphragm if necessary, but obviously includes a substantial dual risk. In recent years, endovascular techniques, be they pure or hybrid procedures, have been added to the surgical armamentarium, making choices not only more numerous but also more difficult. The question is no longer can we solve the problem, it is rather a matter of choosing the best strategy taking into account patient-, surgeon-, procedureand hospital-related factors. The authors advocating this new technique cannot convince me with this new approach. We are making hardly any progress. On the contrary, I believe that we have rather taken a step back: more paraplegia and paraparesis, more fistulizations in the long run, a high mortality rate, taking into account both steps. The wave of frozen elephant trunks that has overwhelmed us in the last few years and has been embraced by a lot of surgeons as the ultimate solution, has apparently not resulted in better results. The total arch replacement, herein described, with the long elephant trunk has not either. So, clearly, the classic elephant trunk technique is not so bad still, and is not lethal. New techniques come and go, but they will only stay if their results exceed those of previously established procedures. This critical comment does not mean that the authors should not be congratulated for their courage in creating a modification

Retrograde cerebral perfusion with hypothermic circulatory arrest in aortic arch surgery: operative and long-term results.

Clinical data were retrospectively collected for 207 consecutive patients who underwent aortic arch surgery using continuous retrograde cerebral perfusion (CRCP) and hypothermic circulatory arrest (HCA) at Tenri Hospital (138 patients) from 1988 to 1999, and at Nagoya University Hospital (69 patients) from 1990 to 2000. One hundred and 3 patients (50%) were operated upon for aortic dissection, and 104 patients (50%) for atherosclerotic aneurysm. Hospital mortality was 12% (25 patients). HCA times were 44+/-20 minutes. Cardiopulmonary bypass time longer than 6 hours, low cardiac output syndrome, respiratory failure, and central nervous system (CNS) dysfunction contributed to hospital deaths. Late mortality was 16% (34 patients). The predictors of late deaths were age (>70 years), total arch replacement, HCA time >60 min., non-dissecting aneurysm, and postoperative CNS injury. Operative results of aortic arch surgery using CRCP was generally satisfactory. However, the long-term results of total arch replacement for patients older than 70 years, non-dissecting aneurysm (particularly ruptured), and postoperative CNS injury were poor. Although prolonged duration of HCA may contribute to these poor results, other factors such as emergent surgery, late death due to aging, and systemic atherosclerosis are also considered to be risk factors.