Total Aortic Repair Research Articles

Total Debranching Plus Antegrade Thoracic Endovascular Aortic Repair without Side Clamping in a Patient with Arch Aneurysm and Ascending Aorta Calcification.

A high-risk patient with aortic arch aneurysm, associated with severe calcification of the ascending aorta and iliac arteries, was treated with total debranching and antegrade thoracic endovascular aortic repair (TEVAR) via the ascending aorta. Proximal anastomosis for a triple-branched graft to the ascending aorta was performed without side clamping using the “real chimney technique.” After bypassing the supra-aortic branches, a TEVAR was performed in an antegrade fashion through the ascending aorta. This case suggests that the approaches mentioned above should be considered in patients with arch aneurysms and severe calcified degeneration.

Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy

BackgroundUse of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach.MethodsWe retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group (n = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups.ResultsHospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups (p = 1.000).ConclusionThe upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

A Case of the Subclavian Artery Aneurysm after Total Aortic Repair Which Was Treated with Hybrid Operation

A Case of the Subclavian Artery Aneurysm after Total Aortic Repair Which Was Treated with Hybrid Operation

A new paradigm in the management of acute type A aortic dissection: Total aortic repair

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and “hemi-arch” with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of “branch first” total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.

A Case of the Subclavian Artery Aneurysm of Marfan Syndrome after Total Aortic Repair Which Was Treated with Hybrid Operation

A Case of the Subclavian Artery Aneurysm of Marfan Syndrome after Total Aortic Repair Which Was Treated with Hybrid Operation

Total aortic repair for acute type A aortic dissection: a new paradigm.

The currently accepted guidelines of open surgical repair for acute type A aortic dissection (ATAAD) include the resection of the primary entry tear, replacement of the ascending aorta and "hemi-arch" with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim being protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk, while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centres. While a superficially compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical but in practise safe paradigm, which aims to achieve total aortic healing in the acute phase.

Total Aortic Repair for Acute Type A Aortic Dissection

Total Aortic Repair for Acute Type A Aortic Dissection

Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection

Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection

Total Aortic Repair for Acute Type A Aortic Dissection Complicated by Malperfusion or Symptomatic Branch Vessel Malalignment

Malperfusion or persistent perfusion of the false lumen with acute type A aortic dissections is a major cause of morbidity and mortality. We describe our experience with total aortic repair in patients with acute type A dissection with recurrent or ongoing branch ischemia, true lumen collapse, or rapid dilatation of a false lumen after initial surgical repair.

Total aortic repair: the new paradigm in the treatment of acute type A aortic dissection

The surgical management of acute type A aortic dissection (ATAAD) is in a period of rapid evolution. Understanding the complex physiology and anatomy of both acute and chronic dissection has been enhanced by the ready availability of state of the art imaging techniques. Technical advances in the intraoperative monitoring of organ perfusion, together with adjuncts to limit organ injury and increasing sophistication in open and endovascular surgery have led to a major reduction in both perioperative morbidity and mortality. In many centers, there has been a transition in mindset and surgical approach away from a purely central aortic operation focusing on the ascending aorta and a 'live to fight another day' philosophy. The current more global perspective recognizes the importance of aortic valve function, malperfusion, false lumen (FL) patency and the potential for future complex aneurysm development. The time is now right to transition into the next phase of sophistication in the management of ATAAD with the aim of achieving not only a safe acute operation, but to either entirely prevent chronic complications or to greatly simplify their management by the creation of an anatomical situation that facilitates future endovascular intervention in place of complex re-do surgery. We present our view on the evolution of surgery for ATAAD leading to our current technique of Branch First Arch replacement and Total Aortic Repair, which not only provides a safe immediate operation, but also offers the hope of a simplified future management if not a total cure for the pathology.

Surgical management of acute type A aortic dissection: branch-first arch replacement with total aortic repair.

Acute type A dissection (ATAAD) remains a morbid condition with reported surgical mortality as high as 25%. We describe our surgical approach to ATAAD and discuss the indications for adjunct techniques such as the frozen elephant trunk or complete aortic repair with endovascular methods. Arch replacement using the "branch-first technique" allows for complete root, ascending aorta, and arch replacement. A long landing zone is created for proximal endografting with a covered stent. Balloon-assisted intimal disruption and bare metal stenting of all residual dissected aorta to the level of the aortic bifurcation is then performed to obliterate the false lumen (FL) and achieve single true lumen (TL) flow. Additional branch vessel stenting is performed as required.

Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection

Traditional surgical techniques for the management of acute type A aortic dissection (ATAAD) focus on open distal anastomosis with or without hemiarch replacement under a period of deep hypothermic circulatory arrest. This is associated with high rates of false lumen (FL) patency, which exposes the patient to the risk of ongoing end-organ malperfusion and to the formation of complex arch and thoracoabdominal dissection aneurysms. Furthermore, persistent malperfusion is a major source of morbidity and mortality and is not easily reversed following traditional central repair. Arch replacement using the “branch first” technique allows for complete root, ascending and arch replacement (1-3). A long landing zone is created for proximal endografting with a covered stent. Extended thoracoabdominal stenting is performed in patients with: Ongoing or recurrent branch vessel ischaemia or malperfusion; Radiological true lumen (TL) collapse; Rapid dilatation of the FL; Markers of compromised TL perfusion. The following video (Video 1) illustrates a case of TAAD with clinical and radiological malperfusion and shows the benefits of “branch first” arch replacement followed by stent grafting in this situation. Video 1 Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection.

Safety and utility of total percutaneous endovascular aortic repair with a single Perclose ProGlide closure device

This study evaluated the safety and efficacy of total percutaneous endovascular aortic aneurysm repair (PEVAR) with a single Perclose ProGlide device (Abbot Vascular, Santa Clara, Calif) compared with endovascular aortic repair with surgical cutdown (SEVAR). The study included 50 abdominal aortic aneurysm patients who were treated with PEVAR with a single Perclose ProGlide device and 96 patients treated with SEVAR. Technical success was defined as successful arterial closure of the common femoral artery without the need for adjunctive surgical or endovascular procedures. The rates of complications, including bleeding requiring transfusion, infection, pseudoaneurysm, paresthesia, and lymphocele, as well as the operating room time and hospital duration were compared between the PEVAR and SEVAR groups. Technical success was obtained in all patients in the PEVAR group. One patient in the SEVAR group needed surgical repair due to access site bleeding. Complication rates were similar between the groups (4% in the PEVAR vs 8% in the SEVAR; P= .495). The PEVAR group had significantly shorter operating room times (153± 47minutes vs 211± 88minutes, P< .001) and hospital lengths of stay (6.7± 6.8days vs 9.3± 4.5days, P< .001). Compared with SEVAR, PEVAR with a single ProGlide device is a safe procedure with a shorter operating room time and hospital stay, without increasing access site complications.

Early and Late Outcomes After Complete Aortic Replacement

The purpose of this report was to analyze our experience with total aortic replacement during a 20-year period. Between 1991 and 2013, 3,012 repairs of the aortic root, ascending, transverse arch, and thoracoabdominal aorta were performed. Of these, we treated 39 patients with complete aortic replacement. Staged repair of the aortic root/ascending/arch and thoracoabdominal segments was used when feasible. Procedures were categorized according to the aorta replaced, whether proximal or distal to the left subclavian artery. We performed 87 operations (41 ascending and 48 thoracoabdominal repairs) in 39 patients; 2 had combined proximal and distal repairs. Mean age was 52.5 ± 15.9 years, and 17 patients (44%) were women. In addition, 39% (14 of 39) had a history of a connective tissue, and 74% (29 of 39) had a history of aortic dissection. Of the 39 patients, 21 (54%) required two stages for complete replacement, 12 (31%) required three stages, 3 (8%) required four stages, and 3 (8%) required more than five stages. The median time to completion of total aortic repair was 8.7 months (interquartile range, 2 to 71.2 months). No early deaths occurred. No stroke occurred after the proximal repair, and 3 patients (6%) suffered paraplegia after the distal repair. Survival at 5, 10, 15 and 20 years was 70.7%, 57.7%, 54%, and 30%, respectively. Complete aortic replacement can be performed with acceptable rates of morbidity and mortality. Most of these patients were younger, had associated dissection, and required multiple stages for completion. As endovascular techniques advance proximally into the ascending aorta and complete endovascular aortic repair comes closer to reality, studies like this will allow comparison.

Predicting the learning curve and failures of total percutaneous endovascular aortic aneurysm repair

Percutaneous endovascular aneurysm repair (PEVAR) has been shown to be feasible; however, technical success is variable, reported to be between 46.2% and 100%. The objective of this study was to quantify the learning curve of the PEVAR closure technique and identify predictors of closure failure. We reviewed patient- and procedure-related characteristics in 99 consecutive patients who underwent PEVAR over a 30-month period in a single academic institution. A suture-mediated closure device (Proglide or Prostar XL) was used. Forward stepwise logistic regression was used to investigate associations between the failure of the closure technique and a number of patient and operative characteristics. To ensure objective assessment of the learning curve, a time-dependent covariate measuring time in calendar quarters was introduced in the model. Poisson regression was used to model the trend of observed failure events of the percutaneous technique over time. Overall PEVAR technical success was 82%. Type of closure device (P<.35), patient's body mass index (P<.86), type of anesthesia (P<.95), femoral artery diameter (P<.09), femoral artery calcification (P<.56), and sheath size as measured in Fr (P<.17) did not correlate with closure failure rates. There was a strong trend for a decreasing number of failure events over time (P<.007). The average decrease in the odds of technical failure was 24% per calendar quarter. The predicted probability of closure failure decreased from 45% per patient at the time of the initiation of our PEVAR program to 5% per patient at the end of the 30-month period. There were two postoperative access-related complications that required surgical repair. Need for surgical cutdown in the event of closure failure prolonged the operative time by a mean of 45 minutes (P<.001). No groin infections were seen in the percutaneous group or the failed group. Technical failure can be reduced as the surgeon gains experience with the suture-mediated closure device utilized during PEVAR. Previous experience with the Proglide device does not seem to influence the learning curve.

TCT-120 The Policy Of Total Percutaneous Abdominal Aortic Aneurysm Repair: One-year Follow-up

Endovascular abdominal aortic aneurysm repair (EVAR) is accepted therapeutic strategy. The use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common and further extends the EVAR indications. The aim of our retrospective analysis was assessment of safety

Three trocars laparoscopic abdominal aortic aneurysm repair

Total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was performed in a 53-year-old woman diagnosed with an infrarenal abdominal aortic aneurysm. The operation was accomplished by a method using three trocars. The operation took 240 minutes. Blood loss was 600 mL. No complications occurred in 13 months of postoperative follow-up. These results show that total laparoscopic abdominal aortic aneurysm repair with three trocars is feasible and worthwhile.

One-stage total thoracic aortic repair for mega-aorta using frozen elephant trunk technique

We report the case of a 71-year-old female with mega-aorta extending from the ascending aorta to the descending aorta, who was successfully treated with a one-stage total thoracic aortic repair by the frozen elephant trunk technique using a stent-graft. We used a home-made frozen elephant trunk with four giant-turco Z-stents on the distal side that was inserted into the downstream descending aorta via an aortic arch guiding pull-through wire. The stent-graft was distally positioned at the level of the 12th thoracic vertebra after total arch replacement had been performed using a four-branch graft. The postoperative course was good, and there was no paraplegia or other complications. A postoperative computed tomography scan demonstrated complete thrombosis of the descending thoracic aneurysm without endoleak. In conclusion, the frozen elephant trunk was effective as a one-stage operation for mega-aorta.

Total percutaneous endovascular abdominal aortic aneurysm repair

To determine the safety and efficacy of total percutaneous endovascular abdominal aortic aneurysm repair using the Perclose ProGlide suture-mediated closure system. From May 2008 to April 2010, 36 abdominal aortic aneurysm patients were undergone total percutaneous endovascular repair. There were 30 male and 6 female patients with a mean age of 68 years. Endografts used included 3 Endurant endografts, 13 Talent endografts, and 20 Zenith endografts. Prior to insertion of the introducer sheath, two ProGlides were pre-set to 18 to 24 F access sites and one to 14 to 16 F access sites. At last, suture the arteriotomy by tying down knots of the ProGlide following removal of the sheath. Technical success, complications, and procedure and access closure times were evaluated. Follow-up protocol consisted of computed tomography angiograms performed at 3, 6, 9, 12 months, and annually thereafter. Twenty patients were operated under local anesthesia and 16 patients under general anesthesia. A total of 68 femoral arteries were closed with 128 devices. Thirty-eight vessels were with 2 devices, while 8 arteries required 3 devices and 2 arteries required 4 devices for hemostasis and an additional 20 vessels only required a single device. Sixty-three (63/68, 92.6%) vessels were closed successfully. Two vessels converted to open closure. Three vessels complicated with hematomas without surgical procedure. The mean follow-up was (12±3) months. There was one asymptomatic femoral artery dissection 3 months after operation. Total percutaneous endovascular abdominal aortic aneurysm repair is safe and effective. But it should be performed at hybrid operating room where can convert to open procedure if necessary.

Total aortic repair in Marfan syndrome using stent grafting with hybrid techniques

A 19-year-old man with Marfan syndrome and a 3-year history of severe mitral regurgitation was admitted with DeBakey type IIIb acute aortic dissection and dilatation of the aortic root (4 cm diameter; A). The diameter of the dissected aorta from the distal arch (5-cm diameter) to the thoracoabdominal aorta increased progressively during admission.