ADULT – Original Submission
Total Aortic Arch Replacement and Frozen Elephant Trunk

https://doi.org/10.1053/j.semtcvs.2020.11.016Get rights and content

Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients’ perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (n = 37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (n = 15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%) and chronic aortic dissection including chronic type A and type B dissections (n = 13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.

Section snippets

INTRODUCTION

Aortic arch pathology commonly involves multiple aortic segments, which often requires staged complex procedures and the management of malperfusion syndrome leading substantial operative risks. The total aortic arch replacement with frozen elephant trunk (TAR FET) technique has developed over past decade and becoming an accepted treatment option for both arch aneurysmal and dissecting pathologies.1, 2, 3, 4 Potentially, this technique allows a single stage procedure, as well as facilitates

Patients

Between August 2014 and April 2020, 41 consecutive patients underwent TAR FET in our institute with the Thoraflex-Hybrid-Plexus (Vascutek, Inchinnan, Scotland) as the only TAR FET device for complex aortic arch disease. Preoperative characteristics are shown in Table 1. Indications involved emergency acute aortic syndrome, including type A dissection or intramural hematoma (n = 15, 36.6%); thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%); and chronic aortic

Perioperative Data

Patients’ baseline characteristics and presenting pathology are shown in Table 1 with no missing data for analysis. Thirty-four male and 7 female patients were treated with TAR FET and 6 patients had previous cardiac or aortic surgery. Emergency surgeries within 24 hours of presentation were required in 16 patients. Eight patients presented with malperfusion and 4 of them presented with cardiac tamponade.

Intraoperative data are listed in Table 2. Overall mean operative, cardiopulmonary bypass,

DISCUSSION

The treatment of complex aortic disease involving the arch has been challenging and evolved over the last decade with the TAR FET technique, and its indications expanded to both chronic and acute dissection.4 Recent series from multicenters 1,2 have shown promising results for this conventionally considered high risk group of patients of mortality risk, stroke, spinal cord injury, visceral and limbs ischemia. In-hospital mortality (9.8%) within our population was comparable to the report series

REFERENCES (16)

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Cited by (17)

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    Aortic arch replacement for extensive and complex arch diseases is technically challenging in clinical practice. Traditional aortic arch surgery involves complicated surgical techniques, circulatory management, and brain protection strategies, and is associated with significant morbidity and mortality.1 Novel endovascular repair techniques offer patients an alternative for aortic repair.

  • Surgical management and outcomes in patients with acute type A aortic dissection and cerebral malperfusion

    2022, JTCVS Open
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    Other authors reported findings of bilateral perioperative strokes revealed by CT or magnetic resonance imaging, suggesting that intraoperative factors such as thrombotic or air microembolism play a significant role.2,20 In the present study, we did not focus our attention on the influence of specific surgical techniques used in arch replacement in functional results; in this respect, ET and frozen ET, currently adopted with increasing frequency in the treatment of A-AAD,21,22 were used in a small number of patients. Because we more specifically evaluated the type of cerebral protection, our data suggest that an antegrade systemic perfusion established from the right axillary artery directly in the true lumen may be effective for restoring the normal flow to the brain and reducing the risk of thrombotic or air microembolism mainly related to retrograde systemic perfusion.

  • Commentary: Total Arch Replacement with Frozen Elephant Trunk: One Stop Shop

    2021, Seminars in Thoracic and Cardiovascular Surgery
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The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest: None.

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