Thoracic Endovascular Repair after Total Aortic Arch Replacement with Frozen Elephant Trunk for Type a Aortic Dissection.

BACKGROUND: The management of residual aortic dissection after initial type A repair with the Frozen elephant trunk technique remains mostly unexplored. This work aimed to evaluate endovascular second-stage surgery for patients with residual aortic dissection. METHODS: A retrospective analysis of consecutive patients that underwent Type A aortic repair with Frozen elephant trunk, followed by a second-stage endovascular procedure was done from March 2016 to December 2021. The primary outcome was aortic-related adverse events or mortality, and secondary outcomes were aortic remodeling and perioperative complications. Remodeling was assessed by comparing the difference in ratios for true lumen/total aortic diameters on pre-operative and follow-up scans. RESULTS: Thirty-four patients underwent second-stage surgery after Type A repair during the study period (7 thoracic endovascular aortic repair extensions, 1 STABLE/PETTICOAT, and 26 STABILISE). Median follow-up was 23 months (range 2-66 months). There were no perioperative deaths or major complications and 1 reoperation for left subclavian re-embolization. At the last follow-up, there was no aortic-related mortality. There were 5 aortic-related adverse events, including another subclavian re-embolization and a preplanned open conversion. Risk factors were connective tissue disorders (P = 0.01) and aortic aneurysms >55 mm (P = 0.03). Distal remodeling reached statistical significance in all segments (P < 0.01) and was greater for patients treated with the STABILISE technique when compared to extended thoracic endovascular aortic repair (P = 0.01). CONCLUSIONS: Second-stage endovascular management of residual aortic dissection after initial Frozen elephant trunk repair showed excellent perioperative and good midterm outcomes and induced significant remodeling of the entire aorta in most cases, particularly with the STABILISE procedure.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection.

BACKGROUND: Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions. METHODS: From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions. RESULTS: Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported. CONCLUSIONS: ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair.

BACKGROUND: Although reduction of a dilated aortic annulus is becoming an essential parameter for durable valve repair, anatomical descriptions of the annulus and surgical landmarks of the subvalvular plane for an external aortic annuloplasty remain to be defined. METHODS: Twenty hearts with normal anatomy with tricuspid aortic valves were studied. Annulus diameter, cusp geometric height, and interleaflet triangles heights were measured. The aortic root was dissected externally down to the subvalvular plane as to perform an external aortic annuloplasty or reimplantation procedure proximal anastomosis. Tissue thickness and dissection heights relative to the annulus were measured at each cusp nadir and at the middle of each interleaflet triangle. RESULTS: The mean annulus diameter, cusp geometric height, and interleaflet triangle heights were, respectively, 24.9 ± 0.2 mm, 19.7 ± 0.3 mm, and 20.1 ± 0.5 mm. External dissection of the aortic root reached the subvalvular plane below the nadir of left coronary cusp (-2.7 ± 0.4 mm), noncoronary (NC) cusp (-3.1 ± 0.3 mm), and the base of left-NC interleaflet triangle (-2.1 ± 0.4 mm). External dissection remained above the nadir of the right coronary cusp (+1.4 ± 0.4 mm), base of left-right interleaflet triangle (+2.4 ± 0.6 mm), and right-NC interleaflet triangle (+3.4 ± 0.3 mm). Mean tissue thickness between the inner and external side of the subvalvular plane was 2.5 ± 0.1 mm. CONCLUSIONS: External dissection of the aortic annulus allows subvalvular placement of an external aortic ring below the left and NC cusps and below or within 3 mm of the right cusp nadir in 80% of cases. An external aortic annuloplasty would induce at least a 5-mm reduction of annulus diameter, corresponding to tissue thickness. Precise anatomical landmarks are important to standardize aortic valve annuloplasty.