Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.

BACKGROUND: Surgical and cerebral protection strategies in aortic arch surgery remain under debate. Perioperative results using deep hypothermic circulatory arrest (DHCA) have been associated with favorable short-term mortality and stroke rates. The present study focuses on late survival in patients undergoing aortic surgery using DHCA. METHODS: A total of 613 patients (mean age, 63.7 years) underwent aortic surgery between January 2003 and December 2015 using DHCA, with 77.3% undergoing hemiarch replacement and 20.4% undergoing arch replacement, with a mean DHCA duration of 29.7 ± 8.5 minutes (range, 10-62 minutes). We examined follow-up extending up to a mean of 3.8 ± 3.4 years (range, 0-14.1 years). RESULTS: Operative mortality was 2.9%, and the stroke rate was 2%. Survival was 92.2% at 1 year and 81.5% at 5 years, significantly lower than the values in an age- and sex-matched reference population. In elective, nondissection first-time surgeries (n = 424), survival was similar to that of the reference group. Acute type A aortic dissection (hazard ratio [HR], 4.84; P = .000), redo (HR, 4.12; P = .000), and descending aortic pathology (HR, 5.54: P = .000) were independently associated with reduced 1-year survival. Beyond 1 year, age (HR, 1.07; P = .000), major complications (HR, 3.11; P = .000), and atrial fibrillation (HR, 2.47; P = .006) were independently associated with poor survival. DHCA time was not significantly associated with survival in multivariable analysis. CONCLUSIONS: Aortic surgery with DHCA can be performed with favorable late survival, with the duration of DHCA period having only a limited impact. However, these results cannot be generalized for very long durations of DHCA (>50 minutes), when perfusion methods may be preferable. In elective, nondissection first-time surgeries, a late survival comparable to that in a reference population can be achieved. Early survival is adversely affected by aortic dissection, redo status, and disease extent.

Safety and pitfalls in frozen elephant trunk implantation.

The frozen elephant trunk (FET) procedure, or open stent grafting, is a tool for the combined open and endovascular treatment via a median sternotomy of extensive aortic disease involving both aortic arch and descending thoracic aorta. The technique aims to stabilize the maximum extent of the thoracic aorta in one step, with the goal of either rendering a secondary intervention to the downstream aorta unnecessary or producing an easy landing zone for secondary thoracic endovascular aortic repair (TEVAR) or open surgery. Even though large case series have reported good results, we still have no conclusive evidence as to which patients and what kind of pathologies benefit from this technique. The surgical sequences described for total arch replacement with the FET procedure are just as varied as the associated devices and indications. This article focuses on important perioperative and surgical aspects, as well as potential complications during FET procedures.

Bare metal stenting for endovascular exclusion of aortic arch thrombi.

BACKGROUND: Aortic thrombi in the ascending aorta or aortic arch are rare but are associated with a relevant risk of major stroke or distal embolization. Although stent grafting is commonly used as a treatment option in the descending aorta, only a few case reports discuss stenting of the aortic arch for the treatment of a thrombus. The use of bare metal stents in this setting has not yet been described. METHODS: We report two cases of ascending and aortic arch thrombus that were treated by covering the thrombus with an uncovered stent. Both procedures were performed under local anesthesia via a femoral approach. A femoral cutdown was used in one case, and a total percutaneous insertion was possible in the second case. RESULTS: Both procedures were successfully performed without any periprocedural complications. Postoperative recovery was uneventful. In both cases, no late complications or recurrent embolization occurred at midterm follow-up, and control CT angiography at 1 respectively 10 months revealed no stent migration, freely perfused supra-aortic branches, and no thrombus recurrence. CONCLUSION: Treating symptomatic thrombi in the ascending aorta or aortic arch with a bare metal stent is feasible. This technique could constitute a minimally invasive alternative to a surgical intervention or complex endovascular therapy with fenestrated or branched stent grafts.

Thoracic stent graft sizing for frozen elephant trunk repair in acute type A dissection.

OBJECTIVE: Although stenting of the descending aorta simultaneously with proximal aortic repair has become an accepted part of the therapy for acute type A dissection, no general recommendations have been accepted regarding the choice of diameter and length of the stent grafts. The present study explored the safety and effectiveness of sizing the stent graft of the hybrid prosthesis in relation to the total aortic diameter and extending the landing zone to the level of the T10-T12 vertebrae. METHODS: The frozen elephant trunk procedure was performed on 32 patients with acute type A aortic dissection. The stent graft size was chosen according to the total aortic diameter measured on contrast-enhanced computed tomography scans. The stent graft was inserted with the distal landing zone at the level of vertebrae T10-T12. All patients underwent computed tomography or magnetic resonance angiography before discharge; 8 patients underwent subsequent endovascular stent extension. RESULTS: The 30-day survival was 100%, with 3.1% (1/32) overall mortality at 17 ± 4 months (range, 1-33) of follow-up. The postoperative complications included pneumonia in 5, pulmonary embolism in 3, sepsis in 1, and permanent recurrent laryngeal nerve damage in 1 patient. No ischemic brain or spinal cord injury occurred. During follow-up, no endoleaks or false lumen patency developed. CONCLUSIONS: Sizing the stent graft of the hybrid prosthesis according to the total aortic diameter and choosing a distal landing zone between vertebrae T10 and T12 is safe, with low midterm mortality and morbidity. It allows an extensive repair of the dissected aorta with early definite occlusion of the false lumen and prepares for potential endovascular extension of the graft.