The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis.

OBJECTIVE: Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure). METHODS: We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS). RESULTS: The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications. CONCLUSIONS: Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

Minimally Invasive Management of Severe Aortoiliac Occlusive Disease.

BACKGROUND: Peripheral arterial disease (PAD) is a complex and highly prevalent pathology. It has been estimated that ∼8.5 million people in the United States are affected by PAD, of which 12%-20% are older than age 60. The TransAtlantic Inter-Society Consensus (TASC) guidelines classified aortoiliac atherosclerotic disease based on morphology and level of lesions. TASC II guidelines recommend bilateral surgical bypass to the femoral arteries for TASC II C and D lesions. The aortobifemoral bypass (ABF) has been considered the gold standard in the treatment of aortoiliac occlusive disease (AIOD). The long-term patency rate of 85%-90% at 5 years and 75%-80% at 10 years has been for a long time unmatched by other methods of revascularization. METHODS: This is a review of the current literature regarding minimally invasive strategies in the care of TASC II C and D aortoiliac disease. RESULTS: Endovascular therapies have led to a paradigm change even in the treatment of highly advanced lesions. Reconstruction of the aortic bifurcation for distal aortic and/or ostial unilateral/bilateral common iliac artery disease can be achieved via the deployment of stents with "kissing" technique and aortic endografts. Laparoscopic aortoiliac surgery for TASC II C and D lesions was first proposed in 1993. Total laparoscopic, laparoscopic-assisted, and laparobotic techniques have been described. Minimal incision aortic surgery (MIAS) describes abdominal incisions varying from 6 to 12 cm and positional adjustment of retractors to access the retroperitoneum for infrarenal aortic aneurysms and/or AIOD. CONCLUSIONS: Although initial enthusiasm laparoscopic aortic surgery and MIAS have failed to gain acceptance in the vascular surgery community due to intrinsic procedural challenges, they are currently practiced in few highly specialized centers. At this moment, high-quality evidence is lacking regarding the further feasibility of these techniques and their applicability in general practice compared to endovascular therapies. While the ABF remains still the optimal choice in select, fit for surgery patients, endovascular therapies offer a less invasive approach that may provide a mortality and morbidity benefit in higher risk patients with acceptable short- and long-term outcomes.

Minimally invasive aortic arch surgery: Early and late outcomes.

BACKGROUND: We analyzed our experience with the aortic arch operations performed through a minimally invasive approach, with emphasis on safety and feasibility, early and late outcomes. MATERIAL AND METHODS: We reviewed the medical records of 71 adult patients with aortic arch aneurysm (58, 82%), dissection (10, 14%) or porcelain aorta (3, 4%) who underwent primary arch surgery through a partial upper sternotomy. RESULTS: The aortic arch was replaced partially in 45 (63%), or totally in 26 (37%) patients. The repair was further extended with the elephant trunk procedure, conventional in 8 (11.3%) or frozen in 15 (21.1%) patients. No conversion to full sternotomy was needed. New permanent renal failure occurred in 1 (1.4%), temporary neurologic deficit in 2 (2.8%) and permanent neurologic deficit in 3 (4.2%) patients. Early mortality was observed in 4 (5.6%) patients. Actuarial survival was 79.2 ± 8.3% at 4 years and cumulative reoperation-free survival was 76.4 ± 9.4% at 4 years. CONCLUSION: Minimally invasive aortic arch surgery is safe and feasible. Early outcomes are at the lower range compared to other published series. Late outcomes are not adversely influenced, as the desired extent of aortic resection can be achieved, producing a durable aortic repair.

How does elective laparoscopic abdominal aortic aneurysm repair compare to endovascular aneurysm repair?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was how elective laparoscopic abdominal aortic aneurysm (AAA) repair compared to endovascular aneurysm repair (EVAR) in terms of survival. There were 229 papers found using the reported search, with 8 papers (5 prospective studies, 1 retrospective study, 1 randomized trial and 1 systematic review) representing the best evidence to answer the question proposed. Current evidence suggests that EVAR is the preferred surgical approach for AAA repair, due to shorter hospital stay and lower perioperative morbidity and mortality rates, as opposed to an open surgical approach. Despite this, EVAR is subject to a number of limitations, including device restrictions in patients with anatomical variations as well as increased risk of future complications stemming from device implantation. We discuss a key study that showed that complications in the EVAR group commonly included endoleak type II and graft thrombosis. More importantly, there were similar rates of complications between those patients receiving EVAR and those receiving minimally invasive aortic surgery. The evidence suggests that elective laparoscopic AAA repair has a favourable safety profile comparable with that of EVAR, with low conversion rates as well as similar mortality and morbidity rates. This has been illustrated in several studies. We discuss a prospective randomized trial of 100 patients, which compared EVAR with hand-assisted laparoscopic surgery. This study showed no deaths in either group after the procedure or at follow-up after 12 months, with similar complication rates between the groups. While the evidence suggests that EVAR is less invasive, it does not always significantly alter the postoperative course or length of hospital stay for patients. We conclude from the evidence available that elective laparoscopic AAA repair may have a role in those patients who are unsuitable for EVAR. Unfortunately, few studies exist directly comparing these two techniques, and those that do are subject to limitations, for example, study population bias, small sample sizes and a lack of comparison in the literature between the common AAA repair techniques.