A Hyperdynamic Arteriovenous Fistula Aneurysm After Long Time Renal Transplantation.

CONCLUSION: Closure of arteriovenous fistula should be considered in patients who underwent successful renal transplantation to avoid potential complications that may result from the presence of unused fistula especially, in patients who are predisposed to aneurysm formation in the future.

Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients.

OBJECTIVES: The aortic valve-sparing David procedure has been applied to the elective treatment of patients with aortic aneurysms with excellent results. The use of this technique in patients with acute aortic dissection type A (AADA) is still a matter of debate. We present our long-term experience with 109 patients with AADA who had the valve-sparing David I procedure. METHODS: Between July 1993 and October 2015, 109 patients with AADA had the valve-sparing David I procedure at our centre. We conducted a retrospective review with follow-up. RESULTS: The mean age was 54 ± 12 years; 78 (72%) patients were men. Marfan syndrome was present in 6 (5%) patients and bicuspid aortic valve in 3 (3%). Only 4 (4%) patients received the isolated David procedure; 50 (46%) underwent additional proximal, 13 (12%) subtotal and 42 (39%) total aortic arch replacement. The in-hospital mortality rate was 11% ( n = 12). Intraoperative/discharge echocardiography showed aortic insufficiency ≤ I° in 93 of 97 patients (96%). Mean follow-up time was 8.3 ± 5.7 years. The survival rate after discharge at 1, 5 and 10 years was 94%, 90% and 78%, respectively. Thirteen percent ( n = 13) of patients underwent valve-related reoperation. Freedom from valve-related reoperation at 1, 5 and 10 years was 96%, 88% and 85%, respectively. Compared to patients who underwent the David I procedure for any reason other than AADA, there were no significant differences in long-term survival rates ( P = 0.29) and freedom from a valve-related reoperation ( P = 0.39). CONCLUSIONS: The valve-sparing David I procedure has acceptable long-term results even in emergent operations for AADA and is not inferior when performed in elective settings.

Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage?

OBJECTIVES: Our goal was to compare the results and outcomes of second-stage completion in patients who had previously undergone the elephant trunk (ET) or the frozen elephant trunk (FET) procedure for the treatment of complex aortic arch and descending aortic disease. METHODS: Between August 2001 and December 2014, 53 patients [mean age 61 ± 13 years, 64% (n = 34) male] underwent a second-stage completion procedure. Of these patients, 32% (n = 17) had a previous ET procedure and 68% (n = 36) a previous FET procedure as a first-stage procedure. RESULTS: The median times to the second-stage procedure were 7 (0-78) months in the ET group and 8 (0-66) months in the FET group. The second-stage procedure included thoracic endovascular aortic repair in 53% (n = 28) of patients and open surgical repair in 47% (n = 25). More endovascular interventions were performed in FET patients (61%, n = 22) than in the ET group (35%, n = 6, P = 0.117). The in-hospital mortality rate was significantly lower in the FET (8%, n = 3) group compared with the ET group (29%, n = 5, P = 0.045). The median follow-up time after the second-stage operation for the entire cohort was 4.6 (0.4-10.4) years. The 5-year survival rate was 76% in the ET patients versus 89% in the FET patients (log-rank: P = 0.11). CONCLUSIONS: We observed a significantly lower in-hospital mortality rate in the FET group compared to the ET group. This result might be explained by the higher rate of endovascular completion in the FET group. We assume that the FET procedure offers the benefit of a more ideal landing zone, thus facilitating endovascular completion.

Does the surgeon's experience have an impact on outcome after total arterial revascularization with composite T-grafts? A risk factor analysis.

OBJECTIVES: When composite T-grafting is performed, total arterial revascularization (TAR) can be accomplished with only two grafts. There is the belief that composite grafting poses a risk of graft failure due to its single inflow via the left internal thoracic artery (LITA). High surgical quality is essential for left internal thoracic artery preparation, T-grafting and length estimation. We investigated whether the surgeon's experience influences postoperative outcome. METHODS: We analysed the data of 1080 consecutive patients (88% male, age: 62 ± 9 years) who underwent composite T-grafting between 1996 and 2011 in our institution. Patients were operated on either by experienced surgeons (Group A) or by surgeons early on in their career (Group B). Primary end-points were mortality, myocardial ischaemia, graft dysfunction and low cardiac output syndrome. Secondary end-points were persistent neurologic deficits (PNDs), blood transfusions and re-thoracotomy. Logistic regression analysis was performed to reveal independent risk factors for adverse outcome. RESULTS: Patients in Group B had a lower logistic EuroSCORE (2.8 vs 2.3%; P < 0.05), longer operative times (cross-clamp time: 41 ± 11 vs 47 ± 14 min; P < 0.001) and received less anastomoses (3.2 ± 0.7 vs 3.1 ± 0.7, P = 0.005). Mortality was low in both groups (Group A 0.6% vs Group B 0.4%; P = 1.0). Myocardial ischaemia occurred in 2.3% (Group A) and 2.5% (Group B; P = 0.82). Graft dysfunction was seen in 0.6% (Group A) and 1.4% (Group B; P = 0.25). Incidence of postoperative low cardiac output syndrome was comparable (Group A 1.4% vs Group B 0.7%; P = 0.53). Both groups showed similar incidence of secondary end-points (persistent neurologic deficit: Group A 2.9 vs 3.2% in Group B; P = 0.84; re-thoracotomy: 1.6% in Group A vs 1.8% in Group B, P = 1.0). Blood transfusions were more common in Group B (P = 0.005). Less surgical experience could only be identified as an independent risk factor for blood transfusion (P = 0.001). CONCLUSIONS: Total arterial revascularization with composite T-grafts can be performed safely by surgeons with different surgical experience. Despite differences in surgical performance parameters (e.g. operation times, blood transfusions), complication rates were extremely low, irrespective of the surgeon's operative experience. Surgeons can be introduced to these procedures in an early phase of training.

Management of early graft infections in the ascending aorta and aortic arch: a comparison between graft replacement and graft preservation techniques.

OBJECTIVES: Treatment of infected thoracic aortic grafts is associated with considerable morbidity and mortality. The replacement of an infected graft is an effective strategy, yet a complex surgical endeavour, especially if the aortic root or aortic arch is involved. In situ graft-sparing surgical therapy with continuous mediastinal irrigation after surgical debridement might offer an alternative in the management of early graft infections in the thoracic aorta. METHODS: Between 1996 and August 2015, 25 patients were treated in our institution for early graft infection after thoracic aortic surgery via sternotomy. In 11 patients, the infected prosthesis was replaced by a cryopreserved homograft or a biological valved pericardial xenograft. In 14 patients, an attempt to salvage the graft was made by resternotomy, aggressive debridement and subsequent continuous mediastinal antibiotic irrigation over a course of 2 weeks, accompanied by systemic antibiotic therapy. RESULTS: In-hospital mortality was comparable (replacement group: 2/11 = 18%, graft-sparing group: 2/14 = 14%, P = ns). The time interval from the initial surgery was significantly shorter in the graft-sparing group (replacement group: 165 days [range 95-300 days] and graft-sparing group: 24 days [range 15-93 days], P = 0.004]. Two patients (14%), who were treated with the graft-sparing approach >100 days after the initial surgery, were retreated for infection, and 1 due to an intra-aortic infection of an aortic arch hybrid stent graft was not amenable to external irrigation (median follow-up: 1.5 years [range 1.1-2.1 years]). One patient in the replacement group (9%) was reoperated on due to homograft degeneration (median follow-up: 6.0 years [3.0-8.9 years]). CONCLUSIONS: In situ graft-sparing surgical therapy is safe and effective if diagnosis and treatment of aortic graft infection is initiated promptly and aggressively (ideally <1 month post-surgery). Our method produces good midterm results (3 years). For aortic graft infections that become clinically apparent >3-6 months after surgery, replacement of grafts with biological conduits (homografts or pericardial xenografts) most likely remains the best treatment option.

Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients.

OBJECTIVE: Combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. The Thoraflex Hybrid graft (Vascutek, Inchinnan, United Kingdom) consists of a 4-branched graft with a stent graft at the distal end allowing a total aortic arch replacement, including the origins of the supra-aortic vessels combined with endoluminal treatment of the proximal descending aorta. We present the midterm results of our first 100 patients who were treated with this frozen elephant trunk prosthesis. METHODS: From April 2010 to October 2014, 100 patients (65 men aged 59 ± 14 years) underwent operation (37 acute dissections, 31 chronic dissections, and 32 aneurysms). Fifty-four percent of patients received concomitant cardiac procedures, and 28% were reoperations. RESULTS: The perioperative mortality was 7% (n = 7). Midterm survival after a follow-up of 3.1 ± 1.4 years was 81% (n = 81). Mean cardiopulmonary bypass time was 243 ± 61 minutes, cardiac ischemia time was 101 ± 65 minutes, and circulatory arrest time was 51 ± 20 minutes. Aortic root replacement was performed in 41 patients (n = 41; valve-sparing: 30% [n = 30]). Twenty-two percent of patients underwent secondary aortic reinterventions during follow-up (15% planned second stage operations). Sixty percent of reinterventions were performed via endovascular approach. Acute dissection patients needed significantly fewer reinterventions (n = 3; 8%). CONCLUSIONS: The Thoraflex Hybrid graft adds to the frozen elephant trunk concept for treating aortic arch and descending aortic disease. Implantation of the Thoraflex Hybrid graft resulted in excellent outcomes and beneficial aortic remodeling during follow-up. This graft increases surgeons' armamentarium in the treatment of complex and diverse aortic arch pathology.

Total aortic arch repair: risk factor analysis and follow-up in 199 patients.

OBJECTIVES: Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair. METHODS: Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution. Forty-four per cent of the patients presented with acute aortic dissections (ADs, 32% with malperfusion), 22% with chronic aortic dissections (CDs), 34% with degenerative aneurysms, 24% underwent reoperations. Our surgical technique involved cold blood cardioplegia for cardiac procedures, non-cardioplegic continuous myocardial blood perfusion during aortic arch repair and early lower body reperfusion after distal aortic arch reconstruction. Anastomosis of head vessels is performed at the end of the procedure. RESULTS: Forty-four per cent of patients underwent aortic root surgery, 90% received a classical elephant trunk (ET) or frozen elephant trunk (FET). Median (interquartile range) cardiopulmonary bypass time, cardiac ischaemia time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion time were 248 min (204-302), 105 min (51-150), 47 min (35-61) and 93 min (72-115), respectively. Operative mortality was 16%, stroke occurred in 10%, dialysis in 21% and spinal cord injury in 5%. Independent risk factors for mortality were age, rethoracotomy for bleeding, postoperative dialysis, maximum lactate value and maximum creatinine kinase-MB (CK-MB) value. 'Beating heart' aortic arch surgery significantly reduced the risk of mortality. Malperfusion syndrome and coronary artery bypass grafting were preoperative predictors of stroke. CD, preoperative renal dysfunction, operation time, rethoracotomy for bleeding and low cardiac output syndrome were risk factors for postoperative dialysis. Freedom from aortic reoperation was 91% (AD), 66% (CD) and 70% (aneurysm) after 2 years. CONCLUSIONS: Aortic arch repair remains a high-risk procedure, especially in multisegment aortic disease. Several peri- and postoperative factors predicted adverse outcome, indicating the need to further improve perioperative management (e.g. organ protection). Indications for FET treatment have to be thoroughly investigated (e.g. FET in CDs).

Aortic valve replacement with sutureless prosthesis: better than root enlargement to avoid patient-prosthesis mismatch?

OBJECTIVES: Aortic valve replacement in patients with a small aortic annulus may result in patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) can reduce PPM, but leads to extended cardiac ischaemia times. Sutureless valves have the potential to prevent PPM while reducing cardiac ischaemia times. METHODS: Between January 2007 and December 2011, a total of 128 patients with a small aortic annulus underwent surgery for aortic valve stenosis at our centre. Thirty-six (17% male, n = 6) patients received conventional valve replacement with ARE and 92 (16% male, n = 18) subjects received sutureless valve implantation (Sorin Perceval). We conducted a comparative, retrospective study with follow-up. RESULTS: The sutureless group showed a significantly higher age (79 years) than the ARE patients (62 years, P < 0.001) and received significantly more concomitant cardiac procedures (33%, n = 30 vs 6%, n = 2, P = 0.001). The mean operation, cardiopulmonary bypass and cross-clamp times were significantly lower in sutureless patients (147 ± 42, 67 ± 26 and 35 ± 13 min, respectively) than in ARE patients (181 ± 41, 105 ± 29 and 70 ± 19 min, respectively, P < 0.001). The mean postoperative effective orifice area (EOA) indexed to the body surface area was 0.91 ± 0.2 cm(2)/m(2) in ARE patients and 0.83 ± 0.14 cm(2)/m(2) in sutureless patients (P = 0.040). The rate of patients with severe PPM was 6% (n = 2) in ARE patients and 11% (n = 8%) in sutureless patients (not significant, n.s.). The 30-day mortality rates were 2% (n = 2) in sutureless patients and 6% (n = 2) in ARE patients (n.s.). The 1- and 5-year survival rates of the sutureless group were 92 and 54% years, respectively, whereas the 1- and 5-year survival rates of the ARE group were 76% (n.s.). CONCLUSIONS: Although the sutureless valve patients received significantly more concomitant procedures, all operation-associated times were significantly shorter. Despite sutureless valve patients being older, the 30-day mortality and survival rates were comparable in the two groups. Since the indexed EOA was only slightly lower and the incidence of severe PPM was not significantly higher in the sutureless valve patients, we conclude that sutureless valve implantation is an alternative to conventional ARE to treat a small aortic annulus and avoid PPM, especially in geriatric patients who benefit from the quick implantation process.

Minimally invasive valve sparing aortic root replacement (David procedure) is safe.

OBJECTIVE: Even though minimally invasive cardiac surgery may reduce morbidity, this approach is not routinely performed for aortic root replacements. The purpose of this pilot study was to assess the safety and feasibility of valve sparing aortic root replacement via an upper mini-sternotomy up to the 3(rd) intercostal space. METHODS: Between April 2011 and March 2014, 26 patients (22 males, age 47.6±13 years) underwent elective minimally invasive aortic valve sparing root replacement (David procedure, group A). Twelve patients underwent additional leaflet repair. Concomitant procedures were: four proximal aortic arch replacements and one coronary artery bypass grafting (CABG) to the proximal right coronary artery (RCA). During the same time period, 14 patients (ten males, age 64.2±9.5 years) underwent elective David procedure via median full sternotomy (group B). Concomitant procedures included six proximal aortic arch replacements. Although the patient cohorts were small, the results of these two groups were compared. RESULTS: In group A, there were no intra-operative conversions to full sternotomy. The aortic cross-clamp and cardiopulmonary bypass (CPB) times were 115.6±30.3 and 175.8±41.9 min, respectively. One patient was re-opened (via same access) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.5±0.3 and 10.4±6.8 days, respectively. There was no 30-day mortality. The patient questionnaire showed that the convalescence time was approximately two weeks. In group B: the cross-clamp and CPB times were 114.1±19.9 and 163.0±24.5 min, respectively. One patient was re-opened (7.1%) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.6±0.7 and 14.2±16.7 days, respectively. There was no 30-day mortality. CONCLUSIONS: Minimally invasive valve sparing aortic root replacement can be safely performed in selected patients. The results are comparable to those operated via a full sternotomy. The key to success is a 'step by step' technique of moving from minimally invasive aortic valve replacements (AVR) to more demanding aortic root replacements. Meticulous hemostasis & attention to surgical details is of utmost importance to prevent perioperative complications.

The elephant trunk is freezing: The Hannover experience.

BACKGROUND: The "elephant trunk" (ET) technique traditionally has been performed to treat complex aortic diseases involving the aortic arch and the descending aorta. Despite the fact that, in recent years, the "frozen elephant trunk" (FET) technique has been used increasingly for such pathologies, discussion is still ongoing in the surgical community regarding which of the 2 techniques is better. We compared our results using the classic ET versus the FET technique. METHODS: From August 2001 to March 2013, a total of 277 patients underwent total aortic arch replacement and either ET (group A) or FET (group B) implantation. In group A, 97 patients (59 men; age 59.7 ± 12.7 years; 44.3% with aneurysm; 55.6% with dissection [48.45% acute]) underwent an ET procedure; 21.64% were reoperations. In group B, 180 patients underwent an FET procedure (126 men; age 59.8 ± 13.2 years; 34.4% with aneurysm; 63.3% with dissection [35% acute]); 30% were reoperations. RESULTS: In group A, in-hospital mortality was 24.7%; postoperative stroke rate was 12.4%. During follow-up, 27.8% underwent a second-stage procedure. In group B, in-hospital mortality was 12.2%; postoperative stroke rate was 13.3%. During follow-up, 27.7% patients underwent further interventions in the downstream aorta. CONCLUSIONS: In selected patients with combined aortic arch and descending aortic aneurysms limited to the proximal descending aorta, the FET approach potentially allows for single-stage therapy, whereas a second-stage operation is inevitable with the classic ET approach. Moreover, owing to the availability of prefabricated, easy-to-use, FET, hybrid prostheses that result in significantly better outcomes in patients who have acute aortic dissection, type A, and if necessary, and provide an ideal "landing zone" for future endovascular completion, the classic ET procedure is "freezing," in the sense that it is being replaced by the FET approach.