Repair of Type Ia Endoleaks Involving the Distal Arch Using Left Subclavian Artery-Left Common Carotid Artery Transposition with a Stented Elephant Trunk.

BACKGROUND: Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk. METHODS: Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient. RESULTS: There were no in-hospital deaths. Fourteen patients required mechanical ventilation for <24 h and one for <48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up. CONCLUSIONS: The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

One-stage hybrid procedure for distal aortic arch disease: mid-term experience at a single center.

BACKGROUND: This study analyzes the outcomes of a one-stage hybrid procedure combining thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in patients with distal aortic arch disease. METHODS: This retrospective study collected 103 hybrid procedures combining TEVAR with extra-anatomic bypass (mean age, 62.2±9.3 years; 90 males) performed from January 2009 to January 2019 at Beijing Anzhen Hospital. We analyzed 30-day and mid-term outcomes including survival rate and the incidence of stroke, spinal cord injury (SCI), and endoleak. RESULTS: Five deaths (4.6%) occurred within 30 days, including type I endoleak in Zone 1 (n=1), hemorrhagic shock (n=1), stroke (n=2), and stent migration (n=1). Two patients developed SCI. The median follow-up time was 39.5 (interquartile range, 13.6-69.0) months. In all, 14 late deaths occurred; these were due to stroke (n=2), severe pneumonia (n=1), aortic rupture caused by type I endoleak (n=3), and sudden death (n=8). Six late endoleaks occurred including three type I and one type II in Zone 1 and two type I in Zone 2. In a competing risks analysis, the incidences of reintervention at 7 years, late death, and survival without reintervention were 8%, 22%, and 70%, respectively. In a Cox risk model, stroke (HR, 21.602; 95% CI: 2.798-166.796; P=0.003) was the only risk factor for 30-day mortality. Stroke (HR, 19.484; 95% CI: 5.245-72.380; P<0.001), SCI (HR, 15.548; 95% CI: 2.754-87.786; P=0.002), and endoleak (HR, 4.626; 95% CI: 1.068-20.040; P=0.041) were independent risk factors for long-term mortality. CONCLUSIONS: The one-stage hybrid procedure provides acceptable mid-term results with good mid-term patency of extra-anatomic bypass. Strict selection of patients suitable for hybrid repair can effectively improve the survival rate and reduce the incidence of complications. At the same time, close follow-up patients should receive close long-term follow-up after hybrid procedure.

Long-term outcome of patients with atrial myxoma after surgical intervention: analysis of 403 cases.

OBJECTIVE: To assess long-term survival and late cardiovascular events in patients with atrial myxoma after surgical intervention. METHODS: Retrospective analysis of 403 patients undergoing resection of atrial myxoma from January 2002 to December 2016 was conducted with a median follow-up period of 4.5 (range: 0.5-15) years. RESULTS: The cross-clamp time and cardiopulmonary bypass times were 41.1 ± 21.4 and 65.2 ± 27.3 min, respectively. A diagnosis of myxoma was histopathologically confirmed in all cases. The early in-hospital mortality rate was 0.7% (n = 3). During the follow-up period, tumor recurrence occurred in six patients and cerebral infarction in nine. There were 48 (11.9%) patients with late onset atrial fibrillation (AF). By multivariate analysis, age (HR = 1.05, 95% CI: 1.02-1.09, P < 0.001), left atrial diameter (HR = 1.23, 95% CI: 1.08-1.36, P = 0.012), and mitral valve surgery (HR = 1.17, 95% CI: 1.05-1.29, P = 0.027) were independent predictors of late onset AF. Twenty-one (5.2%) patients died during the follow-up period. Advanced age (HR = 1.07, 95% CI: 1.04-1.10, P = 0.003) and multiple surgical procedures (HR = 1.18, 95% CI: 1.06-1.29, P = 0.012) were significantly associated with overall mortality. CONCLUSIONS: Atrial myxoma can be resected with good long-term survival. Late onset AF is common after surgery in patients with atrial myxoma. Advanced age, left atrial diameter, and mitral valve surgery were independent predictors of outcomes.

Treatment with Corticosteroid and/or Immunosuppressive Agents before Surgery can Effectively Improve the Surgical Outcome in Patients with Takayasu's Arteritis.

OBJECTIVE: To analyze the clinical outcome of corticosteroid and/or immunosuppressive treatment preoperatively in patients with Takayasu's arteritis. PATIENTS AND METHODS: Forty-six patients with Takayasu's arteritis who received cardiovascular surgery between January 2010 and December 2015 in Beijing Anzhen Hospital were enrolled in this study. Their clinical characteristics, preoperative drug therapy, surgical treatment, and pathological examination results were retrospectively analyzed for the effect of drugs on outcome of the surgery. RESULTS: All 8 patients with active disease prior to surgery had postoperative complications including one death due to stubborn perivalvular regurgitation induced heart failure during the perioperative period. Among 38 patients without active disease prior to surgery, only 4 patients (10.5%) had postoperative complications. Thirty-four patients showed symptomatic relief in the perioperative period, of whom 23 patients treated with corticosteroid and/or immunosuppressive agents preoperatively. CONCLUSION: The surgery can effectively improve the symptoms of patients with Takayasu's arteritis. Active disease of Takayasu's arteritis markedly increased risk for postoperative complication and resulted in poor outcome of the surgery. Treatment with corticosteroid and/or immunosuppressive agents before surgery can effectively control the patient's condition, improve the rate of remission, and effectively reduce the incidence of postoperative complications.

Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition With Stented Elephant Trunk in the Hybrid Repair Era.

BACKGROUND: Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. METHODS: Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51±14 (range 20-69) years. RESULTS: There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33±21months, one patient died. CONCLUSIONS: Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection.

BACKGROUND: Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD). METHODS: From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up. RESULTS: In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%. CONCLUSIONS: Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

Acute Ischemic Pancreatitis Secondary to Aortic Dissection.

BACKGROUND: Acute ischemic pancreatitis secondary to aortic dissection is very rare with an unclarified mechanism. We retrospectively reviewed 6 such cases in our center and present their outcomes herein. METHODS: Between February 2009 and April 2017, 6 patients (male = 2 and female = 4; mean age, 58 ± 8 years [range, 47-70 years]) with acute aortic dissection associated with pancreatitis were admitted to our center. There were 3 type A and 3 type B dissections. One patient developed renal dysfunction and visceral organ ischemia, and 1 developed renal failure and ischemia of the lower extremity. Five patients had a history of hypertension, and 1 had diabetes mellitus. RESULTS: After aggressive medical treatment, 5 patients survived the acute phase of aortic dissection and acute ischemic pancreatitis. Surgery was required in 4 patients and thoracic endovascular aortic repair in 1 patient. There were no severe postoperative complications, and all 5 were discharged. One patient with acute type B dissection refused treatment and died from multiple organ failure. No complications or deaths occurred in the postoperative follow-up period. CONCLUSIONS: Acute ischemic pancreatitis after aortic dissection is a very unusual complication. The potential for this concomitant diagnosis should always be considered during the diagnostic stages. There is no clear consensus regarding the management of aortic dissection associated with acute pancreatitis.

Frozen Elephant Trunk for Acute Type B Dissection Involving the Distal Arch in the Hybrid Repair Era.

BACKGROUND: Hybrid repair of complicated acute type B aortic dissection (ATBAD) with aortic arch involvement is associated with a high rate of endoleak, stroke, and retrograde aortic dissection. Optimal management of this lesion remains uncertain. In this hybrid repair era, surgical results of ATBAD with distal aortic arch involvement using a frozen elephant trunk procedure with transposition of the left subclavian artery (LSCA) to left common carotid artery (LCCA) is reported. METHODS: From April 2011 to April 2016, 53 patients with complicated ATBAD with distal aortic arch involvement underwent a frozen elephant trunk procedure with LSCA-LCCA transposition. Preoperative organ malperfusion included renal ischemia in 10 subjects, renal infarction in 2, lower limb ischemia in 6, and visceral ischemia in 5. RESULTS: There was no inhospital death. Continuous renal replacement therapy was required in 1 patient. Permanent neurologic injury was observed in 1 patient and temporary neurologic dysfunction in 1 patient. Ischemia of the lower limb and viscera was ameliorated after frozen elephant trunk implantation. During follow-up, thoracoabdominal aortic replacement was required in 1 patient, and the Wheat procedure in 1 other patient. The patency rate of the anastomotic site between the LSCA and LCCA was 100%, and shrinkage of the descending aorta occurred in 90.4% of patients (47 of 52) as demonstrated by computed tomography. CONCLUSIONS: Open repair of ATBAD with distal aortic arch involvement using the frozen elephant trunk procedure with LSCA-LCCA transposition obtained satisfactory outcomes. Avoidance of complications using hybrid repair, good postoperative recovery, and a low prevalence of late reintervention were achieved. The satisfactory results favored this technique for this lesion in this hybrid repair era.

The repair of a type Ia endoleak following thoracic endovascular aortic repair using a stented elephant trunk procedure.

BACKGROUND: Type Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent-graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. METHODS: From July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. RESULTS: All cases of type Ia endoleak (100%) were repaired successfully. There were no in-hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow-up. During follow-up, there were 3 deaths. CONCLUSIONS: Acceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion.

Repair of Complicated Chronic Type B Dissection with Distal Aortic Arch Involvement Using Left Subclavian Artery Transposition with Implantation of a Stented Elephant Trunk.

Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP). Preoperative renal dysfunction was observed in three patients, left heart failure in one patient, and spinal cord ischemia in one patient. Results There was one (5.0%, 1/20) in-hospital death. All but one patient required mechanical ventilation for < 24 hours. Mean duration of mechanical ventilation and mean duration of stay in the intensive care unit was 16 ± 4 and 35 ± 16 hours, respectively. No severe complications occurred. There was one death because of unknown cause during follow-up. One case received thoracoabdominal aortic replacement 9 months after surgery. Conclusion Acceptable surgical outcomes were obtained using LSCA transposition with implantation of a stented elephant trunk. This method is an alternative to TEVAR for complicated chronic type B dissection with involvement of the distal aortic arch.

Repair of complicated type B dissection with an aberrant right subclavian artery.

OBJECTIVES: An aberrant right subclavian artery (ARSA) is one of most common congenital anomalies, but the coexistence of type B dissection and an ARSA is extremely rare. Repair of type B dissection poses a technical challenge due to an ARSA. We retrospectively reviewed our experience of surgical treatment of a complicated type B dissection with an ARSA. METHODS: From August 2010 to March 2014, 7 patients with chronic type B dissection with an ARSA underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass in our centre. The mean age was 45 ± 7 (range, 32-54) years. Total arch replacement was performed in 2 patients. Revascularization of the ARSA was done in 5 of 7 patients. RESULTS: There were no in-hospital deaths. The mean time of mechanical ventilation and stay in the intensive care unit was 22 ± 11 and 53 ± 11 h, respectively. Neurological deficit, visceral ischaemia or injury to the spinal cord was not observed. Right upper-limb ischaemia was not observed in patients without ARRA revascularization during follow-up. CONCLUSIONS: In patients not undergoing descending aortic replacement, the stented elephant trunk method is our preferred procedure for this anomaly via a median sternotomy. Repair of type B dissection and revascularization of the ARSA were achieved in a single stage using this technique. Satisfactory surgical results and follow-up outcomes were obtained. There was no right upper-limb ischaemia or neurological deficit in patients without ARSA revascularization, but revascularization of the ARSA is recommended for this vessel anomaly.

Repair of Distal Aortic Arch Aneurysms by Left Subclavian Artery Transposition with Stented Elephant Trunk Implantation.

BACKGROUND: Repair of distal aortic arch aneurysms remains technically challenging using conventional open surgery due to its location. Several techniques, including a conventional prosthetic graft replacement and a hybrid technique, were introduced to manipulate this lesion. We retrospectively reviewed our experience with left subclavian artery (LSCA) transposition with stented elephant trunk implantation for repair of distal aortic arch aneurysms. METHODS: From May 2009 to December 2014, 9 men (mean age 55 ± 16 years) with distal aortic arch aneurysms underwent LSCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with antegrade selective cerebral perfusion via a median sternotomy. One case had a history of endovascular abdominal aortic repair. RESULTS: There was no in-hospital death. The mean time of mechanical ventilation and intensive care unit stay was 22 ± 9 and 53 ± 17 hr, respectively. No severe complications occurred in this group. All patients survived and were discharged. No patient died during the follow-up period. Postoperative computed tomography revealed good patency of the anastomotic site between the LSCA and the left common carotid artery. CONCLUSIONS: Satisfactory surgical results and follow-up outcomes were achieved by simultaneous repair of proximal aortic lesions and complete seal of the lesion involving the distal aortic arch and proximal descending aorta using LSCA transposition with implantation of a stented elephant trunk. Encouraging outcomes favor this technique for distal aortic arch aneurysm.

Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique.

OBJECTIVES: The presence of an isolated left vertebral artery (ILVA) remains a challenging issue for thoracic endovascular aortic repair (TEVAR) of type B dissection if the proximal landing zones are inadequate. We retrospectively reviewed our experience of the surgical management of complicated type B dissection with an ILVA using the stented elephant trunk technique. METHODS: Between February 2009 and May 2013, 7 patients with complicated type B dissection (acute = 2 and chronic = 5) underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All the patients were males with a median age of 53 ± 6 (range 42-59) years. Preoperative lower limb ischaemia was observed in 1 patient, renal dysfunction in 1 patient and visceral ischaemia in 1 patient. RESULTS: There were no in-hospital deaths. The median ventilator support time was 16 ± 3 (range 11-20) h. Ischaemia of the lower limb and viscera was ameliorated after surgical stent-graft implantation. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurological deficits were observed in any patients prior to hospital discharge. One patient underwent TEVAR due to distal aortic dilatation within the mean follow-up period, which was 44 ± 19 months. CONCLUSION: Repair of complicated type B dissection with an ILVA using the stented elephant trunk technique was associated with satisfactory surgical results in patients with inadequate proximal fixation zones. This technique is an alternative to TEVAR for complicated type B dissection with inadequate proximal landing zones.

Stented elephant trunk procedure with left subclavian artery transposition for acute type B dissection with distal arch involvement.

OBJECTIVE: Complete or partial supra-aortic debranching, after thoracic endovascular aortic repair, is appealing treatment for complicated acute type B dissection (ABAD) with aortic arch involvement (AAI) because of reduced surgical trauma. However, unsatisfactory outcomes have been reported. We retrospectively reviewed our experience of left subclavian artery (LSCA) transposition with stented elephant trunk (SET) implantation for complicated ABAD with distal AAI. METHODS: From April 2011 to December 2014, 19 patients (all men; mean age: 44 years) who had complicated ABAD and distal AAI underwent LSCA transposition with SET implantation via a median sternotomy under hypothermic cardiopulmonary bypass with selective cerebral perfusion. Preoperative renal dysfunction was observed in 3 patients, visceral ischemia in 2 patients, and lower-limb ischemia in 1 patient. RESULTS: No in-hospital deaths occurred. Seventeen patients required mechanical ventilation for <24 hours, and 2 cases for <48 hours. The mean time of mechanical ventilation and duration of stay in the intensive care unit was 18 ± 6 hours and 44 ± 16 hours, respectively. Ischemia of the viscera and lower limbs after surgery was ameliorated. Continuous renal replacement therapy was not required in 3 patients who had preoperative renal dysfunction. Complete thrombosis of the false lumen at the distal end of the SET was observed in 17 of 18 (94.4%) patients during follow-up. CONCLUSIONS: This method preserves autologous brachiocephalic vessels, excludes the false lumen, promotes thrombosis and remodeling of the distal aorta, and repairs proximal aortic lesions simultaneously. Satisfactory surgical outcomes and follow-up results were achieved using LSCA transposition with SET implantation.

One-Stage Repair of Acute Type B Dissection With Ascending Thoracic Aortic Dilatation Using a Stented Elephant Trunk Procedure.

BACKGROUND: Acute type B dissection with ascending thoracic aortic dilatation (ATAD) is very common, but remains surgically challenging with the use of the conventional single-stage procedure via median sternotomy or lateral thoracotomy. We report our experience with repair of acute type B dissection with ATAD using a one-stage stented elephant trunk procedure. METHODS: We retrospectively reviewed the medical records of 16 patients (13 males and 3 females) with acute type B dissection with ATAD who underwent ascending thoracic aortic reconstruction combined with a stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion between February 2009 and February 2013. ATAD included ascending aortic aneurysm in four patients, ascending aortic enlargement + aortic regurgitation in three, and ascending aortic aneurysm + aortic root aneurysm in nine. Lower limb ischemia occurred in one case. RESULTS: There was no in-hospital mortality. Drainage of the pericardial sac was indicated for two patients with pericardial effusion. The median durations of ventilator support and intensive care unit stay were 25 ± 18 and 48 ± 7 hours, respectively. Lower limber ischemia was alleviated after implantation of a stented elephant trunk. One patient received thoracoabdominal aortic replacement during follow-up and encountered no postoperative complications. CONCLUSIONS: Satisfactory surgical results and follow-up outcomes can be achieved using the proposed one-stage stented elephant trunk procedure for acute type B dissection with ATAD.

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Preservation of autologous brachiocephalic vessels.

OBJECTIVE: Various techniques have been introduced to treat acute type A dissection during aortic arch reconstruction. We retrospectively reviewed our experience of total arch replacement, with implantation of a stented elephant trunk, using preservation of autologous brachiocephalic vessels in patients with acute type A dissection. METHODS: Between August 2011 and April 2013, 20 patients (16 men, 4 women; mean age, 45 ± 10 years, range, 24-62 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation, using preservation of autologous brachiocephalic vessels under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. RESULTS: No in-hospital deaths occurred. A transient neurologic deficit occurred in 1 patient, who ultimately required tracheotomy. Reoperation was indicated in 1 patient for bleeding. All patients survived and were discharged. During the mean follow-up period of 26 ± 7 months, 1 patient underwent thoracoabdominal aortic replacement, and 1 patient was lost to follow up. The patency of the anastomotic site between the left subclavian artery and the left common carotid artery was confirmed on computed tomography scanning. CONCLUSIONS: This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results. This technique is an alternative approach for suitable patients with acute type A dissection. However, outcomes are preliminary, and long-term follow up is required.

Repair of type A dissection with mitral regurgitation using total arch replacement with mitral valve surgery.

BACKGROUND: Mitral regurgitation (MR) is very rare in patients with type A dissection. We retrospectively reviewed our experience of total arch replacement (TAR) with mitral valve surgery for type A dissection with MR. METHODS: From November 2009 to October 2012, 14 patients with type A dissection (chronic = 11; acute = 3) with MR underwent TAR combined with mitral valve surgery under hypothermic cardiopulmonary bypass with selective cerebral perfusion. The Bentall procedure was performed in 11 patients, aortic valve replacement (AVR) in one patient, coronary artery bypass grafting (CABG) in three patients, and tricuspid valvuloplasty (TVP) in one patient. RESULTS: Thirty-day mortality was 7.1% (1/14). One patient died after transfer to another hospital secondary to renal failure. Low cardiac output syndrome was observed in three patients (21.4%, 3/14), one of whom underwent left ventricular assist device implantation. Continuous renal replacement therapy was performed in four cases (28.6%, 4/14). Two patients underwent reoperation during follow-up period: One patient had mitral paravalvular leakage and the other dilatation of the thoracoabdominal aorta. CONCLUSIONS: Repair of type A dissection with MR can be performed in a single operation. Combined TAR and mitral valve surgery is a much bigger and more complex operation associated with high morbidity.

Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?

OBJECTIVE: We seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality. METHODS: We performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure. RESULTS: The operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P < .001). However, acuity was not identified as a risk factor for operative mortality (odds ratio [OR], 1.67; P = .152). The risk factors were previous cerebrovascular disease (OR, 7.01; P = .001); malperfusion of the brain (OR, 7.10; P = .002), kidneys (OR, 12.67; P = .005), spinal cord (OR, 22.79; P = .008), and viscera (OR 22.98; P = .002); concomitant extra-anatomic bypass (OR, 9.50; P < .001); and cardiopulmonary bypass time >180 minutes (OR, 1.01; P < .001). CONCLUSIONS: In this group of patients with type A dissection, acuity was not a risk factor for operative mortality after the Sun procedure. Patients with previous cerebrovascular disease; malperfusion of the brain, kidneys, spinal cord, and/or viscera; concomitant extra-anatomic bypass; and a longer cardiopulmonary bypass time (>180 minutes) were at greater risk of operative mortality.

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

BACKGROUND: Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Sun's procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Sun's procedure in patients with AAAD. METHODS: Clinical data of 398 consecutive AAAD patients undergoing the Sun's procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. RESULTS: Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). CONCLUSIONS: The Sun's procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Is total arch replacement combined with stented elephant trunk implantation justified for patients with chronic Stanford type A aortic dissection?

OBJECTIVE: Surgical treatment of chronic Stanford type A aortic dissection using total arch replacement combined with stented elephant trunk implantation is controversial owing to the visceral arteries and intercostal arteries originating from the false lumen. METHODS: Eighty-nine patients (mean age, 45.67 +/- 10.18 years; range, 21-68 years) with chronic type A dissection underwent total arch replacement combined with stented elephant trunk implantation between April 2003 and March 2007. Careful assessment of the visceral arteries and location of entry and re-entry was done before surgery. Postoperative patency of the visceral arteries and diameter of the aortic artery and the residual false lumen were evaluated by computed tomography. RESULTS: One (1.12%) hospital death and 2 (2.25%) late deaths occurred at a mean follow-up of 28.5 months (range, 8-52 months). Visceral malperfusion was not observed. Two patients had spinal cord injury and recovered during follow-up. One patient had a transient neurologic deficit and recovered completely before discharge. One patient underwent thoracoabdominal aortic replacement for aneurysmal dilatation of the residual descending aorta 3 months after the operation. Thrombus obliteration of the false lumen at the distal edge of the stented elephant trunk and at the diaphragmatic level was 94.2% (81/86) and 61.6% (53/86), respectively. CONCLUSIONS: Satisfactory results with low morbidity and mortality were obtained. No visceral malperfusion and a low risk of postoperative spinal cord injury favor this technique in patients with chronic type A dissection.