Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality.

OBJECTIVES: The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. METHODS: This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS: The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS: There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.

Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience.

OBJECTIVES: The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022. METHODS: The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022. RESULTS: Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22). CONCLUSIONS: The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.

Frozen elephant trunk in acute aortic dissection: a literature review.

Background: Acute aortic dissection is a life-threatening condition that requires urgent surgical treatment. The frozen elephant trunk (FET) technique, including the Thoraflex hybrid prosthesis, has emerged as an effective strategy for treating complex aortic pathologies. With the widespread application of the FET technique, it continues to evolve, aiming to simplify procedures and reduce complications. These advancements provide improved outcomes and help save lives in patients with acute aortic dissection. Methods: For this review, PubMed databases were utilized from inception to March 2023. A descriptive approach was employed to identify and present the evidence regarding the application of the FET technique in acute settings and its clinical implications on the postoperative course. Results: In the reviewed studies, FET was a commonly used treatment approach for acute type A aortic dissection. A comprehensive analysis of 12 studies, comprising over 4056 FET procedures, revealed varying rates of early mortality (up to 21.1%), perioperative stroke (ranging from 2.7 to 18.0%), and spinal cord ischemia (ranging from 0 to 8.2%). During the follow-up period, which ranged from 6 to 108 months, the mortality rate was reported to be as high as 38%. Conclusions: The surgical management of acute aortic dissection remains challenging, but FET has shown promising results. Experienced teams have achieved acceptable in-hospital mortality and stroke rates, along with a lower risk of spinal cord injury compared to conventional repair. Furthermore, the FET technique has demonstrated positive alterations in the structure of the distal aorta, potentially improving long-term survival and reducing the necessity for future procedures.

Staging TEVAR after FET - an exception or the rule?

Purpose: Frozen elephant trunk (FET) was born as an ideal one-step procedure to treat complex arch and descending thoracic aorta pathology. It was then proved that it frequently needs reintervention, which can often be performed by thoracic endovascular aortic repair (TEVAR) extension since FET provides a safe proximal landing zone. We hereby describe our experience in TEVAR extension after FET, its main indications, technique, and outcomes. Methods: Between 2007 and 2022, 371 patients underwent FET at our center. Of these, 119 needed TEVAR extension. Some required more than one TEVAR, with a total of 154 procedures. The preoperative characteristics, indications, and outcomes were analyzed retrospectively. Results: Of 154 TEVAR procedures, 15 were performed in an urgent setting. Mean time from FET to TEVAR was 22,2 ± 28,73 months. Two patients died in the operating room; no others died during the hospital stay. Survival after 1, 2, 5, and 10 years was 96.2%, 93.9%, 90.1%, and 70.5% respectively. There was no statistically significant difference in the rates of TEVAR extension for patients in which a Thoraflex™ vs E-vita™ graft was used, nor for zone 2 vs zone 3 anastomosis and stent length. Conclusion: Though TEVAR extension is often required after FET, it is a safe and effective procedure with excellent post-operative outcomes in the short-, mid-, and long-term and allows successful treatment of complex aortic pathologies. Rigorous and specialized follow-up after FET is central to identify the right moment to intervene.

Survival and reoperation in acute aortic syndromes-a single-centre experience of 912 patients.

OBJECTIVES: Acute aortic syndromes are associated with poor outcomes, despite diagnostic and therapeutic advances. We analysed trends in volumes and outcomes from 2000 to 2021. METHODS: The study population includes 494 type A acute aortic syndromes (TAAAS) (54.2%) and 418 type B acute aortic syndromes (TBAAS) (45.8%). Primary outcomes were in-hospital mortality, long-term survival and freedom from aortic reoperation. RESULTS: Regardless the type of acute aortic syndrome, patient volumes increased over time. Patients with TBAAS were older, more likely to have comorbid conditions and previous cardiac surgery (P < 0.001), while cerebrovascular accidents were more frequent in TAAAS (P < 0.05). Among TAAAS, 143 (28.9%) required total arch and 351 (71.1%) hemiarch replacement. TBAAS management was medical therapy in 182 (43.5%), endovascular in 198 (47.4%) and surgical in 38 (9.1%) cases. Overall in-hospital mortality was 14.6% [18.2% in TAAAS (95% confidence interval (CI) 14.4-21.2%) vs 10.7% in TBAAS (95% CI 7.8%-13.7%); P = 0.0027]. After propensity score adjustment, in-hospital mortality exhibited a significantly decreasing trend from 2000 to 2021 (P < 0.001) in TAAAS and TBAAS. 1-, 5- and 10-year survival was 74.2%, 62.2% and 45.5% in TAAAS and 75.4%, 60.7% and 41.0% in TBAAS (P = 0.975), with no differences among treatment strategies. The adjusted cumulative reoperation risk at 10 years was more than two-fold in TBAAS versus TAAAS (9.5% vs 20.5%, hazard ratio (HR) = 2.30, 95% I 1.31-4.04). CONCLUSIONS: In the last decades, better patient triage and surgical/endovascular techniques led to substantial improvements in the management of acute aortic syndrome, with reduction in early mortality and reoperation rate. However, long-term mortality is still >50%.

[Management of acute type B aortic dissection: treatment and follow-up]. / Gestione della dissezione aortica acuta di tipo B: trattamento e follow-up.

Aortic dissection is a life-threatening condition caused by a tear in the tunica intima which creates a false lumen into the aortic wall. Acute type B aortic dissection (TBAD) is defined by the presence of the entry tear in the aorta distal to the left subclavian artery, without ascending aorta and arch involvement, and accounts for 25-40% of all aortic dissections. Optimal medical therapy (OMT), focused on blood pressure and heart rate control, remains the gold standard treatment, especially for patients with uncomplicated TBAD, while complicated dissections require surgical therapy. Recent studies have shown that a considerable number of patients treated only with OMT develop late aorta-related complications that increase morbidity and mortality, as well as the need for surgical intervention. During the last decades, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is safe and effective in the treatment of TBAD, both complicated and uncomplicated, with improved long-term survival outcomes and aortic remodeling in combination with OMT compared to OMT alone. However, in cases of acute uncomplicated TBAD the optimal timing for TEVAR is not entirely clarified and there is lack of long-term evidence. Therefore, the role of pre-emptive TEVAR for these patients is still uncertain and the management of acute uncomplicated TBAD remains challenging.

Distal stent graft-induced new entry (dSINE) after frozen elephant trunk: a scoping review.

Background: The introduction of hybrid total arch replacement with the frozen elephant trunk (FET) technique has improved the field of aortic surgery by allowing single-stage treatment of complex aortic pathologies. Although FET has been associated with favorable aortic remodeling, it is also associated with the potential development of distal stent graft-induced new entries (dSINEs). The aim of our review is to collect data about the incidence and the supposed conditions for the occurrence of dSINE after total hybrid arch replacement with FET technique. Methods: The literature review was performed using PubMed databases from inception to January 2022. A descriptive approach to detect and display supposed risk factors and predictors for dSINE occurrence has been adopted. Results: Eight studies summarized the state-of-the-art of dSINE in a total number of 544 FET procedures performed to treat acute and chronic aortic dissections. The scoping review showed dSINEs occurrence in 69 patients (12.7%). The mean time between surgery and the diagnosis ranged from 12.6 to 30.6 months. Most patients that developed dSINE received endovascular treatment, whereas a couple of them needed open surgery. According to our experience, from January 2007 to December 2021, in 225 FET procedures a total of 54 cases of dSINE, both with Thoraflex and E-vita grafts have been detected. The mean time between the surgical procedure and the diagnosis was 27.2±33.6 months. Conclusions: dSINEs are frequent complications after FET. Although not emergent, they require proper treatment. Due to dSINE's asymptomatic nature and potential harm, a rigorous follow-up including angio-computed tomography (CT) should be planned.

Effect of Preoperative Right Ventricular Dysfunction on Heart Transplantation Outcomes.

BACKGROUND: We investigated if the occurrence of preoperative right ventricular dysfunction is capable of influencing heart transplant results in terms of in-hospital mortality, incidence of primary graft dysfunction, and follow-up mortality. METHODS: We retrospectively analyzed 517 patients who underwent heart transplant between January 2000 and December 2020. We defined right ventricular dysfunction (RVD), as central venous pressure (CVP) > 15 mm Hg and CVP/pulmonary capillary wedge pressure ratio > 0.63. We identified 2 subgroups in our population: 33 patients with preoperative RVD and 484 patients without RVD. RESULTS: In-hospital mortality was 7.9%. Severe early graft failure occurred in 6.6% of patients, with 26 patients (5.1%) needing intra-aortic balloon pump and 17 patients (3.3%) needing extracorporeal membrane oxygenation support. Clinical variables that significantly influenced in-hospital mortality were age, peripheral artery disease, and bilirubin > 1.5 mg/dL, while hemodynamic variables influencing in-hospital mortality were CVP (odds ratio [OR], 1.09 [confidence interval {CI}, 1.03-1.15], P = .004], pulmonary artery systolic pressure (OR, 1.02 [CI, 1.00-1.04], P = .05), CVP/pulmonary capillary wedge pressure ratio (OR, 2.78 [CI, 1.14-6.80], P = .025), pulmonary vascular resistance (OR, 1.15 [CI, 1.01-1.32], P = .042), transpulmonary gradient (TPG) (OR, 1.11 [CI, 1.03-1.18], P = .003) , diastolic transpulmonary gradient (OR, 1.10 [CI, 1.02-1.20], P = .015], together with right ventricular dysfunction (OR, 3.56 [CI, 1.44-8.80], P = .011). On the other hand, clinical variables influencing the incidence of early graft failure were body mass index (calculated as weight in kilograms divided by height in meters squared) > 30, peripheral artery disease, bilirubin > 1.5 mg/dL, Model for End-Stage Liver Disease score excluding international normalized ratio before transplant, and preoperative extracorporeal membrane oxygenation support, while hemodynamic variables were pulmonary arterial systolic pressure (OR, 1.03 [CI, 1.00-1.05], P = .016), TPG (OR, 1.08 [1.01-1.17], P = .03), and right ventricular dysfunction (OR, 3.00 [CI, 1.07-8.40] P = .046). On the multivariable analysis, RVD and TPG were independent predictors of in-hospital mortality, while only TPG was a predictor of early graft failure. Follow-up mortality was 38.7% and was influenced by recipient age, recipient body mass index, and preoperative diabetes. Moreover, 1-, 5-, and 10-year survival of patients with preoperative RVD was significantly worse than patients without RVD (log-rank = 0.001). CONCLUSIONS: In our population, RVD influenced both in-hospital and long-term results after heart transplant. For these reasons, it appears crucially important to optimize preoperative right ventricular function to improve these patients' outcomes.

Aortic tissue pathology in reoperative post-dissection repair following prior use of BioGlue.

AIM: The benefits of BioGlue as a surgical adjunct in aortic procedures have been demonstrated in several studies, but limited information is available regarding the associated histopathological findings of aortic tissue at the time of reoperation. The objective of this study was to assess, at reoperation, the histopathological characteristics of aortic tissue which has had BioGlue applied during a previous surgery. METHODS: This prospective, single-center, single-arm study enrolled patients who were undergoing aortic reoperation and who had BioGlue used during previous aortic surgery. Histopathological assessment of aortic specimens obtained intraoperatively was performed on tissue that would have been removed independent of subject participation in the study. RESULTS: A total of 11 patients were enrolled and based on gross assessment, excessive amounts of BioGlue had been applied during the initial surgery in 36.4% of cases. The samples with the greatest amount of residual BioGlue demonstrated moderate to marked inflammatory responses, while the remaining samples demonstrated minimal to moderate inflammatory responses. Calcification of residual BioGlue was noted in 4 cases. Substantial medial degeneration was associated with suture line dehiscence in 4 cases, some of which had a large quantity of residual BioGlue. No evidence of suture degradation was observed. CONCLUSIONS: Cases with surgical anastomosis dehiscence were associated with substantial medial degeneration. While no histologic findings directly linked BioGlue to these degenerative changes, a contributory role cannot be excluded. Following the manufacturer's instructions for appropriate application of BioGlue is crucial to prevent potential complications.

How much should be covered a type B aortic dissection? Just do it, but don't forget about spinal cord protection.

Revascularization of the left subclavian artery (LSA) is considered a method of spinal cord protection from ischemia during thoracic endovascular aortic repair (TEVAR). Coverage of the artery of Adamkiewicz with TEVAR is usually well tolerated because of collateral pathways to this vessel, but on the other side, the LSA is crucial in this regard since it represents the primary source of collateral pathways. In our commentary, we wish to focus the discussion on the LSA revascularization and about the complexity of the anatomy of spinal cord supply in order to underline what have been already studied, analyzed, and recommended from the current guidelines.