Type B aortic dissection: new perspectives.

BACKGROUND: Stanford type B aortic dissection is one of the aortic catastrophes with a high mortality and morbidity that needs immediate or delayed treatment, either surgically or endovascularly. This comprehensive review article addresses the current status of open, endovascular and hybrid treatment options for type B aortic dissections with the focus on new therapeutic perspectives. METHODS: Evaluation of currently available evidence based on randomized and registry data and personal experience. RESULTS: All type B dissections require prompt medical treatment to prevent aortic rupture. Acute complicated dissections are nowadays treated by endografting to reroute blood flow into the true lumen and promote false lumen thrombosis and future aortic remodeling. In acute uncomplicated situations the position of endografting is less clear and should be further delineated; however, on the long run also in these situations endografting might be protective for future aortic catastrophes in certain patient categories. In the chronic dissection with aneurysm formation of the descending thoracic and/or thoracoabdominal aorta, especially in connective tissue disorders, open surgery offers nowadays the best immediate results with long durability. Thoracic endografting plays only a minor role in these circumstances but branched and fenestrated endografting are very promising techniques. Hybrid techniques can offer the solution for high risk patients that are not suitable for open surgery. CONCLUSIONS: Emergent thoracic endografting is the golden standard for all complicated type B dissections while uncomplicated patients with high-risk features might benefit from endovascular repair. Open surgery is limited for chronic post dissection aneurysms. Aortic surveillance is of paramount importance in all situations.

Left heart bypass for thoracoabdominal aortic aneurysm repair: technical aspects.

There are different surgical techniques for providing circulatory support during the repair of thoracoabdominal aortic aneurysms. They all aim at reducing the afterload of the heart and the preservation of distal organ perfusion. Partial or total extracorporeal circulation with or without cooling and left heart bypass (LHB) are actually the most used surgical approaches. The objective of this study was to describe and comment on the technical aspects of the LHB. We briefly describe our results and put them into perspective based on the current literature.

Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†.

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.

The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results.

OBJECTIVE: The classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique. METHODS: Between 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms. RESULTS: Mean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044). CONCLUSIONS: A 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.

Infectious aortitis with multiple mycotic aneurysms caused by Streptococcus agalactiae.

We report a case of a 66-year-old man with multiple thoracoabdominal mycotic aortic aneurysms caused by Streptococcus agalactiae (S agalactiae). The infectious aortitis (IA) was diagnosed by transesophageal echocardiography and computed tomography and confirmed by positive blood cultures. The patient was treated with antibiotics, but, after worsening of the aortitis, a successful surgical procedure was performed. A review of the literature is presented together with a series of 7 other cases of IA caused by S agalactiae.

Reoperation after acute type a aortic dissection repair: a series of 104 patients.

BACKGROUND: Our objective was to analyze the causes, timing, and results of reoperation after primary repair for acute type A dissection. METHODS: One hundred and four consecutive patients underwent a reoperation after previous type A aortic dissection repair (1972 to 2008). Supracoronary ascending aorta replacement (SCAR) was commonly performed during primary repair and it was associated with aortic root replacement in 13 cases and with hemiarch replacement in 26 patients. Progression of aortic dilatation was seen in 91 patients (87%), aortic regurgitation in 21 (20%), and false aneurysm in 15 patients (14%). A redo Bentall procedure was performed in 34 cases, arch replacement in 42 patients, and thoracoabdominal aorta replacement in 20 patients. The median follow-up was 6.5 years (range 0.3 to 23.8 years). RESULTS: The in-hospital mortality after redo surgery was 7.7%. The global survival rate at 1, 5, and 10 years was 92%, 82%, and 58%, respectively. Proximal reoperations were more frequent in patients who had SCAR and flap extension into the aortic root. Patients with an unresected intimal tear and distal extension of dissection flap experienced a higher rate of aortic arch and thoracoabdominal aorta redo procedures. CONCLUSIONS: More extensive acute dissection repair results in a lower rate of reoperation. Mortality for redo surgery after type A acute dissection repair is acceptable. This finding should be taken into account in proposing a widespread of more complex and extensive surgery for type A acute dissection.

The future of aortic surgery in Europe.

At least every ten years, each specialty should reflect upon its past, its present and its future, in order to be able to reconfirm the direction in which it is headed, to adopt suggestions from inside and outside and, consequently, to improve. As such, the aim of this manuscript is to provide the interested reader with an overview of how aortic surgery and (perhaps more accurately) aortic medicine has evolved in Europe, and its present standing; also to provide a glimpse into the future, trying to disseminate the thoughts of a group of people actively involved in the development of aortic medicine in Europe, namely the Vascular Domain of the European Association of Cardio-Thoracic Surgery (EACTS).

Early and late outcome after aortic root replacement with a mechanical valve prosthesis in a series of 528 patients.

BACKGROUND: Aortic root replacement with a mechanical valve prosthesis is a widely accepted surgical technique. This study aims to evaluate short-term and long-term outcomes of this approach and to identify predictors of 30-day mortality. METHODS: We retrospectively analyzed a consecutive series of 528 patients (mean age, 54±13 years) who underwent aortic root replacement for aneurysm (83%), acute type A dissection (15%), or endocarditis (2%) in the period between 1974 and 2008. The mean time of follow-up was 9.0±7.0 years (range, 0 to 36 years). Concomitant aortic surgery was performed in 71%, coronary revascularization in 18%, and mitral valve surgery in 3%. Selective antegrade cerebral perfusion was applied in 25% and deep hypothermic circulatory arrest in 28% of patients. RESULTS: Overall 30-day mortality was 3.2% to 2.5% for elective surgery and 6.5% for urgent surgery. Morbidity included resternotomy for bleeding or tamponade (19%), pacemaker implantation (3.6%), myocardial infarction (4.0%), and neurologic damage (4.2%). Multivariate analysis revealed myocardial infarction (p<0.001) and the lack of glue use (p=0.018) as independent predictors of 30-day mortality. Subanalysis of the selective antegrade cerebral perfusion patients and the deep hypothermic circulatory arrest patients revealed infarction (p=0.005) and coronary artery disease (p=0.45) for selective antegrade cerebral perfusion and wrapping (p=0.035) for deep hypothermic circulatory arrest as independent risk factors. The survival rate was 87%, 73%, and 29% after 5, 10, and 25 years, respectively. CONCLUSIONS: Aortic root replacement with a mechanical valve prosthesis can be performed safely with low mortality and acceptable morbidity. Perioperative myocardial infarction is the strongest independent risk factor of 30-day mortality.

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection.

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Aortic reoperation after freestanding homograft and pulmonary autograft root replacement.

BACKGROUND: Human allografts and pulmonary autografts offer many advantages as an aortic valve and root substitute. The progressive degeneration of the aortic allograft and the pulmonary autograft has been seen as an important disadvantage, and the need for a reoperation has been perceived as challenging and risky for the patients. METHODS: Between March 1992 and October 2009, 53 consecutive patients (mean age 50 ± 13 years; 38 male), who had a previous aortic root replacement, underwent redo surgery for failure of the aortic homograft (n = 42) or the pulmonary autograft (n = 11). The median follow-up (available for 47 of 51 patients) was 44 months. RESULTS: Structural valve deterioration was the main indication for reoperation on the homograft (86%), with an earlier presentation in patients who received homografts from donors more than 55 years old. Failure of the pulmonary autograft occurred primarily because of severe aortic regurgitation predominantly due to dilation of the autograft (n = 5) and autograft valve prolapse (n = 5). The total in-hospital mortality was 3.8% (n = 2). No deaths occurred among patients who previously underwent a Ross procedure. The course was complicated in 25 cases (48%). The cumulative 1-year, 5-year, and 8-year survival rates were 92%, 90%, and 77%, respectively. No late deaths were encountered after reoperation on the pulmonary autograft (maximum follow-up 218 months). Freedom from reoperation (excluding early in-hospital operation) for recurrent aortic valve or root pathology was 97% at 8 years. CONCLUSIONS: Reoperation after freestanding homograft and pulmonary autograft root replacement can be accomplished safely. The total postoperative morbidity rate is still high.

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.

Reoperations for aortic false aneurysms after cardiac surgery.

BACKGROUND: Aortic false aneurysm is a rare complication after cardiac surgery. Aortic dissection, infection, arterial wall degeneration, and poor surgical technique are recognized as risk factors for the occurrence of postsurgical false aneurysm. Despite some recent reports about percutaneous false aneurysm exclusion, a complex surgical reoperation is needed in most of the cases. METHODS: We retrospectively reviewed our experience in 43 patients who received a reoperation for postsurgical aortic false aneurysm in the last 14 years. Thirty-three patients were male. The mean age was 60 ± 12 years. Most of the patients received prior aortic surgery on the aortic root, the ascending aorta, the aortic arch, and the descending thoracic aorta (38 patients). False aneurysm was diagnosed during follow-up evaluation in the absence of any symptoms in 23 cases. Univariate and multivariate analyses on 18 perioperative variables were performed. RESULTS: In-hospital mortality was 6.9% (3 patients). The postoperative course was complicated in 17 cases (39%). At multivariate analysis, a preoperative history of coronary artery disease and postoperative sepsis were independent risk factors for hospital mortality. Survival rates at 1, 5, and 10 years were 94%, 79%, and 68%, respectively. Freedom from reoperation was 86% at 1 year and 72% at 5 and 10 years. CONCLUSIONS: Despite a high postoperative complication rate, a reoperation for postsurgical aortic false aneurysm can be performed with acceptable mortality and good mid-term and long-term outcomes.

Rerouting anomalous hepatic venous connection to the left atrium.

Total hepatic venous drainage into the left atrium is an extremely uncommon abnormality. We present a patient in whom the hepatic veins drained into the left atrium in the absence of other intracardiac or extracardiac anomalies. Surgical correction of the anomalous hepatic venous connection was performed by suturing the hepatic veins to the right atrium.