Management of complex thoracic aortic diseases with aberrant right subclavian artery.

BACKGROUND: We retrospectively evaluated early and intermediate outcomes of hybrid repair of complex thoracic aortic diseases involving an aberrant right subclavian artery. This paper aims to report features and available treatment options for this rare, hard-to-diagnose, and manage, aorta-related vascular condition. METHODS: Between January 2012 and May 2019, 13 patients (mean age, 60.1 ± 9.3 years; nine men) underwent complex thoracic aorta repair surgery. Six patients had a thoracic aortic aneurysm, two had type A aortic dissection, and five had complicated type B aortic dissection. Hybrid repair strategies included de-branching in combination with single-stage aortic arch replacement with the frozen elephant trunk technique performed in four patients, thoracic endovascular aortic repair in six patients, and 2-stage hybrid repair consisting of a total arch replacement with a conventional/frozen elephant trunk (first stage) and subsequent endovascular repair (second stage) in three patients. RESULTS: One early death occurred: a patient with acute type A aortic dissection, who underwent Bentall procedure and aortic arch replacement with the frozen elephant trunk technique, died in-hospital of multiorgan failure 41 days after the procedure. The remaining 12 patients were discharged in stable condition. The median follow-up duration was 36 months (2-71 months). Two late mortalities occurred: a patient with residual type A aortic dissection, who underwent arch replacement with the frozen elephant trunk technique, died of intracranial hemorrhage 3 months after the surgery. And 72 years old female patient died of acute exacerbation of chronic obstructive pulmonary disease 2 months after the surgery. CONCLUSION: Our study indicates that various hybrid strategies can be used to treat complex thoracic aortic diseases involving an aberrant right subclavian artery. The approach of choice depends on the features of disease pathology, the aortic segments involved, and the operating surgeon's experience.

Treatment of Retrograde Type B Aortic Dissection after Endovascular Repair of Abdominal Aortic Aneurysm.

Retrograde ascending aortic dissection during or after thoracic endovascular aortic repair is a nonfrequent complication (2.4%) especially in patients for type B aortic dissections with a high mortality rate (42%). This complication can occur not only during the index hospitalization but also after discharge up to 3 years. However, retrograde type B aortic dissection is much less common after standard endovascular repair for infrarenal abdominal aortic aneurysm. We present a 76-year-old female patient with a history of ascending aorta aneurysm and obesity who was referred to our clinic with retrograde type B aortic dissection 1 month after endovascular aneurysm repair due to infrarenal abdominal (contained) rupture.

Multiple aneurysmatic involvement of sinus of Valsalva.

Forty-five-year-old male patient presented with chest pain and dyspnea lasting for three weeks. Transthoracic echocardiography demonstrated a huge right sinus of Valsalva aneurysm. Contrast-enhanced cardiac computed tomography was performed and revealed three large unruptured sinus of Valsalva aneurysms.

Comparison of percutaneous access and open femoral cutdown in elective endovascular aortic repair of abdominal aortic aneurysms.

Background: The aim of this study was to compare postoperative outcomes of percutaneous access and femoral cutdown methods for elective bifurcated endovascular abdominal aortic aneurysm repair. Methods: Between November 2013 and September 2020, a total of 152 patient (135 males, 17 females; mean age: 70.6±6, range, 57 to 87 years) who underwent endovascular repair due to infrarenal abdominal aortic aneurysm were retrospectively analyzed. According to femoral access type, the patients were grouped into two groups as the total percutaneous femoral access and open cutdown femoral access endovascular repair. Intra- and postoperative data were compared, including operative time, amount of contrast media, bleeding requiring transfusion, return to the operating room, access vessel complications, wound complications, and overall length of hospital stay. Results: Eighty-seven (57.2%) femoral cutdown access repair and 65 (42.8%) percutaneous femoral access repair cases were evaluated in the study. The two groups were comparable in terms of demographic and clinical characteristics (p>0.05), except for chronic obstructive pulmonary disease which was more frequent in the percutaneous access group (p=0.014). After adjustment, age, diabetes mellitus, chronic obstructive pulmonary disease, and obesity were not predictive of percutaneous access failure. Percutaneous femoral access was observed as the only preventing factor for wound infection (odds ratio=0.166, 95% confidence interval: 0.036-0.756; p=0.021). Conclusion: Although femoral access preference does not affect mortality and re-intervention rates, percutaneous endovascular repair reduces operation time, hospital stay, and wound site complications compared to femoral artery exposures.

Comparison between Arch Zones in Modified Frozen Elephant Trunk Procedure for Complex Thoracic Aortic Diseases.

INTRODUCTION: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). METHODS: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). RESULTS: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). CONCLUSION: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Repair of residual aortic dissections with frozen elephant trunk technique.

BACKGROUND: In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection. METHODS: Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies. RESULTS: The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up. CONCLUSION: Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

Hybrid Treatment of Complex Aortic Arch Anomaly with Saccular Aneurysm.

Aortic arch anomalies are not clinically important unless they cause compression symptoms due to aneurysmatic dilatation. Aortic anomalies need to be treated when they cause complex thoracic aortic diseases, and the treatment approach has evolved over time from open surgical methods, which have high mortality and morbidity rates, to hybrid methods. A case of a 68-year-old male patient with complex aortic arch anomaly treated with hybrid arch repair is reported in this study. Aortic branches were common carotid trunk and aberrant right subclavian artery with a saccular aneurysm.

Early and mid-term results of frozen elephant trunk procedure for acute type A aortic dissection.

BACKGROUND: This study aims to investigate the early and mid-term results of total thoracic aorta repair with E-vita OPEN PLUS stent graft, which we used to remove the residual false lumen and prevent late-term complications in patients with acute type A aortic dissections. METHODS: The study included 41 patients (29 males, 12 females; mean age 51.9±10.4 years; range, 30 to 77 years) who underwent total thoracic aorta repair with frozen elephant trunk stent graft for acute type A aortic dissection between November 2013 and November 2017. The reduction in false lumen size and thrombosis were evaluated by repeated computed tomographyangiography on 10th day and third, sixth, and 12th months. RESULTS: Six patients (14.6%) were lost during hospital stay and one patient (2.4%) was lost during the follow-up period. Frozen elephant trunk stent graft"s distal end at descending aorta ended at T6, T7, and T8 levels in 15 (36.6%), 21 (51.2%), and five (12.2%) patients, respectively. The supra-aortic vessels were re-implanted separately in 21 (51.2%) or as island in 20 (48.8%) patients. Transient paraparesis (spinal cord ischemia) was observed in only one patient (2.4%), while permanent neurologic deficit (stroke or coma) was observed in two patients (4.9%). Mean duration of follow-up was 26.5±20.5 months. Computed tomography-angiography at first month showed that false lumen became thrombosed at rates of 93.9% and 54.5% at pulmonary trunk and diaphragmatic level, respectively. CONCLUSION: We believe that total arcus repair in acute type A aortic dissection treatment with single-session frozen elephant trunk technique by ensuring early false lumen thrombosis is safe and successful.

Outcomes After Surgical Resection of Primary Non-Myxoma Cardiac Tumors.

OBJECTIVE: Primary cardiac tumors are rare lesions with different histological type. We reviewed our 17 years of experience in the surgical treatment and clinical results of primary non-myxoma cardiac tumors. METHODS: Between July 2000 and February 2017, 21 patients with primary cardiac tumor were surgically treated in our institution. The tumors were categorized as benign non-myxomas and malignants. Data including the demographic characteristics, details of the tumor histology and grading, cardiac medical and surgical history, surgical procedure of the patients were obtained from the hospital database. RESULTS: Eleven patients were diagnosed with benign non-myxoma tumor (male/female:7/4), ranging in age from 10 days to 74 years (mean age 30.9±26.5 years). Papillary fibroelastoma was the most frequent type (63.6%). There were two early deaths in benign group (all were rhabdomyoma), and mortality rate was 18%. The mean follow-up period was 69.3±58.7 months (range, 3 to 178 months). All survivals in benign group were free of tumor-related symptoms and tumor relapses. Ten patients were diagnosed with malignant tumor (sarcoma/lymphoma:8/2, male/female:3/7), ranging in age from 14 years to 73 years (mean age 44.7±18.9 years). Total resection could be done in only three (30%) patients. The mean follow-up period was 18.7±24.8 months (range, 0-78 months). Six patients died in the first 10 months. CONCLUSION: Complete resection of the cardiac tumors, whenever possible, is the main goal of surgery. Surgical resection of benign cardiac tumors is safe, usually curative and provides excellent long-term prognosis. On the contrary, malignant cardiac tumors still remain highly lethal.

Innominate vein cannulation: easy but neglected technique.

Introduction: Our experience in minimally invasive procedures and improvement of graft technology enables easy and successful operation carried out even with complex thoracic aortic diseases from limited surgical area. However, it should be more than one incision or cannulation site for such intervention. We aimed to present our experience and results of 23 patients who has ascending aorta and aortic arch pathologies of which we operated with J-shaped partial sternotomy and innominate vein cannulation. Methods: From January 2014 to January 2016, 23 patients with aorta and aortic valve pathologies who underwent aortic surgery with J-shaped partial sternotomy and innominate vein cannulation included. Operation findings, cardiopulmonary bypass (CPB) values, postoperative results, surgical mortality and morbidity rates, late conversion to full sternotomy rates, ICU and hospital length of stay were evaluated. Results: The mean age of the patients was 53.7±12 (range 19-68) and 18 (78.2%) were males. Arcus aorta debranching applied to 4 patients (17.3%) and one of these procedures was frozen elephant trunk procedure (4.3%). Neither mortality nor cerebrovascular accident occurred. Mean CPB peak flow was 4.6±0.4 L/min, mean flow index calculated as 2.01±0.38 L/min/m2 and there was no CPB problem intraoperatively. Innominate vein ligation was carried out in 5 patients but no complication was seen except one who had left arm swelling treated with elevation. Conclusion: Innominate vein cannulation with J-shaped partial sternotomy is a reliable and easily applicable method providing effective utilization of limited operative field not only in ascending aorta and aortic arch operations but also with the advancements of hybrid systems used in descending aorta pathologies.

Frozen Elephant Trunk and Antegrade Visceral Debranching in the Surgical Treatment of Type B Aortic Dissection: An Alternative Method.

Intervention is inevitable in complicated Type B aortic dissections. Classical surgical procedures and endovascular interventions are far from ideal treatments due to their high risk of periprocedural complications and mortality. There is often a need for alternative method in cases of difficult anatomy. We present the combined use of frozen elephant trunk and antegrade visceral debranching methods in the treatment of a 54-year-old male patient with complicated Type B aortic dissection.

Comparison between arch zones in modified frozen elephant trunk procedure for complex thoracic aortic diseases

Abstract Introduction: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). Methods: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). Results: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). Conclusion: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Hybrid treatment of complex aortic arch anomaly with saccular aneurysm

Abstract Aortic arch anomalies are not clinically important unless they cause compression symptoms due to aneurysmatic dilatation. Aortic anomalies need to be treated when they cause complex thoracic aortic diseases, and the treatment approach has evolved over time from open surgical methods, which have high mortality and morbidity rates, to hybrid methods. A case of a 68-year-old male patient with complex aortic arch anomaly treated with hybrid arch repair is reported in this study. Aortic branches were common carotid trunk and aberrant right subclavian artery with a saccular aneurysm.

Outcomes after surgical resection of primary non-myxoma cardiac tumors

Abstract Objective: Primary cardiac tumors are rare lesions with different histological type. We reviewed our 17 years of experience in the surgical treatment and clinical results of primary non-myxoma cardiac tumors. Methods: Between July 2000 and February 2017, 21 patients with primary cardiac tumor were surgically treated in our institution. The tumors were categorized as benign non-myxomas and malignants. Data including the demographic characteristics, details of the tumor histology and grading, cardiac medical and surgical history, surgical procedure of the patients were obtained from the hospital database. Results: Eleven patients were diagnosed with benign non-myxoma tumor (male/female:7/4), ranging in age from 10 days to 74 years (mean age 30.9±26.5 years). Papillary fibroelastoma was the most frequent type (63.6%). There were two early deaths in benign group (all were rhabdomyoma), and mortality rate was 18%. The mean follow-up period was 69.3±58.7 months (range, 3 to 178 months). All survivals in benign group were free of tumor-related symptoms and tumor relapses. Ten patients were diagnosed with malignant tumor (sarcoma/lymphoma:8/2, male/female:3/7), ranging in age from 14 years to 73 years (mean age 44.7±18.9 years). Total resection could be done in only three (30%) patients. The mean follow-up period was 18.7±24.8 months (range, 0-78 months). Six patients died in the first 10 months. Conclusion: Complete resection of the cardiac tumors, whenever possible, is the main goal of surgery. Surgical resection of benign cardiac tumors is safe, usually curative and provides excellent long-term prognosis. On the contrary, malignant cardiac tumors still remain highly lethal.