Early histological changes in the porcine aortic media after thoracic stent-graft implantation.

PURPOSE: To describe the histological findings in the aortic wall 5 days after thoracic endovascular aortic repair (TEVAR) in a porcine model. METHODS: Two overlapping stent-grafts were implanted in each of 6 juvenile pigs, covering the entire descending thoracic aorta (DTA). On the 5(th) postoperative day, tissue samples were taken from the DTA in each animal. Medial thickness and medial necrosis were quantified and compared to measurements from the aortas of 6 control animals. RESULTS: Significant medial thinning was observed in stent-covered regions in the test animals. At the proximal landing zone, aortic wall thickness changed from 1387±68 to 782±74 µm within the covered aortic segment (p = 0.028); at the distal landing site, the wall thickness was 365±67 µm within the stent and 501±57 µm distally (p = 0.028). In the overlap zone, the aortic wall measured 524±122 vs. 1053±77 µm in native controls (p = 0.004). Aortic thickness proximal to the graft did not differ from the proximal region of native aortas (1468±96 vs. 1513±80 µm, p = 0.423), but the aorta was significantly thinner distal to the stent (707±38 vs. 815±52 µm, p = 0.004). Laminar necrosis constituted 38%±7% of the media in the proximal landing zone, 54%±4% in the overlap zone, and 46%±13% in the distal landing zone. CONCLUSION: In this porcine model, significant medial thinning and necrosis of the stented aorta was observed. The findings suggest an early phase of vulnerability of the aortic wall, before scarring and adaptive changes have strengthened the residual aorta.

Early aortic growth in acute descending aortic dissection.

OBJECTIVES: Acute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter changes during the dissection's acute and subacute phases. The aim of this study was to evaluate the change in aortic geometry within 30 days after the onset of a descending aortic dissection. METHODS: Patients with acute type B and non-A non-B dissection who had at least 2 computed tomography angiography scans obtained within 30 days after the onset of dissection were evaluated. Exclusion criteria were a thrombosed false lumen, connective tissue disorders and endovascular or open aortic repair performed prior to the second computed tomography angiography. RESULTS: Among 190 patients with acute aortic dissection, 42 patients met our inclusion criteria. Their aortic geometry was analysed according to the computed tomography angiography scans obtained between 0-3 (N = 35), 4-7 (N = 9) and 8-30 (N = 12) days after the dissection onset. The highest aortic diameter growth rate was observed in the first quartile of the thoracic aorta and measured 0.66 (0.06; 1.03), 0.29 (-0.01; 0.41) and 0.06 (-0.13; 0.26) mm/day at 0-3, 4-7 and 8-30 days after the dissection, respectively. Proximal entry location (P = 0.037) and entry located at the arch concavity (P = 0.008) were associated with a higher aortic diameter increase. CONCLUSIONS: Early rapid growth occurs during the first week after the descending aortic dissection-most intensely over the first 3 days, and this is associated with the location of the dissection's entry.

Development of a Novel Adapter to Enable Less-Invasive Left Ventricular Assist Device Implantation via the Left Ventricular Apex.

The first prototype of an adapter to enable left ventricular assist device (LVAD) implantation solely via the left ventricular (LV) apex and without requiring cardiopulmonary bypass (CPB) was tested in healthy and acutely failing pig hearts. The adapter consists of a fixation, blood guiding, and connecting module fitting to a HeartMate 3 (HM3; Abbott, Chicago, IL) pump. Implantation was performed via a left thoracotomy in five pigs (96 ± 18 kg). Invasive blood pressure was measured before (CTRL), 30 minutes after HM3 initiation (HM3_CTRL), during acute heart failure (HF) induced by rapid pacing (CTRL_HF), and 5 minutes after initiating HM3 support (HM3_HF). To further estimate the LVAD performance, blood pressure amplitudes were calculated in the healthy heart without (CTRL) and with HM3 support (HM3_CTRL) as: systolic-diastolic blood pressure. Our adapter implantation and connection to the HM3 pump succeeded in all animals. Compared to the normal beating healthy heart, blood pressure amplitudes were significantly smaller during HM3 support (CTRL: 41 ± 5 mm Hg vs. HM3_CTRL: 20 ± 4 mm Hg; p < 0.05). Under HF conditions, mean blood pressure returned to normal values after pump initiation (CTRL_HF: 29 ± 6 mm Hg, HM3_HF: 83 ± 24 mm Hg). The adapter prototype allowed safe, straightforward, and less-invasive LVAD implantation solely via the LV apex without using CPB and support of the LV during acute HF in the pig heart.

The intraspinal arterial collateral network: a new anatomical basis for understanding and preventing paraplegia during aortic repair.

OBJECTIVES: The anatomical distribution pattern of epidural intraspinal arteries is not entirely understood but is likely to substantially impact maintaining perfusion during segmental artery sacrifice when treating acute and chronic thoraco-abdominal aortic diseases. We investigated the anatomical distribution pattern of intraspinal arteries. METHODS: Twenty fresh, non-embalmed cadaveric human bodies were studied. Anatomical dissection and investigation of the epidural arterial network were performed according to a standardized protocol. We used a generalized mixed linear model to test whether the presence probability for certain vessels differed between vertebrae/segments. RESULTS: There was craniocaudal continuity of all ipsilateral longitudinal connections from T1 to L5 by the anterior radicular artery. The mean [±standard deviation (SD)] number of transverse anastomoses was 9.7 ± 2.1. The presence probability of transverse anastomoses along the spine was different between vertebrae (P < 0.0001). There were 2 distribution peaks along the spine: 1 peak around T4-T6 and 1 around T11. The mean (±SD) number of thoracic and lumbar anterior radiculomedullary arteries (ARMAs) was 3.0 ± 1.1. The probability of the presence of ARMAs along the spine was different for each vertebral segment (P < 0.0001). Between ARMAs there were gaps of up to a maximum of 9 vertebrae. All Adamkiewicz arteries were located caudally to T7. The median segment of the Adamkiewicz presence was T10/11. CONCLUSIONS: The epidural collateral network shows craniocaudal continuity. The number of transverse anastomoses is high. The number of ARMAs is low, and there is considerable variation in their distribution and offspring, which is highly likely to impact perfusion during segmental artery sacrifice when treating thoraco-abdominal aortic disease.

Evaluation of myocardial injury, the need for vasopressors and inotropic support in beating-heart aortic arch surgery.

BACKGROUND: In contrast to the standard cardioplegic cardiac arrest (CA), some centers prefer the beating-heart technique using selective normothermic myocardial perfusion (SMP) during aortic arch repair. The aim of this study was to evaluate myocardial injury and the need for inotropic and vasopressor support in patients undergoing total aortic arch replacement using SMP or CA during arch repair. METHODS: Total arch replacement was performed in 127 patients (65 years [IQR: 56-73 years] years) between March 2013 and May 2018 via the frozen elephant trunk technique. Of those, 25 patients were operated on with selective myocardial perfusion. Blood samples and catecholamine doses were evaluated. We compared the SMP group's and CA group's outcomes. RESULTS: The two groups' risk factors, underlying aortic pathologies, and surgical details were similar. The SMP group's intraoperative norepinephrine application rates were significantly lower than the CA group's (P=0.030), as were their postoperative norepinephrine application rates (norepinephrine: P=0.007). Postoperative cardiac enzymes tended to be lower in the SMP group; the difference in creatine-kinase MB reached statistical significance after 14 hours (P=0.024). Intensive care unit stay was significantly shorter in the SMP group (P=0.041), and in-hospital mortality was comparable (4% in the SMP and 11% in the CA group; P=0.46). CONCLUSIONS: By applying selective normothermic myocardial perfusion, beating-heart aortic arch surgery has the potential to reduce the need for perioperative inotropes, and it might reduce myocardial injury. This approach is a potentially useful adjunct to our armamentarium, particularly in patients with preexisting myocardial damage or in conjunction of arch repair together with other cardiac procedures.

Accuracy of deployment of the Relay non-bare stent graft in the aortic arch.

OBJECTIVES: To minimize the complications with thoracic endovascular aortic repair (TEVAR), a new stent graft with no bare ends was developed, namely the Relay non-bare stent (NBS). We hypothesized that the new features of the NBS graft would enable highly accurate deployment and fewer complications. The aim of this study was to analyse the quality of the Relay NBS with respect to its landing precision. METHODS: Relying on computed tomography angiographs, we evaluated the distance between the stent graft and the target vessel in the proximal landing zone (before and after the intervention as well as the mid-term results). Seventy-eight patients with thoracic aortic pathologies were included. Median computed tomography angiograph follow-up was 16 months. RESULTS: The stent graft was deployable ≤5 mm from the target vessel in 64 (82%) patients; in 14 (18%) of them, the distance to the target vessel was >5 mm. According to the last follow-up computed tomography angiograph, in 35 (55%) patients, the distance to the target vessel was ≤5 mm and in 29 (45%) patients, it was >5 mm. There was no endoleak type Ia immediately after TEVAR or during the follow-up period. A substantial bird beak phenomenon was observed in 3 (4%) and 7 (11%) patients immediately after TEVAR and during the follow-up period, respectively. One patient had a retrograde dissection type A. CONCLUSIONS: The Relay NBS graft can be deployed accurately in the aortic arch in most patients. Retrograde aortic dissection type A seldom occurs after TEVAR using the Relay NBS graft. The distance between the NBS graft and the intended target vessel increases during the follow-up period.

Late surgical conversions after abdominal endovascular aortic repair: underlying mechanisms, clinical results and strategies for prevention.

OBJECTIVES: Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR). METHODS: Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate. RESULTS: Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2-16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection-1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone. CONCLUSIONS: Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum.

Endovascular aortic arch repair using a double-branched approach.

The last 15 years have overwhelmed the surgical community with a range of approaches in treating pathologies involving the aortic arch of which some are here to stay. The ones to stay are-in the authors' opinion-refined classical surgical approaches such as the frozen elephant trunk technique, near-orthotopic combined vascular and endovascular approaches such as subclavian to carotid transposition/bypass and double transposition, and finally, near-orthotopic advanced endovascular solutions such as the double-endovascular repair using fenestrated and/or branched solutions which will be the main focus of this article.

Aortic Replacement After TEVAR-Diameter Correction With Modified Use of the Siena Prosthesis.

BACKGROUND: To report a new technique for diameter correction in patients after thoracic endovascular aortic repair (TEVAR) with large stent-grafts using the Vascutek Siena 4-branch collared prosthesis (Vascutek Terumo, Inchinnan, Scotland, UK) in patients undergoing thoracoabdominal (TA) aortic replacement. METHODS: Within a 24-month period, 39 patients underwent TA replacement at our center. Of these, 6 patients had undergone previous TEVAR with large stent-grafts (42 to 48 mm diameter). Indications for TEVAR were aneurysm formation in 3 patients and residual type B aortic dissection (status post repair of type A dissection) in 3 patients. In these patients, the Vascutek Siena 4-branch prosthesis was used in a reversed fashion, removing the elephant trunk portion and using the sewing collar for diameter correction at the anastomotic site. RESULTS: No 30-day mortality and no stroke or symptomatic spinal cord ischemia was observed. Median diameter of the TEVAR graft at the anastomotic site was 44 mm. Median size of the Siena graft used was 26 mm. Diameter correction was successfully achieved in all patients by tailoring the sewing collar of the Siena 4-branch prosthesis to the individual need according to the diameter of the distal end of the stent-graft. CONCLUSIONS: Using the sewing collar of the Vascutek Siena 4-branch prosthesis for diameter correction in patients undergoing TA replacement after previous TEVAR with large stent-grafts adds a useful adjunct to the armamentarium of options in a growing patient population.

Chronic type B "residual" after type A: what I would do?

"The major goal of surgery for acute type A aortic dissection is to have an alive patient." This motto still remains the most important directive. However, also depending onto the extent of the underlying pathology and consecutively depending onto the extent of primary surgery, there is and will be need for additional classical surgical or interventional treatment sooner or later during follow-up in a substantial number of patients having had surgery for acute type A aortic dissection. This article shall guide the interested reader through the underlying mechanisms as well as treatment options in patients with chronic type B "residual" after type A repair and shall finally suggest preventive strategies to reduce the occurrence of this pathology to a minimum.

True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation.

OBJECTIVES: To evaluate early and mid-term clinical outcomes and to assess the potential of the frozen elephant trunk technique to induce remodelling of downstream aortic segments in acute and chronic thoracic aortic dissections. METHODS: Over a 4-year period, 65 patients (48 men, aged 61 ± 12 years) underwent total aortic arch replacement using the frozen elephant trunk technique for acute (n = 31) and chronic (n = 34) thoracic aortic dissections at our institution. We assessed diameter changes at 3 levels: the L1 segment at the stent graft level; the L2 segment at the thoraco-abdominal transition level and the L3 segment at the coeliac trunk level. True-lumen (TL) and false-lumen (FL) diameter changes were assessed at each level. RESULTS: Fifty-six percent of patients had already undergone previous aortic or cardiac surgery. In-hospital mortality was 6%. Symptomatic spinal cord injury was not observed in this series. During a mean follow-up of 12 ± 12 months, late death was observed in 6% of patients. Aortic reinterventions in downstream aortic segments were performed in 28% at a mean of 394 ± 385 days. TL expansion and FL shrinkage were measured in all segments and were observed at each level. This effect was the most pronounced at the level of the stent graft in patients with chronic aortic dissection, TL diameter increased from 15 ± 17 mm before surgery to 28 ± 2 mm (P = 0.001) after 2 years, and the FL diameter decreased from 40 ± 11 mm before surgery to 32 ± 17 mm (P = 0.026). CONCLUSIONS: The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection.

OBJECTIVES: Our goal was to report our preliminary results in patients with acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair who were treated with the frozen elephant trunk (FET) technique. METHODS: Within a 25-month period, 14 patients with acute complicated Type B aortic dissection underwent surgical repair using the FET technique. The reasons to perform the FET procedure were an ectatic ascending aorta/arch in 6 patients and the lack of an adequate landing zone in 8 patients. RESULTS: No deaths were observed. A non-disabling stroke occurred in 2 patients. Symptomatic spinal cord injury was not observed. The closure of the primary entry tear was successfully achieved in all patients. In 3 patients, a secondary distal thoracic endovascular aortic repair extension was performed during the same hospital stay. The median follow-up period was 6 ± 5 months. CONCLUSIONS: The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease.

Endovascular treatment of acute Type A aortic dissection-the Endo Bentall approach.

Outcome after classical surgical repair of acute Type A aortic dissection has steadily improved over the years and several modifications in cannulation and perfusion added to this achievement. However, subgroups remain where results of classical surgical repair still have room for improvement, particularly patients with severe preoperative malperfusion as well as elderly patients with a limited physiological reserve. So far, only small case series or case reports have been published on the endovascular treatment of dissected ascending aortas. However, a tube alone is not sufficient to fix the entire complex underlying problem in the vast majority of patients with acute Type A aortic dissection. In addition, these published reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule. The concept of an endovascular valve-carrying conduit may significantly increase the number of patients suitable for endovascular therapy and it may soon be common practice.

New insights into spinal cord ischaemia after thoracic aortic procedures: the importance of the number of anterior radiculomedullary arteries for surgical outcome.

OBJECTIVES: Anterior radiculomedullary arteries (ARMAs) link dorsal segmental arteries and the intraspinal compartment of the spinal collateral network. The number of thoracic ARMA is highly variable from one person to another. The impact of the number of ARMAs on spinal cord perfusion during thoracic aortic procedures is unknown. We investigated the influence of the number of thoracic ARMAs on spinal cord perfusion in an aortic surgical large animal model. METHODS: Twenty-six pigs were included (20 treatment animals, 6 sham animals, weight 34 ± 3 kg). The animals underwent ligation of the left subclavian artery and the thoracic segmental arteries via a left lateral thoracotomy with normothermia. After sacrifice, complete body perfusion with coloured cast resin was performed and the number of thoracic ARMAs was documented at autopsy. End points were spinal cord perfusion pressure, cerebrospinal fluid pressure, spinal cord blood flow (microspheres) and neurological outcome. Observation time was 3 h post-ligation. RESULTS: The numbers of thoracic ARMAs ranged between 3 (n = 1) and 13 (n = 1). The mean number was 8. Animals were grouped according to number of thoracic ARMA: 6-7 (5 animals), 8-10 (8 animals) and 11-13 (5 animals). A large number of thoracic ARMAs was linked to (i) a lower drop in spinal cord blood flow from baseline to post-clamp, (ii) the presence and increased magnitude of hyperaemia evident 3 h post-clamp (P < 0.001) and (iii) the presence of early hyperaemia starting immediately post-clamp in animals with 11 or more ARMA (P < 0.001). CONCLUSIONS: We showed that a large number of thoracic ARMA protects against spinal cord injury during descending aortic surgical procedures.1.

Surgical Treatment of Native and Prosthetic Aortic Infection With Xenopericardial Tube Grafts.

BACKGROUND: The study sought to report our results of surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts from the ascending aorta to beyond the bifurcation. METHODS: Within a 28-month period, 20 patients were treated with a bovine self-made pericardial tube graft to replace infected vascular grafts (after conventional surgical aortic replacement or endovascular stent graft implantation) or to treat a contaminated surgical site. An integrated standardized therapeutic concept was applied in all patients, consisting of complete removal of the infected prosthetic material, extensive debridement, and orthotopic vascular reconstruction with self-made tube grafts constructed from a bovine pericardial patch. RESULTS: Four patients died perioperatively (20%) due to sepsis, pulmonary failure, or sudden circulatory arrest. The mean follow-up was 18 months (first quartile 2, third quartile 17 months). Interval computed tomography scans revealed 100% freedom from proven aortic reinfection, but reinfection cannot be ruled out in 4 patients who died of unknown causes during follow-up or because of ongoing sepsis. Three patients required aortic reintervention for a suture-line aneurysm, for graft occlusion, and for the development of a neoaortointestinal fistulation, respectively. CONCLUSIONS: Patients with infectious aortic disease present in a frail state and the initial and the late mortality is substantial. Yet, surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts shows promising short-term results with regard to durability and freedom from reinfection in any aortic segment. Further studies are needed to learn of the long-term behavior of these grafts.

Technical details making aortic arch replacement a safe procedure using the Thoraflex™ Hybrid prosthesis.

SummaryThe development of new devices to improve treatment and to explore new indications that have not yet been adequately addressed is a natural consequence of the clinical demand for solutions to as yet unmet needs. The frozen elephant trunk technique was one of the major steps within the last 15 years to improve on existing treatments as well as to explore new indications. The goal of this article is to provide technical details about advances in implantation techniques for the treatment of acute and chronic thoracic aortic pathological conditions.

A propensity score-matched comparison of deep versus mild hypothermia during thoracoabdominal aortic surgery.

OBJECTIVE: By using deep hypothermic circulatory arrest and non-deep hypothermic circulatory arrest approaches, we examined the impact of distal ischemia time and temperature on intra-abdominal reversible adverse outcomes and permanent adverse outcomes during descending thoracic aortic and thoracoabdominal aortic aneurysm operations. METHODS: A retrospective review of all patients who underwent descending thoracic aortic and thoracoabdominal aortic aneurysm repair between January 2002 and December 2008 was undertaken, including relevant preoperative, intraoperative, and postoperative data, and followed by a propensity score-matched analysis. Of the total of 262 patients, 240 had data complete enough to permit analysis, and 90 were suitable for the propensity-matched study. Reversible adverse outcomes included renal failure, liver failure, and temporary hemodialysis. Permanent adverse outcomes included paraplegia, permanent hemodialysis, and 30-day mortality. RESULTS: Thirty-day mortality was 7.1% (17/240). Overall, reversible adverse outcomes developed in 40.8% of patients and permanent adverse outcomes developed in 10% of patients. The propensity score analysis identified statistically significant decreased odds of developing reversible adverse outcomes in patients undergoing deep hypothermic circulatory arrest (odds ratio, 0.32; confidence interval, 0.12-0.85). Specifically, significantly lower rates of acute renal failure (22% vs 46.4%, P = .03) and liver failure (17.8% vs 34.3%, P = .04) were observed in the deep hypothermic circulatory arrest group compared with the non-deep hypothermic circulatory arrest group. In addition, there were decreased odds of reversible adverse outcomes (odds ratio, 0.22; confidence interval, 0.06-0.79) developing in patients with a stage II elephant trunk procedure. CONCLUSIONS: During descending thoracic aortic and thoracoabdominal aortic aneurysm repairs, the use of deep hypothermic circulatory arrest results in improved postoperative adverse outcome rates compared with non-deep hypothermic circulatory arrest techniques. The development of reversible adverse outcomes is strongly associated with the development of permanent adverse outcomes.

Staged approach prevents spinal cord injury in hybrid surgical-endovascular thoracoabdominal aortic aneurysm repair: an experimental model.

BACKGROUND: In a porcine model, we investigated the impact of sudden stent graft occlusion of thoracic intercostal arteries after open lumbar segmental artery (SA) ligation. METHODS: After randomization into two groups, 20 juvenile Yorkshire pigs (27.1±0.6 kg) underwent open lumbar SA sacrifice (T13-L5) followed by endovascular coverage of all thoracic SAs (T4-T12) at 32°C, either in a single operation (group 1) or in two stages separated by seven days (group 2). Collateral network pressure (CNP) was monitored by catheterization of the SA L1, and postoperative hind limb function was assessed using a modified Tarlov score. RESULTS: The CNP in group 1 decreased to 34% of baseline, whereas CNP after lumbar SA ligation in group 2 fell to 55% of baseline (74±2.4 to 25±3.6 mm Hg vs 74±4.5 to 41±5.5 mm Hg; p<0.0001). Subsequent thoracic stenting (group 2) led to another significant but milder drop (p=0.002 versus stage 1) from the restored CNP (71±4.2 to 54±4.9 mm Hg). Five of ten pigs in group 1 suffered paraplegia, in contrast to none in group 2 (median Tarlov score 6, vs 9; p=0.0031). Histopathologic analysis showed more severe ischemic damage to the lower thoracic (p=0.05) and lumbar spinal cord (p=0.002) in group 1. CONCLUSIONS: These results underline the potential of the staged approach in hybrid procedures. Furthermore they highlight the need for established adjuncts for preventing paraplegia in hybrid and pure stent-graft protocols in which sudden occlusion of multiple SAs occurs.

Long-term outcome after aortic arch replacement with a trifurcated graft.

OBJECTIVE: We describe the long-term results of aortic arch replacement using a trifurcated graft, including an assessment of survival, neurologic complications, and graft patency. METHODS: A retrospective review was conducted on data from 206 consecutive patients (125 male; median age, 67 years; range, 20-87 years) who had a trifurcated graft used for aortic arch replacement between September 1999 and September 2009. Seventy-four patients (35.9%) had chronic dissection, 68 patients (33.0%) had atherosclerotic aneurysms, and 39 patients (18.9%) had degenerative disease. Ninety-one patients (44.2%) had undergone previous cardiac surgery. RESULTS: An elephant trunk was placed in 190 patients (92.2%) and completed in 101 patients (53.1%), with an interval of less than 365 days between stages in 94 of 101 patients. Hospital mortality was 6.8% (14/206). Adverse outcome (death/stroke within the first year postoperatively) occurred in 27.7% of patients (57/206; 50 deaths/7 strokes). Among 152 1-year survivors, the annual rates of transient ischemic attack and stroke were 0.85% and 1.1%, respectively. At 6 years, 75% of patients were still alive, compared with 92% in a matched New York State control population (P < .001). Follow-up computed tomography scans (189 studies in 176/206 patients [85.4%]) revealed 100% patency of the trifurcated graft limbs at a mean of 2.3 years. CONCLUSIONS: Aortic arch replacement using a trifurcated graft is highly durable, with excellent patency in the branch grafts, and is associated with a low incidence of cerebral embolization. However, the long-term outcome in these patients is compromised by extensive comorbidities.