Dataset Information

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

ABSTRACT:

Objective

We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1.

Methods

We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the TAR group, the HAR group was older (68.1 vs 60.9 years; P < .01) and had more thrombosed false lumen (28.8% vs 4.1%, P < .01).

Results

In-hospital death occurred for 7 patients in the HAR group and 1 patient in the TAR group (P = .17). More patients in the TAR group had a postoperative thrombosed false lumen, compared with the HAR group (68% vs 54%, P = .03). In patients with preoperative nonthrombosed false lumen in the HAR group, the rate of postoperative thrombosis was significantly lower than with versus without an open stent (31% vs 65%, P = .01). The rate of freedom from an aortic arch event in the TAR group at 5 years was significantly greater than that in the HAR group (100% vs 83.7%, P = .01).

Conclusions

Stented elephant trunk with TAR provided a high rate of false lumen thrombosis and a low incidence of arch events, whereas an open stent during HAR was not beneficial in terms of false lumen thrombosis and arch event prevention.

SUBMITTER: Hayashi J

PROVIDER: S-EPMC9510885 | biostudies-literature | 2022 Sep

REPOSITORIES: biostudies-literature

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Publications

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

Hayashi Jun J Nakajima Hiroyuki H Asakura Toshihisa T Sho Ri R Tokunaga Chiho C Takazawa Akitoshi A Yoshitake Akihiro A

JTCVS open 20220625

<h4>Objective</h4>We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1.<h4>Methods</h4>We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the ...[more]

PMID: 36172444

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Project description:ObjectiveEmergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called "branched stented anastomosis frozen elephant trunk repair." Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A.MethodsWe compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration.ResultsOf 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75 ± 24, 118 ± 47), total operation (313 ± 83, 470 ± 151), and cardiopulmonary bypass (195 ± 46, 277 ± 96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P < .001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery-related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P < .05).ConclusionsExtended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.

Project description:ObjectiveTraditional total arch replacement with frozen elephant trunk requires 2 separate grafts in the descending thoracic aorta and arch, and frequently requires a graft-to-graft anastomosis, which is prone to bleeding. The Thoraflex (Terumo Aortic) device treats the arch and descending thoracic aorta in a single device but has not been compared directly to traditional total arch replacement with frozen elephant trunk and has not been studied in a real-world context in the United States.MethodsA consecutive sample of total arch replacement with frozen elephant trunk patients across 5 different institutions between January 2018 and January 2024, identified 438 patients of which 83 out of 438 (18.9%) had a Thoraflex device. Propensity score matching in a 1:2 ratio identified 166 well-matched controls. Groups were compared across perioperative outcomes.ResultsOne hundred forty out of 438 (32%) patients presented with acute type A dissection, 112 out of 438 (26%) had an aneurysm, and 87 out of 438 (20%) had chronic dissection with a previous proximal repair. One hundred thirty-two out of 438 (30%) underwent surgery on an emergency or emergency/salvage basis. Median (interquartile range [IQR]) crossclamp times in the Thoraflex and traditional matched groups were 71 (IQR, 48-105) and 82 (IQR, 62-123), respectively, (P = .012). Total circulatory arrest times were 19 minutes (IQR, 13-32 minutes) and 23 minutes (IQR, 17-37 minutes), respectively (P = .009). Total procedure times were 6.1 hours (IQR, 5.2-7.3 hours) and 6.8 hours (IQR, 5.7-8.2 hours), respectively (P = .012). The operative mortality, stroke, and paralysis rates were 11 out of 83 (13%), 16 out of 83 (19%), and 4 out of 83 (5%), respectively, in the Thoraflex group and were not significantly different than matched controls.ConclusionsThe Thoraflex hybrid device facilitates shorter crossclamp and circulatory arrest times for arch replacement, with similar observed mortality and stroke rates compared with matched controls.

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Dataset Information

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

Objective

Methods

Results

Conclusions

Publications

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

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