Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes

Background: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. Methods: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). Results: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. Conclusion: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.

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Single-Stage Treatment of Aneurysm of the Distal Aortic Arch and Proximal Descending Aorta Using the Frozen Elephant Trunk Procedure. Case Report

PRILOZI ◽

10.2478/prilozi-2020-0047 ◽

2020 ◽

Vol 41 (3) ◽

pp. 65-70

Author(s):

Sasko Jovev ◽

Vasil Papestiev ◽

Marjan Shokarovski ◽

Stefanija Hadzievska ◽

Nadica Mehmedovic ◽

...

Keyword(s):

Aortic Arch ◽

Median Sternotomy ◽

Aortic Aneurysms ◽

Single Stage ◽

Frozen Elephant Trunk ◽

Organ Protection ◽

Elephant Trunk ◽

Descending Aorta ◽

Systemic Hypothermia ◽

Elephant Trunk Procedure

AbstractAneurysms of the thoracic aorta involving the distal arch and the proximal descending aorta have traditionally been treated with two open procedures. During the first stage, the aortic arch pathology has been addressed through a median sternotomy. Several weeks or months later, a second stage followed and included completing the repair of the descending aorta through a lateral thoracotomy.We, herein, report a single stage repair of an aneurysm involving the distal aortic arch and the proximal descending aorta using the frozen elephant trunk operative technique. Vascular hybrid stent graft prosthesis, specifically designed for treatment of extensive aortic aneurysms, has been used to replace the arch component and exclude the descending aorta component of the aneurysm through a median sternotomy, using bilateral antegrade cerebral perfusion and mild systemic hypothermia for intraoperative organ protection.

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Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience

Aorta ◽

10.1055/s-0041-1725073 ◽

2021 ◽

Author(s):

Petar Risteski ◽

Isabel Radacki ◽

Andreas Zierer ◽

Aris Lenos ◽

Anton Moritz ◽

...

Keyword(s):

Aortic Arch ◽

Cerebral Perfusion ◽

Operative Mortality ◽

Mild Hypothermia ◽

Aortic Surgery ◽

Graft Infection ◽

Elephant Trunk ◽

Aortic Arch Surgery ◽

Systemic Hypothermia ◽

Antegrade Cerebral Perfusion

Abstract Background The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. Methods Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. Results The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality (p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality (p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. Conclusion Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

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Single-Stage Treatment of Extensive Aortic Pathology Using the Frozen Elephant Trunk Procedure

The Heart Surgery Forum ◽

10.1532/hsf.3063 ◽

2020 ◽

Vol 23 (5) ◽

pp. E606-E610

Author(s):

Petar Risteski ◽

Vasil Papestiev ◽

Stefanija Hadzievska ◽

Nadica Mehmedovic ◽

Nikola Lazovski ◽

...

Keyword(s):

Aortic Arch ◽

Single Stage ◽

Frozen Elephant Trunk ◽

Organ Protection ◽

Elephant Trunk ◽

Descending Aorta ◽

Cardiac Morbidity ◽

Aortic Pathology ◽

Cord Injury ◽

Elephant Trunk Procedure

Background: Extensive pathology involving the aortic arch and descending aorta traditionally has been treated with two open procedures. We report our institutional experience with a single stage frozen elephant trunk procedure for treatment of extensive aortic pathology. Methods: Between June 2018 and October 2019, nine patients (eight males, 89%, mean age 61 ± 6 years) with extensive aortic pathology were operated using the frozen elephant trunk procedure. Five (56%) patients underwent primary operation for chronic arch and proximal descending aneurysm in two (22%) patients, chronic type B aortic dissection in two (22%) patients and penetrating aortic ulcer in one (11%) patient. The other four (44%) patients received reoperative surgery for chronic post-dissection aneurysms. For organ protection during the aortic arch procedure, we used selective antegrade cerebral perfusion and mild systemic hypothermia at 28°C. Results: Early mortality was not observed. A single (11%) patient developed focal stroke. Unilateral vocal cord palsy was present in two (22%) patients. Spinal cord injury was not observed. Reexploration for bleeding was required in two (22%) patients. Prolonged ventilation, liver and kidney failure as well as cardiac morbidity were not observed. Two patients (22%) with anticipated Endoleak type Ib received TEVAR extension at follow up. Mid-term mortality was observed in two (22%) patients, due to pneumonia. Conclusion: The frozen elephant trunk procedure can be used for a single-stage treatment of patients with extensive aortic pathology, due to chronic degenerative aneurysms or post-dissection aneurysms involving the aortic arch and the descending aorta, with acceptable mortality and morbidity.

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Review of frozen elephant trunk repair with the Thoraflex Hybrid device

Future Cardiology ◽

10.2217/fca-2020-0152 ◽

2021 ◽

Author(s):

Vincent Chauvette ◽

Maral Ouzounian ◽

Jennifer Chung ◽

Mark Peterson ◽

Munir Boodhwani ◽

...

Keyword(s):

Aortic Arch ◽

Current Evidence ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Hybrid Device ◽

Future Design ◽

Design Considerations ◽

Elephant Trunk Technique ◽

Aortic Arch Repair ◽

Frozen Elephant Trunk Technique

The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.

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Endovascular Retrieval of Entrapped Elephant Trunk Graft During Complex Hybrid Aortic Arch Repair

CardioVascular and Interventional Radiology ◽

10.1007/s00270-016-1453-8 ◽

2016 ◽

Vol 39 (12) ◽

pp. 1770-1773 ◽

Cited By ~ 2

Author(s):

Karthikeyan Damodharan ◽

Victor T. T. Chao ◽

Kiang Hiong Tay

Keyword(s):

Aortic Arch ◽

Elephant Trunk ◽

Aortic Arch Repair ◽

Complex Hybrid

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Different aortic arch surgery methods for type A aortic dissection: clinical outcomes and follow-up results

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa095 ◽

2020 ◽

Vol 31 (2) ◽

pp. 254-262

Author(s):

Yunxing Xue ◽

Jun Pan ◽

Hailong Cao ◽

Fudong Fan ◽

Xuan Luo ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Clinical Outcomes ◽

Type A ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Aortic Arch Surgery

Abstract OBJECTIVES The aim of this study was to investigate the clinical outcomes and follow-up results among 5 main aortic arch surgery methods for type A aortic dissection in a single centre. METHODS From 2002 to 2018, 958 type A aortic dissection patients who received surgical repair were divided into 5 groups according to the arch surgery method: hemiarch replacement (n = 206), island arch replacement (n = 54), total arch replacement with frozen elephant trunk (n = 425), triple-branched stent (n = 39) and fenestrated stent (n = 234). The indications for the different arch methods were related to the patient’s preoperative status, the location and extent of the dissection and the surgical ability of the surgeons. A comparative study was performed to identify the differences in the perioperative data, and the Kaplan–Meier analysis was used to assess the long-term survival and reintervention rates. Thirty matched surviving patients that were included in each group completed Computed tomography angiography to determine long-term reshaping effect. RESULTS The 30-day mortality rate was 15.8%, and there was no difference among the 5 groups (P = 0.848). The follow-up survival rates were similar among the 5 groups (P = 0.130), and the same was true for patients without reintervention (P = 0.471). In the propensity matching study, patients with stents (frozen elephant trunk, triple-branched stent, fenestrated stent) had a slower aortic dilation rate and a higher ratio of thrombosis in the false lumen at the descending aortic and abdominal aortic levels than patients without stents. CONCLUSIONS No standard method is available for arch surgery, and indications and long-term effects should be identified with clinical data. In our experiences, simpler surgical procedures could reduce mortality in critically ill patients and stents in the distal aorta could improve long-term reshape effects.

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