Neurologic outcome after aortic arch repair with frozen elephant trunk: The pivotal role of hypothermic circulatory arrest time

Objectives The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. Methods Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. Conclusions Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

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Total arch replacement and frozen elephant trunk for aortic dissection in aberrant right subclavian artery

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa029 ◽

2020 ◽

Vol 58 (1) ◽

pp. 104-111 ◽

Cited By ~ 1

Author(s):

Jian-Rong Li ◽

Wei-Guo Ma ◽

Yu Chen ◽

Jun-Ming Zhu ◽

Jun Zheng ◽

...

Keyword(s):

Aortic Dissection ◽

Subclavian Artery ◽

Circulatory Arrest ◽

False Lumen ◽

Hypothermic Circulatory Arrest ◽

Total Arch Replacement ◽

Aberrant Right Subclavian Artery ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Artery Cannulation

Abstract OBJECTIVES Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience. METHODS From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15–40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft. RESULTS ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011–1.348; P = 0.034). CONCLUSIONS The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.

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Aortic arch repair — Report of experiences with deep hypothermic circulatory arrest and with retrograde cerebral perfusion

The AustralAsian Journal of Cardiac and Thoracic Surgery ◽

10.1016/1037-2091(92)90010-n ◽

1992 ◽

Vol 1 (2) ◽

pp. 31-36

Author(s):

George Matalanis ◽

Brian Buxton

Keyword(s):

Aortic Arch ◽

Cerebral Perfusion ◽

Circulatory Arrest ◽

Deep Hypothermic Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Retrograde Cerebral Perfusion ◽

Aortic Arch Repair

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Risk Factor Analysis of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk With Aortic Balloon Occlusion

10.21203/rs.3.rs-554555/v1 ◽

2021 ◽

Author(s):

Luchen Wang ◽

Yunfeng Li ◽

Yaojun Dun ◽

Xiaogang Sun

Keyword(s):

Hospital Stay ◽

Aortic Arch ◽

Circulatory Arrest ◽

Balloon Occlusion ◽

Conventional Group ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

Aortic Balloon Occlusion

Abstract Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 minutes, which increases the surgical risk. We invented an aortic balloon occlusion technique that requires 5 minutes of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods: This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of aortic balloon occlusion group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during the in-hospital stay were also recorded. Results: The 30-day mortality rates were similar between the aortic balloon occlusion group (4.6%) and the conventional group (7.8%, P = 0.241). Multivariate analysis showed aortic balloon occlusion reduced postoperative acute kidney injury (23.1% vs 35.7%, P = 0.013) and hepatic injury (12.3% vs 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions: The aortic balloon occlusion achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.

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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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