In our experience, ASCP was a safe technique for thoracic aorta surgery allowing complex aortic repairs to be performed with good results in terms of hospital mortality and neurologic outcomes. The fact that there was no difference between the two groups suggests that moderate systemic hypothermia (26 degrees C) appears to be a safe and sufficient tool for brain protection. Moreover, the well known hypothermia-related side effects may be avoided.
SummaryTreating complex aortic arch disease with proximal and distal aortic segment involvement is challenging. In recent years, different surgical and endovascular techniques have been applied in a single or multiple-stage approach with the aim to cure and simplify these conditions. The first procedure available for this purpose was the conventional elephant trunk technique. Its recent evolution is the frozen elephant trunk, which treats the descending thoracic aorta using the antegrade release of a self-expandable stent graft. In the following review article, we analyse the advantages and drawbacks of both techniques from clinical and practical perspectives.
The results of the surgical treatment of AAAD are acceptable and mainly influenced by patient's status at presentation. Malperfusion of more organ systems makes the prognosis unfavourable and immediate proximal aortic repair may be sub-optimal. In these situations, alternative management strategies should be considered.
We compared the results of 2 groups of patients who underwent aortic arch replacement with the frozen elephant trunk technique. In the first group, the distal anastomosis was performed in arch zone 2; in the second control group, the distal anastomosis was performed in arch zone 3.
Between January 2007 and April 2018, the frozen elephant trunk technique was used in 282 patients. The median age was 62 years (range 18–83 years), and 233 patients were men (82.6%). Two different frozen elephant trunk prostheses were used: the Jotec E-vita open prosthesis in 167 patients (59.2%) and the Vascutek Thoraflex hybrid prosthesis in 115 patients (40.8%). Patients were divided into 2 groups according to the distal anastomosis site: zone 2 group (69 patients) and zone 3 group (213 patients). The main indications were chronic aortic dissection (n = 164, 58.2%), degenerative aneurysm (n = 72, 25.5%) and acute aortic dissections (n = 45, 16%).
The overall in-hospital mortality rate was 17%: 20% for the zone 2 group and 16% for the zone 3 group, without significant differences, also in terms of cardiopulmonary bypass and myocardial ischaemia times. However, the visceral ischaemia time was significantly shorter for the zone 2 group, whereas the antegrade selective cerebral perfusion time was significantly longer for the same group. Recurrent laryngeal nerve injury rate was lower in the zone 2 group. The overall postoperative paraplegia rate was 3.5%, whereas the occurrence of permanent neurological dysfunction and dialysis was 9% and 19%, respectively, with no significant differences between the groups.
‘Proximalization’ of the distal anastomosis can be used for arch reconstruction, especially in complex cases such as reoperations or acute aortic dissections. Furthermore, with the aid of branched hybrid grafts, a reduction of the visceral ischaemia time is achieved.
Type B aortic dissection can be treated effectively with TEVAR. The incidence of distal SINE is not negligible but is not associated with poor outcomes. The main determinant of SINE seems to be an excessive oversizing, which is particularly evident in the distal end. More accurate sizing can be obtained by evaluating the area of the true lumen.
The frozen elephant trunk technique with the new E-vita open prosthesis combines surgical and interventional technologies and represents a feasible and efficient option in the treatment of complex aortic pathologies. Strict monitoring of the patient has to be carried out in order to detect possible evolution of the aortic lesion, which can require prompt treatment. However, long-term follow-up is required.
Within the limitations of this retrospective study, we can conclude that aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection.
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