Long-Term Surgical Outcomes Following Intraluminal Sutureless Graft Insertion for Type A Aortic Dissection

Abstract

The long-term outcome of sutureless intraluminal graft insertion remains unclarified. Therefore, we reviewed the late surgical outcomes of patients who underwent this procedure for acute type A dissection. Between March 1990 and May 2000, 80 patients aged from 36 to 92 years underwent isolated replacement of the ascending aorta for type A acute aortic dissection. The surgical procedures performed were replacement with an intraluminal sutureless graft in 18 patients (group 1) and suturing of the aorta with a conventional Dacron prosthesis in 62 patients (group 2). The cross-clamp, extracorporeal circulation, circulatory arrest, and operation times were significantly shorter in group 1 than in group 2, and the amount of total blood transfusion was also significantly less in group 1 than in group 2. The hospital mortality rates were 11.1% (2/18) in group 1 and 9.7% (6/62) in group 2 (P> 0.999). The 5-year actuarial survival rates (including operative mortality) were 71% +/- 11% in group 1 and 77% +/- 9% in group 2 (P = 0.268). The event-free survival rates at 5 years were 80% +/- 10% in group 1, and 67% +/- 13% in group 2 (P = 0.780). Regarding graft-related complications, long-term follow-up revealed one graft-related death and one reoperation in group 1 (12.5%), and no graft-related complications in group 2 (0%) (P = 0.047). In conclusion, intraluminal sutureless grafts required less blood transfusion, and shorter cross-clamp, extracorporeal circulation, circulatory arrest, and surgery times. However, the procedure did not improve the hospital mortality or long-term outcome. In fact, the rate of graft-related complications was significantly higher in the intraluminal sutureless group than in the sutured group. Therefore, the intraluminal graft insertion technique should be used only under exceptional circumstances.

Α systematic review and meta-analysis of the efficacy of aortic anastomotic devices

“…Taking into account that surgical mortality for acute aortic dissection with conventional hand-sewn anastomosis ranges from 9% to 35% 83,84 it can be argued that AADs had an all-cause 30-day death rate at the lower extreme of the range. However, no direct comparison between AAD and hand-sewn anastomosis was made, except in two studies, Liu et al 45 (IRG, 10.9%; hand-sewn, 11.1%) and Kawahito et al 34 (IRG, 11.1%; hand-sewn, 9.7%). Only one IRG device-related death was reported.…”

“…devices during open surgery, whereas five studies [13][14][15][16][17] reported a laparoscopic approach. Only two studies 34,45 reported comparative results of postoperative outcomes for hand-sewn anastomosis vs AADs. The rest of the studies reported results for anastomotic devices without a comparative group.…”

“…24 Aortic cross-clamping time. A total of 27 cohorts 10,14,15,17,[21][22][23][24]26,27,[29][30][31][32][34][35][36]40,[47][48][49][50][51] reported results of aortic cross-clamping. Only 11 cohorts provided the variability of the mean aortic clamping time, whereas 2 cohorts (Papadimitriou et al 17 and Segers et al, 15 group A) reported zero aortic clamping time and were not included in the meta-analysis.…”

“…The proportion ranged from 0% to 50% (Oz et al, 29 group B). There were two cases of migration of the device (Lemole et al, 49 Lemole 31 group B) and one case of device-related reoperation (Kawahito et al 34 ).…”

Biomechanical characterization of a novel ring connector for sutureless aortic anastomosis

“…The groove limits the vessel lumen diameter and blood flow that may lead to the occurrence of thrombosis or other complications. The tightened aortic tissue around the vascular ring connector could have become weak and thus would be subject to late disruption, although the reported pathological findings alleviated concerns about this potential problem [14] . Some expandable prostheses make themselves more convenient to be inserted into the aorta, but the procedure and use of the device is more complex, and the sophisticated design also increases the manufacturing cost [15 – 17] .…”