Jaroslav Benedik

Multicenter early experience with extended aortic repair in acute aortic dissection: Is simultaneous descending stent grafting justified?

OBJECTIVE In acute type A aortic dissection, the extension of repair to downstream aorta has been controversially discussed. We present the early results of a multicenter study using a hybrid stent graft prosthesis. METHODS Between January 2005 and January 2010, the data from 191 patients after combined proximal aortic replacement and antegrade stent grafting were collected in the database of the International E-vita open Registry. Of the 191 patients, 68 underwent surgery for acute aortic dissection and were included in the present study. Hypothermic circulatory arrest and selective cerebral perfusion were routinely used. Computed aortic imaging was performed for false lumen evaluation during follow-up. RESULTS The in-hospital mortality rate was 13% (9/68). Along the stent graft, the rate of immediate complete false lumen thrombosis was 86% (51/59) and increased during follow-up (23 ± 17 months) to 94% (46/49). Distally, complete or partial false lumen thrombosis was initially observed in 61% (36/59) and in 82% (40/49) after follow-up. The 1- and 3-year actuarial survival rate was 82% and 74%, respectively. CONCLUSIONS Extended thoracic aortic repair of acute aortic dissection with a hybrid stent graft is feasible at acceptable early mortality and promotes false lumen thrombosis around the stent graft and below.

Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry.

OBJECTIVES Arch replacement combined with antegrade stent grafting of the descending aorta represents a hybrid surgical approach for extensive thoracic aortic disease. This multicentre study evaluates the early results of this method in complex aortic dissection (AD). METHODS Retrospective data acquisition was achieved by institution of an international registry. A hybrid stent graft with integrated vascular prosthesis for arch replacement (E-vita open®) was used. From January 2005 to March 2009, 106 patients (mean age 57; 77% male) with complex AD (55 acute, 51 chronic) were studied. RESULTS As many as 49/106 (46%) patients underwent emergency surgery. Stent-graft deployment and arch replacement (95 total, 11 subtotal) were performed under hypothermic circulatory arrest (HCA (8±6min) and selective antegrade cerebral perfusion (SACP) (74±23min). Stent-graft placement into the true lumen was successful in all but one case (99%). Ascending aortic replacement was performed in 91/106 (86%), aortic valve repair/replacement in 49/106 (46%), coronary artery bypass grafting (CABG) in 17/106 (16%) and mitral valve repair in 2/106 (2%). Cardiopulmonary bypass (CPB) and cardiac arrest times were 242±64 and 144±44min, respectively. In-hospital mortality was 12% (13/106; six acute, seven chronic AD) and new strokes observed in 5/106 (5%). The false lumen (FL) was evaluated in 96/106 (91%) patients postoperatively. At first follow-up computed tomography (CT)-examination, thoracic FL thrombosis was 93% (76 complete, 13 partial) and 58% (31 complete, 25 partial) in the thoraco-abdominal aorta. CONCLUSIONS By combining arch replacement with downstream stent grafting, one-stage repair of complex aortic dissection with almost unanimous thoracic FL thrombosis can be achieved at acceptable perioperative risk.

Aortic remodelling in aortic dissection after frozen elephant trunk

OBJECTIVES Frozen elephant trunk (FET) can be used for continuous downstream aorta treatment in acute aortic dissection (AAD) and chronic aortic dissection (CAD). The study reports the changes in the lumen volumes along the downstream aorta towards remodelling. METHODS In 70 patients (22 CAD, 48 AAD), pre-, postoperative and at least the 1-year follow-up aortic imaging was available. Volume changes of aortic lumen (AL) and true lumen (TL) between examinations along the stent graft aortic segment (A), downstream to coeliac trunk (B) and distally to bifurcation (C) were used for quantification. TL increase >10% with stable AL or AL decrease >10% with stable TL were classified as positive, changes within a 10% threshold as stable, and all other changes as negative remodelling. RESULTS In AAD, positive or stable remodelling occurred in A (90%), B (65%), C (58%) within 1 year, thereafter in 26 patients (follow-up: 47 ± 21 months) in A (92%), B (65%), C (62%). Negative remodelling in ≥2 segments was found in 5/26 (19%) patients. In CAD, positive or stable remodelling occurred in A (100%), B (86%), C (77%) within 1 year, thereafter in 16 patients (follow-up: 46 ± 20 months) in A (75%), B (44%), C (38%). Negative remodelling in ≥2 segments was found in 7/16 (43%) patients, 5 underwent reintervention, and stabilized thereafter. CONCLUSIONS FET facilitates positive remodelling in AAD and CAD down to stent graft level. Distally, 20% AAD and 40% CAD patients remain at risk for secondary reintervention, and can be identified by negative remodelling in ≥2 segments in the follow-up examinations.

Six-year experience with a hybrid stent graft prosthesis for extensive thoracic aortic disease: an interim balance

OBJECTIVES To avoid a two-stage surgical approach for complex thoracic aortic disease with its additive mortality and morbidity, a hybrid stent graft prosthesis was introduced 6 years ago for simultaneous treatment of the ascending, arch and descending aortas, relying proximally on a surgical suture line with an integrated distal stent graft for downstream splinting. We report the mid-term single-centre experience. METHODS Between January 2005 and March 2011, 77 patients (mean age 59 years, male 75%) with acute (AAD, n = 39) or chronic aortic dissection (CAD, n = 23) DeBakey type I or an extensive thoracic aortic aneurysm (TAA, n = 15) underwent one-stage repair. Periodic follow-up studies (100%, mean 29 months) included repeat aortic computed tomography imaging. Major adverse events (MAEs) were defined as permanent stroke, spinal cord injury and dialysis. RESULTS In-hospital mortality was 10% (8 of 77). The incidence of MAE in AAD, CAD and TAA was 5, 13 and 20%, respectively. At the last follow-up, the complete thrombosis of the thoracic false lumen was 92% for AAD, 91% for CAD and the full exclusion of aneurysms 100% in TAA. Throughout the follow-up, freedom from aortic disease-related death was 93% and 5-year survival 79%. Freedom from distal reoperation was 94% in AAD, 95% in CAD and 100% in TAA and the incidence of distal stent graft extension 10% (8 of 77). CONCLUSIONS The durable hybrid one-stage repair of complex thoracic aortic disease is feasible with acceptable mortality. Distal reintervention is infrequent and associated with low risk; thus, the indication for the optimization of the peripheral flow using the endovascular aortic repair techniques is gradually widened.

The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition

OBJECTIVE The DeBakey classification was used to discriminate the extent of acute aortic dissection (AD) and was correlated to long-term outcome and re-intervention rate. A slight modification of type II subgroup definition was applied by incorporating the aortic arch, when full resectability of the dissection process was given. METHODS Between January 2001 and March 2010, 118 patients (64% male, mean age 59 years) underwent surgery for acute AD. As many as 74 were operated on for type I and 44 for type II AD. Complete resection of all entry sites was performed, including antegrade stent grafting for proximal descending lesions. RESULTS Patients were comparable with respect to demographics and preoperative hemodynamic status. They underwent isolated ascending replacement, hemiarch, or total arch replacement in 7%, 26%, and 67% in type I, versus 27%, 37%, and 36% in type II, respectively. Additional descending stent grafting was performed in 33/74 (45%) type I patients. In-hospital mortality was 14%, 16% (12/74) in type I versus 9% (4/44, type II), p=0.405. After 5 years, the estimated survival rate was 63% in type I versus 80% in type II, p=0.135. In type II, no distal aortic re-intervention was required. In type I, the freedom of distal re-interventions was 82% in patients with additional stent grafting versus 53% in patients without, p=0.022. CONCLUSIONS The slightly modified DeBakey classification exactly reflects late outcome and aortic re-intervention probability. Thus, in type II patients, the aorta seems to be healed without any probability of later re-operation or re-intervention.

Angioscopy — a valuable tool in guiding hybrid stent grafting and decision making during type A aortic dissection surgery §

During hypothermic circulatory arrest (HCA), a briefly visible descending aorta is exposed, enabling direct vision to the surgeon. This study evaluated the impact of angioscopy on arch and descending aortic surgery for type A aortic dissection (AD). From December 2007 to March 2009, a flexible bronchovideoscope was used in 21 patients to assure true lumen (TL) positioning of the arterial cannula during open vision aortic cannulation (OVAC; nine of 21 cases) and to inspect the arch and descending aorta for re-entries, guide wire position and target zone for hybrid stent graft (SG) landing (20 of 21 cases). In OVAC, angioscopy secured positioning of the arterial cannula within the TL requiring additional 10-15s of cerebral ischaemia. In 10 of 21 cases, no additional re-entries were found, thus obviating arch replacement in 2 of 21 and stent grafting in 8 of 21. In 11 of 21 cases, SG deployment was guided to the target zone, in three cases incomplete unfolding initiated balloon dilatation. Angioscopy has become an indispensable tool for decision making in AD to apply OVAC, downstream stent grafting and landing zone control with the ability to indicate ballooning at neglectable time requirements during HCA.

Complete reversal of paraplegia after thoracic endovascular aortic repair in a patient with complicated acute aortic dissection using immediate cerebrospinal fluid drainage

Although there are so far no randomized studies, it is generally believed that the risk of neurologic complications following thoracic endovascular aortic repair (TEVAR) compares favorably with open surgery. Nevertheless, stroke and paraplegia from spinal cord ischemia (SCI) in particular, which is encountered in 0.8–7.5% of patients after TEVAR, remain catastrophic complications of this rapidly emerging technique [1, 3, 8, 11]. Previous studies have established a role for prophylactic cerebrospinal fluid (CSF) drainage to prevent paraplegia in patients undergoing extensive thoracoabdominal aortic surgery [6, 9, 14]. In patients undergoing TEVAR, data on the protective effect of prophylactic CSF drainage for preventing SCI are, however, conflicting and thus pre-emptive CSF drainage is used only rarely in those deemed at excessive risk for developing paraplegia with, for example, extensive thoracoabdominal aortic pathology requiring implantation of multiple endoprostheses or insufficient spinal collateral circulation due to prior or concomitant abdominal aortic surgery [10, 12]. So far, few reports have reported on the use of selective CSF drainage after onset of paraplegia with, however, variable clinical successes, ranging from complete reversal to persistent severe neurologic deficit [5, 10, 12]. We report the successful use of immediate CSF drainage after delayed-onset paraplegia in a patient who underwent TEVAR for acute aortic dissection complicated by malperfusion syndrome.

Is there any difference in aortic wall quality between patients with aortic stenosis and those with regurgitation

OBJECTIVES The interaction between aortic valve (AV) and aortic wall pathology is currently unclear. No intraoperative examination or investigation is able to predict postoperative dissection or aneurysm formation in patients operated on for primary AV pathology. The aim of the present study was therefore to evaluate the mechanical and histological properties of the aortic wall in patients operated on for aortic stenosis (AS) or regurgitation (AR). METHODS The aortic walls of 229 patients (age 67.5 ± 11.0 years) operated on for AS (n = 135, Group 1) or AR (n = 94, Group 2) were subjected to mechanical stress testing and postoperative histological examination. Ascending aortic diameter was ≥50 mm in 46/229 patients and 40-49 mm in 52/229 patients. RESULTS AR was associated with an increased tendency to aortic media disruption (P < 0.001) and with media degeneration (P < 0.001) compared with AS patients. The incidence of aortic aneurysm (≥50 mm) was increased in AR patients (35 in AR and 11 in AS, P < 0.01). The aortic wall cohesion was better in patients with an aortic diameter of <40 mm compared with those with moderate dilatation of 40-49 mm (P = 0.009) or an aortic aneurysm (P = 0.002). CONCLUSIONS Our study proves that patients presenting for AV replacement with AR have a poorer quality of the ascending aorta despite a superior thickness compared with patients with AS. In addition, patients with a slightly dilated aorta (40-49 mm) have a poorer cohesion of the aortic wall than those with normal aortic dimensions.

Overall Essen's experience with the E-vita open hybrid stent graft system and evolution of the surgical technique

BACKGROUND The hybrid stent graft prosthesis E-vita open was designed and introduced by us in 2005 to avoid a two-stage surgical approach in the surgical treatment of complex thoracic aortic disease. Experience in ascending aortic and arch replacement with simultaneous stent grafting of the descending aorta was accumulated over the past 8 years. Facilitation of surgical technique by moving the distal suture line from Zone 3 into Zone 2 took place in 2009. We report our mid-term single-center experience comparing both surgical periods. METHODS Between January 2005 and July 2013 a total of 132 patients (mean age 59±11 years) underwent one stage surgery for acute (AAD, n=74), chronic aortic dissection (CAD, n=35) or an extensive thoracic aortic aneurysm (TAA, n=23). Patients were separated in two groups according to distal anastomosis level in Zone 2 (Z2, 41/132) and Zone 3 (Z3, 91/132). Outcome, ischemic and operative times as well as adverse events were monitored during follow up. RESULTS Overall in-hospital mortality was 13% (17/132) without difference between the groups. However, Zone 2 anastomosis resulted in reduction of cardioplegic arrest (117±39 vs. 147±35 minutes; P<0.001), selective cerebral perfusion (52±15 vs. 68±18 minutes; P<0.001) and visceral ischemic time (51±19 vs. 72±23 minutes; P<0.001). The incidence of postoperative temporary hemodialysis decreased from 40% to 20% in Z2 (P=0.028), postoperative re-exploration rate from 15% to 2% (P=0.037). No difference was found in dissection with complete false lumen thrombosis in 83% (90/109) within 10 days, as well as in TAA, where 100% aneurysm exclusion was observed. Three-year survival, freedom from thoracoabdominal aortic surgery and endovascular repair was 93%, 88%, 88%, respectively. Overall 5-year survival was 76% in AAD, 85% in CAD and 79% in TAA patients. CONCLUSIONS The dimension of surgery could be successfully reduced, indicated by significantly shortened ischemic times and postoperative complications. Durable one-stage repair of complex thoracic aortic disease could be achieved in the majority of cases with acceptable mortality. Distal reintervention is infrequent but associated with low risk when indicated.

The past, present and future of minimally invasive therapy in endovascular interventions: A review and speculative outlook

Abstract Cardiovascular disease is a leading cause of death in all developed countries. In response to this need, endovascular management techniques have been developed across a large range of medical specialties. Minimally invasive percutaneous interventions were initially complex and challenging, but with the continued development of equipment and expertise their use has become routine in many fields. With routine use, it has become important to establish the safety and efficacy of endovascular treatments against the respective “gold standard” procedures, especially in light of their initial intended use for the management of patients at unacceptably high risk for standard therapy only. Such evaluation has to take into account the variety and diversity of devices and techniques, as well as the effects of operator dependability. Endovascular techniques are increasingly recognised as valid alternative management options for a variety of conditions, and it is anticipated that the current trend towards minimally invasive techniques will continue in the future, with moves towards increasingly complex endovascular techniques and hybrid interventions.