Julia Morlock

Technical details making aortic arch replacement a safe procedure using the Thoraflex™ Hybrid prosthesis

Summary The development of new devices to improve treatment and to explore new indications that have not yet been adequately addressed is a natural consequence of the clinical demand for solutions to as yet unmet needs. The frozen elephant trunk technique was one of the major steps within the last 15 years to improve on existing treatments as well as to explore new indications. The goal of this article is to provide technical details about advances in implantation techniques for the treatment of acute and chronic thoracic aortic pathological conditions.

The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection

OBJECTIVES Our goal was to report our preliminary results in patients with acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair who were treated with the frozen elephant trunk (FET) technique. METHODS Within a 25-month period, 14 patients with acute complicated Type B aortic dissection underwent surgical repair using the FET technique. The reasons to perform the FET procedure were an ectatic ascending aorta/arch in 6 patients and the lack of an adequate landing zone in 8 patients. RESULTS No deaths were observed. A non-disabling stroke occurred in 2 patients. Symptomatic spinal cord injury was not observed. The closure of the primary entry tear was successfully achieved in all patients. In 3 patients, a secondary distal thoracic endovascular aortic repair extension was performed during the same hospital stay. The median follow-up period was 6 ± 5 months. CONCLUSIONS The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease.

Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery

OBJECTIVES Our goal was to assess the results after orthotopic branched endovascular aortic arch repair using a new double-branch endoprosthesis in patients with thoracic aortic disease affecting the aortic arch who cannot undergo classical surgery. METHODS Within a 4-year period, 15 patients with thoracic aortic disease affecting the aortic arch were treated with the Bolton Relay plus double-branch endoprosthesis (Bolton Medical, Sunrise, FL, USA). We assessed clinical outcome, occurrence of endoleaks and the need for secondary interventions. The median logistic EuroSCORE I level was 13.6 (4.2; 22.8). RESULTS The in-hospital mortality rate was 6.7%. A disabling stroke was observed in 1 (6.7%) patient, whereas non-disabling strokes occurred in 2 (13.3%) patients. Type I and III endoleaks occurred in 6.7%. The median follow-up period was 263 (1st quartile 84; 2nd quartile 564) days. Four patients died during the follow-up period. Aortic-related survival was 100%. CONCLUSIONS Orthotopic branched endovascular aortic arch repair using the Bolton Relay Plus double-branch endoprosthesis is a safe and feasible technique enriching the armamentarium to treat patients with thoracic aortic disease who cannot undergo classical surgery. Aortic-related survival is excellent, and the occurrence of disabling stroke and endoleaks warranting treatment is low. Further studies are needed to assess the long-term durability of this new method.

Inaccurate aortic stent graft deployment in the distal landing zone: incidence, reasons and consequences†

OBJECTIVES The aim of this study was to investigate the accuracy of stent graft deployment in the distal landing zone (LZ) during thoracic endovascular aortic repair (TEVAR). Currently, TEVAR focuses on accurate stent graft deployment in the proximal LZ. Data on landing in the distal LZ are lacking. METHODS Of 195 TEVAR patients (2005-16) with a non-dissected aortic pathology, 59 [median age 73 years (first quartile 68; third quartile 77), 20 women] patients had a distal LZ shorter than 40 mm. In all, the aim was to deploy the stent graft just above the target vessel (coeliac trunk, mesenteric superior or renal artery). Patients were divided into the accurate landing (n = 10) and inaccurate landing (IAL, n = 49) groups according to the distance to the target vessel ≤ 5 mm or > 5 mm after TEVAR, target vessel coverage and the need for a second stent graft in the distal LZ. We assessed the distal LZ, stent graft distance to the target vessel, apposition, migration and endoleak Ib on computed tomography. Median follow-up period was 23 months (5; 48). RESULTS Distal LZ anatomy did not differ between groups. Overall stent graft distance to the target vessel was 10.0 mm (6.5 mm; 16.0 mm). Three patients required a second stent graft in the distal LZ, and in 3 others, the target vessel was accidentally covered. In patients of the accurate landing group primary endoleak Ib occurred less frequently than those in the IAL group (0% vs 33%; P = 0.049). Three (30%) accurate landing and 19 (39%) IAL patients (P = 0.73) presented with substantial stent graft wedge apposition. CONCLUSIONS Accurate stent graft implantation in the distal LZ with the currently available deployment mechanism is often challenging. An inaccurate landing is associated with a higher incidence of endoleak Ib.

Leitlinien Aortenerkrankungen der European Society of Cardiology

ZusammenfassungIn der Aortenmedizin sind noch viele Fragen offen. Leitlinien helfen uns dabei, die bestmögliche Entscheidung zur Therapie einer Aortenerkrankung zu treffen. Dieser Übersichtsbeitrag zu den Leitlinien der European Society of Cardiology (ESC) über Aortenerkankungen fasst die aktuellen Kernempfehlungen bezüglich der Behandlung der Aortenpathologien zusammen. Mehr Informationen zu seltenen Erkrankungen wie Aortentumoren, Aortitis und seltene genetische Aortenerkankungen sind in den Leitlinien ausführlich dargestellt.AbstractIn medicine of the aorta many questions are still unanswered. Guidelines help us to make the best possible decision for treatment of aortic diseases. This review article on the guidelines of the European Society of Cardiology (ESC) on aortic diseases summarizes the current core recommendations with respect to the treatment of aortic pathologies. More information on rare diseases, such as tumors of the aorta, aortitis and rare genetic diseases of the aorta are comprehensively described in the guidelines.

Endovascular treatment of acute Type A aortic dissection—the Endo Bentall approach

Outcome after classical surgical repair of acute Type A aortic dissection has steadily improved over the years and several modifications in cannulation and perfusion added to this achievement. However, subgroups remain where results of classical surgical repair still have room for improvement, particularly patients with severe preoperative malperfusion as well as elderly patients with a limited physiological reserve. So far, only small case series or case reports have been published on the endovascular treatment of dissected ascending aortas. However, a tube alone is not sufficient to fix the entire complex underlying problem in the vast majority of patients with acute Type A aortic dissection. In addition, these published reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule. The concept of an endovascular valve-carrying conduit may significantly increase the number of patients suitable for endovascular therapy and it may soon be common practice.

True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation

OBJECTIVES To evaluate early and mid-term clinical outcomes and to assess the potential of the frozen elephant trunk technique to induce remodelling of downstream aortic segments in acute and chronic thoracic aortic dissections. METHODS Over a 4-year period, 65 patients (48 men, aged 61 ± 12 years) underwent total aortic arch replacement using the frozen elephant trunk technique for acute (n = 31) and chronic (n = 34) thoracic aortic dissections at our institution. We assessed diameter changes at 3 levels: the L1 segment at the stent graft level; the L2 segment at the thoraco-abdominal transition level and the L3 segment at the coeliac trunk level. True-lumen (TL) and false-lumen (FL) diameter changes were assessed at each level. RESULTS Fifty-six percent of patients had already undergone previous aortic or cardiac surgery. In-hospital mortality was 6%. Symptomatic spinal cord injury was not observed in this series. During a mean follow-up of 12 ± 12 months, late death was observed in 6% of patients. Aortic reinterventions in downstream aortic segments were performed in 28% at a mean of 394 ± 385 days. TL expansion and FL shrinkage were measured in all segments and were observed at each level. This effect was the most pronounced at the level of the stent graft in patients with chronic aortic dissection, TL diameter increased from 15 ± 17 mm before surgery to 28 ± 2 mm (P = 0.001) after 2 years, and the FL diameter decreased from 40 ± 11 mm before surgery to 32 ± 17 mm (P = 0.026). CONCLUSIONS The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

Local and Lower Limb Complications during and after Femoral Cannulation for Extracorporeal Life Support

Objective The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation. Methods Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016. Results In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) (p = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients (p = 0.45). Conclusion Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut‐down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled.

Aortic Replacement After TEVAR-Diameter Correction With Modified Use of the Siena Prosthesis

BACKGROUND To report a new technique for diameter correction in patients after thoracic endovascular aortic repair (TEVAR) with large stent-grafts using the Vascutek Siena 4-branch collared prosthesis (Vascutek Terumo, Inchinnan, Scotland, UK) in patients undergoing thoracoabdominal (TA) aortic replacement. METHODS Within a 24-month period, 39 patients underwent TA replacement at our center. Of these, 6 patients had undergone previous TEVAR with large stent-grafts (42 to 48 mm diameter). Indications for TEVAR were aneurysm formation in 3 patients and residual type B aortic dissection (status post repair of type A dissection) in 3 patients. In these patients, the Vascutek Siena 4-branch prosthesis was used in a reversed fashion, removing the elephant trunk portion and using the sewing collar for diameter correction at the anastomotic site. RESULTS No 30-day mortality and no stroke or symptomatic spinal cord ischemia was observed. Median diameter of the TEVAR graft at the anastomotic site was 44 mm. Median size of the Siena graft used was 26 mm. Diameter correction was successfully achieved in all patients by tailoring the sewing collar of the Siena 4-branch prosthesis to the individual need according to the diameter of the distal end of the stent-graft. CONCLUSIONS Using the sewing collar of the Vascutek Siena 4-branch prosthesis for diameter correction in patients undergoing TA replacement after previous TEVAR with large stent-grafts adds a useful adjunct to the armamentarium of options in a growing patient population.