Wei-Guo Ma

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

BACKGROUND Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Suns procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Suns procedure in patients with AAAD. METHODS Clinical data of 398 consecutive AAAD patients undergoing the Suns procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. RESULTS Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). CONCLUSIONS The Suns procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Sun’s procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation

The Suns procedure is a surgical technique proposed by Dr. Li-Zhong Sun in 2002 that integrates total aortic arch replacement using a tetrafurcated graft with implantation of a specially designed frozen elephant trunk (Cronus(®)) in the descending aorta. It is used as a treatment option for extensive aortic dissections or aneurysms involving the ascending aorta, aortic arch and the descending aorta. The technical essentials of Suns procedure include implantation of the special open stented graft into the descending aorta, total arch replacement with a 4-branched vascular graft, right axillary artery cannulation, selective antegrade cerebral perfusion for brain protection, moderate hypothermic circulatory arrest at 25 °C, a special anastomotic sequence for aortic reconstruction (i.e., proximal descending aorta → left carotid artery → ascending aorta → left subclavian artery → innominate artery), and early rewarming and reperfusion after distal anastomosis to minimize cerebral and cardiac ischemia. The core advantage of Suns procedure lies in the use of a unique stented graft, which has superior technical simplicity, flexibility, inherent mechanical durability and an extra centimeter of attached regular vascular graft at both ends. Since its introduction in 2003, the Suns procedure has produced satisfactory early and long-term results in over 8,000 patients in China and more than 200 patients in South American countries. In a series of 1,092 patients, the authors have achieved an in-hospital mortality rate of 6.27% (7.98% in emergent or urgent vs. 3.98% in elective cases). Given the accumulating clinical experience and the consequent, continual evolution of surgical indications, the Suns procedure is becoming increasingly applied/used worldwide as an innovative and imaginative enhancement of surgical options for the dissected (or aneurysmal) ascending aorta, aortic arch and proximal descending aorta, and may become the next standard treatment for type A aortic dissections requiring repair of the aortic arch.

Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?

OBJECTIVE We seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality. METHODS We performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure. RESULTS The operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P < .001). However, acuity was not identified as a risk factor for operative mortality (odds ratio [OR], 1.67; P = .152). The risk factors were previous cerebrovascular disease (OR, 7.01; P = .001); malperfusion of the brain (OR, 7.10; P = .002), kidneys (OR, 12.67; P = .005), spinal cord (OR, 22.79; P = .008), and viscera (OR 22.98; P = .002); concomitant extra-anatomic bypass (OR, 9.50; P < .001); and cardiopulmonary bypass time >180 minutes (OR, 1.01; P < .001). CONCLUSIONS In this group of patients with type A dissection, acuity was not a risk factor for operative mortality after the Sun procedure. Patients with previous cerebrovascular disease; malperfusion of the brain, kidneys, spinal cord, and/or viscera; concomitant extra-anatomic bypass; and a longer cardiopulmonary bypass time (>180 minutes) were at greater risk of operative mortality.

Is extended arch replacement justified for acute type A aortic dissection

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether patients with acute type A aortic dissection have a better outcome after total arch replacement. Altogether, 138 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country they are from, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All studies are retrospective. Five representative studies reported that total arch replacement could be performed safely without increasing operative mortality and morbidity compared with hemiarch replacement, but with an overall longer time of cardiopulmonary bypass and circulatory arrest. The other three reports documented an apparently higher early mortality rate in the total arch group than in the hemiarch group. In terms of long-term results, freedom from reoperation on the distal aorta is similar for patients treated with total arch replacement and with hemiarch replacement at 5 and 10 years in four papers. As for the false lumen, three reports documented that the rate of complete thrombosis of the false lumen in the proximal descending aorta was significantly higher in the total arch group than in the hemiarch group (P <0.05). Only one study reported similar rates of complete thrombosis formation of the distal aorta in the two groups at different follow-up points (P >0.05). The remaining four reports did not provide information about the false lumen. Evidence for long-term outcomes, albeit limited, has proved that better results of thrombosis of the false lumen can be achieved with a more extensive total arch repair. Although the literature shows no advantage of the total arch over a more limited approach, the more extensive approach may be required to achieve this goal when the entry tear extends to, or is localized in, this segment of the aorta. This suggests that a more extensive surgical strategy can be justified when it is based on circumstances, on the individual patients clinical condition, and on the anatomical and pathological features of the dissection.

Open Stented Grafts for Frozen Elephant Trunk Technique: Technical Aspects and Current Outcomes.

With growing experience in patients with aneurysms and dissections in the arch and proximal descending aorta, the frozen elephant trunk (FET) technique has been shown to be safe and effective, and has achieved favorable short to mid-term outcomes. As the FET technique is gaining wider acceptance, there is a growing need for versatile, technically simple, and highly durable open stented grafts involving less complicated deployment mechanisms enabling use in various indications. This paper gives a brief review on the technical aspects and clinical outcomes of currently available open stented grafts used in the FET technique, including the E-vita Open Plus, Thoraflex Hybrid, Cronus, and J Graft. While none of these grafts can claim to be an ideal device, technology continues to improve towards this goal. As newer devices and systems are developed, more widespread use of the FET technique can be expected; such progress promises to improve the clinical outcomes and quality of life for patients with complex aortic diseases.

Sun’s procedure for chronic type A aortic dissection: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation

The Sun’s procedure is a surgical technique that integrates total arch replacement using a tetrafurcated graft with implantation of a special stented graft in the descending aorta, as a treatment option for extensive dissections or aneurysms involving the ascending aorta, aortic arch and descending aorta (1-3). To illustrate our technique for performing the Sun’s procedure (1,2), we present a video of this approach in a 38-year-old man with chronic type A aortic dissection (Video 1). Video 1 Suns procedure for chronic type A aortic dissection: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation Clinical vignette The patient had a history of hypertension for twenty years and experienced an episode of chest and flank pain after exertion one year ago. Transthoracic echocardiogram detected dilated ascending aorta, aortic arch and descending aorta, as well as intimal flaps in the ascending aorta, and a dilated aortic root with severe regurgitation. Computed tomographic angiogram confirmed a chronic type A dissection, with the intimal tear in the ascending aorta, extending distally to the right iliac artery, and the arch vessels involved. Of note, the innominate artery was both aneurysmal and dissected for the entire length extending to the level of bifurcation. There was also a coronary anomaly, in which the left and right coronary arteries arose from the left coronary sinus. Considering the complex pathology of arch vessel involvement, innominate artery aneurysm, aortic root dilation with severe regurgitation and coronary artery anomaly, we decided to perform the Sun’s procedure, in combination with composite root replacement with a mechanical valved conduit.

Total Arch Replacement With Stented Elephant Trunk Technique for Acute Type B Aortic Dissection Involving the Aortic Arch

BACKGROUND Optimal management of patients with acute type aortic dissection is not clear. The clinical experience with total arch replacement combined with stented elephant trunk technique in the treatment of acute type B aortic dissection involving the aortic arch was analyzed. METHODS From January 2006 to April 2011, 24 consecutive patients with acute type B aortic dissection involving the aortic arch underwent total aortic arch replacement with stented elephant trunk implantation. Concomitant procedures included the Bentall procedure in 3 patients, David procedure in 1 patient, and ascending aortic replacement in 7 patients. RESULTS The times of cardiopulmonary bypass and selective cerebral perfusion averaged 168±41 and 21±4 minutes, respectively. One patient died of multiorgan failure 3 days after surgery. Complications occurred in 3 patients (3 of 24; 12.5%), including hoarseness and mediastinal bleeding requiring reoperation, each in 1 patient. One patient experienced transient consciousness dysfunction. The in-hospital mortality was 4.1% (1 of 24). No paraplegia occurred postoperatively. Follow-up was available in 22 patients (22 of 23; 95.7%). During the follow-up, 1 patient died of massive gastrointestinal bleeding 2 months after surgery. Type II endoleak occurred in 1 patient. One patient underwent thoracoabdominal aortic replacement 14 months after surgery. The complete thrombosis ratio of the false lumen was 86.4% (19 of 22) 6 months after surgery. The 5-year survival was 91.7%. CONCLUSIONS Total arch replacement combined with stented elephant trunk technique was safe and feasible for acute type B aortic dissection involving the aortic arch. A low rate of morbidity and mortality and a satisfactory 5-year survival rate were achieved, as well as improved thrombosis of the false lumen.

Twenty-five year outcomes following composite graft aortic root replacement

Operative choices for aortic root disease include traditional root replacement with a composite valved graft as well as various valve‐sparing and root repair procedures.

Risk factors for distal stent graft-induced new entry following endovascular repair of type B aortic dissection.

BACKGROUND Distal stent graft-induced new entry (DSINE) has been increasingly observed following thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We seek to identify the risk factors for DSINE following TEVAR in patients with TBAD. METHODS Between January 2009 and January 2013, we performed TEVAR for 579 patients with TBAD. The clinical data were retrospectively analyzed with univariate and multivariate analyses to identify the risk factors for DSINE. RESULTS Two patients (0.3%) died after the initial TEVAR. Morbidity included spinal cord injury in 2 (0.3%), stroke in 3 (0.5%) and endoleak in 12 (2.1%) patients. Clinical and radiological follow-up was complete in 100% (577/577) averaging 47±16 months. Late death occurred in 6 patients. DSINE occurred in 39 patients (6.7%) at mean 22±17 months after the initial TEVAR, which was managed with re-TEVAR in 25 and medically in 14. At 33±18 months after DSINE, 11 of patients managed medically (11/14) and all patients managed with re-TEVAR (25/25) survived (P=0.048). Freedom from DSINE was 92.7% at 5 years (95% CI: 90.0-94.7%). Using tapered stent grafts with a proximal end 4-8 mm larger than the distal end, TEVAR performed in the acute phase (≤14 days from onset) was associated with a significantly lower incidence of DSINE than TEVAR performed in the chronic phase (4.3%, 7/185 vs. 13.9%, 15/108; P=0.003). Risk factors for DSINE were stent grafts less than 145 mm in length [odds ratio (OR) 2.268; 95% CI: 1.121-4.587; P=0.023] and TEVAR performed in the chronic phase (OR 1.935; 95% CI: 1.004-3.731; P=0.049). CONCLUSIONS Our results show that TEVAR performed during the acute phase and using stent grafts longer than 145 mm could decrease the incidence of DSINE in patients with TBAD. Tapered stent grafts with a proximal end 4-8 mm larger than the distal end may be helpful in preventing DSINE after TEVAR performed in the acute phase than TEVAR performed in the chronic phase, due to the difference in mobility of the dissected flap. Expedite repeat TEVAR is recommended to improve the clinical prognosis for patients with DSINE.

Stented Elephant Trunk Technique for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Repair

BACKGROUND Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique. METHODS Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1±8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results. RESULTS Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2±13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival. CONCLUSIONS The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.