A modified total arch replacement combined with a stented elephant trunk implantation for acute type A dissection under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion

Abstract

ObjectivesSince the optimal management of patients with acute aortic dissection is unclear, this study analyzed total arch replacement combined with stented elephant trunk implantation in the treatment of acute type A aortic dissection.MethodsBetween February 2008 and February 2013, 86 consecutive patients admitted to our hospital for acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under deep hypothermic circulatory arrest. The Bentall, David, and Wheat procedure was performed on 46, 12 and two patients, respectively. Ascending aorta replacement was performed on 26 patients, while two patients in Bentall group and 7 in ascending aorta replacement group underwent coronary artery bypass grafting as a concomitant procedure.ResultsSixty-nine patients were male and 17 patients were female, with an average age of 45.2 ± 2.3 years. The in-hospital mortality rate was 5.8%. Two patients presented with persisting paraplegia. The cardiopulmonary bypass time was 186.3 ± 45.2 minutes and the myocardium ischemia time was 102.6 ± 28.1 minutes. Selective antegrade cerebral perfusion time was 29.4 ± 10.3 minutes. Low-body circulatory arrest time was 18.5 ± 8.4 minutes. Mechanical ventilation time was 80.7 ± 11.3 hours. ICU and hospital stays were 5.3 ± 4.8 and 16.8 ± 5.5 days, respectively. Seven patients underwent reoperation for bleeding. During a mean follow-up of 28.5 months, two patients died and 2 patients were lost to follow-up. Obliteration of the false lumen around the stented graft and at the diaphragmatic level occurred in 97.1% (68 of 70) and 70% (49 of 70) of the patients.ConclusionsModified total arch replacement combined with stented elephant trunk implantation using selective antegrade cerebral perfusion is a safe and effective alternative for patients with acute type A dissection and produces satisfactory clinical outcomes in our center.Electronic supplementary materialThe online version of this article (doi:10.1186/s13019-014-0140-6) contains supplementary material, which is available to authorized users.

Hypothermic circulatory arrest time affects neurological outcomes of frozen elephant trunk for acute type A aortic dissection: A systematic review and meta‐analysis

“…After reviewing shreds of evidence, a total of 35 studies including 3211 patients were entered into the quantitative analysis (Figure 1). 11–44 The median size of reviewed reports was 72 patients (interquartile range 38 – 122). The majority of studies were performed in Chinese institutions, 19 studies including 2026 patients.…”

A Meta-Analysis of Total Arch Replacement With Frozen Elephant Trunk in Acute Type A Aortic Dissection

“…Of 140 potentially relevant articles screened initially, 15 studies [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] of total arch replacement with frozen elephant trunk enrolling patients with acute type A aortic dissection were identified and included. We excluded 11 studies [27][28][29][30][31][32][33][34][35][36][37] duplicating patients (Appendix A, Table E1).…”

“…Additionally, the rates of mid-to longterm reintervention and false lumen non-thrombosis may be lower in patients undergoing the frozen than conventional elephant trunk procedure. Although 8 12,16,19,20,[23][24][25][26] of the 15 studies included in our meta-analysis were conducted in China, it is unclear whether acute type A aortic dissection is more common in China than in Europe or North America. The Cronus prosthesis (Microport Medical, Shanghai, China) is commercially available in China, and so-called Sun's procedure 33 has been widely performed.…”

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

“…When we compared studies performed only in patients with acute type A aortic dissection (n ¼ 12, 1300 patients) 21,23,25,[27][28][29][30]35,37,41,46,47 with studies performed only in patients with nonacute type A dissection and aneurysm (n ¼ 14, 741 patients), 14,15,17,19,22,[24][25][26]34,40,[42][43][44][45] we found the following results: The pooled mortality rate was 9.2% (95% CI, 6.9-12.4) in the patients with acute type A and 7.6% (95% CI, 4.9-11.4) in the patients with nonacute dissection and aneurysm (P ¼ .46). The pooled rate of stroke in these 2 groups was 9.3% (95% CI, 4.5-18.5) and 6.6% (95% CI, 3.1-13.5) (P ¼ .51), and the pooled rate of SCI was 2.4% (95% CI, 1.3-4.2) and 5.2% (95% CI, 3.1-8.5) (P ¼ .05), respectively ( Figure E2).…”