Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection

Yamamoto, Hiroshi; Kadohama, Takayuki; Yamaura, Gembu; Tanaka, Fuminobu; Takagi, Daichi; Kiryu, Kentaro; Itagaki, Yoshinori

doi:10.1016/j.jtcvs.2019.01.125

Cited by 40 publications

(68 citation statements)

References 26 publications

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“… 6 Yamamoto et al reported zone-0 anastomosis TAR using FET for patients with AADA, where they also utilized extra-anatomical reconstruction of the left subclavian artery. 21 The advantage of such proximalized TAR using FET with extra-anatomical reconstruction of the left subclavian artery is not only the merit of avoiding deep distal anastomosis but also avoiding in-situ reconstruction of the left subclavian artery. Pichlmaier et al reported a unique operative technique of bridging the end-to-end anastomoses between the graft branches and the supra-aortic vessels by self-expanding covered stents to reduce suturing time, avoid anastomotic bleeding, and improve vessel alignment to the hybrid graft.…”

Section: Discussionmentioning

confidence: 99%

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee

Nakanishi

Wakabayashi

Ise

et al. 2020

Thorac Cardiovasc Surg

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Abstract Background The aim of the present study was to validate safety of total arch replacement (TAR) using a novel frozen elephant trunk device, operated by trainees as surgical education. Methods Sixty-four patients including 19 patients (29.6%) with acute aortic dissection type A (AADA) underwent TAR in our institute between April 2014 and March 2019 were retrospectively analyzed. Twenty-nine patients were operated by trainees (group T) and 35 patients were operated by attending surgeons (group A). Results Patient characteristics did not differ between groups. Operative time (409.4 ± 87.8 vs. 468.6 ± 129.6 minutes, p = 0.034), cardiopulmonary bypass time (177.7 ± 50.4 vs. 222.9 ± 596.7 minutes, p = 0.019), and hypothermic circulatory arrest time (39.5 ± 13.4 vs. 54.5 ± 18.5 minutes, p = 0.001) were significantly shorter in group A than in group T, but aortic clamping time did not differ between groups (115.3 ± 55.7 vs. 114.2 ± 35.0 minutes, p = 0.924) because the rate of concomitant surgery was higher in group A (37.1 vs. 10.3%, p = 0.014). Thirty-day mortality was 3.1% in the entire cohort. Although operation time was longer in group T, there were no significant difference in postoperative results between the groups, and the experience levels of the main operator were not independent predictors for in-hospital mortality + major postoperative complications. There was no difference in late death and aortic events between groups. Conclusions The present study demonstrated that TAR can be safely performed by trainees, and suggests TAR as a possible and safe educational operation.

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Section: Discussionmentioning

confidence: 99%

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee

Nakanishi

Wakabayashi

Ise

et al. 2020

Thorac Cardiovasc Surg

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“…Of 64 studies reporting outcomes of patients included in this report 13–76 . The proportions of studies from Asia, Europe, and North America were 54.7%, 31.3%, and 10.9%, respectively.…”

Section: Methodsmentioning

confidence: 99%

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

et al. 2021

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Background and Aim of the Study The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta‐analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization. Methods We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR). Results A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in‐hospital mortality were 7.104 (95% confidence interval [CI], 5.691–8.661; I2 = 78.53%), 3.465 (95% CI, 2.852–4.136; I2 = 15.96), 14.969 (95% CI, 11.361–18.977; I2 = 91.26%), and 8.933 (95% CI, 7.128–10.919; I2 = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36–0.81; p = .003; I2 = 0%). Conclusions The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

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“…The desired effects of downstream aortic remodeling in patients without arch tears can be effectively achieved with a hemiarch replacement with frozen elephant trunk, however, which requires 5 fewer suture lines than the technique described Yamamoto and colleagues. 1 Maybe the most remarkable aspect of this report is the fact that the 3 operating surgeons conducted the same operation on all comers during 4 years with little harm to patients, given that type A dissection is an extremely variable and dynamic disease. This eliminates some of the selection bias and allows an objective evaluation of the proposed intervention.In our opinion, zone 0 frozen elephant trunk with arch debranching is a valid concept for type A aortic dissection and has a place in the surgeon's armamentarium, perhaps as a safe alternative to total arch replacement in complex arch tears.…”

mentioning

confidence: 87%

Commentary: Staying out of trouble—Zone 0 frozen elephant trunk and arch debranching for type A aortic dissection

Assi

Atluri

2020

The Journal of Thoracic and Cardiovascular Surgery

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report their experience in Japan with a novel technique for the repair of acute type A aortic dissection. Their noncomparative series includes 108 consecutive patients between 2014 and 2018 who underwent the same procedure regardless of the location of intimal tear. This operation consists of the resection of the ascending aorta from just above the sinotubular junction to just below the brachiocephalic artery, debranching of all arch vessels under moderate hypothermic circulatory arrest and antegrade cerebral perfusion, antegrade deployment of a stent graft into the proximal descending thoracic aorta all the way up to zone 0, and replacement of the ascending aorta with a branched graft, which is then anastomosed to the proximal end of the stent graft and the arch vessels. The technique is similar to others used for open debranching in arch aneurysms, but its application for acute type A dissection is relatively novel. [2][3][4] Technically, the stent graft used (which is not on the US market) is designed with a stentless cuff at the proximal end that makes the graft-to-graft anastomosis less challenging than a graft-to-rigid stent anastomosis, as in the classic frozen elephant trunk procedure. The technical outcomes are excellent (operative mortality, 6.5%; stroke, 3.7%; paraplegia, 0%), and the remodeling of the aorta is full at the level of the stented portion; as expected, however, remodeling decreases significantly in proportion to the distance from the distal end of the stent graft.Yamamoto and colleagues 1 used short frozen elephant trunks, only 6 cm in length in 41.7% of patients, and the longest stent used was 12 cm, with a good portion of the stent being deployed across the arch. This relatively conservative strategy is likely responsible for the absence of spinal cord injury in their series, but it may account for the few early postoperative complications: 1 case of false-lumen rupture and a 5% rate of distal extension thoracic endovascular aortic repair for true-lumen compression or false-lumen rapid expansion during the same hospitalization.It is intriguing that only about 30% of patients had an arch or descending thoracic aorta tears. In other words, 70% of patients underwent total arch debranching without a primary arch and descending thoracic aorta pathology. Despite the good technical outcomes, there is no evidence-based justification for arch replacement or debranching in the absence of arch tear; this is not to say that absence of a tear is a contraindication, either. The desired effects of downstream aortic remodeling in patients without arch tears can be effectively achieved with a hemiarch replacement with frozen elephant trunk, however, which requires 5 fewer suture lines than the technique described Yamamoto and colleagues. 1 Maybe the most remarkable aspect of this report is the fact that the 3 operating surgeons conducted the same operation on all comers during 4 years with little harm to patients, given that type A dissection is an extremely variable and dynamic disease. This eliminates ...

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Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection

Cited by 40 publications

References 26 publications

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

Commentary: Staying out of trouble—Zone 0 frozen elephant trunk and arch debranching for type A aortic dissection

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