Is the classical elephant trunk better than the frozen elephant trunk?

Aortic diseases located in the ascending aorta, aortic arch or proximal descending aorta often require more than one surgical intervention depending on the type of pathology and its extent as well as future anticipated aortic problems. These obstacles were tackled in 1983 by Hans Borst with the introduction of the classic elephant trunk (cET). This was an outstanding and straightforward procedure. Since then, the cET was very often the first surgical approach for patients with extensive aortic pathology of the ascending aorta and arch extending into the downstream aorta. Thirteen years later, Suto and Kato introduced the frozen elephant trunk (fET) which was later on perfectionized by industry and applied in various ways by many surgical groups worldwide. Comparing the cET with the fET raises a lot of difficulties. The lack of randomization and the presence of procedural and complication-related limitations for each technique do not allow for definitive conclusions about the ideal procedure to treat complex aortic pathology. It would be very short-sighted to close all future discussions about the subject with this statement of the Hannover group made in 2011. Since both techniques and its results cannot be compared statistically due to the heterogeneity of patient groups, the lack of randomization, the difference in type and extent of pathology, the differences in surgical techniques, the learning curve in gaining experience in both techniques, and the lack of reporting standards, no scientific conclusion can be drawn as to which technique is most successful. Comparisons may even be considered futile. It is the purpose of this paper merely to make a descriptive observation of both techniques, to discuss some important elements of interest and to give some constructive and useful criticism.

European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria.

BACKGROUND: Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient's conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. METHODS: Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient's comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. DISCUSSION: The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073 .

Perspective: options in managing aortic graft infections.

Thoracic aortic graft infections are infrequent, but are associated with high mortality and morbidity risk. To prevent these life-threatening infections, one must be aware of pathogenesis. When it occurs, a multidisciplinary (surgeon, radiologist, microbiologist, nuclear specialist, infectiologist, anesthesiologist, intensive care specialist) cascade must be initiated. A fast and accurate diagnosis using diagnostic criteria is vital. The appropriate treatment consists of a combination of antibiotics and surgery. Whether or not the vascular prosthesis is preserved depends on a case-by-case basis (tailor-made). Several graft preservation strategies have proven their effectiveness.

Aortic valve replacement using the Freedom SOLO stentless bioprosthesis: clinical and haemodynamic performance in 625 patients at medium-term follow-up.

OBJECTIVES: Our goal was to analyse the haemodynamic and clinical results after implantation of the Freedom SOLO stentless aortic valve replacement by assessing the immediate postoperative results regarding mortality, discharge echocardiographic gradients and reoperation rates and by evaluating these results in the medium term. METHODS: This study was designed as a single-centre retrospective observational trial. Clinical and echocardiographic data were collected retrospectively from 625 patients undergoing an aortic valve replacement using the Freedom Solo stentless valve (LivaNova, London, UK) at the Sint-Jan Hospital, Bruges, between May 2009 and May 2017. RESULTS: The mean age of the patient was 76 ± 6.9 years. Early operative (30-day) mortality was 3.5% overall and 0.8% (n = 2) in patients having isolated aortic valve replacement. Early reinterventions were necessary in 3% of patients (n = 19). Permanent pacemaker implantation was performed in 3%. The mean postoperative peak gradient was 14.3 ± 8.14 mmHg, and the mean gradient was 7.5 ± 4.46 mmHg. Fourteen patients underwent explantation, 2 of which were for structural valve deterioration and 8 for endocarditis. Overall survival at 7 years was 55% [95% confidence interval (CI) 47-62]. At 7 years, freedom from reoperation overall, freedom from operation for endocarditis and freedom from operation for structural valve deterioration were 94% (95% CI 88-97), 97% (95% CI 94-99) and 98% (95% CI 90-99), respectively. CONCLUSIONS: The Freedom Solo stentless aortic valve has proved to be safe, with excellent clinical and haemodynamic results. Structural valve degeneration and explantation occur infrequently, illustrating good durability in the medium term.

Type B aortic dissection: new perspectives.

BACKGROUND: Stanford type B aortic dissection is one of the aortic catastrophes with a high mortality and morbidity that needs immediate or delayed treatment, either surgically or endovascularly. This comprehensive review article addresses the current status of open, endovascular and hybrid treatment options for type B aortic dissections with the focus on new therapeutic perspectives. METHODS: Evaluation of currently available evidence based on randomized and registry data and personal experience. RESULTS: All type B dissections require prompt medical treatment to prevent aortic rupture. Acute complicated dissections are nowadays treated by endografting to reroute blood flow into the true lumen and promote false lumen thrombosis and future aortic remodeling. In acute uncomplicated situations the position of endografting is less clear and should be further delineated; however, on the long run also in these situations endografting might be protective for future aortic catastrophes in certain patient categories. In the chronic dissection with aneurysm formation of the descending thoracic and/or thoracoabdominal aorta, especially in connective tissue disorders, open surgery offers nowadays the best immediate results with long durability. Thoracic endografting plays only a minor role in these circumstances but branched and fenestrated endografting are very promising techniques. Hybrid techniques can offer the solution for high risk patients that are not suitable for open surgery. CONCLUSIONS: Emergent thoracic endografting is the golden standard for all complicated type B dissections while uncomplicated patients with high-risk features might benefit from endovascular repair. Open surgery is limited for chronic post dissection aneurysms. Aortic surveillance is of paramount importance in all situations.

State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair.

During open thoracoabdominal aortic aneurysm repair (OTAAAR), there is an inevitable organ ischemic period that occurs when the abdominal arteries are being reattached to the aortic graft. Despite various protective techniques, the incidence of renal and visceral complications remains substantial. This state-of-the-art review gives an overview of the current and most evidence-based organ protection methods during OTAAAR, based on the most recent publications and personal experience. An electronic search was performed in four medical databases, using the following MeSH terms: thoracoabdominal aneurysm, TAAAR, visceral protection, renal protection, kidney, perfusion, and intestines. Every publication type was considered. The literature search was ended on August 31st, 2017. The left heart bypass (LHB) is currently the most frequent adjunct to provide distal aortic perfusion (DAP) during aortic clamping. Together with systemic hypothermia, it forms the cornerstone in organ protection during aortic clamping. Further renal protection can be obtained by selective renal perfusion (SRP) with cold blood or cold crystalloid solution, the latter enriched with mannitol. The perfusion should be administered in a volume- and pressure-controlled way and, if possible, by use of a pulsatile pump. Selective visceral perfusion (SVP) is not routinely used, as it does not provide adequate blood flow for visceral protection. The best way to protect the intestines is by minimizing the ischemic time. The preservation of renal and visceral function after OTAAAR can only be obtained with specific strategies before, during, and after the operation. This involves a series of measures, including selective digestive decontamination (SDD), avoidance of nephrotoxic drugs, minimizing the renal and intestinal ischemic time, systemic cooling, avoidance of hemodynamic instability, and regional protective perfusion of the kidneys. Future innovations in catheters, cardiac bypass flow types, mechanical components, hybrid vascular grafts, and pharmaceutical protection measures will hopefully further reduce organ complications.

Open surgical repair of post-dissection thoraco-abdominal aortic aneurysms: early and late outcomes of a single-centre study involving over 200 patients.

OBJECTIVES: Chronic, post-dissection thoraco-abdominal aortic aneurysms (TAAAs) are increasingly being treated by (hybrid) endovascular means. Although it is less invasive, thoracic endovascular aortic repair is technically complex with the risk of incomplete aneurysm exclusion, necessitating frequent reinterventions with potentially reduced long-term outcomes. The aim of this study was to evaluate contemporary early and late outcomes after open surgical repair of post-dissection TAAA. METHODS: At our centre, 633 patients underwent open repair for TAAA over a 20-year period (1994-2015), including 217 (34%) patients for post-dissection TAAA, who were included in this analysis. Circulatory support was obtained by either left heart bypass (173 patients, 79.7%), deep hypothermic circulatory arrest (41 patients, 18.9%) or simple aortic cross-clamping in 3 patients. We analysed all relevant perioperative and intraoperative variables with respect to adverse outcomes. Additionally, long-term survival and the need for aortic reinterventions were studied. RESULTS: The mean age was 60.2 ± 11.9 years (men 68.2%). We identified 66 Type I (30.4%), 113 Type II (52.1%), 25 Type III (11.5%), 10 Type IV (4.6%) and 3 Type V (1.4%) TAAAs. Early mortality and spinal cord deficit were 5.9% and 5.5%, respectively. Follow-up was 100% complete (mean 6.0 ± 5.8 years), with long-term survival of 71.4% at 10 years, and freedom from death and reoperation was 68.2% at 10 years. CONCLUSIONS: Although it is more invasive than current endovascular approaches for post-dissection TAAA, open surgical repair can be performed safely with acceptable rates of morbidity and mortality when it is done in a specialized aortic centre. Long-term survival and freedom from aortic reintervention are excellent and should also be taken into account when evaluating less invasive alternatives.

Left heart bypass for thoracoabdominal aortic aneurysm repair: technical aspects.

There are different surgical techniques for providing circulatory support during the repair of thoracoabdominal aortic aneurysms. They all aim at reducing the afterload of the heart and the preservation of distal organ perfusion. Partial or total extracorporeal circulation with or without cooling and left heart bypass (LHB) are actually the most used surgical approaches. The objective of this study was to describe and comment on the technical aspects of the LHB. We briefly describe our results and put them into perspective based on the current literature.

Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience.

OBJECTIVES: The efficacy and durability of actual treatments (open, endovascular and hybrid) for thoracoabdominal aortic aneurysm (TAAA) repair are not yet completely defined. Open surgical repair using a multi-adjunct (ADJ) approach has been the standard of care for many years and may still be an effective treatment option. This study aimed to assess the outcomes of open TAAA repair since the introduction of the available ADJ. METHODS: From 1994 to 2014, 542 consecutive patients underwent open TAAA repair in our institution, routinely receiving aortic distal perfusion and the other ADJ (either for visceral and spinal cord protection). The aetiology of TAAA was identified to be degenerative in 325 (60%) patients and chronic post-dissection in 160 (29.5%) patients. Other causes such as connective tissue disorders, vasculitis and infective aneurysms were less represented (10.5%). Extensive type I and II repair was required in 128 (23.6%) and 285 (52.6%) patients, respectively. All patients were followed up at 3 and 6 months after surgery and yearly thereafter using computed tomography angiogram. RESULTS: The overall 30-day mortality and paraplegia rates were 8.5 and 4.2%, respectively. Age [odds ratio (OR) 1.07 per year, 95% confidence interval (CI) 1.02-1.13], female gender (OR 2.52, 95% CI 1.27-4.99), urgency (OR 2.78, 95% CI 1.12-6.20) and emergency (OR 3.81, 95% CI 1.00-11.50) emerged as independent risk factors for 30-day mortality. Follow-up was 100% complete (mean 6.32 years). Overall 1-, 5- and 10-year survival was 85.9 ± 1.5, 74.2 ± 2.0 and 61.6 ± 2.5%, respectively. The extent of surgical repair did not significantly influence late hospital death (P = 0.56). For patients surviving the first 30 days, a degenerative aneurysm aetiology negatively impaired long-term survival compared with the other diseases [hazard ratio = 1.66; 95% CI (1.13-2.44)]. Five- and 10-year freedom from reoperation was 86.3 ± 1.8 and 80.7 ± 2.3%, respectively, and 8.5% of patients required aortic reinterventions. CONCLUSIONS: In elective cases, open TAAA repair has to be considered an effective option associated with low necessity of reoperation at follow-up. The extent of aortic resection did not affect long-term mortality. Conversely, survival was mainly determined by patient age and preoperative condition.

Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†.

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS.

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and expert's opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer.

An expert panel on the treatment of type B intramural haematoma (IMH) and penetrating atherosclerotic ulcer (PAU) consisting of cardiologists, cardiothoracic surgeons, vascular surgeons and interventional radiologists reviewed the literature to develop treatment algorithms using a consensus method. Data from 46 studies considered relevant were retrieved for a total of 1386 patients consisting of 925 with IMH, and 461 with PAU. The weighted mean 30-day mortality from IMH was 3.9%, 3-year aortic event-related mortality with medical treatment 5.4%, open surgery 23.2% and endovascular therapy 7.1%. In patients with PAU early and 3-year aortic event-mortality rates with open surgery were 15.9 and 25.0%, respectively, and with TEVAR were 7.2 and 10.4%, respectively. According to panel consensus statements, haemodynamic instability, persistent pain, signs of impending rupture and progressive periaortic haemorrhage in two successive imaging studies require immediate surgical or endovascular treatment. In the absence of these complications, medical treatment is warranted, with imaging control at 7 days, 3 and 6 months and annually thereafter. In the chronic phase, aortic diameter >55 mm or a yearly increase ≥ 5 mm should be considered indications for open surgery or thoracic endovascular treatment, with the latter being preferred. In complicated type B aortic PAU and IMH, endovascular repair is the best treatment option in the presence of suitable anatomy.

The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results.

OBJECTIVE: The classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique. METHODS: Between 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms. RESULTS: Mean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044). CONCLUSIONS: A 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.

Infectious aortitis with multiple mycotic aneurysms caused by Streptococcus agalactiae.

We report a case of a 66-year-old man with multiple thoracoabdominal mycotic aortic aneurysms caused by Streptococcus agalactiae (S agalactiae). The infectious aortitis (IA) was diagnosed by transesophageal echocardiography and computed tomography and confirmed by positive blood cultures. The patient was treated with antibiotics, but, after worsening of the aortitis, a successful surgical procedure was performed. A review of the literature is presented together with a series of 7 other cases of IA caused by S agalactiae.