HYBRID AORTIC ARCH SURGERY TO CREATE A LANDING ZONE IN THE ASCENDING AORTA.

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.

Frozen Elephant Trunk with E-Vita Open Hybrid Prosthesis for Surgical Correction of Multisegmental Thoracic Aortic Pathology: Review of Results.

INTRODUCTION: The Frozen Elephant Trunk (FET) surgery allows correction of ascending, arch and proximal descending aortic pathology, using a hybrid prosthesis at the same time. It is a complex intervention and requires a multidisciplinary team that, besides scheduling and performing the surgery, accompanies the patient (pt) throughout the postoperative period. OBJECTIVES: To review short and medium term clinical results with this technique. METHODS: Between January 2010 and September 2017, we operated 34 patients (pts) using FET. The surgery was performed under cardiopulmonary bypass (CPB) with cardio-circulatory arrest in deep hypothermia, always with bilateral antegrade selective cerebral protection and under noninvasive neuromonitorization. Antegrade and retrograde, hematic, cold, intermittent cardioplegia was used. All patients were followed in our outpatient clinic with imaging techniques. RESULTS: The mean age of the pts was 62.8 ± 11.5 years, 16 males. The mean follow-up period was 18.7 ± 16.1 months. Diagnoses were: chronic type A dissection 9 pts, ascending aortic aneurysm and distal arch 9 pts, pseudoaneurysm 1 pt, mega-aorta syndrome 11 pts. No pt was operated in acute situation. Seven pts (20.6%) were reoperations and in 4 pts (11.8%) associated cardiac procedures were required. The left subclavian was conserved in 24 pts (70.6%). CPB, aortic clamping and distal ischemia mean times were, respectively; 260, 149 and 54 minutes. Hospital mortality occurred in five pts (14.7%), 3 of which at the beginning of the series, due to mesenteric ischemia. The hospital morbidity consisted of: ventilator-associated pneumonia 3 pts (8.8%), stroke 2 pts (5.9%), perioperative infarction 1 pt (2.9%) and paraplegia 1 pt (2.9%). Seven pts (20.6%) required 9 endovascular re-interventions (TEVAR) in the distal descending aorta and in two of these an abdominal fenestrated endoprosthesis was implanted by the vascular team. Three pts presented early type IIB endoleaks, which resolved spontaneously in follow-up CT. Among the others there were no endoleaks and the expected involution of the aneurysmal sac and positive remodeling of the aorta was observed. All survivors are clinically stable, asymptomatic, in class NYHA I. CONCLUSION: The overall results are in line with the literature. Mesenteric ischaemia is the leading cause of in-hospital death. FET is a safe and effective intervention. The expandable segment of the hybrid prosthesis is an excellent landing zone to complete the procedure, when necessary, with the second stage TEVAR. Survivors acquire an excellent quality of life in the medium term. Clinical follow-up and lifelong imaging techniques are mandatory.

TEVAR - A Primary or Adjunct Procedure Helpful in the Surgical Correction of Complex Pathology of the Thoracic Aorta?

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) made possible the treatment of aortic disease that previously could only be approached openly, associated with a considerable morbidity and mortality. However, it also brings new challenges influencing patient selection - favourable landing zone, good peripheral access, propensity for endoleak (EL) - that requires rigorous clinical and imaging follow- -up. OBJECTIVE: Review all patients that underwent TEVAR in our Department and assess morbidity and mortality. METHODS: From November 2007 to September 2017, 57 TEVAR were performed in our Department to 52 patients. All patients performed postoperative CT angiography within 30 days after surgery. Follow-up was carried in our Outpatient Clinic with annual imaging. Statistical analysis was performed with SPSSTM 22 (© IBM). RESULTS: Patients' mean age was 65.6 ± 10.3 years and 69.2% were male (n = 36). Mean follow-up was 48.1 ± 34.1 months. The most frequent surgical indication was thoracic aortic aneurysm (42.1%), followed by chronic type B aortic dissection (35.1%), pseudoaneurysm (10.5%), reintervention by EL (7.0%), penetrating aortic ulcer (3.5%) and traumatic dissection of the aorta (1.8%). Surgery was elective in 87.7% of cases and part of a dual stage strategy in 17.3%. In-hospital mortality was 3.9%. Survival at 1, 2 and 5 years was 87.9%, 85.6% and 71.5%, respectively. Reported complications were: need for endovascular reintervention 7.7%; complication of femoral access 7.7%; and cerebellar infarction 1.9%. Throughout follow-up, no EL was detected in 56.1% of patients. There was an incidence of early EL in 38.4%, of which 45.0% had spontaneous resolution, documented in subsequent CT scans. The most frequent was type IA (42.9%) that was also the one with the highest spontaneous resolution rate (62.5%). Mean time to diagnosis of late EL was 36.9 ± 21.4 months and occurred in 11.5% of patients, the most frequent being type IA (50.0%); there was no spontaneous resolution observed. In all cases of reintervention due to EL a good surgical result was obtained. CONCLUSION: TEVAR is a procedure with low morbidity and mortality, good long-term outcome and a relatively low incidence of EL. Most patients do not have EL during their follow-up and have an excellent survival. The most frequent early EL is type IA and about half resolve in the following months. Although rare, late EL did not present spontaneous resolution. The treatment of EL can easily be achieved with new intervention and excellent result.

Simplified Technique for Aortic Arch Replacement in Patients at High Risk for Frozen Elephant Trunk.

INTRODUCTION: Surgical approach of multisegmental pathology of the thoracic aorta, namely aortic arch / descending aorta is challenging. The Frozen Elephant Trunk (FET) has good results, with acceptable risk. However, in the subgroup of patients (pts) older than 75 years and with important comorbidities, the surgical risk is very high. OBJECTIVES: Review short-term results of this original, simplified and potentially hybrid technique developed in our Department for this subgroup of patients. METHODS: From January 2016 to September 2017, 10 pts were operated with this technique - mean age 70.2 ± 15.3 years, 7 males. The diagnoses were: 6 pts with aneurysmal disease and 4 pts with aortic dissection. Four pts had previous cardiac surgery. The surgical concept consists of 3 key points: 1) Use of a patient-tailored graft, built in a back-table, to replace the ascending aorta and arch, with side-branches proximally anastomosed to reroute the supra-aortic vessels, allowing a proximal, long Landing Zone for eventual TEVAR. 2) Debranching of the supra-aortic vessels. 3) Maintain bilateral anterograde selective cerebral perfusion. All pts were operated on cardiopulmonary bypass (CPB) with a period of hypothermic (24oC) cardiocirculatory arrest for the open distal anastomosis. Preservation of the left subclavian artery depended on paraplegia risk and was individually assessed preoperatively. In a second stage, a TEVAR was electively deployed in 2 patients. All patients were followed in our clinic and imaging clinic at 6 months and annually after surgery. RESULTS: Mean CPB, aortic cross clamping and visceral ischemia were, respectively, 196, 120 and 44 minutes. One pt died in- hospital due to bowel ischemia. Four pts had respiratory complications requiring prolonged ventilation. The mean ICU and hospital stay was, respectively, 7,8 and 23,6 days. The mean follow-up was 15.2 months and three pts died during this follow-up. One pt was re-hospitalized with deep sternal wound infection. Of the survivors, one had a stroke at 6 months postoperatively and the remainder are asymptomatic. The postoperative period of the 2 pts submitted to TEVAR was uneventful; to date, they remain surgically stable, without needing re-intervention. CONCLUSION: The technique is effective and avoids the burden of FET. The short-term results are encouraging but, in the long-term, they should be evaluated to determine their role among arch interventions, specially their value in relation to recent pure endovascular techniques with fenestrated or branched endoprosthesis. Long ICU and hospital stay points towards the implementation of measures and protocols to improve them.

Ascending Aorta Aneurysms in Octogenarians.

INTRODUCTION: Older age is often regarded as a relative contraindication for open surgery for aortic aneurysms. These individuals often have a greater comorbidity burden that predispose them for development of postoperative complications. The aim of our study is to evaluate the surgical outcomes of selected octogenarians after open aortic surgery. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 67.7% of the patients were male. The mean age was 81.5 ± 1.8 years. The preoperative comorbidities were hypertension (83.9%), aortic valve disease (54.8%), dyslipidaemia (48.4%), renal impairment (9.7%), type 2 diabetes mellitus (9.7%) and COPD (3.2%). As for the procedures performed the majority was aortic valve replacement and graft interposition (48.4%) followed by graft interposition (35.5%), ascending aorta and arch replacement (9.7%) and graft interposition and combined CABG (6.5%). 16.1% of the procedures were reoperations and 6.5% were performed as urgent. In-hospital mortality was 9.4% and 1-year survival was 77.4%. The mean survival time after surgery was 736.4 ± 530.3 days. As for complications, 22.6% developed respiratory complications, 6.5% had infectious complications and 3.2 developed renal and central nervous system complications. Older age was not related to early (p = 0.266) or late mortality (p = 0.779). There was no association between older age and longer ICU stay (p = 0.781) or total hospital stay (p = 0.985). CONCLUSIONS: Highly selected octogenarians benefit from surgery, having a similar rate of postoperative complications and survival, as described in the literature.

Cardiac Fibroelastoma: 10-Year Experience.

INTRODUCTION: Papillary fibroelastoma is one of the most common types of primary cardiac tumour. Though a rare pathology, its importance relates to its form of presentation, with stroke and sudden death, and the questions regarding its management. OBJECTIVES: To review the casuistic of cardiac tumours in our service, in special the papillary fibroelastomas. METHODS: clinical case series overviewing the period from 1st January 2008 to 30th September 2017. We analysed all patients submitted to cardiac surgery due to cardiac masses or tumours and verified all the pathology results to confirm the diagnosis. RESULTS: In the period selected, around 6500 surgeries were performed. Of those, 59 patients were operated on due to cardiac tumours. 81.4% were myxomas, 13.6% were papillary fibroelastomas, 3.4% were cardiac sarcomas and 1.7% were metastasis. Of the patients that had papillary fibroelastomas (n=8), 5 were male, and the mean age was 51.5 ± 16.2 years. 62.5% (n=5) had origin in the aortic valve and 37.5% (n=3) in the mitral valve. Regarding presentation, 3 patients presented with stroke, 2 patients had episodes of syncope and 3 patients were asymptomatic. After surgery, all patients remained asymptomatic and there was no evidence of recurrence. At the end of follow-up all patients were alive. CONCLUSION: Although a rare pathology, papillary fibroelastomas remain important due to their potential for embolization and cardiac chamber obstruction, therefore should be primarily treated with surgery.

Elective 2nd Stage TEVAR to Complete Frozen Elephant Trunk in the Surgical Correction of Complex Multisegmental Pathology of the Thoracic Aorta.

INTRODUCTION: Classical conventional surgery to treat multi-segmental thoracic aortic disease in two operative stages, sternotomy and left thoracotomy, is associated with significant mortality and complications. The Frozen Elephant Trunk (FET) associated with an endovascular procedure (TEVAR) allows an extensible and simplified surgical approach of the descending and thoracoabdominal aorta without increasing the risk. METHODS: Retrospective study of 8 patients (pts), 5 males, mean age 67.5 ± 4.2 years, with ascending and arch disease associated with descending aortic disease (chronic dissection 2 pts, aneurysmal disease 6 pts), treated between January 2014 and September 2017. All survivors are periodically followed up in our outpatient clinic with CT or MRI angiography. RESULTS: The average follow-up period is 18,7 ± 12,2 months. In the first stage (FET) - the left subclavian was conserved in all cases. In six of these pts, after an average period of 37 days, a TEVAR was performed, to complete the exclusion of the aneurysmal sac or the false lumen in the descending aorta. In 2 pts, the interval was longer and in the same intervention, a fenestrated endoprosthesis was implanted in the abdominal aorta by the vascular team. After TEVAR, mean ICU time was 16 hours and hospitalization was 5,2 days. One pt died in the 1st month post-intervention TEVAR + EVAR fenestrated. The remaining pts are stable and asymptomatic, in Class I NYHA, without endoleaks and with the expected involution of the aneurysmal sac and positive remodeling of the aorta. There were no cases of paraplegia or other neurological complications documented. CONCLUSION: This strategy is safe and effective. Clinical follow- -up associated with close postoperative imaging surveillance is required not only to determine the optimal interval between the two stages, which is dependent on the anatomy and underlying pathology of each patient, but also to identify possible complications. The quality of life of these pts in the medium-term is excellent.

Ascending Aorta Aneyrysms Over 70mm.

INTRODUCTION: Current guidelines suggest that patients with aortic diameter over 55-60 mm should undergo ascending aorta replacement, depending on associated valve pathology and other comorbidities. Studies show that the risk of aortic rupture over 60 mm is over 30%. Even though, we still receive in our practice patients that present with aneurysms of greater dimensions. The aim of our study is to evaluate the surgical outcomes of patients presenting with ascending aorta with diameter larger than 70 mm. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 64.5% of the patients were male. The mean age was 67.9 ± 12.9 years. The preoperative comorbidities were hypertension (64.5%), dyslipidaemia (45.2%), aortic valve disease (35.4%), renal impairment (9.7%) and COPD (3.2%). The average diameter was 82.3 ± 18.6 mm, with values ranging from 70 to 160 millimeters. As for the procedures performed the majority was interposition of prosthetic graft (45.2%), followed by aortic valve replacement and graft interposition (35.5%), Frozen Elephant Trunk (12.9%), tube interposition and combined CABG (3.2%) and aortic root replacement with graft interposition (3.2%). 9.7% of the procedures were reoperations and 9.7% were performed as urgent. In-hospital mortality was 3.2% and 1-year survival was 83.9%. The mean survival time after surgery was 1135.9 ± 777.1 days. As for complications, 29% developed respiratory complications, 9.7% had cardiac complications, 6.5% had central nervous system complications and 3.2% developed renal and vascular complications. Greater diameter was not associated with early (p = 0.929) or late mortality (p = 0.987). CONCLUSIONS: These results show that patients with aneurysms greater than 70 mm can be safely operated on, with no increase in complications in the postoperative period or greater mortality.