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Tian C, Xiao Y, Hu K, Shu C. Transaortic and transfemoral stent deployment approaches related morphological and clinical outcomes after type II hybrid arch repair for type A aortic dissection. Heart Vessels 2025; 40:426-434. [PMID: 39503750 DOI: 10.1007/s00380-024-02482-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 10/30/2024] [Indexed: 04/20/2025]
Abstract
We aimed to evaluate the false lumen patency and late death outcomes of type II hybrid arch repair for type A aortic dissection (TAAD) using the transaortic (TA) and transfemoral (TF) stent deployment approaches. Patients who underwent type II hybrid arch repair for TAAD between September 2013 and November 2020 were enrolled. False lumen patency (classified as patent false lumen, thrombosed false lumen, or false lumen remodeling) and follow-up death were investigated. Multivariate Cox regression and inverse probability of treatment weighting (IPTW) analyses were used to evaluate the association between the outcomes and stent graft deployment approaches. Of the 129 enrolled patients, 23 (17.8%) and 106 (82.2%) were in the TA and TF groups, respectively. During follow-up (median: 42 months, IQR: 32-82 months), higher risks of patent false lumen (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.01-16.6, P = 0.03) and all-cause death (hazards ratio [HR]: 5.8, 95% CI: 1.3-25.8, P = 0.02) were observed in TA group than in TF group. In IPTW analysis, TA group showed consistently higher adjusted risks of patent false lumen (adjusted OR: 4.1, 95% CI: 1.6-10.3, P = 0.003) and all-cause death (adjusted HR: 4.5, 95% CI: 1.1-18.7, P = 0.03) than that of TF group. This study demonstrated the TA and TF deployment approaches related to false lumen patency and survival outcomes after type II hybrid arch repair for TAAD. The TA approach was associated with higher risks of patent false lumen and late death during follow-up. The TF approach should be suggested as the primary choice for stent deployment in type II hybrid arch repair for TAAD.
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Affiliation(s)
- Chuan Tian
- Vascular Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 North Lishi Road, West City District, Beijing, China.
| | - Yutong Xiao
- Vascular Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 North Lishi Road, West City District, Beijing, China
| | - Kejian Hu
- Vascular Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 North Lishi Road, West City District, Beijing, China
| | - Chang Shu
- Vascular Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 North Lishi Road, West City District, Beijing, China
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Hussain M, Jubouri YF, Hammad A, Abubacker I, Franchin M, Mauri F, Piffaretti G, Mohammed I, Jubouri M, Bashir M. The frozen elephant trunk: an overview of hybrid prostheses. Expert Rev Med Devices 2025; 22:193-208. [PMID: 40126036 DOI: 10.1080/17434440.2025.2471455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Accepted: 02/20/2025] [Indexed: 03/25/2025]
Abstract
INTRODUCTION Thoracic aortic pathologies implicating the aortic arch and the descending thoracic aorta (DTA) are primarily managed with total aortic arch replacement (TAR). This can be performed as a single-procedure hybrid fashion using the frozen elephant trunk technique (FET), which utilizes hybrid prosthesis. Nevertheless, FET presents certain challenges such as distal stent graft-induced new entry (dSINE), negative aortic remodeling, and reintervention. AREAS COVERED The narrative review provides an overview of the four majors FET prosthesis, highlighting their design features, mechanical properties, configurations, and variants, and evaluating their clinical outcomes reported in the literature. The leading prosthesises were compared through their mortality and survival rates, neurological outcomes, dSINE, aortic remodeling, and reintervention rates. EXPERT OPINION Four FET devices can be considered the main option on the global market; Thoraflex, E-Vita, Cronus, and Frozenix J Graft. Each hybrid prosthesis (HP) features unique design characteristics, resulting in varying clinical outcomes. Thoraflex and E-Vita are the most widely used and investigated HPs, whilst the use of Cronus and Frozenix is geographically confined to mainly manufacturers' countries. The rates of early mortality, stroke, SCI, dSINE, and reintervention rates were found to be comparable among the four devices, yet, Thoraflex seemed to offer the most optimal clinical profile.
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Affiliation(s)
| | | | - Aya Hammad
- Hull York Medical School, University of York, York, UK
| | | | - Marco Franchin
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Francesca Mauri
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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Karangelis D, Stougiannou TM, Christodoulou KC, Bartolozzi H, Malafi ME, Mitropoulos F, Mikroulis D, Bena M. Hybrid Aortic Arch Replacement with Frozen Elephant Trunk (FET) Technique: Surgical Considerations, Pearls, and Pitfalls. J Clin Med 2024; 13:7075. [PMID: 39685533 DOI: 10.3390/jcm13237075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Revised: 11/12/2024] [Accepted: 11/21/2024] [Indexed: 12/18/2024] Open
Abstract
The involvement of the aortic arch in thoracic aortic aneurysms (TAA), or acute aortic dissections (AAD), represents a challenging clinical entity, mandating a meticulous surgical plan, tailored to each individual case. The advent of endovascular techniques and the introduction of modern arch protheses have led to the implementation of the frozen elephant trunk (FET) technique. This one-step hybrid operation consists of a total aortic arch replacement combined with an antegrade delivery of a stent-graft for the descending aorta, which acts as a proximal landing zone facilitating a potential distal endovascular reintervention. In this manner, this technique addresses acute and chronic arch disease with an acceptable morbidity and mortality. Several FET prosthetic devices are available on the global market and have exhibited favourable outcomes, although with some disadvantages in complex cases; similarly, the hybrid procedure described in this review has also been associated with complications, such as coagulopathy and neurological and graft-related events. The purpose of this review is to thus provide key insights into successful hybrid aortic arch replacements and to discuss useful tips and relevant considerations regarding its use.
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Affiliation(s)
- Dimos Karangelis
- Department of Cardiothoracic Surgery, Democritus University of Thrace University General Hospital, 68100 Alexandroupolis, Greece
| | - Theodora M Stougiannou
- Department of Cardiothoracic Surgery, Democritus University of Thrace University General Hospital, 68100 Alexandroupolis, Greece
| | - Konstantinos C Christodoulou
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, 55131 Mainz, Germany
| | - Henri Bartolozzi
- Department of Cardiothoracic Surgery, Democritus University of Thrace University General Hospital, 68100 Alexandroupolis, Greece
| | - Maria Eleni Malafi
- Department of Cardiothoracic Surgery, Democritus University of Thrace University General Hospital, 68100 Alexandroupolis, Greece
| | - Fotios Mitropoulos
- Department of Adult and Congenital Cardiac Surgery, Mitera Hospital, 15123 Athens, Greece
| | - Dimitrios Mikroulis
- Department of Cardiothoracic Surgery, Democritus University of Thrace University General Hospital, 68100 Alexandroupolis, Greece
| | - Martin Bena
- Department of Cardiac Surgery, CINRE Hospital, 84103 Bratislava, Slovakia
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Jubouri M, Kayali F, Agbobu T, Tahhan O, Moothathamby T, Abdulwahab ER, Velayudhan B, Mohammed I, Bashir M. Thoraflex Hybrid Prosthesis (THP): the profile. Expert Rev Med Devices 2024; 21:165-177. [PMID: 38431273 DOI: 10.1080/17434440.2024.2326539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority. AREAS COVERED This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted. EXPERT OPINION THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Fatima Kayali
- University Hospitals Sussex NHS Foundation Trust, Sussex, UK
| | | | - Owais Tahhan
- Aston Medical School, Aston University, Birmingham, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Eyad R Abdulwahab
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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Murana G, Campanini F, Orioli V, Pagano V, Santamaria V, Di Marco L, Di Bartolomeo R, Pacini D. Frozen elephant trunk in acute aortic dissection: a literature review. Indian J Thorac Cardiovasc Surg 2023; 39:315-324. [PMID: 38093913 PMCID: PMC10713510 DOI: 10.1007/s12055-023-01624-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 12/05/2024] Open
Abstract
Background Acute aortic dissection is a life-threatening condition that requires urgent surgical treatment. The frozen elephant trunk (FET) technique, including the Thoraflex hybrid prosthesis, has emerged as an effective strategy for treating complex aortic pathologies. With the widespread application of the FET technique, it continues to evolve, aiming to simplify procedures and reduce complications. These advancements provide improved outcomes and help save lives in patients with acute aortic dissection. Methods For this review, PubMed databases were utilized from inception to March 2023. A descriptive approach was employed to identify and present the evidence regarding the application of the FET technique in acute settings and its clinical implications on the postoperative course. Results In the reviewed studies, FET was a commonly used treatment approach for acute type A aortic dissection. A comprehensive analysis of 12 studies, comprising over 4056 FET procedures, revealed varying rates of early mortality (up to 21.1%), perioperative stroke (ranging from 2.7 to 18.0%), and spinal cord ischemia (ranging from 0 to 8.2%). During the follow-up period, which ranged from 6 to 108 months, the mortality rate was reported to be as high as 38%. Conclusions The surgical management of acute aortic dissection remains challenging, but FET has shown promising results. Experienced teams have achieved acceptable in-hospital mortality and stroke rates, along with a lower risk of spinal cord injury compared to conventional repair. Furthermore, the FET technique has demonstrated positive alterations in the structure of the distal aorta, potentially improving long-term survival and reducing the necessity for future procedures.
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Affiliation(s)
- Giacomo Murana
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Francesco Campanini
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Valentina Orioli
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Vinvenzo Pagano
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Valeria Santamaria
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
| | - Luca Di Marco
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardio-thoraco-vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna, Italy
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Nakhaei P, Bashir M, Jubouri M, Banar S, Ilkhani S, Borzeshi EZ, Rezaei Y, Mousavizadeh M, Tadayon N, Idhrees M, Hosseini S. Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis. J Card Surg 2022; 37:3848-3862. [PMID: 36069163 DOI: 10.1111/jocs.16918] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. MATERIALS AND METHODS A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. RESULTS A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01-0.06, I2 = 78%) and 3% (95% CI 0.01-0.11, I2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I2 = 89%) while the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I2 = 92%). After subgroup analysis, heterogeneity for distal stent-graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E-Vita stent-grafts were used (both I2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I2 = 15.1%) and Frozenix stent-grafts (I2 = 1%). CONCLUSION Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results.
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Affiliation(s)
- Pooria Nakhaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.,Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sepideh Banar
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Ilkhani
- Department of Surgery and Vascular Surgery, Shohada-ye-Tajrish Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Elahe Zare Borzeshi
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences School of Public Health, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Niki Tadayon
- Department of General and Vascular Surgery, Shohada Medical Centre, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Mousavizadeh M, Bashir M, Jubouri M, Tan SZ, Borzeshi EZ, Ilkhani S, Banar S, Nakhaei P, Rezaei Y, Idhrees M, Hosseini S. Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:265-274. [PMID: 35238527 DOI: 10.23736/s0021-9509.22.12292-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET. EVIDENCE ACQUISITION In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET. EVIDENCE SYNTHESIS Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I2=76%) and 12% for renal failure (95% CI 0.09-0.15; I2=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I2=0%) and 6% (95% CI 0.05-0.08; I2=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I2=0%). CONCLUSIONS Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.
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Affiliation(s)
- Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran - .,Vascular and Endovascular Surgery, Health Education, and Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Elahe Z Borzeshi
- School of Public Health and Safety, Department of Epidemiology, Shahid Beheshti University of Medical Sciences Tehran, Iran
| | - Saba Ilkhani
- Department of Surgery and Vascular Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepideh Banar
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Pooria Nakhaei
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Aboughdir M, Haq M, Harky A, Field M. Addressing the elephant in the room: Conventional versus frozen elephant trunk in complex aortic surgery. J Card Surg 2022; 37:2408-2409. [PMID: 35538550 DOI: 10.1111/jocs.16593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Maryam Aboughdir
- Department of Medicine, St. George's, University of London, London, UK
| | - Mawiyah Haq
- Department of Medicine, St. George's, University of London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Masiello P, Mastrogiovanni G, Presutto O, Chivasso P, Bruno VD, Colombino M, Miele M, Cafarelli F, Leone R, Triggiani D, Iesu S. Frozen elephant trunk procedure for complex aortic arch surgery: The Salerno experience with Thoraflex hybrid. J Card Surg 2021; 37:107-114. [PMID: 34662451 PMCID: PMC9297964 DOI: 10.1111/jocs.16086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Background and Aim of the Study To report early clinical outcomes of the frozen elephant trunk (FET) technique for the treatment of complex aortic diseases after transition from conventional elephant trunk. Methods A single‐center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. Results Between December 2017 and May 2020, 70 consecutive patients (62.7 ± 10.6 years, 59 male) were treated: 41 (58.6%) for emergent conditions and 29 (41.4%) for elective. Technical success was 100%. In‐hospital mortality was 14.2% (n = 12, 17.1% emergent vs. 10.3% elective, P = NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Mean follow‐up was 12.5 months (interquartile range, 3.7–22.3). Overall survival at 3, 6, 12, and 24 months was 90% (95% confidence interval [CI], 83.2—97.3), 85.6% (95% CI, 77.7–94.3), 79.1% (95% CI, 69.9–89.5), 75.6% (95% CI, 65.8–86.9) and 73.5% (95% CI, 63.3–85.3). There were no aortic re‐interventions and no distal stent graft‐induced new entry (dSINE); 5 patients with residual type B dissection underwent TEVAR completion. Conclusions In a real‐world setting, FET with Thoraflex Hybrid demonstrated feasibility and good clinical outcomes, even in emergent setting. Our implant technique optimize cerebral perfusion reporting good results in terms of neurological complications. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.
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Affiliation(s)
- Paolo Masiello
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Generoso Mastrogiovanni
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Oreste Presutto
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Pierpaolo Chivasso
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | | | - Mario Colombino
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Mario Miele
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Francesco Cafarelli
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Rocco Leone
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Donato Triggiani
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Severino Iesu
- Department of Emergency Cardiac Surgery, Cardio-Thoracic-Vascular, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
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Chauvette V, Demers P, Lachapelle K, Chu MW, Dagenais F. First-in-Human Use of the Cook Hybrid Frozen Elephant Trunk Graft: The Canadian Experience. Ann Thorac Surg 2021; 111:1876-1882. [DOI: 10.1016/j.athoracsur.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/10/2020] [Accepted: 08/03/2020] [Indexed: 02/01/2023]
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11
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Luthra S, Tsang GM. Improving outcomes of open stent grafts for Type A acute aortic dissection repair. Ann Thorac Surg 2021; 113:695-696. [PMID: 33711304 DOI: 10.1016/j.athoracsur.2021.02.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Suvitesh Luthra
- Southampton University Hospital, Southampton, UK; UK Aortic Surgery Group, Wessex Cardiothoracic Centre, Division of Cardiac Surgery, Southampton University Hospital, Southampton, Hampshire, SO16 6YD, UK.
| | - Geoffrey M Tsang
- Southampton University Hospital, Southampton, UK; UK Aortic Surgery Group, Wessex Cardiothoracic Centre, Division of Cardiac Surgery, Southampton University Hospital, Southampton, Hampshire, SO16 6YD, UK
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12
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Rezaei Y, Bashir M, Mousavizadeh M, Daliri M, Aljadayel HA, Mohammed I, Hosseini S. Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization. J Card Surg 2021; 36:1922-1934. [PMID: 33665866 DOI: 10.1111/jocs.15452] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022]
Abstract
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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Affiliation(s)
- Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Mostafa Mousavizadeh
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Daliri
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Abo Aljadayel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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13
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Permanyer E, Ruyra X, Evangelista A. The aortic arch management for type A aortic dissection: aggressive but experienced. J Thorac Dis 2020; 12:3429-3432. [PMID: 32642271 PMCID: PMC7330748 DOI: 10.21037/jtd.2020.01.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eduard Permanyer
- Department of Cardiac Surgery, Quironsalud Teknon Heart Institute, Barcelona, Spain
| | - Xavier Ruyra
- Department of Cardiac Surgery, Quironsalud Teknon Heart Institute, Barcelona, Spain
| | - Artur Evangelista
- Department of Cardiology, Quironsalud Teknon Heart Institute, Barcelona, Spain
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14
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Çekmecelioğlu D, Köksoy C, Coselli J. The frozen elephant trunk technique in acute DeBakey type I aortic dissection. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2020; 28:411-418. [PMID: 32953202 PMCID: PMC7493599 DOI: 10.5606/tgkdc.dergisi.2020.20462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022]
Abstract
Although advances in the field of cardiovascular surgery have improved outcomes for patients with acute DeBakey type I aortic dissection, postoperative in-hospital mortality and morbidity remain substantial. The frozen elephant trunk technique has become a treatment option for this disease and was developed primarily to extend repair into the proximal descending thoracic aorta during aortic arch repair (because the descending thoracic aorta is largely inaccessible via median sternotomy), thus avoiding, delaying, or facilitating subsequent repair of residual native aorta. In this review, we discuss the evidence for and future development of frozen elephant trunk reconstruction for acute DeBakey type I aortic dissection.
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Affiliation(s)
- Davut Çekmecelioğlu
- Department of Surgery, Baylor College of Medicine, Texas, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Texas, USA
| | - Cüneyt Köksoy
- Department of Surgery, Baylor College of Medicine, Texas, USA
| | - Joseph Coselli
- Department of Surgery, Baylor College of Medicine, Texas, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Texas, USA
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15
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Oo A, Field ML. Frozen elephant trunk: reflections of the UK Aortic Group. Ann Cardiothorac Surg 2020; 9:228-229. [PMID: 32551257 DOI: 10.21037/acs.2020.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Aung Oo
- Clinical Lead for Aortovascular Surgery, The Barts Heart Centre, London, UK
| | - Mark L Field
- Clinical Lead for Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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16
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Mougin J, Charbonneau P, Guihaire J, Schwein A, Tyrrell MR, Maurel B, Fabre D, Haulon S. Endovascular management of chronic post-dissection aneurysms of the aortic arch. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:402-415. [PMID: 32337939 DOI: 10.23736/s0021-9509.20.11395-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.
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Affiliation(s)
- Justine Mougin
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Philippe Charbonneau
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Julien Guihaire
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Adeline Schwein
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | | | - Blandine Maurel
- Service of Vascular Surgery, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Dominique Fabre
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Stéphan Haulon
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France -
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Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med 2019; 8:135-147. [PMID: 31942440 PMCID: PMC6957356 DOI: 10.5492/wjccm.v8.i8.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.
AIM To review the available literature to determine if there was any evidence.
METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.
RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived.
CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude.
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Affiliation(s)
- Massimo Capoccia
- Department of Aortic and Cardiac Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Marc O Maybauer
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Anaesthesiology and Intensive Care Medicine, Phillips University, Marburg 35037, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane QLD 4032, Queensland, Australia
- Advanced Critical Care and Transplant Institute, Integris Baptist Medical Centre, Oklahoma City, OK 73112, United States
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