Accepted Manuscript Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality? Wei-Guo Ma , MD Jun Zheng , MD Wei Zhang , MD Kai Sun , MD, PhD Bulat A. Ziganshin , MD Long-Fei Wang , MD Rui-Dong Qi , MD Yong-Min Liu , MD Jun-Ming Zhu , MD Qian Chang , MD John A. Elefteriades , MD Li-Zhong Sun , MD PII:
S0022-5223(14)00733-8
DOI:
10.1016/j.jtcvs.2014.06.005
Reference:
YMTC 8651
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 16 April 2014 Revised Date:
31 May 2014
Accepted Date: 4 June 2014
Please cite this article as: Ma W-G, Zheng J, Zhang W, Sun K, Ziganshin BA, Wang L-F, Qi R-D, Liu Y-M, Zhu J-M, Chang Q, Elefteriades JA, Sun L-Z, Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?, The Journal of Thoracic and Cardiovascular Surgery (2014), doi: 10.1016/j.jtcvs.2014.06.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality? Wei Zhang, MD,a Kai Sun, MD, PhD,b
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Wei-Guo Ma, MD,a,b,c Jun Zheng, MD,a,b
Bulat A. Ziganshin MD,c Long-Fei Wang, MD,a Rui-Dong Qi, MD,a,b Yong-Min Liu, MD,a,b Jun-Ming Zhu, MD,a,b Qian Chang, MD,b John A. Elefteriades, MD,c and
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Li-Zhong Sun, MD,a,b
Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood
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Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses,a Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences and State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease,b Beijing, China; Aortic Institute at Yale-New Haven, Yale University School of Medicine,c New Haven, Connecticut, USA
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Drs. Ma and Zheng contribute equally to this work
This study was supported in part by International Science and Technology Cooperation Program of China (2012DFA31110) and Project of Healthcare Professional Leadership in Beijing (2011-1-3)
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Corresponding Author: Li-Zhong Sun, MD Department of Cardiovascular Surgery Beijing Anzhen Hospital of Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases 2 Anzhen Road Beijing 100029 China Phone/Fax: +86 10 6445 6168 E-mail: [email protected] Word Count: 3500 words
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ABSTRACT
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Objective: To compare the early outcomes of frozen elephant trunk with total aortic arch replacement using 4-branched graft (Sun’s procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality and
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determine whether the acuity of TAAD significantly affects operative mortality.
Methods: Univariate and multivariate analysis of clinical data of 803 TAAD patients undergoing the Sun’s procedure.
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Results: Operative mortality was 6.5% (52/803).
Overall incidence of stroke and spinal
cord injury was 2.0% (16/803) and 2.4% (19/803), respectively.
Acute patients had a
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higher incidence of operative death (8.1% versus 4.3%; P = .031), stroke (2.2% versus 0.6%; P = .046) and respiratory morbidities (20.8% versus 8.6%; P < .001). However,
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acuity was not identified as a risk factor for operative mortality (odds ratio, OR 1.67; P = .152), whereas risk factors were: prior cerebrovascular disease (OR 7.01; P = .001), malperfusion of the brain (OR 7.10; P = .002), kidneys (OR 12.67; P = .005), spinal cord (OR 22.79; P = .008) and viscera (OR 22.98; P = .002), concomitant extra-anatomic bypass (OR 9.50; P < .001) and cardiopulmonary bypass time > 180 minutes (OR 1.01; P < .001). 2
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Conclusions: In this group of type A dissection patients, acuity is not a risk factor for Patients with prior cerebrovascular disease,
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operative mortality after Sun’s procedure.
malperfusion of the brain, kidneys, spinal cord and viscera, concomitant extra-anatomic bypass and longer cardiopulmonary bypass time (> 180 minutes) are at higher risks of
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operative mortality.
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ULTRAMINI ABSTRACT
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In 803 type A dissection patients undergoing frozen elephant trunk with total arch replacement (Sun’s procedure), acuity is not a risk factor for operative mortality. However, prior cerebrovascular disease, malperfusion of the brain, kidneys, spinal cord
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and viscera, extra-anatomic bypass and longer cardiopulmonary bypass time increase the
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risk of mortality.
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Stanford type A aortic dissection (TAAD) remains one of the most lethal conditions and
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is associated with significant morbidity and mortality. The patient is at the greatest risk in the acute phase, within 14 days of initial event, when complications brought on by hemorrhage or rupture are most likely.1, 2
Although the last two decades have seen
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advances in surgical techniques and postoperative care, evidence for improving outcomes
patients with TAAD.
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is modest,3 and there are still several contentious issues in the surgical management of The most fundamental issue is the optimal surgical approach,
especially the extent of distal aortic repair.4-6
Some surgeons advocate a more limited
approach such as ascending aortic/hemiarch repair,6 while others support the frozen
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elephant trunk (FET) technique,7-9 which has improved the clinical outcomes of TAADs involving the aortic arch and proximal descending aorta considerably.10, 11
However,
surgical opinion is divided on the use of this extensive approach in TAAD patients.3, 7, 8, 12, The event of acute dissection itself is the dominant risk factor, as is need for
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This raises another concern that surgical repair in the
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preoperative resuscitation.3, 14
acute phase is associated with a higher operative mortality rate than in the chronic phase, as evidenced by Safi’s report with an operative mortality of 20% in acute and 4% in chronic TAAD patients.1
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For those reasons, we retrospectively analyzed the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft, namely, the Sun’s We seek
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procedure,15-18 in 803 consecutive patients with TAAD treated by our group.
to compare the early outcomes between acute and chronic groups of TAAD patients after the Sun’s procedure, to identify the risk factors for operative mortality in both groups,
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and to determine whether the acuity of aortic dissection significantly affects the operative
PATIENTS AND METHODS
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mortality of this extensive surgical approach for treatment of type A aortic dissections.
The Ethics Committees of Fu Wai Hospital and Cardiovascular Institute and Beijing
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Anzhen Hospital, Capital Medical University approved this retrospective study. .
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Patients
Between April 2003 and September 2012, our group performed Sun’s procedure for 803
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patients with TAAD. were male.
Mean age was 46.1 ± 10.8 years (range, 17-78) and 640 (79.7%)
According to the interval between onset of symptoms and surgery,2 an acute
TAAD (≤ 14 days) was diagnosed in 456 patients and chronic TAAD (> 14 days) in 347. In acute TAADs, this interval was 5.0 ± 3.8 days (median 4 days, range 5 hours - 14 days); within the first 10 hours after onset of dissection, 6.6% of patients (30/456) presented and 1.3% (6/456) underwent surgery.
The median time from onset to surgery 6
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in chronic TAADs was 37 days (mean, 189 days, range 14.2 days to 10 years).
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preoperative diagnosis of TAAD was confirmed by transthoracic echocardiography or
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computed tomographic angiography (CTA) in all patients.
A total of 101 (12.6%) cases of clinically apparent malperfusion occurred in 88 (10.9%)
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patients, with 56 (12.3%) and 32 (9.2%) in the acute and chronic groups, respectively.
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Lower limb malperfusion was most common (6.0%, 48/803, followed by cerebral (2.6%, 21/803), coronary (1.7%, 14/803), renal (0.9%, 7/803) and visceral ischemia (0.9%, 7/803) (Table 1).
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Selection Criteria
In patients with TAAD, the Sun’s procedure was indicated in either of the pathological
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conditions: 1) the primary entry located in the arch or descending aorta; 2) severe arch vessel pathology, including dissection, occlusion, stenosis or aneurysm changes; 3)
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intimal intussusception in the arch; 4) concomitant Marfan syndrome; 5) dissection in a dilated arch of > 4 cm in diameter and extending beyond the descending aorta.19
For
patients with none of the above conditions, a different approach would be proposed, such as ascending aortic or hemiarch repair, or total arch repair without FET.20
If a TAAD
patient had the pathological indications but developed malperfusion preoperatively, this procedure would still be performed as long as no end-organ failure had occurred, such as 7
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coma, paraplegia, hemiplegia, intestinal necrosis or hepatic failure.
Senior age was not
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a contraindication.
Surgical Techniques
The Sun’s procedure refers to total aortic arch replacement using a 4-branched vascular
The surgical technique has been described elsewhere in detail.15-23 Briefly,
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aorta.15-18
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graft combined with implantation of a specially designed FET into the descending
it is performed with right axillary artery cannulation for cardiopulmonary bypass (CPB) and selective antegrade cerebral perfusion, under moderate hypothermic circulatory arrest at 25℃, and involves implantation of an FET, Cronus® (MicroPort Medical Co. Ltd,
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Shanghai, China) in the descending aorta, followed by total arch replacement with a 4-branched vascular graft, with a special sequence for aortic reconstruction (i.e., proximal
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descending aorta → left carotid artery → ascending aorta → left subclavian artery → innominate artery), and early rewarming and reperfusion after distal anastomosis to
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minimize cerebral and coronary ischemia.
Associated operations, such as aortic root
replacement or coronary artery bypass grafting (CABG), are performed during the cooling phase, if indicated.
Definition of Outcomes and Risk Factors
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The endpoint was operative mortality, including all deaths, regardless of cause, occurring 1) during the same hospitalization in which the operation was performed, even if after 30 Stroke was
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days; and 2) after discharge from hospital, but within 30 postoperative days.
defined as any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain lasting more than 24 hours.
Coronary artery disease was
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documented by preoperative CTA, or based on prior history of myocardial infarction or
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coronary angiograms or percutaneous coronary interventions. Renal failure was defined as a rise in serum creatinine of 1 mg/dL above baseline or a new requirement for renal dialysis.
Malperfusion syndrome was defined as end-organ ischemia caused by branch
Statistical Analysis
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vessel involvement and resulting in clinical symptoms and functional impairment.
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Data were analyzed with SPSS for Windows version 13.0 (SPSS Inc., Chicago, IL). Variables were expressed as mean ± standard deviation or percentages, and compared
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with the Student t test, Pearson χ2 test or Fisher’s exact test as appropriate. Univariate analysis was used to evaluate variables that may affect operative mortality in both groups. Variables with a P value < .05 in univariate analysis were assessed with multivariate analysis using a forward stepwise binary logistic regression model.
All statistical tests
were 2-sided and any P value of < .05 was considered significant.
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RESULTS Operative Data
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The location of intimal tear was confirmed during the operation (Table 2). Of note, an intimal tear in the aortic arch was found only in acute patients (92, 20.2%).
The chronic
patients had more tears in the descending aorta (106/347, 30.5% versus 101/456; P =
Aortic root or valve procedures were performed in 221 (48.5%) acute and
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acute group.
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.007) and unidentifiable tears (43/347, 12.4% versus 17/456, 3.7%; P > .001) than the
163 (47.0%) chronic patients, including aortic valve repair in 63 (13.8%) and 22 (6.3%; P = .001), and Bentall operation in 130 (28.5%) and 119 (34.3%), in acute and chronic groups, respectively.
A total of 109 concomitant operations were done in 102 (12.7%)
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patients, including CABG in 43 (9.4%) and 24 (6.9%), extra-anatomic bypass in 11 (2.5%) and 16 (4.6%), mitral valve operation in 2 (0.4%) and 13 (3.7%), in acute and The time of CPB, cross-clamp and selective cerebral
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chronic groups, respectively.
perfusion in the acute group was remarkably longer than the chronic group (199 ± 50
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versus 184 ± 52 minutes, P < .001; 112 ± 47 versus 98 ± 29 minutes, P < .001; and 25 ± 8 versus 24 ± 8 minutes, P = .038).
Prolonged aortic cross-clamp (> 100 minutes) and
CPB (> 180 minutes) occurred predominantly in the acute group (P < .001).
Operative Mortality and Morbidity
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The overall operative mortality was 6.5% (52/803), including 15 deaths (4.3%) in the chronic and 37 (8.1%) in the acute groups, respectively (P = .031).
The leading cause
of deaths in acute patients.
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was multiorgan failure, identified in 24 of 52 (46.2%) patients, resulting in 3.5% (16/456) Stroke and low cardiac output syndrome led to 9 (2.0%) and
7 (1.5%) deaths in acute versus 1 (0.3%) and 3 (0.9%) in chronic groups, respectively.
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Three (0.4%) patients died of acute renal failure. Other causes included respiratory
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failure, cardiac arrest, mediastinal infection, abdominal aortic rupture and coagulopathy, each in 1 case (Table 3).
Patients with malperfusion had an overall mortality of 19.3% (17/88), predominantly in Major reasons were
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the acute group (25.0%, 14/56 versus 9.4%, 3/32; P < .001).
multiorgan failure in 8 cases, stroke in 4, low cardiac output syndrome and acute renal Malperfusion of two organs or more occurred in 8 (1.8%) acute and 4
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failure, each in 2.
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(1.2%) chronic patients, with 5 (62.5%) deaths exclusively in the acute group (Table 6).
The operative mortality rate did not differ significantly, either among 4 age groups in acute (P = .185) and chronic (P = .927) patients, or between acute and chronic patients in 4 age groups (P > .05).
Acute patients ≥ 60 years of age had a mortality of 12.8% (6/47),
which is higher than other age groups but with no statistical significance (P = .185) (Table 4). 11
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The acute patients had higher incidence of stroke (13/456, 2.2% versus 3/347, 0.6%; P
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= .046) and respiratory complications (95/456, 20.8% versus 30/347, 8.6%; P < .001). The overall incidence of stroke and spinal cord injury was 2.0% (16/803) and 2.4% (19/803), respectively.
Stroke occurred in 13 (2.2%) and 3 (0.6%) (P = .046), and
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caused 9 (69.2%) and 1 (33.3%) deaths in the acute and chronic groups, respectively.
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Spinal cord injury occurred in 11 (2.4%) acute versus 8 (2.3%) chronic patients (P > .05), including paraplegia in 7 (1.5%) versus 2 (0.6%), and paraparesis in 4 (0.9%) versus 6 (1.7%). Albeit present only in 1.6% (13/803), low cardiac output syndrome caused 7 of 7 (100%) deaths in acute versus 3 of 6 (50.0%) chronic patients.
Renal failure occurred
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in 27 (3.4%) cases, with 18 (3.9%) in acute and 9 (2.6%) in chronic groups (P > .05). The overall incidence of recurrent laryngeal nerve injury and limb ischemia was 1.1%
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(9/803) and 0.9% (7/803), respectively.
Prolonged ventilation > 48 hours was required
in 84 (18.4%) cases in the acute versus 26 (7.5%) chronic groups (P < .001), and tracheal
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reintubation occurred in 33 (7.2%) acute versus 12 (3.5%) cases (P = .021).
Pneumonia
occurred in 10 (1.2%) cases, and pneumothorax and pleural effusion, each in 2 (0.2%) (Table 3).
Postoperative reintervention was required in 40 (5.0%) patients, with 20 in each group. Reexploration for bleeding was required in 25 (3.1%) cases, and drainage of pericardial 12
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effusion in 7 (0.9%).
Intimal tear at the distal end of the open stent graft necessitated
endovascular stent grafting in 3 cases.
Other reoperations included thoracoabdominal
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aortic repair in 2 chronic patients, redo Bentall procedure for aortic root bleeding, axilloaxillary bypass for left arm ischemia, and amputation for left leg thrombotic
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necrosis, each in 1.
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Univariate and Multivariate Analysis
Univariate analysis identified 16 variables associated with operative mortality and showed the risk of operative mortality after Sun’s procedure in acute patients was 1.95 times higher than in chronic patients (P = .031; odds ratio [OR] 1.95; 95% confidence However, multivariate analysis failed to identify
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interval [CI] 1.00-3.63) (Table 7).
acuity as a risk factor (OR 1.67; 95% CI 0.83-3.38; P = .152).
Risk factors for
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operative mortality were: prior cerebrovascular disease (OR 7.01; 95% CI 2.16-22.73; P = .001), malperfusion of the brain (OR 7.10; 95% CI 2.08-24.21; P = .002), kidneys (OR
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12.67; 95% CI 2.11-75.97; P = .005), spinal cord (OR 22.79; 95% CI 2.27-228.97; P = .008) and viscera (OR 22.98; 95% CI 3.23-163.38; P = .002), concomitant extra-anatomic bypass (OR 9.50; 95% CI 3.25-27.81; P < .001) and CPB time > 180 minutes (OR 1.01; 95% CI 1.00-1.016; P < .001).
Coronary malperfusion may also
affect the operative mortality (OR 4.50; 95% CI 1.00-20.22; P = .050) (Table 5).
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DISCUSSION Over the past two decades, the surgical outcomes of TAAD have improved considerately
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and various techniques have been proposed for surgical repair. However, the operative mortality is still high and several aspects of surgical management remain controversial. The most important issue is the extent of distal aortic repair,4-6 regarding the use of a
Although it is being used more widely,8, 10 the safety of FET in the
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FET technique.8
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limited approach such as ascending/hemiarch repair6 or an extensive approach like the
acute setting is still under debate,24 owing to its technical complexity, longer time of cerebral perfusion and circulatory arrest, which might increase the risks of mortality and neurologic events.12, 13
Another important concern is that surgical repair in the acute
chronic phase.1
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phase of TAAD was reported to be associated with higher operative mortality than in the This study on the early outcome of Sun’s procedure in a large series of
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issues.
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803 patients with acute and chronic TAADs is helpful in addressing these two important
Firstly, this study has addressed the issue of safety of FET technique in patients with TAAD. The overall operative mortality was 6.5%, and the incidence of stroke and spinal cord injury was 2.0% and 2.4%, respectively. Except respiratory morbidities, other postoperative complications such as renal failure, reexploration for bleeding, recurrent nerve injury and limb ischemia were consistently infrequent, occurring in only 14
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3.3%, 3.1%, 1.1% and 0.9%, respectively.
These early results indicate that the Sun’s
procedure is a safe surgical approach for patients with acute and chronic TAAD and will Moreover, in our previous
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possibly pave the way for wider use of the FET technique.24
series of 148 acute TAADs, we achieved a mortality of only 4.7%, which compared favorably to a similar group of patients undergoing hemiarch repair who had a mortality Uchida and associates also reported that FET technique could be performed
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of 6.1%.19
lumen.9
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safely for acute TAAD and may reduce the need for reinterventions on the residual false Results of both studies argue in favor of wider use of the extensive FET when
making a decision on the extent of distal repair for patents with TAAD.
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Secondly, although the operative mortality of Sun’s procedure was significantly higher in the acute group than chronic group (8.1% versus 4.3%, P = .031), multivariate analysis
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proved that acuity did not affect the operative mortality (OR 1.67; 95% CI 0.83-3.38; P = .152) in this cohort. This is in agreement with Sabik and colleagues’ conclusion that
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acuity of dissection was not a risk factor for early mortality.25
In this series of 803
TAAD patients, risk factors for operative mortality following Sun’s procedure were prior cerebrovascular disease, malperfusion syndrome (including cerebral, renal, spinal cord and visceral ischemia), extra-anatomic bypass and CPB time > 180 minutes. These results imply that, in the absence of aforementioned risk factors, performing an emergent FET with total arch replacement in the setting of an acute TAAD does not impose greater 15
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risk of operative mortality, compared to an identical procedure performed electively in the setting of a chronic TAAD. This study adds evidence that cardiovascular surgeons
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can safely use this more aggressive FET technique with total arch replacement for cases of acute type A dissections without fear of worse outcomes for the patient.
As devices
and systems are evolving towards an ideal open stent graft, with accrual of evidence from
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registry data with longer follow-up,26 FET with total arch replacement may become the
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next standard of care for patients with type A aortic dissection in whom arch repair is required.8, 15, 16, 27
The results of this study showed FET with total arch replacement was not associated with
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higher early mortality and morbidity compared to totally conventional techniques. One of the reasons for such favorable outcome may be the special FET used in this procedure, It can be implanted very easily and quickly, thereby decreasing circulatory
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the Cronus®.
arrest time, as evidenced by the cerebral perfusion time of 25 ± 8 minutes in this series,
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which is much shorter than the weighted value of 52 ± 31 minutes in the meta-analysis of Tian and associates.10
The technical simplicity makes a lower learning curve, which is
very important to wider and quicker spread of this approach in regions with a large patient population. The sewing cuffs at the proximal and distal ends make anastomosis easier, which are helpful in minimizing the risk of proximal endoleak and facilitating manipulations in subsequent operations should there be any.16
Our algorithm dictating 16
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surgical strategies based on our subcategorization of the Stanford system that divides
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TAAD into subtypes may also contribute to the better results of Sun’s procedure.19
Looking at the impact of age on outcome, we failed to identify age as a risk factor for operative mortality, which is similar to the results of Chiappini and associates.28
The
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most likely reason for this paradoxical finding is the predominance of younger patients in In contrast, 1/3 of
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this series, with only 90 of 803 (11.2%) patients aged ≥ 60 years.
patients in the International Registry of Aortic Dissection (IRAD),29 and 29.9% in the German Registry for Acute Aortic Dissection Type A (GERAADA) were aged ≥ 70 years.30
However, in contemporary FET cohorts the patients are also relatively young,
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with their mean age being 45-61 years, irrespective of geographic differences.10, 31, 32 In a group of 355 acute TAAD patients, Kimura and associates33 found that the early and
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late surgical outcomes were not better in patients aged ≤ 45 years, with an increased risk of reoperation, which was possibly because ascending aortic/hemiarch replacement was
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performed in more than 80% of patients.
Their study conversely implies that the more
extensive FET procedure should be chosen in younger patients.
Malperfusion phenomena have an incidence of 16% to 33%, and clinically apparent malperfusion of any type increases mortality risk.3, 34, 35
In this cohort, 4 of the 7 risk
factors for operative mortality belong to malperfusion syndrome, which occurred in 88 17
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(10.9%) patients and led to a mortality of 19.3%, with an even higher 25.0% in the acute group.
Of all malperfusion phenomena, visceral malperfusion is the most lethal,
23-fold increased the death risk (OR 22.98).
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heralding an extremely poor prognosis,3 as evidenced by a mortality of 71.4% (5/7) and a Spinal cord malperfusion carried almost
the same risk (OR 22.79) with a death rate of 50.0% (2/4).
Renal malperfusion often
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responds well to aortic repair,3 but increased the risk of death by 12.67 times in this series
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with a mortality of 42.8% (3/7). Although with an OR of 4.50, the impact of coronary malperfusion needs to be further validated in a larger sample with more events (P = .050).
The results of this study highlight the malignant impact of malperfusion on the
clinical outcome of TAAD patients.
In many patients, malperfusion itself is an
organs.
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indication for aortic repair, which is expected to save life and reperfuse the ischemic In some cases, reperfusion necessitates concomitant procedures, which will
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inevitably entail longer duration of CPB, cross-clamp and circulatory arrest, thus forming a vicious cascade of “malperfusion → concomitant procedure → longer time of CPB,
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cross-clamp and circulatory arrest → higher mortality”.
This is corroborated by the
results of multivariate regression, in which malperfusion (of 4 organs), extra-anatomic bypass (to correct malperfusion) and a resultant longer CPB time are all identified as independent risk factors for operative mortality.
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This retrospective study has several limitations.
First, more than 80% of our patients are
diagnosed in peripheral or remote hospitals and transferred over a long distance to our Many severe patients died from aortic rupture, tamponade or malperfusion
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institution.
during transfer, while in the emergency room or even while awaiting surgical repair, and we were treating a group of less severe patients who have survived the initial attack of Second, our patients were young with a mean age of 46 and only 12.2%
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aortic dissection.
29.9% of patients were aged ≥ 70 years.
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of them aged ≥ 60 years, in contrast to the IRAD29 and GERAADA30 registries in which ≥ In the European series, patients are 'all comers'
with most of them presenting within the first few hours of dissection, while only 6.6% of our acute patients presented within the first 10 hours after onset.
Therefore, it is very
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difficult to make direct comparisons between our data and those of Europe and North Third, results of this study are certainly influenced by the vast experience
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gained by our group, which is the largest aortic surgical center in China, with an annual case volume of 1100.
Most importantly, data of late survival and freedom from late distal
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elsewhere.
Such favorable conditions are not commonly found or replicated
reintervention are limited, and our efforts of long-term follow-up of patients are ongoing.
CONCLUSIONS In this group of patients with type A dissection, acuity is not a risk factor for operative mortality of frozen elephant trunk and total arch replacement (Sun’s procedure). 19
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Patients with prior cerebrovascular disease, malperfusion of the brain, kidneys, spinal cord and viscera, concomitant extra-anatomic bypass and longer cardiopulmonary bypass
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time (> 180 minutes) are at higher risks of operative mortality.
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Safi HJ, Miller CC, 3rd, Reardon MJ, Iliopoulos DC, Letsou GV, Espada R, et al. Operation for acute and chronic aortic dissection: recent outcome with regard to neurologic deficit and early death. Ann Thorac Surg. 1998;66:402-11. Fann JI, Glower DD, Miller DC, Yun KL, Rankin JS, White WD, et al. Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg. 1991;102:62-73; discussion -5. Bonser RS, Ranasinghe AM, Loubani M, Evans JD, Thalji NM, Bachet JE, et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011;58:2455-74. Elefteriades JA. Editorial comment: extended resection in acute type A aortic dissection. Cardiol Clin. 2010;28:349-50. Coady MA, Rizzo JA, Hammond GL, Mandapati D, Darr U, Kopf GS, et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms? J Thorac Cardiovasc Surg. 1997;113:476-91; discussion 89-91. Kim JB, Chung CH, Moon DH, Ha GJ, Lee TY, Jung SH, et al. Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection. Eur J Cardiothorac Surg. 2011;40:881-7. Ius F, Fleissner F, Pichlmaier M, Karck M, Martens A, Haverich A, et al. Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience. Eur J Cardiothorac Surg. 2013;44:949-57. Roselli EE. Trade in the hammer for a power driver-perspectives on the frozen elephant trunk repair for aortic arch disease. Ann Cardiothorac Surg. 2013;2:633-9. Uchida N, Shibamura H, Katayama A, Shimada N, Sutoh M, Ishihara H. Operative strategy for acute type a aortic dissection: ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. Ann Thorac Surg. 2009;87:773-7. Tian DH, Wan B, Di Eusanio M, Black D, Yan TD. A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery. Ann Cardiothorac Surg. 2013;2:581-91. Shrestha M, Pichlmaier M, Martens A, Hagl C, Khaladj N, Haverich A. Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results. Eur J Cardiothorac Surg. 2013;43:406-10. Svensson LG. Device discordancy: lost cords, quick-fix seekers, quality, and ethics. J Thorac Cardiovasc Surg. 2006;131:261-3.
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19. 20.
21.
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17.
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16.
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15.
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Flores J, Kunihara T, Shiiya N, Yoshimoto K, Matsuzaki K, Yasuda K. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg. 2006;131:336-42. Goossens D, Schepens M, Hamerlijnck R, Hartman M, Suttorp MJ, Koomen E, et al. Predictors of hospital mortality in type A aortic dissections: a retrospective analysis of 148 consecutive surgical patients. Cardiovasc Surg. 1998;6:76-80. Ma WG, Zheng J, Liu YM, Zhu JM, Sun LZ. Dr. Sun's procedure for type A aortic dissection: total arch replacement using tetrafurcate graft with stented elephant trunk implantation. Aorta. 2013;1:59-64. Ma WG, Zhu JM, Zheng J, Liu YM, Ziganshin BA, Elefteriades JA, et al. Sun's procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg. 2013;2:642-8. Ma WG, Zheng J, Dong SB, Lu W, Sun K, Qi RD, et al. Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection. Ann Cardiothorac Surg. 2013;2:621-8. Sun LZ, Ma WG, Zhu JM, Zheng J, Liu YM, Ziganshin BA, et al. Sun's procedure for chronic type A aortic dissection: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg. 2013;2:665-6. Sun LZ, Qi R, Zhu JM, Liu YM, Chang Q, Zheng J. Repair of acute type A dissection: our experiences and results. Ann Thorac Surg. 2011;91:1147-52. Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation. 2011;123:971-8. Liu ZG, Sun LZ, Chang Q, Zhu JM, Dong C, Yu CT, et al. Should the "elephant trunk" be skeletonized? Total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection. J Thorac Cardiovasc Surg. 2006;131:107-13. Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, et al. Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: experience with 107 patients. J Thorac Cardiovasc Surg. 2009;138:1358-62. Sun L, Qi R, Chang Q, Zhu J, Liu Y, Yu C, et al. Surgery for acute type A dissection with the tear in the descending aorta using a stented elephant trunk procedure. Ann Thorac Surg. 2009;87:1177-80.
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Di Eusanio M, Di Bartolomeo R. The Sun procedure-a new paradigm of treatment in DeBakey type 1 acute aortic dissection? Ann Cardiothorac Surg. 2013;2:629-30. Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg. 2000;119:946-62. Yan TD, Tian DH, LeMaire SA, Misfeld M, Elefteriades JA, Chen EP, et al. The ARCH Projects: design and rationale (IAASSG 001). Eur J Cardiothorac Surg. 2014;45:10-6. Haverich A. Aortic arch replacement with frozen elephant trunk-when not to use it. Ann Cardiothorac Surg. 2013;2:592-6. Chiappini B, Schepens M, Tan E, Dell' Amore A, Morshuis W, Dossche K, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J. 2005;26:180-6. Trimarchi S, Eagle KA, Nienaber CA, Rampoldi V, Jonker FH, De Vincentiis C, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140:784-9. Rylski B, Hoffmann I, Beyersdorf F, Suedkamp M, Siepe M, Nitsch B, et al. Acute aortic dissection type A: Age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of over 2000 patients. Ann Surg. 2013. Jakob H, Tsagakis K, Pacini D, Di Bartolomeo R, Mestres C, Mohr F, et al. The International E-vita Open Registry: data sets of 274 patients. J Cardiovasc Surg (Torino). 2011;52:717-23. Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013;145:S197-201. Kimura N, Tanaka M, Kawahito K, Itoh S, Okamura H, Yamaguchi A, et al. Early- and long-term outcomes after surgery for acute type a aortic dissection in patients aged 45 years and younger. Circ J. 2011;75:2135-43. Pacini D, Leone A, Belotti LM, Fortuna D, Gabbieri D, Zussa C, et al. Acute type A aortic dissection: significance of multiorgan malperfusion. Eur J Cardiothorac Surg. 2013;43:820-6. Imoto K, Uchida K, Karube N, Yasutsune T, Cho T, Kimura K, et al. Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection. Eur J Cardiothorac Surg. 2013;44:419-25.
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Tables TABLE 1. Preoperative clinical profiles Acute (N = 456, %)
Chronic (N = 347, %)
Age (y)
46.2 ±10.5
45.9 ±11.2
P value
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Variable
Age group
.063
.750
126 (27.6)
100 (28.8)
.711
40-49 years
156 (34.2)
112 (32.3)
.565
50-59 years
127 (27.9)
92 (26.5)
.673
≥60 years
47 (10.3)
Gender 376 (82.5)
43 (12.4)
Female
.554 .026
264 (76.1)
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Male
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S0022-5223(14)00733-8
DOI:
10.1016/j.jtcvs.2014.06.005
Reference:
YMTC 8651
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 16 April 2014 Revised Date:
31 May 2014
Accepted Date: 4 June 2014
Please cite this article as: Ma W-G, Zheng J, Zhang W, Sun K, Ziganshin BA, Wang L-F, Qi R-D, Liu Y-M, Zhu J-M, Chang Q, Elefteriades JA, Sun L-Z, Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?, The Journal of Thoracic and Cardiovascular Surgery (2014), doi: 10.1016/j.jtcvs.2014.06.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality? Wei Zhang, MD,a Kai Sun, MD, PhD,b
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Wei-Guo Ma, MD,a,b,c Jun Zheng, MD,a,b
Bulat A. Ziganshin MD,c Long-Fei Wang, MD,a Rui-Dong Qi, MD,a,b Yong-Min Liu, MD,a,b Jun-Ming Zhu, MD,a,b Qian Chang, MD,b John A. Elefteriades, MD,c and
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Li-Zhong Sun, MD,a,b
Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood
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Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses,a Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences and State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease,b Beijing, China; Aortic Institute at Yale-New Haven, Yale University School of Medicine,c New Haven, Connecticut, USA
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Drs. Ma and Zheng contribute equally to this work
This study was supported in part by International Science and Technology Cooperation Program of China (2012DFA31110) and Project of Healthcare Professional Leadership in Beijing (2011-1-3)
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Corresponding Author: Li-Zhong Sun, MD Department of Cardiovascular Surgery Beijing Anzhen Hospital of Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases 2 Anzhen Road Beijing 100029 China Phone/Fax: +86 10 6445 6168 E-mail: [email protected] Word Count: 3500 words
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ABSTRACT
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Objective: To compare the early outcomes of frozen elephant trunk with total aortic arch replacement using 4-branched graft (Sun’s procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality and
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determine whether the acuity of TAAD significantly affects operative mortality.
Methods: Univariate and multivariate analysis of clinical data of 803 TAAD patients undergoing the Sun’s procedure.
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Results: Operative mortality was 6.5% (52/803).
Overall incidence of stroke and spinal
cord injury was 2.0% (16/803) and 2.4% (19/803), respectively.
Acute patients had a
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higher incidence of operative death (8.1% versus 4.3%; P = .031), stroke (2.2% versus 0.6%; P = .046) and respiratory morbidities (20.8% versus 8.6%; P < .001). However,
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acuity was not identified as a risk factor for operative mortality (odds ratio, OR 1.67; P = .152), whereas risk factors were: prior cerebrovascular disease (OR 7.01; P = .001), malperfusion of the brain (OR 7.10; P = .002), kidneys (OR 12.67; P = .005), spinal cord (OR 22.79; P = .008) and viscera (OR 22.98; P = .002), concomitant extra-anatomic bypass (OR 9.50; P < .001) and cardiopulmonary bypass time > 180 minutes (OR 1.01; P < .001). 2
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Conclusions: In this group of type A dissection patients, acuity is not a risk factor for Patients with prior cerebrovascular disease,
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operative mortality after Sun’s procedure.
malperfusion of the brain, kidneys, spinal cord and viscera, concomitant extra-anatomic bypass and longer cardiopulmonary bypass time (> 180 minutes) are at higher risks of
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operative mortality.
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ULTRAMINI ABSTRACT
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In 803 type A dissection patients undergoing frozen elephant trunk with total arch replacement (Sun’s procedure), acuity is not a risk factor for operative mortality. However, prior cerebrovascular disease, malperfusion of the brain, kidneys, spinal cord
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and viscera, extra-anatomic bypass and longer cardiopulmonary bypass time increase the
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risk of mortality.
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Stanford type A aortic dissection (TAAD) remains one of the most lethal conditions and
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is associated with significant morbidity and mortality. The patient is at the greatest risk in the acute phase, within 14 days of initial event, when complications brought on by hemorrhage or rupture are most likely.1, 2
Although the last two decades have seen
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advances in surgical techniques and postoperative care, evidence for improving outcomes
patients with TAAD.
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is modest,3 and there are still several contentious issues in the surgical management of The most fundamental issue is the optimal surgical approach,
especially the extent of distal aortic repair.4-6
Some surgeons advocate a more limited
approach such as ascending aortic/hemiarch repair,6 while others support the frozen
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elephant trunk (FET) technique,7-9 which has improved the clinical outcomes of TAADs involving the aortic arch and proximal descending aorta considerably.10, 11
However,
surgical opinion is divided on the use of this extensive approach in TAAD patients.3, 7, 8, 12, The event of acute dissection itself is the dominant risk factor, as is need for
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This raises another concern that surgical repair in the
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preoperative resuscitation.3, 14
acute phase is associated with a higher operative mortality rate than in the chronic phase, as evidenced by Safi’s report with an operative mortality of 20% in acute and 4% in chronic TAAD patients.1
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For those reasons, we retrospectively analyzed the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft, namely, the Sun’s We seek
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procedure,15-18 in 803 consecutive patients with TAAD treated by our group.
to compare the early outcomes between acute and chronic groups of TAAD patients after the Sun’s procedure, to identify the risk factors for operative mortality in both groups,
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and to determine whether the acuity of aortic dissection significantly affects the operative
PATIENTS AND METHODS
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mortality of this extensive surgical approach for treatment of type A aortic dissections.
The Ethics Committees of Fu Wai Hospital and Cardiovascular Institute and Beijing
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Anzhen Hospital, Capital Medical University approved this retrospective study. .
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Patients
Between April 2003 and September 2012, our group performed Sun’s procedure for 803
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patients with TAAD. were male.
Mean age was 46.1 ± 10.8 years (range, 17-78) and 640 (79.7%)
According to the interval between onset of symptoms and surgery,2 an acute
TAAD (≤ 14 days) was diagnosed in 456 patients and chronic TAAD (> 14 days) in 347. In acute TAADs, this interval was 5.0 ± 3.8 days (median 4 days, range 5 hours - 14 days); within the first 10 hours after onset of dissection, 6.6% of patients (30/456) presented and 1.3% (6/456) underwent surgery.
The median time from onset to surgery 6
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in chronic TAADs was 37 days (mean, 189 days, range 14.2 days to 10 years).
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preoperative diagnosis of TAAD was confirmed by transthoracic echocardiography or
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computed tomographic angiography (CTA) in all patients.
A total of 101 (12.6%) cases of clinically apparent malperfusion occurred in 88 (10.9%)
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patients, with 56 (12.3%) and 32 (9.2%) in the acute and chronic groups, respectively.
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Lower limb malperfusion was most common (6.0%, 48/803, followed by cerebral (2.6%, 21/803), coronary (1.7%, 14/803), renal (0.9%, 7/803) and visceral ischemia (0.9%, 7/803) (Table 1).
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Selection Criteria
In patients with TAAD, the Sun’s procedure was indicated in either of the pathological
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conditions: 1) the primary entry located in the arch or descending aorta; 2) severe arch vessel pathology, including dissection, occlusion, stenosis or aneurysm changes; 3)
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intimal intussusception in the arch; 4) concomitant Marfan syndrome; 5) dissection in a dilated arch of > 4 cm in diameter and extending beyond the descending aorta.19
For
patients with none of the above conditions, a different approach would be proposed, such as ascending aortic or hemiarch repair, or total arch repair without FET.20
If a TAAD
patient had the pathological indications but developed malperfusion preoperatively, this procedure would still be performed as long as no end-organ failure had occurred, such as 7
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coma, paraplegia, hemiplegia, intestinal necrosis or hepatic failure.
Senior age was not
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a contraindication.
Surgical Techniques
The Sun’s procedure refers to total aortic arch replacement using a 4-branched vascular
The surgical technique has been described elsewhere in detail.15-23 Briefly,
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aorta.15-18
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graft combined with implantation of a specially designed FET into the descending
it is performed with right axillary artery cannulation for cardiopulmonary bypass (CPB) and selective antegrade cerebral perfusion, under moderate hypothermic circulatory arrest at 25℃, and involves implantation of an FET, Cronus® (MicroPort Medical Co. Ltd,
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Shanghai, China) in the descending aorta, followed by total arch replacement with a 4-branched vascular graft, with a special sequence for aortic reconstruction (i.e., proximal
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descending aorta → left carotid artery → ascending aorta → left subclavian artery → innominate artery), and early rewarming and reperfusion after distal anastomosis to
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minimize cerebral and coronary ischemia.
Associated operations, such as aortic root
replacement or coronary artery bypass grafting (CABG), are performed during the cooling phase, if indicated.
Definition of Outcomes and Risk Factors
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The endpoint was operative mortality, including all deaths, regardless of cause, occurring 1) during the same hospitalization in which the operation was performed, even if after 30 Stroke was
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days; and 2) after discharge from hospital, but within 30 postoperative days.
defined as any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain lasting more than 24 hours.
Coronary artery disease was
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documented by preoperative CTA, or based on prior history of myocardial infarction or
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coronary angiograms or percutaneous coronary interventions. Renal failure was defined as a rise in serum creatinine of 1 mg/dL above baseline or a new requirement for renal dialysis.
Malperfusion syndrome was defined as end-organ ischemia caused by branch
Statistical Analysis
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vessel involvement and resulting in clinical symptoms and functional impairment.
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Data were analyzed with SPSS for Windows version 13.0 (SPSS Inc., Chicago, IL). Variables were expressed as mean ± standard deviation or percentages, and compared
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with the Student t test, Pearson χ2 test or Fisher’s exact test as appropriate. Univariate analysis was used to evaluate variables that may affect operative mortality in both groups. Variables with a P value < .05 in univariate analysis were assessed with multivariate analysis using a forward stepwise binary logistic regression model.
All statistical tests
were 2-sided and any P value of < .05 was considered significant.
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RESULTS Operative Data
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The location of intimal tear was confirmed during the operation (Table 2). Of note, an intimal tear in the aortic arch was found only in acute patients (92, 20.2%).
The chronic
patients had more tears in the descending aorta (106/347, 30.5% versus 101/456; P =
Aortic root or valve procedures were performed in 221 (48.5%) acute and
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acute group.
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.007) and unidentifiable tears (43/347, 12.4% versus 17/456, 3.7%; P > .001) than the
163 (47.0%) chronic patients, including aortic valve repair in 63 (13.8%) and 22 (6.3%; P = .001), and Bentall operation in 130 (28.5%) and 119 (34.3%), in acute and chronic groups, respectively.
A total of 109 concomitant operations were done in 102 (12.7%)
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patients, including CABG in 43 (9.4%) and 24 (6.9%), extra-anatomic bypass in 11 (2.5%) and 16 (4.6%), mitral valve operation in 2 (0.4%) and 13 (3.7%), in acute and The time of CPB, cross-clamp and selective cerebral
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chronic groups, respectively.
perfusion in the acute group was remarkably longer than the chronic group (199 ± 50
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versus 184 ± 52 minutes, P < .001; 112 ± 47 versus 98 ± 29 minutes, P < .001; and 25 ± 8 versus 24 ± 8 minutes, P = .038).
Prolonged aortic cross-clamp (> 100 minutes) and
CPB (> 180 minutes) occurred predominantly in the acute group (P < .001).
Operative Mortality and Morbidity
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The overall operative mortality was 6.5% (52/803), including 15 deaths (4.3%) in the chronic and 37 (8.1%) in the acute groups, respectively (P = .031).
The leading cause
of deaths in acute patients.
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was multiorgan failure, identified in 24 of 52 (46.2%) patients, resulting in 3.5% (16/456) Stroke and low cardiac output syndrome led to 9 (2.0%) and
7 (1.5%) deaths in acute versus 1 (0.3%) and 3 (0.9%) in chronic groups, respectively.
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Three (0.4%) patients died of acute renal failure. Other causes included respiratory
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failure, cardiac arrest, mediastinal infection, abdominal aortic rupture and coagulopathy, each in 1 case (Table 3).
Patients with malperfusion had an overall mortality of 19.3% (17/88), predominantly in Major reasons were
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the acute group (25.0%, 14/56 versus 9.4%, 3/32; P < .001).
multiorgan failure in 8 cases, stroke in 4, low cardiac output syndrome and acute renal Malperfusion of two organs or more occurred in 8 (1.8%) acute and 4
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failure, each in 2.
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(1.2%) chronic patients, with 5 (62.5%) deaths exclusively in the acute group (Table 6).
The operative mortality rate did not differ significantly, either among 4 age groups in acute (P = .185) and chronic (P = .927) patients, or between acute and chronic patients in 4 age groups (P > .05).
Acute patients ≥ 60 years of age had a mortality of 12.8% (6/47),
which is higher than other age groups but with no statistical significance (P = .185) (Table 4). 11
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The acute patients had higher incidence of stroke (13/456, 2.2% versus 3/347, 0.6%; P
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= .046) and respiratory complications (95/456, 20.8% versus 30/347, 8.6%; P < .001). The overall incidence of stroke and spinal cord injury was 2.0% (16/803) and 2.4% (19/803), respectively.
Stroke occurred in 13 (2.2%) and 3 (0.6%) (P = .046), and
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caused 9 (69.2%) and 1 (33.3%) deaths in the acute and chronic groups, respectively.
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Spinal cord injury occurred in 11 (2.4%) acute versus 8 (2.3%) chronic patients (P > .05), including paraplegia in 7 (1.5%) versus 2 (0.6%), and paraparesis in 4 (0.9%) versus 6 (1.7%). Albeit present only in 1.6% (13/803), low cardiac output syndrome caused 7 of 7 (100%) deaths in acute versus 3 of 6 (50.0%) chronic patients.
Renal failure occurred
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in 27 (3.4%) cases, with 18 (3.9%) in acute and 9 (2.6%) in chronic groups (P > .05). The overall incidence of recurrent laryngeal nerve injury and limb ischemia was 1.1%
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(9/803) and 0.9% (7/803), respectively.
Prolonged ventilation > 48 hours was required
in 84 (18.4%) cases in the acute versus 26 (7.5%) chronic groups (P < .001), and tracheal
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reintubation occurred in 33 (7.2%) acute versus 12 (3.5%) cases (P = .021).
Pneumonia
occurred in 10 (1.2%) cases, and pneumothorax and pleural effusion, each in 2 (0.2%) (Table 3).
Postoperative reintervention was required in 40 (5.0%) patients, with 20 in each group. Reexploration for bleeding was required in 25 (3.1%) cases, and drainage of pericardial 12
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effusion in 7 (0.9%).
Intimal tear at the distal end of the open stent graft necessitated
endovascular stent grafting in 3 cases.
Other reoperations included thoracoabdominal
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aortic repair in 2 chronic patients, redo Bentall procedure for aortic root bleeding, axilloaxillary bypass for left arm ischemia, and amputation for left leg thrombotic
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necrosis, each in 1.
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Univariate and Multivariate Analysis
Univariate analysis identified 16 variables associated with operative mortality and showed the risk of operative mortality after Sun’s procedure in acute patients was 1.95 times higher than in chronic patients (P = .031; odds ratio [OR] 1.95; 95% confidence However, multivariate analysis failed to identify
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interval [CI] 1.00-3.63) (Table 7).
acuity as a risk factor (OR 1.67; 95% CI 0.83-3.38; P = .152).
Risk factors for
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operative mortality were: prior cerebrovascular disease (OR 7.01; 95% CI 2.16-22.73; P = .001), malperfusion of the brain (OR 7.10; 95% CI 2.08-24.21; P = .002), kidneys (OR
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12.67; 95% CI 2.11-75.97; P = .005), spinal cord (OR 22.79; 95% CI 2.27-228.97; P = .008) and viscera (OR 22.98; 95% CI 3.23-163.38; P = .002), concomitant extra-anatomic bypass (OR 9.50; 95% CI 3.25-27.81; P < .001) and CPB time > 180 minutes (OR 1.01; 95% CI 1.00-1.016; P < .001).
Coronary malperfusion may also
affect the operative mortality (OR 4.50; 95% CI 1.00-20.22; P = .050) (Table 5).
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DISCUSSION Over the past two decades, the surgical outcomes of TAAD have improved considerately
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and various techniques have been proposed for surgical repair. However, the operative mortality is still high and several aspects of surgical management remain controversial. The most important issue is the extent of distal aortic repair,4-6 regarding the use of a
Although it is being used more widely,8, 10 the safety of FET in the
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FET technique.8
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limited approach such as ascending/hemiarch repair6 or an extensive approach like the
acute setting is still under debate,24 owing to its technical complexity, longer time of cerebral perfusion and circulatory arrest, which might increase the risks of mortality and neurologic events.12, 13
Another important concern is that surgical repair in the acute
chronic phase.1
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phase of TAAD was reported to be associated with higher operative mortality than in the This study on the early outcome of Sun’s procedure in a large series of
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issues.
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803 patients with acute and chronic TAADs is helpful in addressing these two important
Firstly, this study has addressed the issue of safety of FET technique in patients with TAAD. The overall operative mortality was 6.5%, and the incidence of stroke and spinal cord injury was 2.0% and 2.4%, respectively. Except respiratory morbidities, other postoperative complications such as renal failure, reexploration for bleeding, recurrent nerve injury and limb ischemia were consistently infrequent, occurring in only 14
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3.3%, 3.1%, 1.1% and 0.9%, respectively.
These early results indicate that the Sun’s
procedure is a safe surgical approach for patients with acute and chronic TAAD and will Moreover, in our previous
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possibly pave the way for wider use of the FET technique.24
series of 148 acute TAADs, we achieved a mortality of only 4.7%, which compared favorably to a similar group of patients undergoing hemiarch repair who had a mortality Uchida and associates also reported that FET technique could be performed
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of 6.1%.19
lumen.9
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safely for acute TAAD and may reduce the need for reinterventions on the residual false Results of both studies argue in favor of wider use of the extensive FET when
making a decision on the extent of distal repair for patents with TAAD.
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Secondly, although the operative mortality of Sun’s procedure was significantly higher in the acute group than chronic group (8.1% versus 4.3%, P = .031), multivariate analysis
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proved that acuity did not affect the operative mortality (OR 1.67; 95% CI 0.83-3.38; P = .152) in this cohort. This is in agreement with Sabik and colleagues’ conclusion that
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acuity of dissection was not a risk factor for early mortality.25
In this series of 803
TAAD patients, risk factors for operative mortality following Sun’s procedure were prior cerebrovascular disease, malperfusion syndrome (including cerebral, renal, spinal cord and visceral ischemia), extra-anatomic bypass and CPB time > 180 minutes. These results imply that, in the absence of aforementioned risk factors, performing an emergent FET with total arch replacement in the setting of an acute TAAD does not impose greater 15
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risk of operative mortality, compared to an identical procedure performed electively in the setting of a chronic TAAD. This study adds evidence that cardiovascular surgeons
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can safely use this more aggressive FET technique with total arch replacement for cases of acute type A dissections without fear of worse outcomes for the patient.
As devices
and systems are evolving towards an ideal open stent graft, with accrual of evidence from
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registry data with longer follow-up,26 FET with total arch replacement may become the
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next standard of care for patients with type A aortic dissection in whom arch repair is required.8, 15, 16, 27
The results of this study showed FET with total arch replacement was not associated with
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higher early mortality and morbidity compared to totally conventional techniques. One of the reasons for such favorable outcome may be the special FET used in this procedure, It can be implanted very easily and quickly, thereby decreasing circulatory
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the Cronus®.
arrest time, as evidenced by the cerebral perfusion time of 25 ± 8 minutes in this series,
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which is much shorter than the weighted value of 52 ± 31 minutes in the meta-analysis of Tian and associates.10
The technical simplicity makes a lower learning curve, which is
very important to wider and quicker spread of this approach in regions with a large patient population. The sewing cuffs at the proximal and distal ends make anastomosis easier, which are helpful in minimizing the risk of proximal endoleak and facilitating manipulations in subsequent operations should there be any.16
Our algorithm dictating 16
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surgical strategies based on our subcategorization of the Stanford system that divides
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TAAD into subtypes may also contribute to the better results of Sun’s procedure.19
Looking at the impact of age on outcome, we failed to identify age as a risk factor for operative mortality, which is similar to the results of Chiappini and associates.28
The
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most likely reason for this paradoxical finding is the predominance of younger patients in In contrast, 1/3 of
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this series, with only 90 of 803 (11.2%) patients aged ≥ 60 years.
patients in the International Registry of Aortic Dissection (IRAD),29 and 29.9% in the German Registry for Acute Aortic Dissection Type A (GERAADA) were aged ≥ 70 years.30
However, in contemporary FET cohorts the patients are also relatively young,
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with their mean age being 45-61 years, irrespective of geographic differences.10, 31, 32 In a group of 355 acute TAAD patients, Kimura and associates33 found that the early and
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late surgical outcomes were not better in patients aged ≤ 45 years, with an increased risk of reoperation, which was possibly because ascending aortic/hemiarch replacement was
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performed in more than 80% of patients.
Their study conversely implies that the more
extensive FET procedure should be chosen in younger patients.
Malperfusion phenomena have an incidence of 16% to 33%, and clinically apparent malperfusion of any type increases mortality risk.3, 34, 35
In this cohort, 4 of the 7 risk
factors for operative mortality belong to malperfusion syndrome, which occurred in 88 17
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(10.9%) patients and led to a mortality of 19.3%, with an even higher 25.0% in the acute group.
Of all malperfusion phenomena, visceral malperfusion is the most lethal,
23-fold increased the death risk (OR 22.98).
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heralding an extremely poor prognosis,3 as evidenced by a mortality of 71.4% (5/7) and a Spinal cord malperfusion carried almost
the same risk (OR 22.79) with a death rate of 50.0% (2/4).
Renal malperfusion often
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responds well to aortic repair,3 but increased the risk of death by 12.67 times in this series
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with a mortality of 42.8% (3/7). Although with an OR of 4.50, the impact of coronary malperfusion needs to be further validated in a larger sample with more events (P = .050).
The results of this study highlight the malignant impact of malperfusion on the
clinical outcome of TAAD patients.
In many patients, malperfusion itself is an
organs.
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indication for aortic repair, which is expected to save life and reperfuse the ischemic In some cases, reperfusion necessitates concomitant procedures, which will
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inevitably entail longer duration of CPB, cross-clamp and circulatory arrest, thus forming a vicious cascade of “malperfusion → concomitant procedure → longer time of CPB,
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cross-clamp and circulatory arrest → higher mortality”.
This is corroborated by the
results of multivariate regression, in which malperfusion (of 4 organs), extra-anatomic bypass (to correct malperfusion) and a resultant longer CPB time are all identified as independent risk factors for operative mortality.
18
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This retrospective study has several limitations.
First, more than 80% of our patients are
diagnosed in peripheral or remote hospitals and transferred over a long distance to our Many severe patients died from aortic rupture, tamponade or malperfusion
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institution.
during transfer, while in the emergency room or even while awaiting surgical repair, and we were treating a group of less severe patients who have survived the initial attack of Second, our patients were young with a mean age of 46 and only 12.2%
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aortic dissection.
29.9% of patients were aged ≥ 70 years.
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of them aged ≥ 60 years, in contrast to the IRAD29 and GERAADA30 registries in which ≥ In the European series, patients are 'all comers'
with most of them presenting within the first few hours of dissection, while only 6.6% of our acute patients presented within the first 10 hours after onset.
Therefore, it is very
America.
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difficult to make direct comparisons between our data and those of Europe and North Third, results of this study are certainly influenced by the vast experience
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gained by our group, which is the largest aortic surgical center in China, with an annual case volume of 1100.
Most importantly, data of late survival and freedom from late distal
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elsewhere.
Such favorable conditions are not commonly found or replicated
reintervention are limited, and our efforts of long-term follow-up of patients are ongoing.
CONCLUSIONS In this group of patients with type A dissection, acuity is not a risk factor for operative mortality of frozen elephant trunk and total arch replacement (Sun’s procedure). 19
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Patients with prior cerebrovascular disease, malperfusion of the brain, kidneys, spinal cord and viscera, concomitant extra-anatomic bypass and longer cardiopulmonary bypass
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time (> 180 minutes) are at higher risks of operative mortality.
20
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Tables TABLE 1. Preoperative clinical profiles Acute (N = 456, %)
Chronic (N = 347, %)
Age (y)
46.2 ±10.5
45.9 ±11.2
P value
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Variable
Age group
.063
.750
126 (27.6)
100 (28.8)
.711
40-49 years
156 (34.2)
112 (32.3)
.565
50-59 years
127 (27.9)
92 (26.5)
.673
≥60 years
47 (10.3)
Gender 376 (82.5)
43 (12.4)
Female
.554 .026
264 (76.1)
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Male
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