Heart Vessels DOI 10.1007/s00380-014-0612-6
ORIGINAL ARTICLE
Results of “elephant trunk” total aortic arch replacement using a multi‑branched, collared graft prosthesis Stefan R.B. Schneider · Angelo M. Dell’Aquila · Ali Akil · Dominik Schlarb · Guiseppe Panuccio · Sven Martens · Andreas Rukosujew
Received: 24 July 2014 / Accepted: 1 December 2014 © Springer Japan 2014
Abstract We report on our experience with a simplified elephant trunk (ET) procedure with a multi-branched prosthesis (Vascutek® Siena™ Collared Graft). It consists of a proximal portion (20 cm) with prefabricated side branches, a collar and a distal portion (30 cm). The collar, which can be trimmed into any desired diameter, constitutes the suture portion to the descending aorta. Radiopaque markers in the distal portion indicate the landing zone. Between January 2011 and June 2013, 20 consecutive patients (10 women; mean age, 66 ± 9.3 years) underwent ET procedure, including 6 re-do cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7– 29.7 mm). Concomitant procedures included ascending aortic replacement in 16 patients; root replacement in 2; AVR in 2, CABG in 3 and mitral repair in 1 patient. CPB time was 263 ± 94 min; mean duration of ACP was 65 ± 14 min. Two patients died on POD 8 and 78, respectively. Major adverse events included stroke (n = 1), resternotomy for bleeding Part of this work was presented at the 28th meeting of the Association of Cardiac Surgeons in Madrid in June 2013. S. R. B. Schneider and A. M. Dell’Aquila contributed equally. S. R. Schneider (*) · A. M. Dell’Aquila · A. Akil · D. Schlarb · S. Martens · A. Rukosujew Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert‑Schweitzer‑Campus 1, Gebäude A1, 48149 Münster, Germany e-mail: [email protected] G. Panuccio Department of Vascular and Endovascular Surgery, Universitätsklinikum Münster, Albert‑Schweitzer‑Campus 1, Gebäude A1, 48149 Münster, Germany
(n = 2), renal failure requiring temporary dialysis (n = 1) and recurrent nerve paresis (n = 2). After a mean follow-up of 10 ± 8 months, all discharged patients were alive. Seven patients underwent stent-graft implantation of the descending aorta and one patient underwent open descending aortic replacement. The last generation of multi-branched arch prosthesis and especially the Vascutek® Siena™ Collared Graft make ET procedure a reasonable treatment option even in patients with acute aortic dissection. Keywords Aortic arch replacement · Elephant trunk procedure · Ascending aortic aneurysm · Aortic dissection Abbreviations ET Elephant trunk ACP Antegrade cerebral perfusion AVR Aortic valve replacement CPB Cardiopulmonary bypass CABG Coronary aortic bypass grafting PAU Perforating aortic ulcer NIRS Near infrared spectroscopy POD Postoperative day SLEDD Slow low effective daily dialysis AVR Aortic valve replacement HIT Heparin-induced thrombocytopenia SD Standard deviation GRF Gelatin–resorcinol–formaldehyde ROTEM Rotational thromboelastometry CTC Computed tomography of the cerebrum
Introduction Aortic arch surgery has always been a demanding procedure. In 1983, Borst et al. [1] developed the elephant trunk
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Heart Vessels
Fig. 2 Intraoperative view of the four branch prosthesis. Intraoperative view of the four branch prosthesis. Please note the collar for the distal anastomosis
Fig. 1 Four branch prosthesis for elephant trunk procedure (Siena Plexus 4 Branch). Four branch prosthesis for elephant trunk procedure (Siena Plexus 4 Branch)
(ET) procedure, where a free-floating portion of the arch prosthesis in the descending aorta serves as a stable suture site for vascular prosthesis during a second-stage surgery or offers a landing zone for later stent-graft implantation in the descending aorta. Ordinary vascular prosthesis used for the ET procedure offer no radiographically visible markers for detection of their distal portion during stent-graft implantation. Furthermore for suturing of the distal anastomosis, the ET is primarily inverted into the arch. The suture is then performed through a double layer of the prosthesis and size matching with an aneurysmatic descending aorta can be technically demanding. We report on our experience with a simplified ET procedure with an innovative prosthesis (Vascutek® Siena™ Collared Graft). This prosthesis, first described by Neri and colleagues [2], consists of a proximal portion (20 cm), a collar and a distal portion (30 cm) (Fig. 1). The collar, made of a gelatin-coated woven polyester, constitutes the suture portion to the descending aorta. This can be trimmed into any desired diameter for the suture. The manufacturer offers different versions of the prosthesis, either without side branches or with one or four prefabricated side
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branches. The branches serve as prosthetic replacement for the supraaortic branches, and another one can easily be used for cannulation of the prosthesis (Fig. 2). Another innovation consists in the presence of radiopaque markers in the distal portion, extending from the collar to the distal end of the prosthesis, which facilitates second-stage endovascular procedures. This special characteristic helps to avoid the above-mentioned difficulties of the classic ET procedure.
Patients and methods Our local ethics committee approved the study and patient consent was waived. Patients Between January 2011 and June 2013, 20 patients (10 women; mean age, 66 ± 9 years) underwent ET procedure. All patients with primary implantation of a Vascutek Siena™ collared graft were included in the study. Preoperative characteristics of the patients are summarized in Table 1. There were 8 (40 %) emergency cases, 3 (15 %) urgent cases and 9 (45 %) elective cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7–29.7 mm). Six patients (30 %) had undergone previous heart surgery; one of those had an underlying Loeys–Dietz syndrome. Previous heart surgeries included proximal thoracic aortic repair in 6 cases (30 %). Concomitant procedures included ascending aortic replacement in
Heart Vessels Table 1 Preoperative data Age Sex Female Male Underlying disease Acute dissection Chronic dissection Aneurysm PAU Loeys–Dietz syndrome Previous operations Previous sternotomy Previous proximal thoracic aortic repair Comorbidities
66 n 10 10 n 6 4 8 2 1 n 6 6
SD ± 93 % 50 50 % 30 20 40 10 5 % 30 30 %
Hypertension Smoking history Diabetes Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease
n 15 5 4 3 1 5
75 25 20 15 5 25
Renal failure
3
15
16 patients; root replacement in 2; aortic valve replacement in 2, CABG in 3 and mitral repair in 1 patient. Among the comorbidities, arterial hypertension was the most frequent one (n = 15, 75 %). Five patients (25 %) had a history of smoking and four patients (20 %) suffered from diabetes. Chronic obstructive pulmonary disease was present in five (25 %) patients, coronary heart disease in three (15 %) and three patients (15 %) had a history of renal failure on hospital admission. One patient had a preclinical diagnosis of heparin-induced thrombocytopenia type II (HIT II). Operative data and statistical analysis Surgeries were performed by two experienced surgeons. If descending aortic repair was necessary, we preferred a two-stage approach, with the second stage scheduled after complete recovery of the patient. The standard surgical procedure in our institution consists of arterial cannulation of the right axillary artery and venous cannulation of the right femoral vein. In most cases, the extracorporeal circulation was started before median sternotomy to prevent damage to the aneurysmatic aorta or its branches, especially in cases of reoperation. Median sternotomy was performed to gain surgical access to the chest cavity. For heart arrest, we used cold blood cardioplegia administered either in an antegrade way via the ascending aorta, retrograde through the coronary sinus or a combination of both. With the help of the extracorporeal circulation, systemic cooling of the patient
to deep or moderate hypothermia (25–30 °C) was achieved [3]. After Trendelenburg positioning of the patient, the aorta was cross-clamped and the truncus brachiocephalicus was restricted using a tourniquet to facilitate antegrade unilateral perfusion of the brain via the axillary artery cannula [4]. Normally, flow rates of 0.8–1.3 l/min (10 ml/kg/min) were achieved [3]. Then the aortic clamp was removed for open arch surgery. Brain perfusion was monitored by continuous near infrared spectroscopy (NIRS) during the entire surgery [5]. If the cerebral oxygen saturation showed a drop below 60 %, an additional perfusion catheter was introduced into the left carotid artery for bilateral cerebral perfusion. This was necessary in only one case and can be done in less than a minute. The distal portion of the prosthesis was shortened to a length of 5–6 cm to prevent thrombus formation and/or malperfusion that might lead to spinal cord ischemia. Sutures were performed with Teflon felt reinforcement and afterward secured with BioGlue. In selected cases the aortic wall was reconstructed using GRF glue [6], the use of which is widely under discussion [7]. The collar is trimmed with a pair of scissors to match the descending aorta. The adequate sizing is merely an “eyeballing” measurement and depends on the surgeon’s experience and personal preferences. We tend to slightly undersize the prosthesis to achieve a size reduction of the aneurysm. After finishing the distal anastomosis the prosthesis offers a side branch for arterial cannulation. Through this side branch we started distal body perfusion while performing the supraaortic anastomosis, thus minimizing the ischemic time of the lower body. In cases of severe diffuse bleeding, we prefer to perform definitive sternal closure within 48 h after the primary surgery when bleeding has stopped [8]. A cell saver is used on all aortic surgeries. Once the patient is hemodynamically stable, we schedule a postoperative CT scan of the aorta. During the postoperative course, we focus especially on controlling arterial blood pressure. We aim for a systolic blood pressure below 120 mmHg. To achieve these values we administer ß-blockers (e.g., metoprolol) [9, 10] and ACE inhibitors or AT1 antagonists (e.g., enalapril/candesartan). Those substances ideally serve as anti-impulse therapy [11] and furthermore have proven beneficial for remodeling of the aortic wall in animal and human cohort studies [12–14]. In case of a remaining dissection membrane with organ perfusion through the false lumen, we administer vitamin K antagonists (phenprocoumon) to prevent thrombotic closure of the false lumen [15]; this might be necessary especially in patients with chronic dissection. All patients were referred to our vascular surgery unit for follow-up and indication of 2nd-stage stent-graft implantation after recovery. Neurologic complication was defined as clinical neurologic deficit (paresis, epileptic seizure, cognitive deficit)
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with or without pathologic findings on CTC scan lasting more than 24 h within 30 days after surgery. Baseline data characteristics of patients were prospectively collected. Data are summarized as mean ± SD. Data analysis was performed using commercially available statistical software packages (SPSS, Version 22.0/SPSS Inc., Chicago, IL; Microsoft Excel 2011, Microsoft Corporation, Redmond WA, USA).
Results The operative data are summarized in Table 2. Mean bypass time was 263 min (±94 min), mean cross-clamp time was 157 min (±45 min) and mean circulatory arrest time was 65 min (±14 min). Six patients (33 %) underwent successful 2nd-stage procedure on the descending thoracic aorta (5 endovascular stents, 1 open procedure), one of them received an endovascular stent as a one-stage procedure on the same day and four others after primary recovery from open surgery on POD 38, 57, 207 and 110. One patient suffered from mesenteric embolism during stent-graft implantation on POD 424. The procedure had to be stopped and emergency laparotomy was performed. The patient survived and was discharged after a prolonged ICU stay. Another patient had already received a stenting of his descending thoracic aorta before surgery, retrograde dissection occurred as complication of the stent graft and he was referred to our center for emergency surgery. Intraoperatively, we directly sutured the stent to the distal portion of the elephant trunk prosthesis. One patient underwent open descending aortic replacement on POD 92, his postoperative course was uneventful and he was discharged home. The details on the 2nd-stage procedures are summarized in Table 4. The overall survival was 90 % after a mean follow-up of 9.6 months (±7.5 months). The Kaplan–Meier survival curve is displayed in Fig. 3. There were no intraoperative deaths. The 30-day mortality was 5 % (1/20). One early death occurred on POD 8; the cause of death was MOF. One late death occurred due to pericardial tamponade and intracerebral bleeding on POD 78. The deceased patients had suffered from acute aortic dissection and were referred to our center as emergency cases. One of them had suffered from bleeding complications and required mass transfusion. Neurologic complications included stroke (hemiplegia) in 1 case, recurrent nerve palsy in 2 cases, one epileptic seizure and one intracerebral hemorrhage leading to death. In our cohort no patient suffered from spinal cord ischemia. Five patients (25 %) underwent secondary sternal closure as they presented with severe diffuse bleeding; two patients (10 %) required reoperation due to bleeding after
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Heart Vessels Table 2 Operative details Acuity
n 8 3 9
Emergent Urgent Elective Arterial cannulation site
n 18 1 1
Right axillary artery Ascending Aorta/Transverse arch Femoral artery Concomitant procedures
n 16 2 2 3 1 min 65 157 263 Units 16 22
Ascending aortic replacement Conduit AVR CABG Mitral valve surgery Perfusion–ischemic times Selective antegrade cerebral perfusion time Cardiac ischemic time (X-clamp) Total cardiopulmonary bypass time Transfusion requirements Packed red blood cells Fresh frozen plasma Platelets
5
% 40 15 45 % 90 5 5 % 80 10 10 15 5 SD ±14,0 ±45 94 SD ±17 ±28 ±5
Table 3 Early complications Death Intraoperative 30 days In hospital Neurologic complications Stroke/Hemiparesis Palsy of recurrent nerve Intracerebral hemorrhage Epileptic seizure Multi-organ failure Myocardial ischemia requiring stent implantation Secondary sternal closure Bleeding requiring reoperation (after primary sternal closure) Late pericardial tamponade Renal failure Re-intubation (atelectasis) Deep sternal wound infection
%
n 0 1 1 n 1 2 1 1 1 1
0 5 5 % 5 10 5 5 5 5
5 2
25 10
2 1 1
10 5 5
2
10
primary sternal closure and two patients (10 %) suffered from late pericardial tamponade that was resolved by emergency surgery. One of them had a preclinical diagnosis of HIT type II, thus argatroban was used for effective
Heart Vessels Table 4 Procedures on the descending aorta Patient number
POD
Result
1 2 3 4
424 38 57 0
2nd-Stage stent implantation stopped due to mesenteric embolism during the procedure 2nd-Stage successful stent implantation 2nd-Stage successful stent implantation Patient was status post-stent implantation of the descending aorta
5 6 7
207 0 110
2nd-Stage successful stent implantation Successful stent implantation as single-stage procedure 2nd-Stage successful stent implantation
8
92
2nd-Stage open replacement of the descending aorta
anticoagulation during cardiopulmonary bypass. Unfortunately, there is no antagonist for argatroban; therefore, this patient suffered severe diffuse bleeding and required mass transfusion as well as open chest management with secondary sternal closure after the bleeding had stopped. One patient (5 %) developed postoperative renal failure requiring temporary dialysis; there was one case (5 %) of re-intubation due to atelectasis and we report two cases (10 %) of deep sternal wound infection. Mean stay on ICU was 19 days (±19 days); postoperative hospital stay was 27 days (±22 days). The postoperative data are summarized in Table 3.
Comment According to our experience, the multi-branched, collared graft (Vascutek Siena™) is a good treatment option for aortic arch pathologies. The presence of the collar allows an easy anastomosis with any diameter of the distal aorta and the radiopaque markers facilitate 2nd-stage stent-graft implantation. Those two characteristics mark the main difference with other branched prostheses. The 30-day mortality of 5 % (n = 1) we experienced in our relatively small cohort fits the mortality rates reported by other authors (3.7–18.4 %) [16–18]. Among the possible complications in aortic surgery, especially bleeding and neurologic complications are of major concern. Although the design of the prosthesis facilitates sizing and suturing of the distal anastomosis, we did not experience less bleeding episodes, but that may be due to the relatively high number of re-do surgeries (n = 6, 30 %), emergency patients (n = 8, 40 %) and patients with acute dissection (n = 6, 30 %) in our small cohort. The case of a patient with diagnosis of HIT type II on admission was especially demanding. We had to use argatroban for effective anticoagulation during the cardiopulmonary bypass and he suffered severe diffuse bleeding and required mass transfusion as well as open chest management with secondary sternal closure after the bleeding had stopped.
Bleeding complications often occur in connection with preclinical medication: Antiplatelet agents such as clopidogrel, acetylic salicylic acid or newer substances like ticagrelor are administered as first-line therapy of acute chest pain [19]. In many cases, the diagnosis of dissection might be missed or the dissection may be the cause of myocardial ischemia. In emergency patients (in our study n = 8, 40 %) presenting with aortic dissection, one should not lose time waiting for the effects of the preclinical medication to pass. Furthermore, patients with acute aortic dissection and surgery with hypothermic cardiac arrest experience impairment of blood coagulation [20, 21]. We face this challenge by a differentiated analysis of the coagulation using ROTEM and specific administration of cellular and noncellular blood products [22], but in many cases even this differentiated therapy does not have the desired success. In cases of severe diffuse bleeding, we prefer performing definitive sternal closure within 48 h after the primary surgery when bleeding has stopped [8]. Neurologic complications with permanent or transient stroke incidences between 1.2 and 20 % have been reported in the literature [18, 23, 24]. In our small cohort one patient suffered permanent stroke and one patient a lethal intracerebral hemorrhage (n = 2, 10 %). Despite all the challenges aortic pathologies carry with them, the Vascutek Siena collared prosthesis offers several advantages. Those include easier size matching of the distal anastomosis, prefabricated side branches that can be used for easier anastomosis of the supraaortic branches and for cannulation of a specially positioned side branch after the distal anastomosis is completed, thus shortening circulatory arrest times. In 2013, Lida and colleagues published a case report describing a “flanged ET technique” [25], which is a similar concept. They describe how they create a double-layer flange by plicating the vascular prosthesis to facilitate the distal anastomosis and reduce bleeding complications. They used this technique in a patient with aneurysmatic aorta. The collared multi-branched prosthesis on the other hand offers a prefabricated single-layer collar that basically
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Heart Vessels
Fig. 3 Kaplan–Meier survival curve
serves the same purpose. The single-layer oversized collar facilitates performing the suture and can easily be trimmed to the descending aortic stump, by cutting it to the appropriate size with a pair of scissors. When Neri and colleagues first described the use of their prosthesis in four patients [2], they limited its use to patients with arch aneurysms. We extended the indication to emergency cases including patients with acute aortic dissection. There is an ongoing discussion among surgeons whether extensive aortic reconstruction with root and arch replacement is justified in acute aortic dissections [16]. Complete arch replacement is less time consuming nowadays and has become possible even in patients with acute type A dissection. Some years ago, we would have preferred a more limited surgery with hemiarch replacement and readaptation of the dissection membrane with GRF glue in type A dissections. Watanuki states that in his series, false lumen obliteration in the descending aorta without second-stage procedure [16] was frequent, making the ET a stand-alone procedure. This is possible if the ET covers a remaining tear in the proximal descending aorta. Shresta advocates for a
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liberal indication for the ET procedure as well. He believes that patients in need of arch replacement should receive an elephant trunk, because there is no additional risk compared to a simple arch procedure, and in case a 2nd-stage procedure becomes necessary, this will be easier with the ET in place [26]. Even in patients who will not be in need of stentgraft implantation, there remains the advantage of an easily performed distal anastomosis. In these cases, the ET may be shortened to 2–3 cm. Radiopaque markers on the distal prosthesis mark the landing zone and facilitate later treatment of the descending aorta with stent grafts. The main limitation of this cohort study lies in the small number of patients for statistical comparisons with other studies. However this number constitutes a reasonable cohort, considering the pathology and its management, taking into account that it is a single-center experience. Only five patients received 2nd-stage stent implantation, one patient was status post-stent implantation, in one patient stent implantation was not successful and one patient received open descending aortic repair. With a 33 % rate of 2nd-stage procedure after a mean follow-up of 9.6 months,
Heart Vessels
we report numbers lower than the average of 45 % reported in a recent review by Lus and co-workers [18], but the same as the 32 % reported by Shresta et al. [26]. We indicated the ET procedure for patients with type A dissection even if the diameter of the dissected descending aorta was normal, because a large number of patients might develop aneurysm of the descending aorta later on [27] and it carries no additional risk compared to the standard arch replacement [26]. So far, we can report only on a short follow-up interval. Longer follow-up is required to show if the advantages we assume can be proven in the long term. Conflict of interest None declared.
References 1. Borst HG, Walterbusch G, Schaps D (1983) Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg 31:37–40 2. Neri E, Massetti M, Sani G (2004) The “elephant trunk” technique made easier. Ann Thorac Surg 78:e17–e18 3. Minatoya K, Ogino H, Matsuda H, Sasaki H, Tanaka H, Kobayashi J, Yagihara T, Kitamura S (2008) Evolving selective cerebral perfusion for aortic arch replacement: high flow rate with moderate hypothermic circulatory arrest. Ann Thorac Surg 86:1827–1831 4. Strauch JT, Bohme Y, Franke UF, Wittwer T, Madershahian N, Wahlers T (2005) Selective cerebral perfusion via right axillary artery direct cannulation for aortic arch surgery. Thorac Cardiovasc Surg 53:334–340 5. Orihashi K, Sueda T, Okada K, Imai K (2004) Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion. Eur J Cardiothorac Surg 26:907–911 6. Guilmet D, Bachet J, Goudot B, Laurian C, Gigou F, Bical O, Barbagelatta M (1979) Use of biological glue in acute aortic dissection. preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 77:516–521 7. Bingley JA, Gardner MAH, Stafford EG, Mau TK, Pohlner PG, Tam RKW, Jalali H, Tesar PJ, O’Brien MF (2000) Late complications of tissue glues in aortic surgery. Ann Thorac Surg 69:1764–1768 8. Boeken U, Assmann A, Mehdiani A, Akhyari P, Lichtenberg A (2011) Open chest management after cardiac operations: outcome and timing of delayed sternal closure. Eur J Cardiothorac Surg 40:1146–1150 9. Kodama K, Nishigami K, Sakamoto T, Sawamura T, Hirayama T, Misumi H, Nakao K (2008) Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection. Circulation 118:S167–S170 10. Ohnuma T, Kimura N, Sasabuchi Y, Asaka K, Shiotsuka J, Komuro T, Mouri H, Lefor AT, Adachi H, Sanui M (2014) Lower heart rate in the early postoperative period does not correlate with long-term outcomes after repair of type A acute aortic dissection. Heart Vessels. doi:10.1007/s00380-014-0486-7 11. Wheat MW (1965) Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg 50:364–373 12. Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz HC (2008) Angiotensin II blockade and aortic-root dilation in marfan’s syndrome. N Engl J Med 358:2787–2795 13. Habashi JP, Judge DP, Holm TM, Cohn RD, Loeys BL, Cooper TK, Myers L, Klein EC, Liu G, Calvi C, Podowski M, Neptune ER, Halushka MK, Bedja D, Gabrielson K, Rifkin DB, Carta L,
Ramirez F, Huso DL, Dietz HC (2006) Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of marfan syndrome. Science 312:117–121 14. Lunder M, Žiberna L, Janić M, Jerin A, Skitek M, Šabovicˇ M, Drevenšek G (2013) Low-dose atorvastatin, losartan, and particularly their combination, provide cardiovascular protection in isolated rat heart and aorta. Heart Vessels 28:246–254 15. Song S, Yoo K, Kim D, Cho B, Yi G, Chang B (2011) Effects of early anticoagulation on the degree of thrombosis after repair of acute DeBakey type I aortic dissection. Ann Thorac Surg 92:1367–1375 16. Watanuki H, Ogino H, Minatoya K, Matsuda H, Sasaki H, Ando M, Kitamura S (2007) Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 84:1585–1591 17. Kieffer E, Koskas F, Godet G, Bertrand M, Bahnini A, Benhamou A, Cluzel P, Eyraud D (2000) Treatment of aortic arch dissection using the elephant trunk technique. Ann Vasc Surg 14:612–619 18. Ius F, Hagl C, Haverich A, Pichlmaier M (2011) Elephant trunk procedure 27 years after borst: what remains and what is new? Eur J Cardiothorac Surg 40:1–12 19. Authors/Task Force Members, Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van’t Hof A, Widimsky P, Zahger D, ESC Committee for Practice Guidelines (CPG), Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Document Reviewers, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Hasdai D, Astin F, Åström-Olsson K, Budaj A, Clemmensen P, Collet J, Fox KA, Fuat A, Gustiene O, Hamm CW, Kala P, Lancellotti P, Maggioni AP, Merkely B, Neumann F, Piepoli MF, Van de Werf F, Verheugt F, Wallentin L (2012) ESC guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the european society of cardiology (ESC). Eur Heart J 33:2569–2619 20. Wilde JT (1997) Hematological consequences of profound hypothermic circulatory arrest and aortic dissection. J Card Surg 12(2 Suppl):201–206 21. Delsart P, Beregi J, Devos P, Haulon S, Midulla M, MounierVehier C (2014) Thrombocytopenia: an early marker of late mortality in type B aortic dissection. Heart Vessels 29:220–230 22. Hanke AA, Herold U, Dirkmann D, Tsagakis K, Jakob H, Görlinger K (2012) Thromboelastometry based early goal-directed coagulation management reduces blood transfusion requirements, adverse events, and costs in acute type A aortic dissection: a pilot study. Transfus Med Hemother 39:121–128 23. Svensson LG (1992) Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 7:301–312 24. Konishi T, Higuchi K, Fukata M, Takeda M, Akisima S, Fukuda S (1999) Extended aortic replacement in acute dissection by the separated elephant trunk technique. Ann Thorac Surg 67:1664–1668 25. Iida Y, Koizumi N, Matsuyama K, Ogino H (2013) Flanged elephant trunk technique at distal anastomosis for total arch replacement with multibranched arch graft. Ann Vasc Surg 27:831–833 26. Shrestha M, Martens A, Krüger H, Maeding I, Ius F, Fleissner F, Haverich A (2014) Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J Cardiothorac Surg 45:289–296 27. Park K, Lim C, Choi JH, Chung E, Choi SI, Chun EJ, Sung K (2009) Midterm change of descending aortic false lumen after repair of acute type I dissection. Ann Thorac Surg 87:103–108
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ORIGINAL ARTICLE
Results of “elephant trunk” total aortic arch replacement using a multi‑branched, collared graft prosthesis Stefan R.B. Schneider · Angelo M. Dell’Aquila · Ali Akil · Dominik Schlarb · Guiseppe Panuccio · Sven Martens · Andreas Rukosujew
Received: 24 July 2014 / Accepted: 1 December 2014 © Springer Japan 2014
Abstract We report on our experience with a simplified elephant trunk (ET) procedure with a multi-branched prosthesis (Vascutek® Siena™ Collared Graft). It consists of a proximal portion (20 cm) with prefabricated side branches, a collar and a distal portion (30 cm). The collar, which can be trimmed into any desired diameter, constitutes the suture portion to the descending aorta. Radiopaque markers in the distal portion indicate the landing zone. Between January 2011 and June 2013, 20 consecutive patients (10 women; mean age, 66 ± 9.3 years) underwent ET procedure, including 6 re-do cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7– 29.7 mm). Concomitant procedures included ascending aortic replacement in 16 patients; root replacement in 2; AVR in 2, CABG in 3 and mitral repair in 1 patient. CPB time was 263 ± 94 min; mean duration of ACP was 65 ± 14 min. Two patients died on POD 8 and 78, respectively. Major adverse events included stroke (n = 1), resternotomy for bleeding Part of this work was presented at the 28th meeting of the Association of Cardiac Surgeons in Madrid in June 2013. S. R. B. Schneider and A. M. Dell’Aquila contributed equally. S. R. Schneider (*) · A. M. Dell’Aquila · A. Akil · D. Schlarb · S. Martens · A. Rukosujew Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert‑Schweitzer‑Campus 1, Gebäude A1, 48149 Münster, Germany e-mail: [email protected] G. Panuccio Department of Vascular and Endovascular Surgery, Universitätsklinikum Münster, Albert‑Schweitzer‑Campus 1, Gebäude A1, 48149 Münster, Germany
(n = 2), renal failure requiring temporary dialysis (n = 1) and recurrent nerve paresis (n = 2). After a mean follow-up of 10 ± 8 months, all discharged patients were alive. Seven patients underwent stent-graft implantation of the descending aorta and one patient underwent open descending aortic replacement. The last generation of multi-branched arch prosthesis and especially the Vascutek® Siena™ Collared Graft make ET procedure a reasonable treatment option even in patients with acute aortic dissection. Keywords Aortic arch replacement · Elephant trunk procedure · Ascending aortic aneurysm · Aortic dissection Abbreviations ET Elephant trunk ACP Antegrade cerebral perfusion AVR Aortic valve replacement CPB Cardiopulmonary bypass CABG Coronary aortic bypass grafting PAU Perforating aortic ulcer NIRS Near infrared spectroscopy POD Postoperative day SLEDD Slow low effective daily dialysis AVR Aortic valve replacement HIT Heparin-induced thrombocytopenia SD Standard deviation GRF Gelatin–resorcinol–formaldehyde ROTEM Rotational thromboelastometry CTC Computed tomography of the cerebrum
Introduction Aortic arch surgery has always been a demanding procedure. In 1983, Borst et al. [1] developed the elephant trunk
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Heart Vessels
Fig. 2 Intraoperative view of the four branch prosthesis. Intraoperative view of the four branch prosthesis. Please note the collar for the distal anastomosis
Fig. 1 Four branch prosthesis for elephant trunk procedure (Siena Plexus 4 Branch). Four branch prosthesis for elephant trunk procedure (Siena Plexus 4 Branch)
(ET) procedure, where a free-floating portion of the arch prosthesis in the descending aorta serves as a stable suture site for vascular prosthesis during a second-stage surgery or offers a landing zone for later stent-graft implantation in the descending aorta. Ordinary vascular prosthesis used for the ET procedure offer no radiographically visible markers for detection of their distal portion during stent-graft implantation. Furthermore for suturing of the distal anastomosis, the ET is primarily inverted into the arch. The suture is then performed through a double layer of the prosthesis and size matching with an aneurysmatic descending aorta can be technically demanding. We report on our experience with a simplified ET procedure with an innovative prosthesis (Vascutek® Siena™ Collared Graft). This prosthesis, first described by Neri and colleagues [2], consists of a proximal portion (20 cm), a collar and a distal portion (30 cm) (Fig. 1). The collar, made of a gelatin-coated woven polyester, constitutes the suture portion to the descending aorta. This can be trimmed into any desired diameter for the suture. The manufacturer offers different versions of the prosthesis, either without side branches or with one or four prefabricated side
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branches. The branches serve as prosthetic replacement for the supraaortic branches, and another one can easily be used for cannulation of the prosthesis (Fig. 2). Another innovation consists in the presence of radiopaque markers in the distal portion, extending from the collar to the distal end of the prosthesis, which facilitates second-stage endovascular procedures. This special characteristic helps to avoid the above-mentioned difficulties of the classic ET procedure.
Patients and methods Our local ethics committee approved the study and patient consent was waived. Patients Between January 2011 and June 2013, 20 patients (10 women; mean age, 66 ± 9 years) underwent ET procedure. All patients with primary implantation of a Vascutek Siena™ collared graft were included in the study. Preoperative characteristics of the patients are summarized in Table 1. There were 8 (40 %) emergency cases, 3 (15 %) urgent cases and 9 (45 %) elective cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7–29.7 mm). Six patients (30 %) had undergone previous heart surgery; one of those had an underlying Loeys–Dietz syndrome. Previous heart surgeries included proximal thoracic aortic repair in 6 cases (30 %). Concomitant procedures included ascending aortic replacement in
Heart Vessels Table 1 Preoperative data Age Sex Female Male Underlying disease Acute dissection Chronic dissection Aneurysm PAU Loeys–Dietz syndrome Previous operations Previous sternotomy Previous proximal thoracic aortic repair Comorbidities
66 n 10 10 n 6 4 8 2 1 n 6 6
SD ± 93 % 50 50 % 30 20 40 10 5 % 30 30 %
Hypertension Smoking history Diabetes Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease
n 15 5 4 3 1 5
75 25 20 15 5 25
Renal failure
3
15
16 patients; root replacement in 2; aortic valve replacement in 2, CABG in 3 and mitral repair in 1 patient. Among the comorbidities, arterial hypertension was the most frequent one (n = 15, 75 %). Five patients (25 %) had a history of smoking and four patients (20 %) suffered from diabetes. Chronic obstructive pulmonary disease was present in five (25 %) patients, coronary heart disease in three (15 %) and three patients (15 %) had a history of renal failure on hospital admission. One patient had a preclinical diagnosis of heparin-induced thrombocytopenia type II (HIT II). Operative data and statistical analysis Surgeries were performed by two experienced surgeons. If descending aortic repair was necessary, we preferred a two-stage approach, with the second stage scheduled after complete recovery of the patient. The standard surgical procedure in our institution consists of arterial cannulation of the right axillary artery and venous cannulation of the right femoral vein. In most cases, the extracorporeal circulation was started before median sternotomy to prevent damage to the aneurysmatic aorta or its branches, especially in cases of reoperation. Median sternotomy was performed to gain surgical access to the chest cavity. For heart arrest, we used cold blood cardioplegia administered either in an antegrade way via the ascending aorta, retrograde through the coronary sinus or a combination of both. With the help of the extracorporeal circulation, systemic cooling of the patient
to deep or moderate hypothermia (25–30 °C) was achieved [3]. After Trendelenburg positioning of the patient, the aorta was cross-clamped and the truncus brachiocephalicus was restricted using a tourniquet to facilitate antegrade unilateral perfusion of the brain via the axillary artery cannula [4]. Normally, flow rates of 0.8–1.3 l/min (10 ml/kg/min) were achieved [3]. Then the aortic clamp was removed for open arch surgery. Brain perfusion was monitored by continuous near infrared spectroscopy (NIRS) during the entire surgery [5]. If the cerebral oxygen saturation showed a drop below 60 %, an additional perfusion catheter was introduced into the left carotid artery for bilateral cerebral perfusion. This was necessary in only one case and can be done in less than a minute. The distal portion of the prosthesis was shortened to a length of 5–6 cm to prevent thrombus formation and/or malperfusion that might lead to spinal cord ischemia. Sutures were performed with Teflon felt reinforcement and afterward secured with BioGlue. In selected cases the aortic wall was reconstructed using GRF glue [6], the use of which is widely under discussion [7]. The collar is trimmed with a pair of scissors to match the descending aorta. The adequate sizing is merely an “eyeballing” measurement and depends on the surgeon’s experience and personal preferences. We tend to slightly undersize the prosthesis to achieve a size reduction of the aneurysm. After finishing the distal anastomosis the prosthesis offers a side branch for arterial cannulation. Through this side branch we started distal body perfusion while performing the supraaortic anastomosis, thus minimizing the ischemic time of the lower body. In cases of severe diffuse bleeding, we prefer to perform definitive sternal closure within 48 h after the primary surgery when bleeding has stopped [8]. A cell saver is used on all aortic surgeries. Once the patient is hemodynamically stable, we schedule a postoperative CT scan of the aorta. During the postoperative course, we focus especially on controlling arterial blood pressure. We aim for a systolic blood pressure below 120 mmHg. To achieve these values we administer ß-blockers (e.g., metoprolol) [9, 10] and ACE inhibitors or AT1 antagonists (e.g., enalapril/candesartan). Those substances ideally serve as anti-impulse therapy [11] and furthermore have proven beneficial for remodeling of the aortic wall in animal and human cohort studies [12–14]. In case of a remaining dissection membrane with organ perfusion through the false lumen, we administer vitamin K antagonists (phenprocoumon) to prevent thrombotic closure of the false lumen [15]; this might be necessary especially in patients with chronic dissection. All patients were referred to our vascular surgery unit for follow-up and indication of 2nd-stage stent-graft implantation after recovery. Neurologic complication was defined as clinical neurologic deficit (paresis, epileptic seizure, cognitive deficit)
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with or without pathologic findings on CTC scan lasting more than 24 h within 30 days after surgery. Baseline data characteristics of patients were prospectively collected. Data are summarized as mean ± SD. Data analysis was performed using commercially available statistical software packages (SPSS, Version 22.0/SPSS Inc., Chicago, IL; Microsoft Excel 2011, Microsoft Corporation, Redmond WA, USA).
Results The operative data are summarized in Table 2. Mean bypass time was 263 min (±94 min), mean cross-clamp time was 157 min (±45 min) and mean circulatory arrest time was 65 min (±14 min). Six patients (33 %) underwent successful 2nd-stage procedure on the descending thoracic aorta (5 endovascular stents, 1 open procedure), one of them received an endovascular stent as a one-stage procedure on the same day and four others after primary recovery from open surgery on POD 38, 57, 207 and 110. One patient suffered from mesenteric embolism during stent-graft implantation on POD 424. The procedure had to be stopped and emergency laparotomy was performed. The patient survived and was discharged after a prolonged ICU stay. Another patient had already received a stenting of his descending thoracic aorta before surgery, retrograde dissection occurred as complication of the stent graft and he was referred to our center for emergency surgery. Intraoperatively, we directly sutured the stent to the distal portion of the elephant trunk prosthesis. One patient underwent open descending aortic replacement on POD 92, his postoperative course was uneventful and he was discharged home. The details on the 2nd-stage procedures are summarized in Table 4. The overall survival was 90 % after a mean follow-up of 9.6 months (±7.5 months). The Kaplan–Meier survival curve is displayed in Fig. 3. There were no intraoperative deaths. The 30-day mortality was 5 % (1/20). One early death occurred on POD 8; the cause of death was MOF. One late death occurred due to pericardial tamponade and intracerebral bleeding on POD 78. The deceased patients had suffered from acute aortic dissection and were referred to our center as emergency cases. One of them had suffered from bleeding complications and required mass transfusion. Neurologic complications included stroke (hemiplegia) in 1 case, recurrent nerve palsy in 2 cases, one epileptic seizure and one intracerebral hemorrhage leading to death. In our cohort no patient suffered from spinal cord ischemia. Five patients (25 %) underwent secondary sternal closure as they presented with severe diffuse bleeding; two patients (10 %) required reoperation due to bleeding after
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Heart Vessels Table 2 Operative details Acuity
n 8 3 9
Emergent Urgent Elective Arterial cannulation site
n 18 1 1
Right axillary artery Ascending Aorta/Transverse arch Femoral artery Concomitant procedures
n 16 2 2 3 1 min 65 157 263 Units 16 22
Ascending aortic replacement Conduit AVR CABG Mitral valve surgery Perfusion–ischemic times Selective antegrade cerebral perfusion time Cardiac ischemic time (X-clamp) Total cardiopulmonary bypass time Transfusion requirements Packed red blood cells Fresh frozen plasma Platelets
5
% 40 15 45 % 90 5 5 % 80 10 10 15 5 SD ±14,0 ±45 94 SD ±17 ±28 ±5
Table 3 Early complications Death Intraoperative 30 days In hospital Neurologic complications Stroke/Hemiparesis Palsy of recurrent nerve Intracerebral hemorrhage Epileptic seizure Multi-organ failure Myocardial ischemia requiring stent implantation Secondary sternal closure Bleeding requiring reoperation (after primary sternal closure) Late pericardial tamponade Renal failure Re-intubation (atelectasis) Deep sternal wound infection
%
n 0 1 1 n 1 2 1 1 1 1
0 5 5 % 5 10 5 5 5 5
5 2
25 10
2 1 1
10 5 5
2
10
primary sternal closure and two patients (10 %) suffered from late pericardial tamponade that was resolved by emergency surgery. One of them had a preclinical diagnosis of HIT type II, thus argatroban was used for effective
Heart Vessels Table 4 Procedures on the descending aorta Patient number
POD
Result
1 2 3 4
424 38 57 0
2nd-Stage stent implantation stopped due to mesenteric embolism during the procedure 2nd-Stage successful stent implantation 2nd-Stage successful stent implantation Patient was status post-stent implantation of the descending aorta
5 6 7
207 0 110
2nd-Stage successful stent implantation Successful stent implantation as single-stage procedure 2nd-Stage successful stent implantation
8
92
2nd-Stage open replacement of the descending aorta
anticoagulation during cardiopulmonary bypass. Unfortunately, there is no antagonist for argatroban; therefore, this patient suffered severe diffuse bleeding and required mass transfusion as well as open chest management with secondary sternal closure after the bleeding had stopped. One patient (5 %) developed postoperative renal failure requiring temporary dialysis; there was one case (5 %) of re-intubation due to atelectasis and we report two cases (10 %) of deep sternal wound infection. Mean stay on ICU was 19 days (±19 days); postoperative hospital stay was 27 days (±22 days). The postoperative data are summarized in Table 3.
Comment According to our experience, the multi-branched, collared graft (Vascutek Siena™) is a good treatment option for aortic arch pathologies. The presence of the collar allows an easy anastomosis with any diameter of the distal aorta and the radiopaque markers facilitate 2nd-stage stent-graft implantation. Those two characteristics mark the main difference with other branched prostheses. The 30-day mortality of 5 % (n = 1) we experienced in our relatively small cohort fits the mortality rates reported by other authors (3.7–18.4 %) [16–18]. Among the possible complications in aortic surgery, especially bleeding and neurologic complications are of major concern. Although the design of the prosthesis facilitates sizing and suturing of the distal anastomosis, we did not experience less bleeding episodes, but that may be due to the relatively high number of re-do surgeries (n = 6, 30 %), emergency patients (n = 8, 40 %) and patients with acute dissection (n = 6, 30 %) in our small cohort. The case of a patient with diagnosis of HIT type II on admission was especially demanding. We had to use argatroban for effective anticoagulation during the cardiopulmonary bypass and he suffered severe diffuse bleeding and required mass transfusion as well as open chest management with secondary sternal closure after the bleeding had stopped.
Bleeding complications often occur in connection with preclinical medication: Antiplatelet agents such as clopidogrel, acetylic salicylic acid or newer substances like ticagrelor are administered as first-line therapy of acute chest pain [19]. In many cases, the diagnosis of dissection might be missed or the dissection may be the cause of myocardial ischemia. In emergency patients (in our study n = 8, 40 %) presenting with aortic dissection, one should not lose time waiting for the effects of the preclinical medication to pass. Furthermore, patients with acute aortic dissection and surgery with hypothermic cardiac arrest experience impairment of blood coagulation [20, 21]. We face this challenge by a differentiated analysis of the coagulation using ROTEM and specific administration of cellular and noncellular blood products [22], but in many cases even this differentiated therapy does not have the desired success. In cases of severe diffuse bleeding, we prefer performing definitive sternal closure within 48 h after the primary surgery when bleeding has stopped [8]. Neurologic complications with permanent or transient stroke incidences between 1.2 and 20 % have been reported in the literature [18, 23, 24]. In our small cohort one patient suffered permanent stroke and one patient a lethal intracerebral hemorrhage (n = 2, 10 %). Despite all the challenges aortic pathologies carry with them, the Vascutek Siena collared prosthesis offers several advantages. Those include easier size matching of the distal anastomosis, prefabricated side branches that can be used for easier anastomosis of the supraaortic branches and for cannulation of a specially positioned side branch after the distal anastomosis is completed, thus shortening circulatory arrest times. In 2013, Lida and colleagues published a case report describing a “flanged ET technique” [25], which is a similar concept. They describe how they create a double-layer flange by plicating the vascular prosthesis to facilitate the distal anastomosis and reduce bleeding complications. They used this technique in a patient with aneurysmatic aorta. The collared multi-branched prosthesis on the other hand offers a prefabricated single-layer collar that basically
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Heart Vessels
Fig. 3 Kaplan–Meier survival curve
serves the same purpose. The single-layer oversized collar facilitates performing the suture and can easily be trimmed to the descending aortic stump, by cutting it to the appropriate size with a pair of scissors. When Neri and colleagues first described the use of their prosthesis in four patients [2], they limited its use to patients with arch aneurysms. We extended the indication to emergency cases including patients with acute aortic dissection. There is an ongoing discussion among surgeons whether extensive aortic reconstruction with root and arch replacement is justified in acute aortic dissections [16]. Complete arch replacement is less time consuming nowadays and has become possible even in patients with acute type A dissection. Some years ago, we would have preferred a more limited surgery with hemiarch replacement and readaptation of the dissection membrane with GRF glue in type A dissections. Watanuki states that in his series, false lumen obliteration in the descending aorta without second-stage procedure [16] was frequent, making the ET a stand-alone procedure. This is possible if the ET covers a remaining tear in the proximal descending aorta. Shresta advocates for a
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liberal indication for the ET procedure as well. He believes that patients in need of arch replacement should receive an elephant trunk, because there is no additional risk compared to a simple arch procedure, and in case a 2nd-stage procedure becomes necessary, this will be easier with the ET in place [26]. Even in patients who will not be in need of stentgraft implantation, there remains the advantage of an easily performed distal anastomosis. In these cases, the ET may be shortened to 2–3 cm. Radiopaque markers on the distal prosthesis mark the landing zone and facilitate later treatment of the descending aorta with stent grafts. The main limitation of this cohort study lies in the small number of patients for statistical comparisons with other studies. However this number constitutes a reasonable cohort, considering the pathology and its management, taking into account that it is a single-center experience. Only five patients received 2nd-stage stent implantation, one patient was status post-stent implantation, in one patient stent implantation was not successful and one patient received open descending aortic repair. With a 33 % rate of 2nd-stage procedure after a mean follow-up of 9.6 months,
Heart Vessels
we report numbers lower than the average of 45 % reported in a recent review by Lus and co-workers [18], but the same as the 32 % reported by Shresta et al. [26]. We indicated the ET procedure for patients with type A dissection even if the diameter of the dissected descending aorta was normal, because a large number of patients might develop aneurysm of the descending aorta later on [27] and it carries no additional risk compared to the standard arch replacement [26]. So far, we can report only on a short follow-up interval. Longer follow-up is required to show if the advantages we assume can be proven in the long term. Conflict of interest None declared.
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Ramirez F, Huso DL, Dietz HC (2006) Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of marfan syndrome. Science 312:117–121 14. Lunder M, Žiberna L, Janić M, Jerin A, Skitek M, Šabovicˇ M, Drevenšek G (2013) Low-dose atorvastatin, losartan, and particularly their combination, provide cardiovascular protection in isolated rat heart and aorta. Heart Vessels 28:246–254 15. Song S, Yoo K, Kim D, Cho B, Yi G, Chang B (2011) Effects of early anticoagulation on the degree of thrombosis after repair of acute DeBakey type I aortic dissection. Ann Thorac Surg 92:1367–1375 16. Watanuki H, Ogino H, Minatoya K, Matsuda H, Sasaki H, Ando M, Kitamura S (2007) Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 84:1585–1591 17. Kieffer E, Koskas F, Godet G, Bertrand M, Bahnini A, Benhamou A, Cluzel P, Eyraud D (2000) Treatment of aortic arch dissection using the elephant trunk technique. Ann Vasc Surg 14:612–619 18. Ius F, Hagl C, Haverich A, Pichlmaier M (2011) Elephant trunk procedure 27 years after borst: what remains and what is new? Eur J Cardiothorac Surg 40:1–12 19. Authors/Task Force Members, Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van’t Hof A, Widimsky P, Zahger D, ESC Committee for Practice Guidelines (CPG), Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Document Reviewers, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Hasdai D, Astin F, Åström-Olsson K, Budaj A, Clemmensen P, Collet J, Fox KA, Fuat A, Gustiene O, Hamm CW, Kala P, Lancellotti P, Maggioni AP, Merkely B, Neumann F, Piepoli MF, Van de Werf F, Verheugt F, Wallentin L (2012) ESC guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the european society of cardiology (ESC). Eur Heart J 33:2569–2619 20. Wilde JT (1997) Hematological consequences of profound hypothermic circulatory arrest and aortic dissection. J Card Surg 12(2 Suppl):201–206 21. Delsart P, Beregi J, Devos P, Haulon S, Midulla M, MounierVehier C (2014) Thrombocytopenia: an early marker of late mortality in type B aortic dissection. Heart Vessels 29:220–230 22. Hanke AA, Herold U, Dirkmann D, Tsagakis K, Jakob H, Görlinger K (2012) Thromboelastometry based early goal-directed coagulation management reduces blood transfusion requirements, adverse events, and costs in acute type A aortic dissection: a pilot study. Transfus Med Hemother 39:121–128 23. Svensson LG (1992) Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 7:301–312 24. Konishi T, Higuchi K, Fukata M, Takeda M, Akisima S, Fukuda S (1999) Extended aortic replacement in acute dissection by the separated elephant trunk technique. Ann Thorac Surg 67:1664–1668 25. Iida Y, Koizumi N, Matsuyama K, Ogino H (2013) Flanged elephant trunk technique at distal anastomosis for total arch replacement with multibranched arch graft. Ann Vasc Surg 27:831–833 26. Shrestha M, Martens A, Krüger H, Maeding I, Ius F, Fleissner F, Haverich A (2014) Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J Cardiothorac Surg 45:289–296 27. Park K, Lim C, Choi JH, Chung E, Choi SI, Chun EJ, Sung K (2009) Midterm change of descending aortic false lumen after repair of acute type I dissection. Ann Thorac Surg 87:103–108
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