Frozen Elephant Trunk Procedure for Treatment of Acute Complicated Type B Aortic Dissections

Abstract

Introduction: This study aimed to define midterm clinical outcomes and morphological changes of acute complicated type B aortic dissections after the application of frozen elephant trunk technique. Patients and Methods: Data were collected from 143 patients treated with frozen elephant trunk procedure for complex thoracic aortic diseases between May 2012 and October 2018. Twenty-seven patients with acute complicated type B aortic dissection were included in the study. Results: The mean age of the study population was 56.9 ± 9.1 years, and 23 (85.2%)patients were male. Complete false lumen thrombosis in the descending aorta before the distal end of the stent graft was achieved in 88.9% of cases. There was no late mortality observed at a mean follow-up of 50.7 ± 22.5 months. Only one patient died due to multiple organ failure 62 days after the operation. Five patients underwent secondary distal aortic endovascular repair because of stent graft-induced new entry (n= 3) and second-stage treatment for post-dissection aneurysm (n= 2). Conclusion: Aortic arch involvement in acute complicated type B aortic dissections requires more extensive treatment, and frozen elephant trunk procedure serves as an alternative treatment modality.

Keywords

• Aortic pathology
• descending aorta
• false lumen
• frozen elephant trunk
• type B dissection

Komplike Akut Tip B Aortik Diseksiyonların Tedavisinde Donmuş Fil Hortumu Prosedürü

Abstract

Giriş: Bu çalışma, akut komplike tip B aortik diseksiyonlarında donmuş fil hortumu tekniği uygulanmasından sonraki orta dönem klinik sonuçları ve morfolojik değişikleri tanımlamayı amaçlamıştır. Hastalar ve Yöntem: Veriler, Mayıs 2012-Ekim 2018 tarihleri arasındaki kompleks torasik aorta hastalıkları nedeniyle donmuş fil hortumu prosedürü ile tedavi edilen 143 hastadan toplandı. Akut komplike tip B aortik diseksiyonu olan 27 hasta çalışmaya dahil edildi. Bulgular: Çalışma popülasyonunun ortalama yaşı 56.9 ± 9.1 yıl ve 23 (%85.2) hasta erkekti. Olguların %88.9’unda stent-greft seviyesindeki inen aortada tam yalancı lümen trombozu sağlandı. Ortalama 50.7 ± 22.5 aylık takipte geç dönem mortalite gözlenmedi. Sadece bir hasta operasyondan 62 gün sonrasında çoklu organ yetmezliği nedeniyle kaybedildi. Beş hastaya stent-greft kaynaklı yeni yırtık (n= 3) ve postdiseksiyon anevrizması (n= 2) için ikinci bir distal aortik endovasküler onarım yapıldı. Sonuç: Akut komplike tip B aortik diseksiyonlarda arkus aortanın tutulumu daha genişletilmiş bir tedavi gerektirmektedir ve donmuş fil hortumu prosedürü bu yönde hizmet eden alternatif bir yöntemdir.

Keywords

• Aortic patoloji
• donmuş fil hortumu
• tip B aortik diseksiyon
• inen aorta
• yalancı lümen

References

1. 1. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). Eur J Vasc Endovasc Surg 2009;37:149-59.
2. 2. Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153-64.
3. 3. Elefteriades JA, Hartleroad J, Gusberg RJ, Salazar AM, Black HR, Kopf GS, et al. Long-term experience with descending aortic dissection: the complication-specific approach. Ann Thorac Surg 1992;53:11-21.
4. 4. Fattori R, Montgomery D, Lovato L, Kische S, Di Eusanio M, Ince H, et al. Survival after endovascular therapy in patients with type B aortic dissection; a report from the International Registry of Acute Aortic Dissection (IRAD). J Am Coll Cardiol Intv 2013;6:876-82.
5. 5. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al.; INSTEAD Trial. Randomized comparison of strategies for type B aortic dissection: the Investigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120:2519-28.
6. 6. Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, et al.; INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013;6:407-16.
7. 7. Weiss G, Wolner I, Folkmann S, Sodeck G, Schmidli J, Grabenwoger M, et al. The location of the primary entry tear in acute type B aortic dissection affects early outcome. Eur J Cardiothorac Surg 2012;42:571-6.
8. 8. Tsai TT, Isselbacher EM, Trimarchi S, Bossone E, Pape L, Januzzi JL, et al.; International Registry of Acute Aortic Dissection. Acute type B aortic dissection: does aortic arch involvement affect management and outcomes? Insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2007;116:150-6.

9. 9. Williams JB, Andersen ND, Bhattacharya SD, Scheer E, Piccini JP, McCann RL, Hughes GC. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255-62.
10. 10. Kim JB, Sundt TM. Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg 2014;3:406-12.
11. 11. Estrera AL, Miller CC 3rd, Safi HJ, Goodrick JS, Keyhani A, Porat EE, et al. Outcomes of medical management of acute type B aortic dissection. Circulation 2006;114:384-9.
12. 12. Eggebrecht H, Thompson M, Rousseau H, Czerny M, Lönn L, Mehta RH, et al.; European Registry on Endovascular Aortic Repair Complications. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications. Circulation 2009;120:276-81.
13. 13. Fattori R, Tsai TT, Myrmel T, Evangelista A, Cooper JV, Trimarchi S, et al. Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv 2008;1:395-402.
14. 14. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2006;114:357-64.
15. 15. Milewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg 2010;140:590-7.
16. 16. Bünger CM, Kische S, Liebold A, Leibner M, Glass A, Schareck W, et al. Hybrid aortic arch repair for complicated type B aortic dissection. J Vasc Surg 2013;58:1490-6.
17. 17. Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012;144:1286-300.
18. 18. Zhu JM, Qi RD, Chen L, Liu W, Li CN, Fan ZM, et al. Stented elephant trunk procedure with left subclavian artery transposition for acute type B dissection with distal arch involvement. Thorac Cardiovasc Surg 2015;150:1160-5.
19. 19. Tsagakis K, Pacini D, Di Bartolomeo R, Benedik J, Cerny S, Gorlitzer M, et al. Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry. Eur J Cardiothorac Surg 2011;39:87-93.
20. 20. Tsagakis K, Pacini D, Di Bartolomeo R, Gorlitzer M, Weiss G, Grabenwoger M, et al. Multicenter early experience with extended aortic repair in acute aortic dissection: is simultaneous descending stent grafting justified? J Thorac Cardiovasc Surg 2010;140:116-20.
21. 21. Karck M, Chavan A, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up. Eur J Cardiothorac Surg 2005;28:286-90.
22. 22. Pacini D, Tsagakis K, Jakob H, Mestres CA, Armaro A, Weiss G, et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg 2011;92:1663-70.
23. 23. Weiss G, Tsagakis K, Jakob H, Di Bartolomeo R, Pacini D, Barberio G, et al. The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience. Eur J Cardiothorac Surg 2015;47:106-14.
24. 24. Eggebrecht H, Nienaber CA, Neuhauser M, Baumgart D, Kische S, Schmermund A, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006;27:489-98.
25. 25. Di Eusanio M, Pantaleo A, Cefarelli M, Castrovinci S, Di Bartolomeo R. Frozen elephant trunk surgery in type B aortic dissection. Ann Cardiothorac Surg 2014;3:400-2.
26. 26. Uchida N, Kodama H, Katayama K, Takasaki T, Katayama A, Takahashi S, et al. Endovascular aortic repair as second-stage surgery after hybrid open arch repair by the frozen elephant trunk technique for extended thoracic aneurysm. Ann Thorac Cardiovasc Surg 2013;19:257-61.