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Surgical strategy to balance less invasiveness with complete aortic repair and less neurologic and aorta-related complications for extended thoracic aortic disease including aortic arch
Tomohiro Mizuno, Tsuyoshi Hachimaru, Keiji Oi, Masahumi Yashima, Eiki Nagaoka, Hidehiko Kuroki, Dai Tasaki, Tatsuki Fujiwara, Masashi Takeshita, Ryoji Kinoshita, Hirokuni Arai.
Tokyo Medical and Dental University, Graduate School of Medical and Dental Science, Tokyo, Japan.

OBJECTIVE: Treatment of extended thoracic aortic disease including aortic arch has dramatically progressed since stent grafts were commercially available. In order to obtain excellent postoperative results, it is important to balance less invasiveness with complete aortic repair and less early and long-term complications.
METHODS: From 2007 to 2015, we treated 99 patients who had extended thoracic aortic disease including aortic arch. Regarding our present surgical strategy, total arch replacement (TAR) is the first choice for aortic arch disease, and TEVAR is also the first choice for distal arch and thoracic descending aortic disease in order to avoid left thoracotomy as much as possible, but left thoracotomy approach (LT) is selected if TEVAR is difficult or even contraindicated. Hybrid approach is indicated in patients whose aortic disease is expanded from aortic arch to thoracic descending aorta, and 2-staged operation (LT after TAR) is necessary if TEVAR is not indicated. We estimated our present surgical strategy.
RESULTS: One-debrancing TEVAR (1DT) was performed in 14 patients, and TAR in 46, open stent surgery (OS) in 8, total debranching TEVAR (TDT) in 19 (Bavaria type II: 15), LT in 12 including 4 2-staged operation). There was no operative mortality in total, but there was 1 in-hospital mortality in TAR (rupture case). All patients were extubated in the operation theater in 1DT, 84% of the patients in TDT could be extubated within 24 h after surgery, 57% in TAR, 33% in LT, and respiratory support in LT was significantly longer than that in TAR and TDT (p=0.003). No spinal cord injury (SCI) occurred in TDT, but SPI was more frequent in OS. Endoleak did not occur in TDT and OS except for one patient, whose endoleak disappeared after coiling to the left subclavian artery. Localized aortic dissection was observed perioperatively in one patient in type I TDT, which was treated with ascending aorta replacement. The 3-year freedom from aorta-related complication was 0% in all groups except for OS (2 stent graft migration in OS).
CONCLUSIONS: Our surgical strategy with the combination of open repair and TEVAR is effective to balance invasiveness with postoperative outcomes.

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