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Four branch elephant trunk prosthesis for the treatment for type A aortic dissection: midterm follow-up advantages
Jens Brickwedel, Hermann Reichenspurner, Marcel Coutandin, Christian Detter.
University Heart Center Hamburg, Hamburg, Germany.

OBJECTIVE: Frozen elephant trunk (FET) surgery is a modern treatment modality which should be considered for complex type A aortic dissection (TAAD). Reimplantation of the supra-aortic vessels can be performed by using either a so-called island technique(island group) or individually, using a four-branched FET graft (branched group) (Vascutek, Scotland).
METHODS: Between July 2011 and December 2015 a total of 56 consecutive patients (mean age 65.1±10.7 years) underwent FET surgery. Of these, 37 patients were operated for TAAD and further evaluated for midterm follow-up. In 6 patients, left common carotid artery (LCCA) to left subclavian artery (LSA) bypass was performed followed by proximal stent graft deployment in zone 2 with overstenting of LSA and single branched reimplantation of the innominate antery and LCCA. Patients were routinely followed-up by computerized scan (CT) at 3 months postoperatively and annually thereafter.
RESULTS: There were 15 patients in the island group and 22 in the branched group. Overall, there were 7 deaths within 30 days (mortality 18.9%). Of these, 5 patients suffered acute aortic rupture. The incidence of cerebral ischemia was 10.8% (n=4). Spinal ischemia was only documented in 1 patient (2.7%) who had previous TEVAR and EVAR. There were no statistically significant differences (p=ns) regarding mortality, neurological complications (26% vs. 10%), cerebral perfusion (89±45min vs. 108±42min) and circulatory arrest (93±40min vs. 90±40min) times, transfusion rates (5±3 units vs. 4±3 units), and re-explorations for bleeding (3 vs. 2) between groups.
In the island group, follow-up CT-scans revealed a remaining aneurysm of the brachiocephalic trunk in 2 patients, and a false lumen arch aneurysm of the island reimplanted supra-aortic vessels in 1 patient. The branched group did not show any pathology of the arch or the supra-aortic vessels.
CONCLUSIONS: Although early results did not differ among groups, patients being operated for TAAD using FET surgery might benefit from reimplantation of the supra-aortic vessels using a branched prosthesis to avoid further vascular complications. Overstenting of LSA at zone 2 level combined with LCCA-to-LSA bypass may facilitate the procedure. Larger studies or registries and longer follow-up periods are needed to establish the significance of these reimplantation techniques.

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