International Society for Minimally Invasive Cardiothoracic Surgery

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Frozen Elephant Trunk Procedure For Acute Aortic Dissection Type A: Early And Long-term Results
Eduard Charchyan, Denis Breshenkov, Yuriy Belov.
Petrovsky National Research Centre of Surgery, Moscow, Russian Federation.

BACKGROUND: The question of choosing the optimal aortic arch repair in acute type A aortic dissection remains unresolved to this day. The effect of expanding the volume of aortic arch repair with total aortic arch replacement (TAR) using Frozen Elephant Trunk (FET) procedure on early and late outcomes in comparison with partial aortic arch repair (PAR) is presented.
METHODS:From 2013 to 2023, 124 patients underwent emergency surgery, with acute Stanford type A aortic dissection. We performed TAR in 96 (78,7%), of them 71 (74%) cases using the frozen elephant trunk (FET) technique. In group of PAR (ascending aorta replacement (AAR) or hemiarch), we included 26 (21,3%) patients. We performed TAR for all patients since 2015. Patients were comparable in preoperative parameters (p>0.05). The groups underwent a retrospective comparative analysis of early and long-term results. The comparison of measurement data was by t-test, the enumeration data was by X 2 test, the survival were assessed using the Kaplan-Meier method.
RESULTS: The PAR group had significantly higher lactate after circulatory arrest (CA) (6.81.9 vs. 30.6, p=0.0001), multiorgan failure (5 (19%) vs. 5 (5.2%), p=0.021), respiratory failure (6 (23%) vs. 8 (8.3%), p=0.037), and ICU stay (13(3) vs. 4(1), p=0.0095). The TAR group noted a 100% resolution of malperfusion syndrome. Hospital mortality was 4 (4.2%) and 2 (7.7%) in the TAR and PAR groups, respectively (p = 0.461). Patients who performed FET procedure, positive remodeling was noted in segments I in 98.5%, in segment II - 72%, in segment III - 42%. Total thrombosis of the false lumen was detected in 98.5% of cases at the stent-graft level, in segment II - 34% of cases, in segment III - 10% of cases.In the follow up period, in the TAR group, additional TEVAR (n =2) and Extent III thoracoabdominal aortic replacement (TAAR) (n=1) were performed, while in the PAR - FET (n=2), Extent III TAAR (n=1) and single-stage total aortic replacement were required, respectively. The freedom from reoperations was comparable (96% (TAR) and 87.3% (PAR), p = 0.3757). The odds ratio of reoperations with PAR was higher at 5.636 (95%CI= 1.176 - 27), RR = 4.923, 95% CI = 1.18 - 20.6. CONCLUSIONS: In our experience, early and late outcomes in the TAR group were significantly better, while hospital mortality was comparable in both groups. These differences prove that TAR in patients with acute type A aortic dissection, with sufficient experience of the surgical team, does not worsen the prognosis compared to a more conservative approach and allows for complete resolution of malperfusion, and allows for the prevention of long-term complications.


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