AORTA = ΑΕΙΡΩ = HOLDING UP

Surgery of the Aortic ArchWhat is the best operation?

Dimitrios DougenisAthens

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

1997

•Aneurysm

Congenital or developmental

Marfan’s syndrome, Ehlers–Danlos syndrome

Degenerative

Cystic medial degeneration

Nonspecific (atherosclerotic)

Traumatic

Blunt and penetrating trauma

Inflammatory

Takayasu’s arteritis, Behηet’s syndrome, Kawasaki’sdisease

Microvascular disorders (i.e., polyarteritis)

Infectious (mycotic)

Bacterial, fungal, spirochetal, viral

Mechanical

Post-stenotic, associated with arteriovenous fistula

Anastomotic (postarteriotomy)

•Pseudoaneurysm

•Dissection

1.Type A (DeBakey types I and II), ascending aorta involved

2.Type B (DeBakey type III), descending aorta involved

•Penetrating atherosclerotic ulcer

•Intramural hematoma

•Atherosclerotic disease

Table 1. A clinicopathological classification of the diseases of the thoracic aorta amenable to surgery. Modification from Kouchoukos and Dougenis 3

Kouchoukos and DougenisNEJM, 1997

Aortic Arch Chronic Aneurysms

Department of Cardiac Surgery, Medical School, Athens, GR

Aortic Dissection

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

RisksThe complexity of aortic arch surgery carries with it seriousrisk. Complications include:

• Stroke• Damage to spinal cord• Bleeding• Heart • Lung and/or Renal failure• Organ Malperfusion

Many ‘Arrows’ for our Arch

•Hemiarch•Total Arch•Light Arch•Elephant Trunk•Frozen Elephant Trunk•EVAR

Type I and Type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis Prashanth Vallabhajosyula, Wilson Szeto, NimeshDesai, Joseph E. Bavaria, ACS 2013

Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular

Domain of EACTS.

Shrestha M, Bachet J, Bavaria J, Carrel TP, De Paulis R, Di Bartolomeo R, Etz CD, Grabenwöger M, Grimm M, Haverich A, Jakob H, Martens A, Mestres CA, Pacini D, Resch T, Schepens M, Urbanski PP, Czerny M.

Eur J Cardiothorac Surg. 2015 May;47(5):759-69. doi: 10.1093/ejcts/ezv085. Epub 2015 Mar 13. Review.

The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications.

?

VARIOUS CANULATION SITES

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

Protect the brain!

Cerebral Protection- Antegrade selective cerebral perfusion- Moderate Systemic Hypothermia

23-25C

Arrest of Cerebral Circulation

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

RESULTS AT FOLLOW-UP

SURVIVAL

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

1 y 5y 10y 20y

Freedom from

Redo % 92.6±1 84.3±1.5 79.4±2 75.6±2.4

No. Patients

at risk 613 345 148 11

Elective

Urgent/Emergent

1 y 5y 10y

20y

Elective

Freedom from redo % 91.4±1.3 82.7±2 77.2±2.4

74.5±2.8

No. Patients at risk 385 227 103 9

Urgent/Emergent

Freedom from redo % 94.6±1.4 86.9±2.4 83.5±2.8

77.1±4.4

No. Patients at risk 228 119 45 1

Log-rank: p=0.129

RESULTS AT FOLLOW-UPFREEDOM FROM REOPERATION

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

N° ptsHosp. Mort.

(%)PND (%) TND (%)

Kazui,2006 472 9.3 3.2 4.7

Khalady,2007 501 11.6 9.6 13.4

Sasaki,2007 305 2.3 1.6 6.6

Halkos,2009 205 8.8 4.3 4.5

Krahebuhl, 2010 133 3.0 6.0 8.2

Minakawa, 2010 122 8.2 4.1 5.7

Misfeld, 2012 365 9.0 9.0 15.9

Di Bartolomeo, 2016 938 12.0 6.4 12.3

El-Sayed, 2017 587 6.0 6.0 5.0

ASCP - RESULTS

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

Eur J Cardiothorac Surg. 2016 Aug;50(2):249-55.

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.Urbanski PP1, Luehr M2, Di Bartolomeo R3, Diegeler A4, De Paulis R5, Esposito G6, Bonser RS7, Etz CD8, Kallenbach K9, RylskiB10, Shrestha ML11, Tsagakis K12, Zacher M4, Zierer A13.

OBJECTIVES:The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade.

METHODS:

Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least

one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and

retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included.

RESULTS:Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956(77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques,including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively.

3 arch arteries (total) 956 (77.6%),

2 arch arteries (subtotal) 155 (12.6%)

1 arch artery (partial) 121 (9.8%)

From: Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still

an issueEur J Cardiothorac Surg. 2016;50(2):249-255. doi:10.1093/ejcts/ezw055

Eur J Cardiothorac Surg | © The Author 2016. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.

11.4 % mortality rate

72%

CONCLUSIONS:

The surgical risk in elective aortic arch surgery has remained high during the last decade despite the

advance in surgical techniques.

However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably

among the centres.

The incompleteness of data gathered retrospectively was not effective enough to determine advantages of

particular cannulation, perfusion, protection or surgical techniques; and therefore,

we strongly recommend further prospective multicentre studies, preferably registries, in which all

relevant data have to be clearly defined and collected.

Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumens.Urbanski PP1, Bougioukakis P2, Deja MA3, Diegeler A2, Irimie V2, Lenos A2, Zembala MO4.Author informationEur J Cardiothorac Surg. 2016 May;49(5):1382-90.OBJECTIVES:Surgical management of chronic aortic dissection is controversial, especially when the dissection extends into the abdominal aorta in which the visceral arteries originate from different lumens and is combined with aortic arch pathology necessitating surgery. The aim of the study was to evaluate the results of open surgery in this complex aortic pathology.

METHODS:Between June 2002 and 2015, a total of 17 patients (median age 57, range 32-76 years) necessitating complete arch replacement presented complex chronic dissection of the thoraco-abdominal aorta with the visceral arteries originating from different lumens. Fourteen patients (82%) had had previous cardiac surgery, which was performed on the proximal aorta in all but one because of acute type A dissection. Nine patients without considerable dilatation of the descending aorta received aortic arch replacement with distal resection of the dissection membrane, and 8 patients with progressive dilatation of the thoracic aorta underwent aortic arch and descending aorta replacement via clamshell approach.

RESULTS:No early (defined as 30-day, 90-day and in-hospital period) deaths, strokes or spinal cord injuries occurred. Only 1 patient (6%) presented

From: Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumensEur J Cardiothorac Surg. 2015;49(5):1382-1390. doi:10.1093/ejcts/ezv386

Eur J Cardiothorac Surg | © The Author 2015. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.

...an area that needs to be further developed

COOPERATION

From: Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumensEur J Cardiothorac Surg. 2015;49(5):1382-1390. doi:10.1093/ejcts/ezv386

Eur J Cardiothorac Surg | © The Author 2015. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.

Open aortic arch surgery in chronic dissection with visceral arteries originating from different lumens.Urbanski PP1, Bougioukakis P2, Deja MA3, Diegeler A2, Irimie V2, Lenos A2, Zembala MO4.Author informationEur J Cardiothorac Surg. 2016 May;49(5):1382-90.OBJECTIVES:Surgical management of chronic aortic dissection is controversial, especially when the dissection extends into the abdominal aorta in which the visceral arteries originate from different lumens and is combined with aortic arch pathology necessitating surgery. The aim of the study was to evaluate the results of open surgery in this complex aortic pathology.

METHODS:Between June 2002 and 2015, a total of 17 patients (median age 57, range 32-76 years) necessitating complete arch replacement presented complex chronic dissection of the thoraco-abdominal aorta with the visceral arteries originating from different lumens. Fourteen patients (82%) had had previous cardiac surgery, which was performed on the proximal aorta in all but one because of acute type A dissection. Nine patients without considerable dilatation of the descending aorta received aortic arch replacement with distal resection of the dissection membrane, and 8 patients with progressive dilatation of the thoracic aorta underwent aortic arch and descending aorta replacement via clamshell approach.

RESULTS:No early (defined as 30-day, 90-day and in-hospital period) deaths, strokes or spinal cord injuries occurred. Only 1 patient (6%) presented temporary neurological dysfunctions (delirium, agitation), which resolved completely before discharge, and an injury of the recurrent laryngeal nerve was documented in 2 patients (12%). Temporary dialysis was necessary in 1 case. The follow-up was complete for all patients. All but one patient, who died due to leukaemia 23 months after surgery, were alive at the last follow-up (median duration 33 months, range 2-118 months). No patient needed a reoperation or an intervention on the thoracic and/or abdominal aorta. Moreover, no noticeable progression of the chronic dissection in the downstream aorta was documented in any patient.

CONCLUSIONS:The results after conventional aortic arch repair with distal resection of the dissection membrane and, if necessary, with replacement of the

Editorial

Repair of acute type A aortic dissection: moving towards a more aggressive approach but keeping the old gold standards Dimitrios DougenisEuropean Journal of Cardio-Thoracic Surgery, Volume 49, Issue 1, 1 January 2016, Pages 131–133

From: Repair of acute type A aortic dissection: moving towards a more aggressive approach but keeping the

old gold standardsEur J Cardiothorac Surg. 2015;49(1):131-133. doi:10.1093/ejcts/ezv163

Eur J Cardiothorac Surg | © The Author 2015. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.

Eur J Cardiothorac Surg. 2016 Apr;49(4):1249-54.

Acute non-A-non-B aortic dissection: surgical or conservative approach

?

Primary tear in ARCH open surgery

Primary tear in DTA Conservatively

.. Morning excellent session by Prof. Riambau and invited panelists…

Subacute stage…Better remodeling

J Thorac Cardiovasc Surg. 2017 Jul;154(1):100-106.e1. doi: 10.1016/j.jtcvs.2016.12.060. Epub 2017 Feb 10.

Objective analysis of midterm outcomes of conventional and hybrid aortic arch repair by propensity-

score matching.Hiraoka A1, Chikazawa G2, Totsugawa T2, Tamura K2, Ishida A2, Sakaguchi T2, Yoshitaka H2.

OBJECTIVE:The aim of this study is to evaluate the objective outcomes of conventional total aortic arch repair (CTAR) and hybrid arch repair by using propensity-score matching to reduce selection bias.

METHODS:Between January 2006 and April 2016, 470 consecutive patients underwent isolated aortic arch repair (excluding hemiarch or partial arch

reconstruction, and cases with concomitant cardiac surgeries) at a single cardiovascular institute. We categorized 337 total aortic arch

repair with antegrade cerebral perfusion under circulatory arrest as the CTAR group and 58 hybrid aortic arch repair (HAR) with thoracic endovascular aortic repair as the HAR group. Seventy-five patients with scheduled and staged thoracic

endovascular aortic repair after total aortic arch repair with elephant trunk were excluded. Then, we compared early and midterm outcomes between the propensity-matched group (43 CTAR vs HAR pairs).

RESULTS:There were no significant differences in 30-day and operative deaths between the CTAR and HAR groups (4.7% [2/43] vs 7.0% [3/43]; P = .4142 and 11.6% [5/43] vs 16.3% [7/43]; P = .5637). Although there were no significant differences in the incidences of other major complications,

permanent stroke was observed more frequently in the HAR group (0% [0/43] vs 11.6% [5/43]; P = .0064) compared with the

CTAR group. Matching analysis, however, revealed an equivalent 5-year survival rate between the CTAR and HAR groups (80.5% vs 59.9%; P = .1300).

J Thorac Cardiovasc Surg. 2017 Jul;154(1):100-106.e1. doi: 10.1016/j.jtcvs.2016.12.060. Epub 2017 Feb 10.

Objective analysis of midterm outcomes of conventional and hybrid aortic arch repair by propensity-

score matching.Hiraoka A1, Chikazawa G2, Totsugawa T2, Tamura K2, Ishida A2, Sakaguchi T2, Yoshitaka H2.

OBJECTIVE:The aim of this study is to evaluate the objective outcomes of conventional total aortic arch repair (CTAR) and hybrid arch repair by using propensity-score matching to reduce selection bias.

METHODS:Between January 2006 and April 2016, 470 consecutive patients underwent isolated aortic arch repair (excluding hemiarch or partial arch

reconstruction, and cases with concomitant cardiac surgeries) at a single cardiovascular institute. We categorized 337 total aortic arch

repair with antegrade cerebral perfusion under circulatory arrest as the CTAR group and 58 hybrid aortic arch repair (HAR) with thoracic endovascular aortic repair as the HAR group. Seventy-five patients with scheduled and staged thoracic

endovascular aortic repair after total aortic arch repair with elephant trunk were excluded. Then, we compared early and midterm outcomes between the propensity-matched group (43 CTAR vs HAR pairs). CONCLUSIONS:Matching analysis revealed a significantly greater incidence of stroke in the HAR group but equivalent midterm outcomes in the hybrid group compared with the CTAR group

CONCLUSIONS:Matching analysis revealed a significantly greater incidence of stroke in the HAR group but equivalent midterm outcomes in the hybrid group compared with the CTAR group

RESULTS:

Very close to catastrophe

Carotid-anonymous arteryAnd carotid-subclavian artery

bypass

Aneurysm, zone 2

• Aortic arch surgery is associated with satisfactory earlyand long-term results

• Urgent cases impact long-term survival

• Antegrade Selective Cerebral Perfusion is confirmed tobe a safe method of brain protection allowing complexaortic repairs to be performed with good results in termsof hospital mortality and neurologic outcomes

• TEVAR remains an excellent approach in selectedcases

Conclusions

Alma Mater Studiorum, University of Bologna, Cardiac Surgery Unitluca.dimarco@aosp.bo.it

Type I and Type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis Prashanth Vallabhajosyula, Wilson Szeto, NimeshDesai, Joseph E. Bavaria, ACS 2013

Type I and Type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis Prashanth Vallabhajosyula, Wilson Szeto, NimeshDesai, Joseph E. Bavaria, ACS 2013

Conclusions: Hybrid aortic arch replacement can be performed with good postoperative and midterm results in a cohort of old patients with significant comorbidity. With greater experience, early and midterm outcomes continue to improve. The hybrid arch technique may represent a technical advancement in the field of aortic arch surgery.

Debrancig Elephant Trunk

11.3% 9.5%mortality

DebrancigElephant Trunk

11.3% 9.5%mortality

Stroke 7.6% 6.2%Spinal CI 3.6% 5.0%

Very close to catastrophe

Carotid-anonymous arteryAnd carotid-subclavian artery

bypass

Aneurysm, zone 2

•Aneurysm

Congenital or developmental

Marfan’s syndrome, Ehlers–Danlos syndrome

Degenerative

Cystic medial degeneration

Nonspecific (atherosclerotic)

Traumatic

Blunt and penetrating trauma

Inflammatory

Takayasu’s arteritis, Behηet’s syndrome, Kawasaki’sdisease

Microvascular disorders (i.e., polyarteritis)

Infectious (mycotic)

Bacterial, fungal, spirochetal, viral

Mechanical

Post-stenotic, associated with arteriovenous fistula

Anastomotic (postarteriotomy)

•Pseudoaneurysm

•Dissection

1.Type A (DeBakey types I and II), ascending aorta involved

2.Type B (DeBakey type III), descending aorta involved

•Penetrating atherosclerotic ulcer

•Intramural hematoma

•Atherosclerotic disease

Table 1. A clinicopathological classification of the diseases of the thoracic aorta amenable to surgery. Modification from Kouchoukos and Dougenis 3

Kouchoukos and DougenisNEJM, 1997

1997

Editorial

Repair of acute type A aortic dissection: moving towards a more aggressive approach but keeping the old gold standards Dimitrios DougenisEuropean Journal of Cardio-Thoracic Surgery, Volume 49, Issue 1, 1 January 2016, Pages 131–133

From: Repair of acute type A aortic dissection: moving towards a more aggressive approach but keeping the

old gold standardsEur J Cardiothorac Surg. 2015;49(1):131-133. doi:10.1093/ejcts/ezv163

Eur J Cardiothorac Surg | © The Author 2015. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.