Background (1)
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Transcript of Background (1)
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Background (1)
・ In 1998, we developed a modified elephant trunk (ET) technique using a single four-branched arch graft with a sewing “collar” and “long ET” prosthesis to treat extensive thoracic aneurysms.
・ An extensive aortic arch pathology involving the descending aorta remains a surgical challenge and an optimal technique remains controversial.
single four-branched arch graft
(Kuki S, et.al., Eur J Cardiothorac Surg 2000;18:246-248)
(Kuki S, et.al., Eur J Cardiothorac Surg 2000;18:246-248)(Kuki S, et.al., Circulation 2002;106:I253-258)
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・We have made minor changes to the original technique and applied this technique for a wide variety of aortic pathologies.
Background (2)
(Hara H, et.al., J Thorac Cardiovasc Surg 2009;137:777-778)(Taniguchi K, et.al., Ann Thorac Surg 2007;84:1729-34)(Shudo Y, et.al., Ann Thorac Surg 2007;84:659-661)
ObjectivesIn this study, we investigate the early operative results and long-term outcome of total arch replacement with long ET in 132 consecutive patients since October 1998.
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Operative strategiesOn the basis of the “uninvolved” descending aorta diameter (at Th6-Th8),
one of the two following strategies was adopted in principle.
・ Descending aorta: 35 mm or less.
・ The first stage procedure was attempted as a “permanent ET”.
・ Single-ET strategy: n=99
・ Staged-ET strategy: n=33
40mm
・ Descending aorta: greater than 35 mm.
・ Two-stage operation was planned, with the second performed within an appropriate period after the initial operation.
30mm
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Operative technique (1)
CPB is established via the bicaval and right axillary artery cannulae, and the ascending aorta is incised.
While cooling the patient, a proximal anastomosis is performed.
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Operative technique (2)
Then the patient cooled to 25°C, a long elephant trunk is inserted into the descending aorta aided by a catching catheter under an open distal condition.
ET diameter and length:
•ET diameter: Undersized by 10-20% of outer diameter of descending aorta at Th6-Th8.
•ET length: Determined preoperatively by measuring the aorta from the base of the innominate artery to Th6-Th8.
3-0 Tevdek suture
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Operative technique (3)
The arch vessels are individually reconstructed while re-warming the patient.
A distal anastomosis is then performed at the base of the innominate artery between the proximal graft and distal aorta, incorporating the ET tube graft.
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Concomitant Procedures and Operative Data
Cardiopulmonary bypass time (min) 204±54
Aortic cross-clamp time (min) 100±42
Selective cerebral perfusion time (min) 86±26
Open distal time (min)* 25±8
Valve surgery (AVR, MVR, TAP) 14 (11%)
CABG 14 (11%)
Aortic root replacement (modified Bentall) 13 (10%)
Reconstruction of left vertebral artery 6 (5%)
Others 2 (2%)
* : Hypothermic circulatory arrest time of the lower body for open distal anastomosis.
Operative Data
Concomitant Procedures
(49 procedures in 46 (35%) patients)
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Results (1): Early Mortality and Morbidity
Operative mortality (≤30 days): 2 ( 1.5%) TAAA rupture: 2
Hospital mortality (>30 days): 7 ( 5.3%) TAAA rupture: 1, Pneumonia: 2, Mediastinitis: 2 MOF from biliary sepsis: 1, Aorto-esophageal fistula: 1
Hemorrhagic complication Re-exploration for bleeding: None
Neurological complications Permanent stroke: 3 (2.3%) Paraplegia: 3 (2.3%), Paraparesis: 1 (0.8%) Transient paraplegia (recovered within 24 hours): 4 (3.0%) Recurrent nerve palsy (new-onset), Phrenic nerve palsy: None
Downstream operation (rapid 2-stage surgery) Thoracotomy approach: 12 Transluminal approach (TEVAR): 8
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Results (2): Complete thromboexclusion around ET
Single-ET strategy Staged-ET strategy(n=99) (n=33)
n=86(87%)
n=13n=22
(67%)
n=11
Failure of thromboexclusion
N=13 (13%)
Second-stage procedure: 11Being followed: 2Aortic rupture: None
Failure of thromboexclusion
N=22 (67%)
Second-stage procedure: 16Being followed: 2Aortic rupture: 4*
(including the 1 patient who refused the second-stage operation)*
SuccessSuccess Failure Failure
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Results (3): Late Mortality and Morbidity
Aneurysm-related mortality: 4 ( 3%) TAAA rupture: 1, Iliac aneurysm rupture: 1 Aorto-pulmonary fistula: 1, ET graft infection: 1
Aneurysm-nonrelated mortality: 14 ( 10.6%) Pneumonia: 3, Stroke: 3, Neoplasm: 3, Heart failure: 2 Neoplasm: 3, Sepsis: 1, Arrhythmia: 1, Unknown: 1
Subsequent operation : 10 ( 7.6%) Thoracotomy approach: 6, Transluminal approach: 1 Thoracoabdominal aortic repair: 2 Abdominal aortic repair (infra-renal): 1
Late complications Aorto-esophageal fistula (alive): 1 Distal aneurysm expansion: None Peripheral thromboembolism: None
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0.0
0.2
0.4
0.6
0.8
1.0
0 12 24 36 48 60 72 84 96
Results (4): Survivals (Average follow up: 45 ± 37 months)
86%80%
Months after operation
Patients at risk:
102 80 67 52 42 36 25 17
Per
cen
t su
rviv
al (
%)
100
80
60
40
20
0
68%
77%
89%
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Most patients assigned to the single-stage strategy showed complete thromboexclusion of the perigraft space around the ET with lowering the need for a second-stage procedure.
In addition, most patients assigned to the two-stage strategy showed persistent perigraft perfusion around the ET and required a rapid second-stage procedure.
Our procedure with long ET for arch aneurysms using an undersized graft is uniformly applicable for a wide variety of aortic pathologies with achieving satisfactory short-term and long-term outcomes.
Conclusion