Mustafa AKBULUT, Adnan AK, Serpil TAŞ, Özgür ARSLAN, Arzu ANTAL, Davut ÇEKMECELİOĞLU, Mesut ŞİŞMANOĞLU, Altuğ TUNÇER

Rezidü aort diseksiyonlarının frozen elephant trunk tekniği ile onarımı

Amaç: Bu çalışmada, daha önce akut tip A aort diseksiyonu nedeniyle suprakoroner aort onarımı yapılan hastalarda, patent yalancı lümene bağlı komplikasyonlara yönelik frozen elephant trunk ile yapılan tekrar ameliyatların orta dönem sonuçları analiz edildi. Çalışma planı: Ocak 2013 - Eylül 2018 tarihleri arasında tip A aort diseksiyonu nedeniyle çıkan aorta replasman yapılan ve daha sonra rezidü distal diseksiyon nedeniyle frozen elephant trunk işlemi yapılan toplam 23 hasta (17 erkek, 6 kadın; ort. yaş 51.5±9.7 yıl; dağılım, 30-67 yıl) çalışmaya alındı. Tanı ve takip amaçlı, tüm hastaların bilgisayarlı tomografi anjiyografisi çekildi ve hem reentran hem de aort çapları değerlendirildi. Kalp fonksiyonlarını ve kapakçık patolojilerini değerlendirmek için ekokardiyografi çekildi. Bulgular: Frozen elephant trunk stent greftini tespit etmek için Ishimaru bölge 0 (n=11, %47.8), Ishimaru bölge 1 (n=1, %4.3), Ishimaru bölge 2 (n=4, %17.4) ve Ishimaru bölge 3 (n=7, %30.4) kullanıldı. Ortalama kardiyopulmoner baypas ve antegrad selektif serebral perfüzyon süresi sırasıyla 223.9±71.2 dk. ve 88.9±60.3 dk. idi. Hastane içi mortalite %13 iken, takip sırasında bir (%4.3) aort ile ilişkili ölüm ve dört (%17.4) yeniden müdahale gözlendi. Sonuç: Tekrar ameliyatların ölüm oranlarının endişe verici düzeyde yüksek olması nedeniyle, devam eden diseksiyonların varlığında erken onarım düşünülmelidir. Frozen elephant trunk işlemi ile tekrar ameliyatların kabul edilebilir sonuçları olup, uygulanacak işleme hastanın ameliyat öncesi risk faktörlerine göre karar verilmelidir

Repair of residual aortic dissections with frozen elephant trunk technique

Background: In this study, we present our mid-term results ofreoperation with the frozen elephant trunk procedure due to patentfalse lumen-related complications in patients previously undergoingsupracoronary aortic repair for acute type A aortic dissection.Methods: Between January 2013 and September 2018, a totalof 23 patients (17 males, 6 females; mean age 51.5±9.7 years;range, 30 to 67 years) who underwent ascending aortic replacementdue to type A aortic dissection and, later, frozen elephant trunkprocedure for residual distal dissection were included. For diagnosticpurposes and follow-up, computed tomography angiography wasperformed in all patients, and both re-entry and aortic diameterswere evaluated. Echocardiography was used to evaluate cardiacfunction and valve pathologies.Results: The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1(n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3(n=7, 30.4%) were used for frozen elephant trunk stent graft fixation.The mean duration of cardiopulmonary bypass and antegradeselective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min,respectively. In-hospital mortality was 13%, while there was one(4.3%) aortic-related death and four (17.4%) re-interventions duringfollow-up.Conclusion: Early repair should be considered in the presenceof persistent dissections due to alarmingly high mortality ratesof reoperations. Reoperation with the frozen elephant trunkprocedure has acceptable results and the decision of the procedureto be performed should be based on preoperative risk factors ofthe patient.

PDF

___

1. Geirsson A, Bavaria JE, Swarr D, Keane MG, Woo YJ, Szeto WY, et al. Fate of the residual distal and proximal aorta after acute type a dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007;84:1955-64.
2. Tan ME, Morshuis WJ, Dossche KM, Kelder JC, Waanders FG, Schepens MA. Long-term results after 27 years of surgical treatment of acute type a aortic dissection. Ann Thorac Surg 2005;80:523-9.
3. Danner BC, Natour E, Horst M, Dikov V, Ghosh PK, Dapunt OE. Comparison of operative techniques in acute type A aortic dissection performing the distal anastomosis. J Card Surg 2007;22:105-10.
4. Tsagakis K, Tossios P, Kamler M, Benedik J, Natour D, Eggebrecht H, et al. The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition. Eur J Cardiothorac Surg 2011;40:1078-84.
5. Malvindi PG, van Putte BP, Sonker U, Heijmen RH, Schepens MA, Morshuis WJ. Reoperation after acute type a aortic dissection repair: a series of 104 patients. Ann Thorac Surg 2013;95:922-7.
6. DeBakey ME, McCollum CH, Crawford ES, Morris GC Jr, Howell J, Noon GP, et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118-34.
7. Akbulut M, Ak A, Arslan Ö, Çekmecelioğlu D, Taş S, Antal Dönmez A, et al. Early and mid-term results of frozen elephant trunk procedure for acute type A aortic dissection. Turk Gogus Kalp Dama 2019;27:135-42.
8. Tsai TT, Evangelista A, Nienaber CA, Trimarchi S, Sechtem U, Fattori R, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2006;114:I350-6.
9. Zierer A, Voeller RK, Hill KE, Kouchoukos NT, Damiano RJ Jr, Moon MR. Aortic enlargement and late reoperation after repair of acute type A aortic dissection. Ann Thorac Surg 2007;84:479-86.
10. Kobuch R, Hilker M, Rupprecht L, Hirt S, Keyser A, Puehler T, et al. Late reoperations after repaired acute type A aortic dissection. J Thorac Cardiovasc Surg 2012;144:300-7.
11. Moz M, Misfeld M, Leontyev S, Borger MA, Davierwala P, Mohr FW. Aortic arch reoperation in a single centre: early and late results in 57 consecutive patients. Eur J Cardiothorac Surg 2013;44:e82-6.
12. Bajona P, Quintana E, Schaff HV, Daly RC, Dearani JA, Greason KL, et al. Aortic arch surgery after previous type A dissection repair: results up to 5 years. Interact Cardiovasc Thorac Surg 2015;21:81-5.
13. Quintana E, Bajona P, Schaff HV, Dearani JA, Daly RC, Greason KL, et al. Open aortic arch reconstruction after previous cardiac surgery: outcomes of 168 consecutive operations. J Thorac Cardiovasc Surg 2014;148:2944-50.
14. de la Cruz KI, Green SY, Preventza OA, Coselli JS. Aortic Arch Replacement in Patients With Chronic Dissection: Special Considerations. Semin Cardiothorac Vasc Anesth 2016;20:314-21.
15. Brechtel K, Kalender G, Stock UA, Wildhirt SM. Hybrid debranching and TEVAR of the aortic arch off-pump, in re-do patients with complicated chronic type-A aortic dissections: a critical report. J Cardiothorac Surg 2013;8:188.
16. Bünger CM, Kische S, Liebold A, Leißner M, Glass A, Schareck W, et al. Hybrid aortic arch repair for complicated type B aortic dissection. J Vasc Surg 2013;58:1490-6.