96 by huanghengdong


									                          Background (1)
 ・An extensive aortic arch pathology involving the descending aorta remains a
  surgical challenge and an optimal technique remains controversial.

 ・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.
                                    (Kuki S, et.al., Eur J Cardiothorac Surg 2000;18:246-248)
                                    (Kuki S, et.al., Circulation 2002;106:I253-258)

single four-branched
      arch graft

                                   (Kuki S, et.al., Eur J Cardiothorac Surg 2000;18:246-248)
                     Background (2)
・We have made minor changes to the original technique and applied
 this technique for a wide variety of aortic pathologies.
                     (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)

  In 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.
                   Operative strategies
On the basis of the “uninvolved” descending aorta diameter (at Th6-Th8),
  one of the two following strategies was adopted in principle.

・Single-ET strategy: n=99
  ・Descending aorta: 35 mm or less.
  ・The first stage procedure was attempted
   as a “permanent ET”.

・Staged-ET strategy: n=33
  ・Descending aorta: greater than 35 mm.
  ・Two-stage operation was planned, with                                   40mm
   the second performed within an
   appropriate period after the initial
                Operative technique (1)

CPB is established via the bicaval and
right axillary artery cannulae, and the   While cooling the patient, a
ascending aorta is incised.               proximal anastomosis is performed.
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
3-0 Tevdek suture    aorta from the base of the
                     innominate artery to Th6-Th8.
              Operative technique (3)

A distal anastomosis is then performed
at the base of the innominate artery      The arch vessels are individually
between the proximal graft and distal     reconstructed while re-warming
aorta, incorporating the ET tube graft.   the patient.
Concomitant Procedures and Operative Data
Concomitant Procedures
    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%)
                                           (49 procedures in 46 (35%) patients)

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
        * : Hypothermic circulatory arrest time of the lower body for open distal anastomosis.
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
Results (2): Complete thromboexclusion around ET
 Single-ET strategy        (n=99)        Staged-ET strategy                               (n=33)

      Success          Failure                       Success
                        n=13                            n=11               Failure
             n=86                                                            (67%)

           Failure of                                      Failure of
       thromboexclusion                                thromboexclusion
          N=13 (13%)                                      N=22 (67%)
  Second-stage procedure: 11                  Second-stage procedure: 16
  Being followed: 2                           Being followed: 2
  Aortic rupture: None                        Aortic rupture: 4*
                                    * (including the 1 patient who refused the second-stage operation)
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
                                            Results (4): Survivals
                                                                     (Average follow up: 45 ± 37 months)
                1.0                   89%
Percent survival (%)




                                  Patients at risk:
                                      102     80         67   52     42        36      25       17

                              0        12     24   36     48    60    72               84       96
                                               Months after operation

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.

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