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Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection
Journal Pre-proof Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection Andrea Axtell, MD, MPH, Matthew Eagleton, MD, Mark Conrad, MD, Eric Isselbacher, MD, Thoralf Sundt, MD, Arminder Jassar, MBBS, FRCS PII:
S0003-4975(20)30206-X
DOI:
https://doi.org/10.1016/j.athoracsur.2019.12.077
Reference:
ATS 33480
To appear in:
The Annals of Thoracic Surgery
Received Date: 14 October 2019 Revised Date:
16 December 2019
Accepted Date: 27 December 2019
Please cite this article as: Axtell A, Eagleton M, Conrad M, Isselbacher E, Sundt T, Jassar A, Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection, The Annals of Thoracic Surgery (2020), doi: https://doi.org/10.1016/j.athoracsur.2019.12.077. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by The Society of Thoracic Surgeons
Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection Running Head: Arch Replacement and FET for Acute Type B
Andrea Axtell, MD, MPH1, Matthew Eagleton, MD2, Mark Conrad, MD2, Eric Isselbacher, MD3, Thoralf Sundt, MD1, Arminder Jassar, MBBS, FRCS1
1 Division of Cardiac Surgery; MGH 2 Division of Vascular and Endovascular Surgery, MGH 3 Department of Cardiology, MGH
Corresponding Author: Arminder Jassar 55 Fruit Street Boston, MA 02114 [email protected]
Abstract The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe three patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.
1
In patients with acute complicated type B aortic dissection without adequate proximal landing zone, thoracic endovascular aortic repair (TEVAR) is not feasible. While some uncomplicated patients with retrograde aortic arch extension can be managed non-operatively, patients with distal malperfusion present a challenge. We describe three patients who presented with an acute type B aortic dissection with associated visceral malperfusion who were treated with total arch replacement and frozen elephant trunk (FET).
Case Reports Case 1 A 76-year-old man presented with acute chest/abdominal pain and decreased sensation and weakness in the right lower extremity. CT imaging demonstrated an acute type B aortic dissection with an intimal tear distal to the left subclavian artery. The dissection flap extended retrograde into the inferior aspect of the aortic arch; the true lumen was severely compressed in the descending aorta, with radiologic malperfusion of the SMA (Figure 1 A) and right renal artery. Extension of the dissection flap into the aortic arch precluded safe TEVAR placement, even with carotid-subclavian bypass. Intraoperatively, a wire was advanced from the right femoral artery to the true lumen of the ascending aorta under intravascular ultrasound (IVUS) guidance. Cardiopulmonary bypass was initiated via the right axillary artery and the ascending aorta was cross-clamped. After completing the proximal anastomosis at the level of the sinotubular junction, the heart was perfused with warm blood (Beating heart technique)1. During corporeal arrest bilateral antegrade perfusion was afforded by clamping the innominate artery and direct ostial cannulation of the left carotid artery. A large intimal tear extended from the level of the left carotid artery to 2
distal to the left subclavian artery. A second fenestration was identified in the proximal descending aorta by aortoscopy using a sterile bronchoscope. The supra-aortic vessels were transected and the ostium of the left subclavian artery oversewn. The intimal tear was plicated using two felt strips. A 37x150mm Gore C-TAG (Gore) was deployed into the descending aorta. Aortoscopy confirmed that the stent covered the distal intimal tear. Arch reconstruction was completed using a 30mm 4-branched Siena graft (Terumo) with the distal anastomosis in zone II (suture-line incorporating the aortic wall, the TEVAR graft and the Siena graft.) After separating from bypass, flow in visceral vessels was assessed with IVUS and angiography. The SMA and right renal artery were compromised. Three stents were placed into the SMA. A 6x22 iCAST stent was placed into the right renal artery. The patient was discharged to rehab on postoperative day 15. Follow-up CTA demonstrated marked expansion of the true lumen with patent visceral vessels (Figure 1B).
Case 2 A 39-year-old man presented with acute onset chest/back pain. CT imaging demonstrated aortic dissection originating distal to the left subclavian and extending to the bilateral external iliac arteries (Figure 2A). Despite appropriate hemodynamic control, his symptoms recurred. Repeat CTA demonstrated interval retrograde extension of his dissection to the left subclavian and common carotid arteries with a new entry tear in the aortic arch (Figure 2B). There was concern for visceral ischemia due to rising creatinine and lactate levels. There was inadequate proximal landing zone for TEVAR (Figure 2C), even if a left carotid-subclavian bypass was performed.
3
Under circulatory arrest, the patient was noted to have a fenestration at the level of the left subclavian artery with the dissection flap extending proximally into the arch and a second fenestration in the proximal descending aorta. A 34x150mm Gore C-TAG device was deployed with its proximal extent in Zone II. A beating heart total arch replacement was performed using a 24mm Siena graft. He was discharged home on postoperative day 10. Follow-up CTA demonstrated thrombosis of the excluded false lumen with remodeling of the stented aorta (Figure 2D).
Case 3 A 58-year-old man presented to his local hospital with severe chest/back pain and an aortic dissection with entry tear in the aortic arch at the level of the left carotid artery and extending distally to the iliac arteries (Figure 3A). He progressed to somnolence, hypotension, renal failure, and acidosis requiring intubation and hemodynamic support prior to transfer to our facility. Repeat imaging demonstrated contained rupture (Figure 3B) of the arch with the dissection extending into the celiac and SMA with complete thrombosis of the left renal artery. Intraoperatively, a tear was identified in the aortic arch just distal to the left carotid artery; this was reapproximated using pledgeted sutures. A wire was then placed in the proximal aorta under aortoscopy guidance and a 34x107mm Valiant (Medtronic Inc) stent graft was deployed covering the tear site. A beating heart total arch replacement was performed using a 28mm Siena graft. On table angiography revealed compromised filling of the SMA (Figure 3C); therefore, three self-expanding stents were placed with excellent recanalization (Figure 3D). A self-expanding stent was also placed in the left renal artery. Brain imaging was obtained and although a head CT was negative, scattered foci of subacute ischemic infarcts were noted on
4
MRI. He was discharged to an inpatient facility on postoperative day 28 with only mild right sided residual weakness.
Comment TEVAR has become the preferred approach for patients with acute complicated type B aortic dissection2, however, is not feasible in patients without appropriate landing zones, such as in the case of concomitant aneurysm or retrograde extension into the aortic arch, (4-25% of cases)3. All three patients in this report were evaluated and discussed jointly by the cardiac and vascular surgery teams and were deemed to be anatomically unsuitable for TEVAR as a primary treatment strategy. Several treatment algorithms have been proposed for these patients including open descending aortic replacement, or a hybrid approach involving arch debranching and TEVAR. These are associated with significant morbidity, and in the case of endovascular approaches, carry a risk of retrograde type A dissection. While FET has been widely used for treatment of type A dissection, few authors have reported its use in acute type B dissection.4,5 This approach provides the benefit of single stage treatment of the acute problem, eliminates the risk of retrograde type A dissection and provides effective distal aortic remodeling and a favorable platform for future distal aortic intervention if needed. It should also be noted that two patients in this report underwent additional visceral artery stenting due to residual malperfusion of the mesenteric and renal arteries. This underscores the fact that proximal true lumen re-expansion with TEVAR does not guarantee restoration of visceral flow. While this is readily recognized in the treatment of acute type B dissections, this possibility should also be considered for all patients with Debakey I dissection that present with
5
malperfusion as mortality for these patients remain high despite a successful central repair. At our institution, we have adopted an approach of “verified complete reperfusion” (VCR) for all Debakey type I dissections. This involves operating in the hybrid OR, early discussion between the cardiac and vascular surgeons regarding the operative plan, and utilization of transesophageal echocardiography, IVUS or angiography to confirm distal true lumen expansion and reestablishment of visceral perfusion after central aortic repair. In case of ongoing compromise, additional interventions can be performed immediately (generally via antegrade approach through the ascending aortic graft) prior to leaving the operating room. In summary, we demonstrate the feasibility of a total arch replacement with FET technique to treat patients with acute type B aortic dissection where TEVAR is not feasible. This approach may be reasonable in patients with unsuitable proximal landing zones, or those at high risk of retrograde dissection who require urgent repair.
6
References 1.
Martens A, Beckmann E, Kaufeld T, et al. Total aortic arch repair: risk factor analysis and follow-up in 199 patients. Eur J Cardio-Thoracic Surg. 2016;50(5):940-948.
2.
Zeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: Superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010;140(6):S109-S115.
3.
Kim JB, Sundt TM. Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg. 2014;3(4):406-412.
4.
Weiss G, Tsagakis K, Jakob H, et al. The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience. Eur J Cardiothorac Surg. 2015;47(1):106-14.
5.
Zhao H-P, Zhu J-M, Ma W-G, Zheng J, Liu Y-M, Sun L-Z. Total arch replacement with stented elephant trunk technique for acute type B aortic dissection involving the aortic arch. Ann Thorac Surg. 2012;93(5):1517-1522.
7
Figure Legends Figure 1: (A) Preoperative CT demonstrating compressed true lumen (red arrow) and compromised SMA (blue arrow). (B) Postoperative CT demonstrating thoracic and visceral stents.
Figure 2: (A) Initial CT demonstrating origin of dissection flap distal to left subclavian. (B) Subsequent CT with dissection flap extending to left carotid. (C) Multiplanar aortic reconstruction with inadequate proximal landing zone for TEVAR. (Red arrow – bovine trunk, blue arrow – proximal extent of intimal fenestration, *left carotid artery, **left subclavian artery.) (D) Postoperative CT showing thrombosis of false lumen.
Figure 3: (A) Initial CT with dissection flap originating at left carotid. (B) Subsequent CT with contained rupture. (C) Intraoperative angiography with malperfusion of SMA (arrow) (D) Improved perfusion after SMA stenting.
8
S0003-4975(20)30206-X
DOI:
https://doi.org/10.1016/j.athoracsur.2019.12.077
Reference:
ATS 33480
To appear in:
The Annals of Thoracic Surgery
Received Date: 14 October 2019 Revised Date:
16 December 2019
Accepted Date: 27 December 2019
Please cite this article as: Axtell A, Eagleton M, Conrad M, Isselbacher E, Sundt T, Jassar A, Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection, The Annals of Thoracic Surgery (2020), doi: https://doi.org/10.1016/j.athoracsur.2019.12.077. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by The Society of Thoracic Surgeons
Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection Running Head: Arch Replacement and FET for Acute Type B
Andrea Axtell, MD, MPH1, Matthew Eagleton, MD2, Mark Conrad, MD2, Eric Isselbacher, MD3, Thoralf Sundt, MD1, Arminder Jassar, MBBS, FRCS1
1 Division of Cardiac Surgery; MGH 2 Division of Vascular and Endovascular Surgery, MGH 3 Department of Cardiology, MGH
Corresponding Author: Arminder Jassar 55 Fruit Street Boston, MA 02114 [email protected]
Abstract The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe three patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.
1
In patients with acute complicated type B aortic dissection without adequate proximal landing zone, thoracic endovascular aortic repair (TEVAR) is not feasible. While some uncomplicated patients with retrograde aortic arch extension can be managed non-operatively, patients with distal malperfusion present a challenge. We describe three patients who presented with an acute type B aortic dissection with associated visceral malperfusion who were treated with total arch replacement and frozen elephant trunk (FET).
Case Reports Case 1 A 76-year-old man presented with acute chest/abdominal pain and decreased sensation and weakness in the right lower extremity. CT imaging demonstrated an acute type B aortic dissection with an intimal tear distal to the left subclavian artery. The dissection flap extended retrograde into the inferior aspect of the aortic arch; the true lumen was severely compressed in the descending aorta, with radiologic malperfusion of the SMA (Figure 1 A) and right renal artery. Extension of the dissection flap into the aortic arch precluded safe TEVAR placement, even with carotid-subclavian bypass. Intraoperatively, a wire was advanced from the right femoral artery to the true lumen of the ascending aorta under intravascular ultrasound (IVUS) guidance. Cardiopulmonary bypass was initiated via the right axillary artery and the ascending aorta was cross-clamped. After completing the proximal anastomosis at the level of the sinotubular junction, the heart was perfused with warm blood (Beating heart technique)1. During corporeal arrest bilateral antegrade perfusion was afforded by clamping the innominate artery and direct ostial cannulation of the left carotid artery. A large intimal tear extended from the level of the left carotid artery to 2
distal to the left subclavian artery. A second fenestration was identified in the proximal descending aorta by aortoscopy using a sterile bronchoscope. The supra-aortic vessels were transected and the ostium of the left subclavian artery oversewn. The intimal tear was plicated using two felt strips. A 37x150mm Gore C-TAG (Gore) was deployed into the descending aorta. Aortoscopy confirmed that the stent covered the distal intimal tear. Arch reconstruction was completed using a 30mm 4-branched Siena graft (Terumo) with the distal anastomosis in zone II (suture-line incorporating the aortic wall, the TEVAR graft and the Siena graft.) After separating from bypass, flow in visceral vessels was assessed with IVUS and angiography. The SMA and right renal artery were compromised. Three stents were placed into the SMA. A 6x22 iCAST stent was placed into the right renal artery. The patient was discharged to rehab on postoperative day 15. Follow-up CTA demonstrated marked expansion of the true lumen with patent visceral vessels (Figure 1B).
Case 2 A 39-year-old man presented with acute onset chest/back pain. CT imaging demonstrated aortic dissection originating distal to the left subclavian and extending to the bilateral external iliac arteries (Figure 2A). Despite appropriate hemodynamic control, his symptoms recurred. Repeat CTA demonstrated interval retrograde extension of his dissection to the left subclavian and common carotid arteries with a new entry tear in the aortic arch (Figure 2B). There was concern for visceral ischemia due to rising creatinine and lactate levels. There was inadequate proximal landing zone for TEVAR (Figure 2C), even if a left carotid-subclavian bypass was performed.
3
Under circulatory arrest, the patient was noted to have a fenestration at the level of the left subclavian artery with the dissection flap extending proximally into the arch and a second fenestration in the proximal descending aorta. A 34x150mm Gore C-TAG device was deployed with its proximal extent in Zone II. A beating heart total arch replacement was performed using a 24mm Siena graft. He was discharged home on postoperative day 10. Follow-up CTA demonstrated thrombosis of the excluded false lumen with remodeling of the stented aorta (Figure 2D).
Case 3 A 58-year-old man presented to his local hospital with severe chest/back pain and an aortic dissection with entry tear in the aortic arch at the level of the left carotid artery and extending distally to the iliac arteries (Figure 3A). He progressed to somnolence, hypotension, renal failure, and acidosis requiring intubation and hemodynamic support prior to transfer to our facility. Repeat imaging demonstrated contained rupture (Figure 3B) of the arch with the dissection extending into the celiac and SMA with complete thrombosis of the left renal artery. Intraoperatively, a tear was identified in the aortic arch just distal to the left carotid artery; this was reapproximated using pledgeted sutures. A wire was then placed in the proximal aorta under aortoscopy guidance and a 34x107mm Valiant (Medtronic Inc) stent graft was deployed covering the tear site. A beating heart total arch replacement was performed using a 28mm Siena graft. On table angiography revealed compromised filling of the SMA (Figure 3C); therefore, three self-expanding stents were placed with excellent recanalization (Figure 3D). A self-expanding stent was also placed in the left renal artery. Brain imaging was obtained and although a head CT was negative, scattered foci of subacute ischemic infarcts were noted on
4
MRI. He was discharged to an inpatient facility on postoperative day 28 with only mild right sided residual weakness.
Comment TEVAR has become the preferred approach for patients with acute complicated type B aortic dissection2, however, is not feasible in patients without appropriate landing zones, such as in the case of concomitant aneurysm or retrograde extension into the aortic arch, (4-25% of cases)3. All three patients in this report were evaluated and discussed jointly by the cardiac and vascular surgery teams and were deemed to be anatomically unsuitable for TEVAR as a primary treatment strategy. Several treatment algorithms have been proposed for these patients including open descending aortic replacement, or a hybrid approach involving arch debranching and TEVAR. These are associated with significant morbidity, and in the case of endovascular approaches, carry a risk of retrograde type A dissection. While FET has been widely used for treatment of type A dissection, few authors have reported its use in acute type B dissection.4,5 This approach provides the benefit of single stage treatment of the acute problem, eliminates the risk of retrograde type A dissection and provides effective distal aortic remodeling and a favorable platform for future distal aortic intervention if needed. It should also be noted that two patients in this report underwent additional visceral artery stenting due to residual malperfusion of the mesenteric and renal arteries. This underscores the fact that proximal true lumen re-expansion with TEVAR does not guarantee restoration of visceral flow. While this is readily recognized in the treatment of acute type B dissections, this possibility should also be considered for all patients with Debakey I dissection that present with
5
malperfusion as mortality for these patients remain high despite a successful central repair. At our institution, we have adopted an approach of “verified complete reperfusion” (VCR) for all Debakey type I dissections. This involves operating in the hybrid OR, early discussion between the cardiac and vascular surgeons regarding the operative plan, and utilization of transesophageal echocardiography, IVUS or angiography to confirm distal true lumen expansion and reestablishment of visceral perfusion after central aortic repair. In case of ongoing compromise, additional interventions can be performed immediately (generally via antegrade approach through the ascending aortic graft) prior to leaving the operating room. In summary, we demonstrate the feasibility of a total arch replacement with FET technique to treat patients with acute type B aortic dissection where TEVAR is not feasible. This approach may be reasonable in patients with unsuitable proximal landing zones, or those at high risk of retrograde dissection who require urgent repair.
6
References 1.
Martens A, Beckmann E, Kaufeld T, et al. Total aortic arch repair: risk factor analysis and follow-up in 199 patients. Eur J Cardio-Thoracic Surg. 2016;50(5):940-948.
2.
Zeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: Superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010;140(6):S109-S115.
3.
Kim JB, Sundt TM. Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg. 2014;3(4):406-412.
4.
Weiss G, Tsagakis K, Jakob H, et al. The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience. Eur J Cardiothorac Surg. 2015;47(1):106-14.
5.
Zhao H-P, Zhu J-M, Ma W-G, Zheng J, Liu Y-M, Sun L-Z. Total arch replacement with stented elephant trunk technique for acute type B aortic dissection involving the aortic arch. Ann Thorac Surg. 2012;93(5):1517-1522.
7
Figure Legends Figure 1: (A) Preoperative CT demonstrating compressed true lumen (red arrow) and compromised SMA (blue arrow). (B) Postoperative CT demonstrating thoracic and visceral stents.
Figure 2: (A) Initial CT demonstrating origin of dissection flap distal to left subclavian. (B) Subsequent CT with dissection flap extending to left carotid. (C) Multiplanar aortic reconstruction with inadequate proximal landing zone for TEVAR. (Red arrow – bovine trunk, blue arrow – proximal extent of intimal fenestration, *left carotid artery, **left subclavian artery.) (D) Postoperative CT showing thrombosis of false lumen.
Figure 3: (A) Initial CT with dissection flap originating at left carotid. (B) Subsequent CT with contained rupture. (C) Intraoperative angiography with malperfusion of SMA (arrow) (D) Improved perfusion after SMA stenting.
8