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Medicina
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Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair
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Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Surgery".

Deadline for manuscript submissions: closed (20 August 2021) | Viewed by 13393

Special Issue Editors

Prof. Dr. Ugolino Livi

E-Mail Website
Guest Editor
Department of Cardiothoracic Science, Department of Medical Area (DAME), University of Udine, Piazzale Santa Maria della Misericordia, 15, 33100 Udine, Italy
Interests: heart transplantation; mechanical circulatory support; mitral valve disease; prosthetic cardiac valves; aortic disease
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Mauro Rinaldi

E-Mail Website
Co-Guest Editor
Cardiac Surgery, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
Interests: cardiac surgery; cardiology; heart; pacemakers; echocardiography; heart failure; heart valve diseases; surgery; transplantation; infection

Special Issue Information

Dear Colleagues,

Although over the past twenty years, technological innovations have led to a significant decrease in morbidity and mortality in aortic arch surgery. neurological complications remain a major concern in this surgical setting. Traditionally, treatment of arch pathologies has always pertained to open cardiac surgery, but the advent of combined vascular and endovascular procedures has opened a new scenario in this field, and cardiac and vascular surgeons and interventional radiologists have joined together, contributing to increase knowledge and expertise. 

In cardiac surgery, this strict and mutually advantageous collaboration has resulted in the clinical introduction of the frozen elephant trunk technique; moreover, owing to great advances in the stent-graft technology, with the development of specifically dedicated arch-debranching grafts, hybrid procedures have become among the most suitable options in some patients, especially when cardiopulmonary bypass is contraindicated. Finally, the last frontier has probably been reached with total endovascular treatment of the aortic arch, already emerging as an important option in selected patients.     

However, most of all, this multidisciplinary collaboration has led to a new interpretation of the management of thoracic aorta and arch diseases leading to the creation of specialized aortic centers where specific knowledge can be shared and the most adequate treatment options can be selected for each patient. Indeed, due to the progressive aging of the general population, which exposes us with increasing frequency to the cardiovascular complications of atherosclerosis, more of these complex procedures on high-risk elderly patients are to be expected.

The purpose of this focused edition is to cover many aspects of the current treatment of aortic arch disease, creating an appealing interplay of best clinical evidence and surgical experiences involving experts of this field and to provide a comprehensive and timely overview on the state of the art, techniques, and perspectives, with special regard to the hybrid and totally endovascular approaches to aortic arch pathologies.       

Prof. Dr. Ugolino Livi
Prof. Dr. Mauro Rinaldi
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Medicina is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Aortic arch replacement
  • Elephant trunk
  • Frozen elephant trunk
  • Total endovascular repair
  • Hybrid procedure
  • Debranching of supra-aortic vessels

Published Papers (6 papers)

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Research

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12 pages, 1017 KiB  
Article
An Integrated Approach for Treatment of Acute Type A Aortic Dissection
by Igor Vendramin, Andrea Lechiancole, Daniela Piani, Sandro Sponga, Concetta Di Nora, Daniele Muser, Uberto Bortolotti and Ugolino Livi
Medicina 2021, 57(11), 1155; https://doi.org/10.3390/medicina57111155 - 24 Oct 2021
Cited by 3 | Viewed by 1406
Abstract
Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, [...] Read more.
Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004–2010 (Era 1, n = 90), 2011–2016 (Era 2, n = 87), and 2017–2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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11 pages, 1606 KiB  
Article
Hybrid Surgery to Manage Aortic Arch Pathology
by Guido Gelpi, Claudia Romagnoni, Francesco Epifani, Monica Contino and Carlo Antona
Medicina 2021, 57(9), 909; https://doi.org/10.3390/medicina57090909 - 30 Aug 2021
Viewed by 2245
Abstract
Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in [...] Read more.
Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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Review

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12 pages, 2752 KiB  
Review
Total Endovascular Aortic Arch Repair: From Dream to Reality
by Augusto D’Onofrio, Raphael Caraffa, Giorgia Cibin, Michele Antonello and Gino Gerosa
Medicina 2022, 58(3), 372; https://doi.org/10.3390/medicina58030372 - 2 Mar 2022
Cited by 7 | Viewed by 2996
Abstract
The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of [...] Read more.
The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of this review is to describe the two most commonly used branched devices for endovascular arch stent-grafting: Nexus (Endospan, Herzlia, Israle) and RelayBranch (Terumo Aortic, Glasgow, United Kingdom). Nexus is a CE-certified off-the-shelf, single branch, double stent graft system. It consists of two different components: a main module for the aortic arch and the descending aorta with a side-branch for the brachiocephalic artery (BCA), and a curved module for the ascending aorta that lands into the sino-tubular junction and connects to the main module through a side-facing self-protecting sleeve. Nexus may be used in urgent-emergency cases and also in patients with only one suitable supra-aortic target vessel but, on the other hand, it makes cerebral blood flow dependent on one source vessel only. The RelayBranch Thoracic Stent-Graft System is a custom made, double branched endograft with a wide window on its superior portion to accommodate two inner tunnels for BCA and left common carotid artery connection; bilateral cervical accesses are generally used to advance guidewires for catheterization of the inner tunnels in a retrograde fashion. RelayBranch can be customized on every patient’s specific anatomy and provides a double blood source for the brain, but it cannot be used in urgent-emergency conditions. Therefore, in order to optimize outcomes, the choice of the most appropriate device should be made considering pros and cons of each system and patient’s anatomy by an experienced aortic team. In conclusion, total endovascular aortic arch exclusion is a promising reality in selected high-risk patients. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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11 pages, 4303 KiB  
Review
Hybrid Approach in Acute and Chronic Aortic Disease
by Michele Murzi, Pier Andrea Farneti, Antonio Rizza, Silvia Di Sibio, Cataldo Palmieri and Marco Solinas
Medicina 2022, 58(1), 49; https://doi.org/10.3390/medicina58010049 - 29 Dec 2021
Cited by 1 | Viewed by 1921
Abstract
The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a [...] Read more.
The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, which carries a substantial rate of mortality and morbidity. For these reasons, hybrid arch repair that involves a combination of open surgery with endovascular aortic stent graft placement has been introduced as a therapeutic alternative for those patients deemed unfit for open surgical procedures. Hybrid repair requires varying degrees of invasiveness and can be performed as a single-stage procedure or as a two-stage procedure. The choice of the technique is multifactorial, depending on the characteristics of the diseased arch with regard to position of the stent graft proximal landing zone, patient fitness and comorbid status, as well as surgical expertise and hospital facilities. Among the evolving hybrid procedures is the so-called “frozen” or stented elephant trunk technique. Adapted from the classical elephant trunk technique, this approach facilitates the repair of a concomitant aortic arch and proximal descending aortic aneurysms in a single stage under circulatory arrest. This technique is increasingly being used to treat extensive thoracic aortic disease and has shown promising results. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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13 pages, 3371 KiB  
Review
Frozen Elephant Trunk Technique in Acute Type A Aortic Dissection: Is It for All?
by Pierpaolo Chivasso, Generoso Mastrogiovanni, Mario Miele, Vito Domenico Bruno, Antonio Rosciano, Antonio Pio Montella, Donato Triggiani, Mario Colombino, Francesco Cafarelli, Rocco Leone, Paolo Masiello and Severino Iesu
Medicina 2021, 57(9), 894; https://doi.org/10.3390/medicina57090894 - 28 Aug 2021
Cited by 7 | Viewed by 2393
Abstract
Acute type A aortic dissection (ATAAD) is an indisputable emergency with very poor outcomes without surgical treatment. Although the aortic arch is often involved in the aortic dissection, its optimal management during surgical therapy remains uncertain. A conservative tear-oriented approach has traditionally been [...] Read more.
Acute type A aortic dissection (ATAAD) is an indisputable emergency with very poor outcomes without surgical treatment. Although the aortic arch is often involved in the aortic dissection, its optimal management during surgical therapy remains uncertain. A conservative tear-oriented approach has traditionally been adopted, limiting the procedure to the ascending aorta (or hemiarch) replacement. However, dilation of the residual dissected aorta and subsequent rupture may occur, requiring further intervention in the future. In the last two decades, the frozen elephant trunk (FET) technique has become a valid and attractive option to treat aortic disease when the arch and the thoracic aorta are involved, both in elective and in emergency settings. Here, we report a review of the contemporary literature regarding the short- and long-term outcomes of the FET technique in ATAAD repair. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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Other

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8 pages, 1341 KiB  
Commentary
Frozen Elephant Trunk in Aortic Arch Disease: Different Devices for Different Pathologies
by Carlo Mariani, Giacomo Murana, Alessandro Leone, Luca Di Marco and Davide Pacini
Medicina 2021, 57(10), 1090; https://doi.org/10.3390/medicina57101090 - 12 Oct 2021
Cited by 4 | Viewed by 1780
Abstract
The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in [...] Read more.
The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in the proximal descending thoracic aorta. In Europe, two hybrid prostheses are available: the E-evita Open Plus hybrid stent graft system provided by JOTEC (Hechingen, Germany) and the ThoraflexTM Hybrid (Vascutek, Inchinnan Scotland). Recommendations for use are extensive pathologies of the arch in case of acute and chronic aortic dissection, degenerative aneurysm and intramural hematoma. The FET approach allows the replacement of the whole arch in one stage with the option of direct treatment of the proximal descending thoracic aorta based on the stent component, creating a safe landing zone for further endovascular treatment more distally. The remarkable feature of this technique is the possibility to perform more proximally (from zone 3 to zone 0) the distal anastomosis in to the arch. This allows for an easier distal anastomosis, reduced hypothermic circulatory arrest time and decreased risk of paraplegia (<5%). Early results are promising and according to the most recent series the rate of developing post-operative renal insufficiency ranges from 3 to 10%, the risk of stroke from 3% to 8% and mortality from 8–15%. The aim of the article will be to provide some knowledge about the use and application of FET procedures in different aortic situations. Full article
(This article belongs to the Special Issue Aortic Arch Treatment: From Surgical Replacement to Endovascular Repair)
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