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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.

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Presentation on theme: "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."— Presentation transcript:

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

2 ・ We have made minor changes to the original technique and applied this technique for a wide variety of aortic pathologies. Background (2) (Hara H,, J Thorac Cardiovasc Surg 2009;137:777-778) (Taniguchi K,, Ann Thorac Surg 2007;84:1729-34) (Shudo Y,, Ann Thorac Surg 2007;84:659-661) Objectives 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.

3 Operative strategies On 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

4 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.

5 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

6 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.

7 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%) CABG14 (11%) Aortic root replacement (modified Bentall)13 (10%) Reconstruction of left vertebral artery6 (5%) Others2 (2%) * : Hypothermic circulatory arrest time of the lower body for open distal anastomosis. Operative Data Concomitant Procedures (49 procedures in 46 (35%) patients)

8 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

9 Results (2): Complete thromboexclusion around ET Single-ET strategyStaged-ET strategy (n=99)(n=33) n=86 (87%) n=13 n=22 (67%) n=11 Failure of thromboexclusion N=13 (13%) Second-stage procedure: 11 Being followed: 2 Aortic rupture: None Failure of thromboexclusion N=22 (67%) Second-stage procedure: 16 Being followed: 2 Aortic rupture: 4* (including the 1 patient who refused the second-stage operation) * Success Failure

10 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

11 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 Percent survival (%) 100 80 60 40 20 0 68% 77% 89%

12 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

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