Sun's Procedure of Total Arch Replacement Using a Tetrafurcated Graft with Stented Elephant Trunk Implantation: Analysis of Early Outcome in 398 Patients with Acute Type A Aortic Dissection

Overview

Journal Ann Cardiothorac Surg

Publisher AME Publishing Company

Date 2013 Oct 11

PMID 24109570

Citations 34

Authors

Wei-Guo Ma

Jun Zheng

Song-Bo Dong

Wei Lu

Kai Sun

Rui-Dong Qi

Yong-Min Liu

Jun-Ming Zhu

Qian Chang

Li-Zhong Sun

Affiliations

Soon will be listed here.

Abstract

Background: Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Sun's procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Sun's procedure in patients with AAAD.

Methods: Clinical data of 398 consecutive AAAD patients undergoing the Sun's procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis.

Results: Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007).

Conclusions: The Sun's procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Citing Articles

Clinical analysis of Hem-o-lok closure of the left subclavian artery stump in acute Stanford type A aortic dissection.

Li J, Sha T, Dong P, Li X, Zhang P, Zhao Z Front Cardiovasc Med. 2024; 11:1472815.

PMID: 39639970 PMC: 11617507. DOI: 10.3389/fcvm.2024.1472815.

A nomogram for individualized prediction of new-onset postoperative atrial fibrillation in acute type A aortic dissection patients: a retrospective study.

Yang Z, Liu C, Fu C, Zhao X Front Cardiovasc Med. 2024; 11:1429680.

PMID: 39234610 PMC: 11371795. DOI: 10.3389/fcvm.2024.1429680.

Clinical outcomes of the type II hybrid procedure for the repair of extensive aortic arch pathology.

Xue Y, Lou Y, Wang X, Wang S, Shi Y, Chen D J Thorac Dis. 2024; 16(5):3260-3271.

PMID: 38883664 PMC: 11170404. DOI: 10.21037/jtd-24-586.

Clinical outcome of a branch-first approach with a novel continuous whole-brain perfusion strategy for total arch surgery.

Zhao Z, Chi H, Chen L, Wang J, Xiao C J Cardiothorac Surg. 2024; 19(1):217.

PMID: 38627813 PMC: 11020813. DOI: 10.1186/s13019-024-02704-z.

Mid-term outcomes of total neointima implantation in surgical repair of acute type A aortic dissection.

Lin Y, Xie L, Zhang Z, He J, Dai X, Chen L J Clin Hypertens (Greenwich). 2024; 26(2):155-165.

PMID: 38214206 PMC: 10857477. DOI: 10.1111/jch.14762.

References

Ma W, Zheng J, Liu Y, Zhu J, Sun L . Dr. Sun's Procedure for Type A Aortic Dissection: Total Arch Replacement Using Tetrafurcate Graft With Stented Elephant Trunk Implantation. Aorta (Stamford). 2016; 1(1):59-64. PMC: 4682700. DOI: 10.12945/j.aorta.2013.13.015. View

Pansini S, Gagliardotto P, Pompei E, Parisi F, Bardi G, Castenetto E . Early and late risk factors in surgical treatment of acute type A aortic dissection. Ann Thorac Surg. 1998; 66(3):779-84. DOI: 10.1016/s0003-4975(98)00555-4. View

Sun L, Qi R, Chang Q, Zhu J, Liu Y, Yu C . Surgery for acute type A dissection with the tear in the descending aorta using a stented elephant trunk procedure. Ann Thorac Surg. 2009; 87(4):1177-80. DOI: 10.1016/j.athoracsur.2009.01.042. View

Glower D, Speier R, White W, Smith L, Rankin J, Wolfe W . Management and long-term outcome of aortic dissection. Ann Surg. 1991; 214(1):31-41. PMC: 1358411. DOI: 10.1097/00000658-199107000-00006. View

Flores J, Kunihara T, Shiiya N, Yoshimoto K, Matsuzaki K, Yasuda K . Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg. 2006; 131(2):336-42. DOI: 10.1016/j.jtcvs.2005.09.050. View

Trimarchi S, Eagle K, Nienaber C, Rampoldi V, Jonker F, De Vincentiis C . Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010; 140(4):784-9. DOI: 10.1016/j.jtcvs.2009.11.014. View

Januzzi J, Isselbacher E, Fattori R, Cooper J, Smith D, Fang J . Characterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD). J Am Coll Cardiol. 2004; 43(4):665-9. DOI: 10.1016/j.jacc.2003.08.054. View

Bachet J . ICVTS on-line discussion A. Patency of distal false lumen in acute dissection. Interact Cardiovasc Thorac Surg. 2007; 6(2):207-8. DOI: 10.1510/icvts.2006.132233A. View

Shen K, Tang H, Jing R, Liu F, Zhou X . Application of triple-branched stent graft for Stanford type A aortic dissection: potential risks. Eur J Cardiothorac Surg. 2012; 41(3):e12-7. DOI: 10.1093/ejcts/ezr259. View

10.

Shrestha M, Pichlmaier M, Martens A, Hagl C, Khaladj N, Haverich A . Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results. Eur J Cardiothorac Surg. 2012; 43(2):406-10. DOI: 10.1093/ejcts/ezs296. View

11.

Imoto K, Uchida K, Karube N, Yasutsune T, Cho T, Kimura K . Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection. Eur J Cardiothorac Surg. 2013; 44(3):419-24. DOI: 10.1093/ejcts/ezt060. View

12.

Pacini D, Leone A, Belotti L, Fortuna D, Gabbieri D, Zussa C . Acute type A aortic dissection: significance of multiorgan malperfusion. Eur J Cardiothorac Surg. 2012; 43(4):820-6. DOI: 10.1093/ejcts/ezs500. View

13.

Rylski B, Hoffmann I, Beyersdorf F, Suedkamp M, Siepe M, Nitsch B . Acute aortic dissection type A: age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of over 2000 patients. Ann Surg. 2013; 259(3):598-604. DOI: 10.1097/SLA.0b013e3182902cca. View

14.

Conzelmann L, Hoffmann I, Blettner M, Kallenbach K, Karck M, Dapunt O . Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection type A (GERAADA). Eur J Cardiothorac Surg. 2012; 42(3):557-65. DOI: 10.1093/ejcts/ezs025. View

15.

Olsson C, Thelin S, Stahle E, Ekbom A, Granath F . Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation. 2006; 114(24):2611-8. DOI: 10.1161/CIRCULATIONAHA.106.630400. View

16.

Weigang E, Conzelmann L, Kallenbach K, Dapunt O, Karck M . German registry for acute aortic dissection type A (GERAADA)--lessons learned from the registry. Thorac Cardiovasc Surg. 2010; 58(3):154-8. DOI: 10.1055/s-0029-1240806. View

17.

Rampoldi V, Trimarchi S, Eagle K, Nienaber C, Oh J, Bossone E . Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg. 2006; 83(1):55-61. DOI: 10.1016/j.athoracsur.2006.08.007. View

18.

Murzi M, Glauber M . Should an endovascular procedure be combined with resection for type a aortic dissection?. Ann Thorac Surg. 2009; 88(4):1387-8. DOI: 10.1016/j.athoracsur.2009.01.009. View

19.

Kimura N, Tanaka M, Kawahito K, Itoh S, Okamura H, Yamaguchi A . Early- and long-term outcomes after surgery for acute type a aortic dissection in patients aged 45 years and younger. Circ J. 2011; 75(9):2135-43. DOI: 10.1253/circj.cj-10-1222. View

20.

Bonser R, Ranasinghe A, Loubani M, Evans J, Thalji N, Bachet J . Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011; 58(24):2455-74. DOI: 10.1016/j.jacc.2011.06.067. View