RESUMEN
Introduction: Despite a high rate of success when performed in specialised centres, current techniques for thoraco-abdominal aortic repair are associated with serious complications. The problem of spinal cord ischaemia remains unsolved. Surgical technique: The new hybrid graft for thoraco-abdominal aortic repair was developed based on the frozen elephant trunk principle. The device consists of a proximal stent graft for transabdominal retrograde delivery to the descending thoracic aorta, combined with a distal six branched abdominal device for open aortic repair. An additional seventh branch is provided for possible lumbar artery re-implantation. Because the stent graft is implanted via a transabdominal approach, it avoids the need for thoracotomy and extracorporeal circulation. A 56 year old patient with Loeys-Dietz syndrome was placed in a supine position. The aorto-iliac axis was exposed via a midline transperitoneal approach. Following an end to side anastomosis of the iliac branch to the left common iliac artery, the stent graft portion was inserted into the thoracic aorta via the coeliac trunk ostium. After stent implantation and graft de-airing by needle puncture, retrograde blood flow to the abdominal aortic segment, and the lumbar and visceral arteries was established via the end to side iliac anastomosis creating an extra-anatomic bypass. Subsequently, the visceral and renal arteries were anastomosed to the branches. Finally, the aorta was opened and surgical graft attached via the collar. The reconstruction ended with end to end anastomoses of both common iliac arteries to the graft branches. Discussion: The first and successful implantation of the new Thoracoflo hybrid device via a novel surgical technique is reported, eliminating the need for thoracotomy and extracorporeal circulation for thoraco-abdominal aortic repair.
RESUMEN
Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.
Asunto(s)
Estenosis de la Válvula Aórtica , Endocarditis , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/terapia , Complicaciones Posoperatorias/cirugía , Marcapaso Artificial/efectos adversos , Estenosis de la Válvula Aórtica/cirugía , Factores de Riesgo , Endocarditis/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversosRESUMEN
OBJECTIVE: Fenestrated or branched endovascular aortic repair (FB-EVAR) usually represents the last stage in endovascular treatment of postdissection aneurysm after thoracic endograft coverage of entry tear and false lumen embolization. METHODS: The study was a retrospective analysis of all patients with postdissection thoracoabdominal aneurysm treated with FB-EVAR in a single center. Short-term outcomes included technical success, operative mortality, and morbidities. Midterm outcomes included secondary intervention, false lumen thrombosis rate, aneurysm size regression, and subsequent survival. RESULTS: Twenty patients (95% male with a mean age of 64 ± 9 years) were treated between January 2014 and December 2017. The technical success was 100%. There was one death (5%) within 30 days. Postoperative complications included two patients with spinal cord ischemia (10%; one partial and one full). The median follow-up period was 12 months (range, 0-31 months). A secondary intervention was required in six patients, including thoracic stent graft relining for type III endoleak (n = 2), covered stent relining for junctional leak between main body and renal stent (n = 2), and iliac false lumen embolization (n = 2). Twelve patients completed the 1-year follow-up computed tomography angiogram, and their mean aneurysm diameters were 71 ± 18, 66 ± 19, and 62 ± 19 mm preoperatively, immediate postoperatively, and at 1 year, respectively; the corresponding false lumen thrombosis rates were 0% (0/20), 58% (7/12), and 92% (11/12), respectively. One more patient died during follow-up from a non-aneurysm-related cause. The estimated overall survival rates were 95 ± 5%, 88 ± 8%, and 88 ± 8% at 6, 12, and 18 months, respectively. CONCLUSIONS: FB-EVAR was feasible for postdissection thoracoabdominal aneurysm. Despite the associated perioperative risk and high probability of planned or unplanned reintervention, the procedure led to favorable aortic remodeling with false lumen thrombosis and aneurysm regression.