| Part?Single-stage hybrid repair for DeBakey type I aortic dissection in a high-risk population:a single center 7.5-year experienceObjectives:To evaluate the efficacy of the Less invasive one-stop hybrid ZO total aortic arch repair(HTAR)without deep hypothermic circulatory arrest in management of Debakey type I aortic dissection(IAD).Design:The adverse outcome was defined as a single composite endpoint comprising peri-operative mortality,permanent neurologic deficit,and renal failure necessitating hemodialysis at discharge.Methods:A retrospective review of prospectively collected data was conducted of 120 consecutive patients with IAD undergoing one-stop HTAR(urgent/emergency,n=97,80.8%)involve reconstruction of the ascending aorta(zone 0)and total arch exclusion with thoracic endovascular aortic repair(TEVAR)during a 7.5-year period.Multivariate analysis of 27 potential preoperative and intra-operative risk factors was performed to examine composite endpoint and late mortality.Results:The Median duration of CPB was 134±46 minutes(interquartile range,102-163minutes),and that of cross-clamping was 56±26 minutes(interquartile range,38-65minutes).The mean length of the implanted stent graft was 197± 7mm(range,160-207 mm)and the mean diameter was 34±1mm(range,32-38mm).No endograft caudal migration occurred.Type I endoleaks occurred in 3 patients with acute IAD during the operation and were successfully treated with 3 cuffs(Cook Medical).Total early(30-day or in-hospital)mortality was 9.2%(n=11).The incidence of the composite endpoint was 11.7%(n=14).On multivariate analysis,malperfusion syndromes was the predictors of composite endpoint(odds ratio[OR],4.789;95%CI,1.362-16.896;P=0.015)and previous cerebrovascular accident(OR,13.74;95%CI,2.330-81.039;P =0.004)and myocardial ischemia time(OR,1.038;95%CI,1.015-1.061;P=0.001)predicted late mortality.The overall survival was 84.7%during a median follow-up of 3.4 years.Freedom from late aortic adverse events was 93.1%at 5 years,including secondary aorta intervention and endoleak.The maximal diameters of true lumen increased significantly in stented thoracic(14.4±6.5mm to 29.7±5.3mm,P<0.001),in lower thoracic(14.2±6mm to 21.6±7.2mm,P<0.001)and abdominal(11,7±4.8mm to 17.4±4.1mm,P<0.001)aorta.Conclusions:IAD was treated safely and durably by ZoneO one-stop HTAR,peri-operative mortality and morbidity were not substantially higher despite their older age and high risk.Our study has demonstrated that in high-risk patients with IAD,the operation of one-stop HTAR without DHCA provide a feasible treatment option with acceptable mid-and long-term results.This evolving hybrid total aortic arch repair approach may extend the indications for use of endovascular prostheses in the treatment of high risk patients with IAD.Part ? Total aortic arch repair for Debakey I aortic dissection:a comparative study of Zone 0 hybrid arch exclusion versus traditional open repairObjective:We compared the short-and mid-term outcomes between patients who had undergone frozen elephant trunk(FET)and total arch replacement(TAR)technique(FET+TAR)for type I aortic dissection(IAD)and those who had undergone one-stop hybrid zone 0 total arch repair(HTAR).Methods:From January 2010 to December 2015,729 patients were treated for acute type I aortic dissection.116 patients(group A)underwent one-stop HTAR,613 patients(group B)underwent FET+TAR.Various concomitant procedures were performed in both groups.The primary endpoint was early major composite adverse events within 30 days after operation or at discharge(EMCAEs was defined as a single composite endpoint comprising peri-operative mortality,permanent neurologic deficit,and renal failure necessitating hemodialysis at discharge.)and mid-term major composite adverse events(MMCAEs was defined as a single composite endpoint comprising all-cause death,stroke and orta rupture).Results:The operative mortality was 8.7%(10/116)in group A(P =0.841)and 9.3%(57/613)in group B.20 in group A(17.4%)and 107 patients in group B(17.4%)experienced a postoperative EMCAEs(P =0.993).Compared with group B,group A had longer stay in intensive care unit(hours)(5[2-7]vs 3[2-5],P<0.001).Group A had similar MMCAEs rate(19.8%vs 15.7%;P =0.543),however,higher repeated aorta intervene rate([2.6%vs 0.5%],HR=6.954,[95%CI,1.549-31.215,P=0.011])compared with group B.In the multivariate analysis,age(OR,1.054,95%CI[1.031-1.077],P<0.001),preoperatively renal dysfunction(OR,5.754,95%CI[2.671-12.397],P<0.001)and cardiopulmonary bypass time(OR,1.012,95%CI[1.009-1.016],P<0.001)independently predicted operative mortality.Predictors of long-term mortality(during a median follow-up period of 3.12 years)were age(HR,1.033,95%Cl[1.014-1.052],P<0.001),cardiopulmonary bypass time(HR,1.003,95%CI[1.001-1.006],P =0.008),operation time(HR,1.163,95%CI[1.037-1.304],P<0.001).3-year survival was 86%vs 88%in one-stop HTAR and FET+TAR(log-rank P =0.671).Conclusions:IAD was treated safely and durably by one-stop HTAR.Although patients in one-stop HTAR group were somewhat older than other patients,operative mortality was not substantially higher despite their older age and more comorbidity.These results argue favorably for the use of the one-stop HTAR technique in the management of higher risk patients with IAD.Part ? Objective analysis of midterm outcomes of conventional and hybrid aortic arch repair for Debakey I aortic dissection by propensity-score matchingObjective:The aim of this study is to evaluate the objective outcomes of one-stop hybrid zone 0 total arch repair(HTAR)and frozen elephant trunk(FET)and total arch replacement(TAR)technique(FET+TAR)in the management of type I aortic dissection(IAD)involving aortic arch by using propensity-score matching to reduce selection bias.Methods:Between January 2010 and December 2015,729 consecutive patients underwent total aortic arch repair(excluding hemiarch or partial arch reconstruction,and cases with none aorta-related cardiac surgeries)at a single cardiovascular institute.We categorized 613 FET+TAR repair with antegrade cerebral perfusion under circulatory arrest as the FET+TAR group and 116 one-stop HTAR with thoracic endovascular aortic repair as the one-stop HTAR group.Using propensity score methodology,these patients were matched with 2 separate groups of 83 patients who underwent isolated FET+TAR or one-stop HTAR during the same period.Then,we compared early and midterm outcomes between the propensity-matched group(83 FET+TAR)one-stop HTAR pairs).The primary endpoint was early major composite adverse events(EMCAEs)and mid-term major composite adverse events plus(MMCAEs+;MMCAEs+ was defined as a single composite endpoint comprising all-cause deat,stroke,aorta rupture and repeated aorta intervene).All paired patients were stratified by the EuroSCORE(European System for Cardiac Operative Risk Evaluation Score).Cutoffs for Logistic EuroSCORE(low,?7%and high,>7%)was identified by median.2 groups' cumulative MMCAEs+ rates in each risk tertile were compared.Results:There were no significant differences in early major composite adverse events(EMCAEs)and operative deaths(30-day or in-hospital)between the FET+TAR and one-stop HTAR groups(28,9%vs 16.9%;P=0.067 and 18.1%vs 8.4%;P=0.073).There were no significant differences in the incidences of mid-term composite major adverse([28.9%vs 18.1%],HR=1.844,[95%CI,0.886-3.839,P =0.102]).During a median follow-up of 3.0 years,matching analysis revealed an equivalent 3-year survival rate between the FET+TAR and one-stop HTAR groups(88.6%vs 76.9%;P=0.056).After stratification by Logistic EuroSCORE,the cumulative MMCAEs+ rates were similar between the 2 groups in low risk group.But in the high EuroSCORE group,patients who underwent one-stop HTAR had a higer survival rate(log rank P =0.039)and a lower MMCAEs+ rate(logrank P =0.070)than did the groups that underwent FET+TAR.Conclusions:Among contemporary cases,both traditional and hybrid total aortic arch replacement had acceptable results.Comparing these 2 different surgical treatment options is challenging,and an individualized approach offers the best results.Matching analysis revealed equivalent midterm outcomes in the one-stop HTAR group compared with the FET+TAR group.Surgical total arch replacement has improved through new methods and ACP.Hybrid(combined surgical/endovascular)total arch replacement was developed for use in high-risk patients.The choice of technique did not significantly affect permanent adverse outcome rates.In a high-risk population,hybrid approaches have the potential to be alternatives to a conventional approach.Further development,however,is required for hybrid repair to become a superior option. |
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