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OBJECTIVE: To compare early and mid-term outcomes after repair of extensive aneurysm of the thoracic aorta using the conventional elephant trunk or frozen elephant trunk (FET) procedures. METHODS: Fifty-seven patients with extensive thoracic aneurysmal disease were treated using elephant trunk (n = 36) or FET (n = 21) procedures. Patients with aortic dissection, descending thoracic aorta (DTA) diameter less than 40 mm, and thoracoabdominal aneurysms were excluded from the analysis, as were those who did not undergo antegrade selective cerebral perfusion during circulatory arrest. Short-term and mid-term outcomes were compared according to elephant trunk/FET surgical management. RESULTS: Preoperative and intraoperative variables were similar in the two groups, except for a higher incidence of female sex, coronary artery disease and associated procedures in elephant trunk patients. Hospital mortality (elephant trunk: 13.9% versus FET: 4.8%; P = 0.2), permanent neurologic dysfunction (elephant trunk: 5.7% versus FET: 9.5%; P = 0.4) and paraplegia (elephant trunk: 2.9% versus FET: 4.8%; P = 0.6) rates were similar in the two groups. Follow-up was 100% complete. In the elephant trunk group, 68.4% of patients did not undergo a second-stage procedure during follow-up for a variety of reasons. Of these patients, the DTA diameter was greater than 51 mm in 72.2% and two (6.7%) died due to aortic rupture while awaiting stage-two intervention. Endovascular second-stage procedures were successfully performed in all FET patients with residual DTA aneurysmal disease (n = 3), whereas nine of 11 elephant trunk patients who returned for second-stage procedures required conventional surgical replacement through a lateral thoracotomy. Kaplan-Meier estimate of 4-year survival was 75.8 ± 7.6 and 72.8 ± 10.6 in elephant trunk and FET patients, respectively (log-rank P = 0.8). CONCLUSION: In patients with extensive aneurysmal disease of thoracic aorta, elephant trunk and FET procedures seem to be associated with similar satisfactory early and mid-term outcomes. The FET approach leads to single-stage treatment of all aortic disease in most patients, and facilitates endovascular second-stage treatment in patients with residual DTA disease. The elephant trunk staged-approach appears to leave a considerable percentage of patients at risk for adverse aortic events.

OBJECTIVE: The objective of our study was to report our hospital and long-term results after reinterventions on the thoracic aorta. METHODS: Between 1986 and 2011, 224 reoperations on the proximal thoracic aorta after previous aortic surgery were performed in our institution. The number of reinterventions quadrupled during the course of the study period. Mean patient age was 58.1 years, and 174 patients (77.7%) were male. An urgent/emergency operation was performed in 39 patients (17.4%). Indications for surgery included degenerative and chronic postdissection aneurysm (n = 166), false aneurysm (n = 31), active prosthetic infection (n = 16), acute dissection (n = 10), and other (n = 1). Surgical procedures involved the aortic root in 40.6% of patients, the ascending aorta in 9.4%, the aortic arch in 24.6%, and the entire proximal thoracic aorta in 25.4%. RESULTS: Hospital mortality was 12.1%. On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.1023/minute; P < .001), and urgent/emergency status (odds ratio, 5.6; P < .001) emerged as independent predictors of hospital mortality. The follow-up was 98.7% complete. Estimated 1-, 5-, and 10-year survival rates were 84.4%, 72.5%, and 48.5%, respectively. Eighteen reinterventions were performed during follow-up-16 because of the progression of aortic disease at the proximal aorta (n = 2) and downstream aorta (n = 14). Freedom from reoperation at 1, 5, and 10 years was 95.6%, 90.2%, and 81.5%, respectively. CONCLUSIONS: Reoperative aortic surgery was associated with satisfactory short- and long-term results, especially if carried out on an elective basis. The extent of the aortic replacement did not impact survival and was associated with a reduced need for reintervention. The progressive nature of aortic disease and the favorable results of elective primary aortic interventions suggest favoring aggressive aortic resections at initial surgery.

Background The impact of different cannulation strategies on outcomes of aortic arch surgery remains controversial. This retrospective study sought to evaluate central cannulation (ascending aorta, right axillary, and innominate artery) compared with femoral artery cannulation for aortic arch surgery, and to identify among preoperative and intraoperative variables the independent predictors of death and permanent neurologic dysfunction (PND) in aortic arch surgery. Methods All patients were operated through a median sternotomy using antegrade selective cerebral perfusion with moderate hypothermia as a method of brain protection. Treatment bias was addressed by use of propensity-score matching and multivariate regression analysis. Logistic regression models were used to identify the independent predictors of hospital mortality and PND. Results Of the 473 patients undergoing aortic arch surgery, 273 (57.7%) underwent femoral cannulation (FC), and 200 (42.3%) underwent central cannulation (CC). The CC and FC cannulation were associated with similar risk of in-hospital death (absolute risk reduction [ARR]: 0.7%; p = 0.880) and PND (ARR:-2.6%, p = 0.361) in the overall cohort and after adjusting for propensity-based matching (ARR for hospital mortality: 2.2%, p = 0.589; ARR for PND: 3.4%, p = 0.271). Female gender (odds ratio [OR]:2.1, p = 0.030), type A acute dissection or intramural hematoma (OR: 2.2; p = 0.041), and CPB time (OR: 1.010/minute, p = 0.015) were independent predictors of in-hospital death. Female gender (OR: 2.4; p = 0.033), type A acute dissection or intramural hematoma (OR: 4.2; p = 0.005), and diabetes (OR: 6.6, p = 0.007) were independent predictors of PND. Conclusions During aortic arch surgery, CC and FC are associated with a similar risk of postoperative death and PND. Type A acute aortic dissection and cardiopulmonary bypass time remain strong risk factors for mortality and PND.

BACKGROUND: A growing body of evidence has shown that delayed management of traumatic injury of the thoracic aorta determines survival benefits as compared with immediate treatment. However, few data exist comparing outcomes after delayed open surgical or endovascular management. Accordingly, we reviewed our experience with delayed management, stratifying the data according to type of repair; open surgical versus endovascular. METHODS: Since 1992, delayed aortic repair has represented our first-line management for all blunt traumatic thoracic aortic injury (BTTAI) patients, except for those who presented with or became unstable due to impending aortic rupture. These patients were converted to urgent primary aortic repair. Thus, between 1992 and 2010, a total of 77 BTTAI patients were managed according to this policy. There were 57 (74%) men having a mean age of 33.4 years. Thirty-one (41.3%) patients underwent open surgical repair (SR), 44 (58.6%) underwent endovascular repair (ER), and 2 died while awaiting aortic repair. At admission, the clinical and trauma characteristics were similar in both groups. The trauma-to-repair time span (in days) was 200 (Q1-Q3: 27 to 340) and 10 (Q1-Q3: 2 to 79) for SR and ER patients, respectively (p = 0.001). Due to unpaired hemodynamic or imaging signs of impending aortic rupture, 15 patients required urgent repair, which was endovascular in 11 (25%) cases and surgical in 4 (12.9%). RESULTS: Overall, hospital mortality was 3.9% (n = 3), being 0% in SR patients and 2.3% (n = 1) in ER patients (p = 0.398). No new postoperative paraplegia occurred; a cerebellar stroke occurred in 1 (2.3%) ER patient receiving intentional coverage of the left subclavian artery. During follow-up (96.1% complete at 95 ± 70 months), no late deaths occurred. At 15 years, the estimates of survival and freedom from secondary aortic procedures were 96% and 100%, respectively. CONCLUSIONS: Delayed management of traumatic aortic injury was associated with satisfactory short- and long-term results without significant differences between open surgical and endovascular repair. However, the reduced invasiveness of endovascular repair can optimize operative timing allowing prompt aortic repair in unstable patients, earlier repair in stable patients, and, when indicated, easier concomitant non-aortic surgery.

Patients with dissecting or aneurysmal disease of the aortic arch represent a unique challenge for the cardiac surgeon, and the employment of valid surgical and endovascular techniques and appropriate methods of cerebral protection is crucial for obtaining satisfactory postoperative results. Open surgical repair remains the approach of choice, even if supported by increasingly improved endovascular procedures. At present, a wide range of surgical, endovascular and hybrid procedures is available for the treatment of these high-risk patients. The aim of this review is to describe the different procedures used in patients with aortic arch pathology and to review the main results available in the literature.