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Objective: The operative strategies for retrograde acute type A aortic dissection with a primary intimal tear remain controversial because resection of an intimal tear via a median sternotomy is difficult. We evaluated the frozen elephant trunk technique for treating this type of aortic dissection., Methods: The frozen elephant trunk technique was used for acute retrograde type A aortic dissection with a primary intimal tear in the descending aorta in 25 consecutive patients (16 men, 9 women; median age, 64 years) seen between 1997 and 2011 at the Hiroshima City Asa Hospital. Three patients had Marfan syndrome. Fourteen patients had ischemia of the lower half of the body, 2 had stroke, 3 had coronary ischemia, and 10 had pericardial tamponade., Results: There were no hospital deaths. Postoperative complications occurred in 2 patients, including stroke and mediastinitis. Two late deaths occurred over a median follow-up period of 58 months (12-169 months), one caused by stroke and the other by colon cancer. Two patients needed additional operations: one required a second operation for descending aorta replacement because of ulceration caused by the stent graft, and the other required an endovascular stent graft because of dilatation of the descending aorta. Computed tomography follow-up scans revealed that the false lumen was completely thrombosed and obliterated in all 25 patients with stent grafts., Conclusions: The frozen elephant trunk technique for retrograde type A aortic dissection yielded acceptable outcomes, despite the high preoperative morbidity, and might improve the prognosis of dissection., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The aimed to describe the frozen elephant trunk (FET) technique and partial remodeling (PR) for acute type A aortic dissection (ATAAD), considering the long-term prognosis on the basis of our 13 years of experience., Methods: There were 80 consecutive patients (mean age: 66.4 years) with an FET and PR technique for ATAAD between September 1997 and February 2010. We indicated a PR for all 80 patients without dilatation of the sinuses and a FET for 20 patients with a distal entry in the descending aorta, 14 patients with a dilatation more than 4cm on the distal arch and 46 patients with a narrow true lumen younger than 70 years with a narrow true lumen. During moderate hypothermic circulation with selective cerebral perfusion and distal perfusion from the femoral artery, a stent graft (mean diameter: 27.7mm, mean length: 9.9mm, mean distal depth: thoracic vertebra (Th) 6.0th) was inserted through the transected proximal aortic arch. The plication of the sinotubular junction (N=42) or partial remodeling for right and/or non-coronary cusp (N=38) was performed after total arch replacement with a four-branched prosthesis., Results: Four patients died in hospital. Early morbidity included two (2.5%) strokes but no spinal cord injury. In long-term follow-up (mean 94.6 months), five patients died of non-aortic events and two re-operations (Bentall and stent grafting to the descending aorta) were required. No patients had patent false lumen on the stent graft and residual aortic regurgitation, according to late follow-up computed tomography (CT) and echogram. The 10-year survival was 75% and the overall 10-year re-operation free rate on the thoracic aorta was 95%., Conclusion: FET and modified PR techniques could be effective for improving the long-term outcome on the distal and proximal aorta in an ATAAD., (Crown Copyright © 2011. Published by Elsevier B.V. All rights reserved.)

Purpose: We describe the long-term efficacy of early entry closure for acute type B aortic dissection by open stent grafting based on long-term results and changes in the false lumen on enhanced computed tomography (CT)., Methods: We performed open stent grafting for acute type B aortic dissection in 28 28 patients between 1998 a 2008. They included 14 patients with complicated type B aortic dissection (11 patients with limb and/or visceral ischemia and 4 patients with impending rupture). Uncomplicated type B aortic dissection was present in 14 patients, including 4 patients with an ulcer-like projection and 10 patients who had stable dissection with a patent false lumen., Results: Two patients who had the ischemic type died within 30 days. Postoperative complications occurred in two patients, including one case of paraplegia and one of mediastinitis. Two more deaths occurred during a median follow-up period of 45 months (range 6-114 months), with one related to open stent-graft infection and one due to pneumonia. The overall survival rate 5 years after open stent grafting was 77%. According to follow-up by CT, the false lumen was completely thrombosed and obliterated in all 26 patients with stent grafts., Conclusion: Early entry closure for both complicated and uncomplicated acute type B aortic dissection with an open stent graft has an acceptable early outcome and provides a high aortic remodeling rate.

Objectives: This study describes the long-term safety and effectiveness of extended aortic arch replacement with the frozen elephant trunk technique from our 12 years of experience., Methods: Between September 1997 and September 2008, 156 patients (mean age 67.9 years) with different pathologies from the aortic arch to the extended descending aorta in 100 dissections (acute A/acute B/chronic B=66/26/8) and 56 thoracic arteriosclerotic aneurysms (TAAs) had the frozen elephant technique performed upon them. During moderate hypothermic circulation with selective cerebral perfusion, the stent graft was inserted through the transected proximal aortic arch with trans-oesophageal echo guidance., Results: Six patients (3.2%) (acute A/acute B/chronic B/TAA=3/2/0/1) died in hospital. Postoperative morbidity induced four (2.6%) strokes (acute A/acute B/chronic B/TAA=2/0/0/2) and three (2.0%) spinal injuries (paraplegia in two and transient paraparesis in one) (acute A/acute B/chronic B/TAA=0/0/1/2). In the long-term follow-up (mean 63.3 + or - 39.2 months, maximum 144 months) 16 patients died. The survival rate was 99.3%, 86.5% and 74.9% at 1, 5 and 10 years, respectively. An additional operation was performed in 15 (9.4%) (ascending aorta/aortic root/descending aorta/abdominal aorta=1/2/5/7) including three stent-graft-related events (2.1%), and the additional repair proved successful. A follow-up computed tomography (CT) image was available for 96.0% (143/149) of patients who survived longer than 12 months. The size of false lumen or aneurysm increased in four patients, was unchanged in 20 patients (14.0%), shrank in 66 (46.2%) and was completely obliterated in 55 (37.1%)., Conclusions: The frozen elephant technique could be an attractive treatment for extended aortic arch disease to the extended descending aorta for acute aortic dissection as well as arteriosclerotic aneurysm., (Crown Copyright 2010. Published by Elsevier B.V. All rights reserved.)

Objective: To describe the fate of the false lumen remaining in the descending thoracic aorta after extensive primary repair of the thoracic aorta by the modified elephant trunk technique with a stent graft for acute type A aortic dissection, particularly the changes of the false lumen on enhanced CT scanning., Methods: The subjects were 65 consecutive patients who received arch replacement with an open stent graft for type A acute aortic dissection. CT scanning was performed at 1, 3, 12, 36, and 60 months postoperatively to detect thrombus formation, absorption of thrombus, and obliteration of the false lumen after its exclusion by the stent graft. The aorta was measured at four levels, which were the distal border of the stent graft, the middle and distal parts of the descending thoracic aorta, and the origin of the superior mesenteric artery., Results: Obliteration was recognized in all patients at the distal border of the stent graft and absorption of thrombus was seen in 90% at the middle of the descending thoracic aorta within 1 year after surgery. However, the false lumen remained patent at the superior mesenteric artery (SMA) level in 50% of the patients., Conclusions: In patients with acute type A aortic dissection, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by stent grafting, and this method may reduce the necessity for further operations to manage a residual false lumen.

This study is retrospectively to evaluate strategies for organ malperfusion on the view point of two mechanisms (true lumen collapse in the aorta=Ao type, or branch dissection=Br type) in acute type B aortic dissection. There were 16 of Ao type and 4 of Br type in 20 patients with organ malperfusion. In Ao type, we performed entry closure in 12 patients, surgical bypass grafting in two to superior mesenteric artery (SMA) in one and femoral artery in two, and surgical fenestration in two. In Br type, we performed interventional non-covered stenting to the orifice of visceral arteries in two patients, surgical bypass to SMA with ileum resection in one, and surgical bypass to SAM and renal arteries in one. Five patients in 16 of Ao type died within 30 days that had two multiple organ failure after entry closure, one aortic injury during endovascular stent graft repair, two more multiple organ failure after femoral bypass, however, all four patients in Br type were rescued. Central aortic operation to true lumen collapse with entry closure for Ao type ischemia and organ reperfusion with extra-anatomical bypass or non-covered stent to ischemic arteries for Br type ischemia should be performed before catastrophic status.