Frozen Elephant Trunk in Acute Aortic Dissection

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1 Frozen Elephant Trunk in Acute Aortic Dissection Derek R. Brinster, M.D. Professor of Cardiovascular and Thoracic Surgery Hofstra North Shore-LIJ School of Medicine Director of Aortic Surgery for the North Shore-LIJ Health System

2 Aortic Dissections Elephant trunk defined Methods of Frozen Elephant Trunk Frozen Elephant Trunk rationale Evidence

3 Definitions

4 Aortic Dissection Macura et al. p. 309 AJR, August 2003

5 AORTIC DISSECTIONS Indications for surgery Type A/ Type I & II: All patients Type B / Type III Uncomplicatedà medical management Complicatedà surgery (open standard v. stent graft) Prevention of future morbidity with immediate stent grafting?

6 Surgical Background Despite advances, many large series including recent ones, reveal a >25% post operative mortality rate. IRAD, JAMA: 2002 Only 55% return to independent living Hagan et al, 2000: Fann et al, 1995 Tan et al. Ann Thor Surg 2005

7 Natural History: Survival

8 Figure 3. Unadjusted Kaplan-Meier survival curve stratified by in-hospital management from date of hospital discharge. Thomas T. Tsai et al. Circulation. 2006;114:I-350-I-356 Copyright American Heart Association, Inc. All rights reserved.

9 The False Lumen

10 False Lumen Dynamic Obstruction Trimarchi et al. Annals of Cardiothoracic Surgery, Vol 3, No 4, 2014

11 Fate of Descending Aorta after Conventional Type I Dissection 20% 40% of patients require a second operation for aneurysmal dilatation of the descending aorta A large false lumen, with an area of the true lumen <30% 6 months after surgery, is the strongest predictor for secondary dilatation of the diseased downstream aorta. Immer et al Circulation. 2005;112[suppl I]:I- 249 I-252.

12 INSTEAD-XL: 5 Year Outcomes TEVAR with OMT versus OMT Aortic progression (27.0% versus 46.1%; P=0.04) Nienaber et al Circ Cardiovasc Interv Aug;6(4):407-16

13 INSTEAD-XL: 5 Year Outcomes TEVAR with OMT versus OMT Aorta-specific mortality (6.9% versus 19.3%; P=0.04) Nienaber et al Circ Cardiovasc Interv Aug;6(4):407-16

14 INSTEAD-XL: 5 Year Outcomes TEVAR with OMT versus OMT All-cause mortality (11.1% versus 19.3%; P=0.14) Nienaber et al Circ Cardiovasc Interv Aug;6(4):407-16

15 Rationale for the Frozen Elephant Trunk -FET Reduce the Reoperation Rate Reduce the False Lumen

16 The insertion of the invaginated prosthesis into the descending thoracic aorta. Marc A.A.M. Schepens MMCTS 2007;2007:mmcts European Association for Cardio-thoracic Surgery

17 Extraction of the prosthesis out of the descending aorta leaving the trunk behind. Marc A.A.M. Schepens MMCTS 2007;2007:mmcts European Association for Cardio-thoracic Surgery

18 Completion of the repair European Association for Cardio-thoracic Surgery Marc A.A.M. Schepens MMCTS 2007;2007:mmcts

19 Type A Dissection: Frozen Elephant Trunk Vallabhajosyula Ann Cardiothorac Surg 2013;2(3):

20 JOTEC E-vita

21 ThoraFlex Vascutek

22 Immediate Therapy Malperfusion of true lumen Complex primary and reentry tears of arch/descending aorta Facilitate arch reconstruction

23 Long Term Therapy Survival False Lumen Consequence Re-intervention rate

24 Data Retrospective, observational studies Bias Level C evidence

25

26

27 10% 5% 4% 10% 90% 92%

28 Mortality : Proximal Aortic Repair (PAR) v. Distal Aortic Repair (DAR) J Card Surg 2015;30:

29 Hybrid Reduces Mortality (Not Significant) Mortality Conventional Surgery v. FET J Card Surg 2015;30:

30 Distal Reintervention Rate: Proximal Aortic Repair (PAR) v. Distal Aortic Repair (DAR) J Card Surg 2015;30:

31 Hybrid Reduces the need for Reintervention (Significant) Distal Reintervention Rate: Proximal Aortic Repair (PAR) v. Distal Aortic Repair (DAR) J Card Surg 2015;30:

32 Hybrid Reduces the need for Reintervention (Significant) Complete FL thrombosis: FET 98% v. Antegrade/retrograde TEVAR 45% (Significant) Distal Reintervention Rate: Proximal Aortic Repair (PAR) v. Distal Aortic Repair (DAR) J Card Surg 2015;30:

33 DAR Reduces the need for Reintervention (Significant) Complete FL thrombosis: FET 98% v. Hybrid 45% (Significant) FET Reintervention 3.6% v. Hybrid 5.2 % (Significant) J Card Surg 2015;30: Distal Reintervention Rate: Surgery v. FET

34 Balance Alive Patient Long term morbidity

35 Summary Residual False Lumen 50-70% after standard surgical repair (30% after standard total arch) 13-25% of patients with False Lumen need another procedure in 5 years 8-25% operative mortality associated with open reoperation

36 Frozen Elephant Trunk in Acute Aortic Dissection Derek R. Brinster, M.D. Professor of Cardiovascular and Thoracic Surgery Hofstra North Shore-LIJ School of Medicine Director of Aortic Surgery for the North Shore-LIJ Health System

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