Hybrid Technologies for Reconstruction of Proximal Aortic Dissection

The aim of the study is to evaluate the efficacy of various types of hybrid technology in compare to the classical repair of the aortic arch of type I aortic dissection treatment in the in-hospital period.

Materials and Methods. A retrospective observational study has been conducted, the results of surgical treatment of 213 patients with DeBakey type I aortic dissection operated on within the period from 2001 to 2017 were compared. Patients were divided into three groups: in group 1, patients undergone a hemiarch type of aortic repair or the total arch replacement (n=121); in group 2, a hemiarch aortic reconstruction and implantation of bare metal stent was performed (n=55); in group 3, a frozen elephant trunk technique was used (n=37). Taking into consideration the retrospective character of the investigation and nonequivalence of the groups by separate characteristics, they were equalized to improve the reliability of the results using the PSM (propensity score matching) pseudorandomization method. As a result, three groups of comparison were formed which were equalized by the PSM method and called PSM 1, 2, and 3. The mortality and complication rate in the in-hospital period, as well as the frequency of false lumen thrombosis development depending on the treatment method, have been analyzed.

Results. The mortality rate in the PSM 1 group was 15 patients: group 1 (standard technique) — 10 patients (9%), group 2 (uncoated stents) — 5 patients (11%). A significant difference was found in the number of major bleedings (group 1 — 8%, group 2 — 21%, p=0.031) and cases of bowel ischemia (group 1 — 1%, group 2 — 9%, p=0.028). Complete false lumen thrombosis of the thoracic aorta was observed significantly more often in group 1 than in group 2 (22% vs 5%, p=0.015).

In the examined group PSM 2, hospital mortality rate was 4 patients: group 1 — 3 patients (12%), group 3 — 1 patient (3%). No differences between the groups were found in the number of complications. In group 3, complete false lumen thrombosis of the thoracic aorta was observed in 59% of cases, whereas in group 1 it was found only in 4% of patients (p<0.001).

In comparison group PSM 3, the mortality was 8 patients: group 2 — 5 patients (11%), group 3 — 3 patients (9%). The number of neurological complications differed significantly: in group 2 — 27%, in group 3 — 6% (p=0.019). Besides, 3% of cases of complete false lumen thrombosis were found in group 2, while there appeared 55% (p<0.001) of such patients in group 3.

Conclusion. The comparative analysis showed that the use of bare metal stents and hybrid prostheses demonstrated a comparable low level of in-hospital mortality compared to the standard surgical technique of aortic arch reconstruction. At the same time, the use of the bare metal stents is associated with a higher rate of perioperative complications (bleeding, postoperative bowel ischemia, neurological complications) compared to the standard treatment and repair of the aortic dissection using hybrid prostheses. Complete thrombosis of the false lumen occurred significantly less commonly in case of using bare metal stents than with standard treatment and hybrid prostheses.

1. Zhang J., Jiang Y., Gao C., Feng J., Wang A. Risk factors for hospital death in patients with acute aortic dissection. Heart Lung Circ 2015; 24(4): 348–353, https://doi.org/10.1016/j.hlc.2014.10.009.
2. de la Cruz K.I., Green S.Y., Preventza O.A., Coselli J.S. Aortic arch replacement in patients with chronic dissection: special considerations. Semin Cardiothorac Vasc Anesth 2016; 20(4): 314–321, https://doi.org/10.1177/1089253216659144.
3. Koechlin L., Schuerpf J., Bremerich J., Sommer G., Gahl B., Reuthebuch O., Gurke L., Mujagic E., Eckstein F., Berdajs D.A. Acute aortic dissection with entry tear at the aortic arch: long-term outcome. Interact Cardiovasc Thorac Surg 2021; 32(1): 89–96, https://doi.org/10.1093/icvts/ivaa228.
4. Hagan P.G., Nienaber C.A., Isselbacher E.M., Bruckman D., Karavite D.J., Russman P.L., Evangelista A., Fattori R., Suzuki T., Oh J.K., Moore A.G., Malouf J.F., Pape L.A., Gaca C., Sechtem U., Lenferink S., Deutsch H.J., Diedrichs H., Marcos y Robles J., Llovet A., Gilon D., Das S.K., Armstrong W.F., Deeb G.M., Eagle K.A. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283(7): 897–903, https://doi.org/10.1001/jama.283.7.897.
5. Mennander A.A. Commentary: effectiveness versus efficiency in surgery for DeBakey type I aortic dissection. J Thorac Cardiovasc Surg 2019; 158(5): 1296–1297, https://doi.org/10.1016/j.jtcvs.2019.01.077.
6. Pethig K., Schäfers H.J., Borst H.G. Functional results after aortic valve repair in aortic root ectasia. J Heart Valve Dis 1996; 5(3): 247–250.
7. Preventza O., de la Cruz K.I., Coselli J.S. Commentary: in surgery for acute type A aortic dissection, follow the principles and do what you need to do. J Thorac Cardiovasc Surg 2020; 159(3): 768–769, https://doi.org/10.1016/j.jtcvs.2019.03.031.
8. Genoni M., Paul M., Jenni R., Graves K., Seifert B., Turina M. Chronic β-blocker therapy improves outcome and reduces treatment costs in chronic type B aortic dissection. Eur J Cardiothorac Surg 2001; 19(5): 606–610, https://doi.org/10.1016/s1010-7940(01)00662-5.
9. Montagner M., Heck R., Kofler M., Buz S., Starck C., Sündermann S., Kurz S., Falk V.; Kempfert Germany Dzhk German Centre For Cardiovascular Research Partner Site Berlin Germany J. New hybrid prosthesis for acute type A aortic dissection. Surg Technol Int 2020; 36: 95–97.
10. Nallamothu B.K., Saint S., Kolias T.J., Eagle K.A. Clinical problem-solving. Of nicks and time. N Engl J Med 2001; 345(5): 359–363, https://doi.org/10.1056/nejm200108023450508.
11. Zhang L., Peng Z., Yu C., Yang X., Qiu J., Wang D. Mid-term results of hybrid arch repair for DeBakey type I aortic dissection. Chin Med J (Engl) 2021; 135(4): 493–495, https://doi.org/10.1097/cm9.0000000000001556.
12. Sirota D.A., Zhulkov M.O., Khvan D.S., Alsov S.A., Chernyavskiy A.M., Mironenko S.P., Strunin O.V., Nartsissova G.P. Abdominal ischaemia syndrome as a complication of type A acute aortic dissection. Patologiya krovoobrashcheniya i kardiokhirurgiya 2019; 23(3): 98–103, https://doi.org/10.21688/1681-3472-2019-3-98-103.
13. Lin C.Y., Tung T.H., Wu M.Y., Tseng C.N., Tsai F.C. Surgical outcomes of DeBakey type I and type II acute aortic dissection: a propensity score-matched analysis in 599 patients. J Cardiothorac Surg 2021; 16(1): 208, https://doi.org/10.1186/s13019-021-01594-9.
14. Kazui T., Washiyama N., Muhammad B.A., Terada H., Yamashita K., Takinami M., Tamiya Y. Extended total arch replacement for acute type a aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000; 119(3): 558–565, https://doi.org/10.1016/s0022-5223(00)70136-x.
15. Sun L.Z., Qi R.D., Chang Q., Zhu J.M., Liu Y.M., Yu C.T., Lv B., Zheng J., Tian L.X., Lu J.G. Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: experience with 107 patients. J Thorac Cardiovasc Surg 2009; 138(6): 1358–1362, https://doi.org/10.1016/j.jtcvs.2009.04.017.
16. Uchida N., Shibamura H., Katayama A., Shimada N., Sutoh M., Ishihara H. Operative strategy for acute type A aortic dissection: ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. Ann Thorac Surg 2009; 87(3): 773–777, https://doi.org/10.1016/j.athoracsur.2008.11.061.
17. Aftab M., Plichta R., Roselli E.E. Acute DeBakey type I dissection repair using frozen elephant trunk: the Cleveland Clinic technique. Semin Cardiothorac Vasc Anesth 2017; 21(3): 200–205, https://doi.org/10.1177/1089253216676090.
18. Uchida N. Open stent grafting for complex diseases of the thoracic aorta: clinical utility. Gen Thorac Cardiovasc Surg 2013; 61(3): 118–126, https://doi.org/10.1007/s11748-012-0151-y.
19. Sirota D.A., Khvan D.S., Lyashenko M.M., Alsov S.A., Zhulkov M.O., Chernyavskiy A.M. Use of uncoated metal stents in surgery of aortic dissection. Angiologiya i sosudistaya hirurgiya 2018; 24(4): 110–116.
20. Ho D., Imai K., King G., Stuart E.A. Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Political Anal 2007; 15(3): 199–236, https://doi.org/10.1093/pan/mpl013.
21. Ho D., Imai K., King G., Stuart E.A. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw 2011; 42(8): 1–28, https://doi.org/10.18637/jss.v042.i08.
22. Malaisrie S.C., Szeto W.Y., Halas M., Girardi L.N., Coselli J.S., Sundt T.M. III, Chen E.P., Fischbein M.P., Gleason T.G., Okita Y., Ouzounian M., Patel H.J., Roselli E.E., Shrestha M.L., Svensson L.G., Moon M.R.; AATS Clinical Practice Standards Committee: Adult Cardiac Surgery. 2021 The American Association for Thoracic Surgery expert consensus document: surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162(3): 735–758.e2, https://doi.org/10.1016/j.jtcvs.2021.04.053.
23. Khvan D.S., Zhulkov M.O., Sirota D.A., Fomichev A.V., Chernyavskiy A.M. Aortic root repair in acute aortic dissection type A. Kardiologiya i serdechno-sosudistaya khirurgiya 2021; 14(1): 66–70, https://doi.org/10.17116/kardio20211401166.
24. Kozlov B.N., Panfilov D.S., Sonduev E.L., Lukinov V.L. Predictors of early adverse events after ascending aortic replacement. Sibirskij zurnal kliniceskoj i eksperimental’noj mediciny 2022; 37(1): 108–117, https://doi.org/10.29001/2073-8552-2022-37-1-108-117.
25. Kumagai M., Minatoya K. Operation for aortic regurgitation after replacement of ascending aorta. Kyobu Geka 2021; 74(10): 781–786.
26. Shrestha M., Martens A., Kaufeld T., Beckmann E., Bertele S., Krueger H., Neuser J., Fleissner F., Ius F., Abd Alhadi F., Hanke J., Schmitto J.D., Cebotari S., Karck M., Haverich A., Chavan A. Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years. Eur J Cardiothorac Surg 2017; 52(5): 858–866, https://doi.org/10.1093/ejcts/ezx218.
27. Uchida N., Katayama A., Higashiue S., Shiono M., Hata M., Minami K., Yamanaka K., Miyamoto S., Sawa Y., Kuratani T., Kato M. A new device as an open stent graft for extended aortic repair: a multicentre early experience in Japan. Eur J Cardiothorac Surg 2016; 49(4): 1270–1278, https://doi.org/10.1093/ejcts/ezv310.
28. Léobon B., Roux D., Saccani S., Glock Y., Fournial G. Combined surgery of acute type A aortic dissections by ascending aorta replacement and bare stent. Arch Mal Coeur Vaiss 2007; 100(9): 753–759.
29. Piccardo A., Regesta T., Pansini S., Dell’Aquila A.M., Concistrè G., Martinelli L., Passerone G. Fate of the aortic valve after root reconstruction in type A aortic dissection: a 20-year follow up. J Heart Valve Dis 2009; 18(5): 507–513.
30. Komarov R.N., Belov Yu.V., Karavaykin P.A., Soborov M.A. Replacement of ascending aorta and aortic arch combined with implantation of bare stent Djumbodis® Dissection System as a treatment of type I aortic dissection. Patologiya krovoobrashcheniya i kardiokhirurgiya 2016; 20(4): 66–75, https://doi.org/10.21688/1681-3472-2016-4-66-75.
31. Tsagakis K., Jakob H. Which frozen elephant trunk offers the optimal solution? Seminars in Thoracic and Cardiovascular Surgery 2019; 31(4): 679–685, https://doi.org/10.1053/j.semtcvs.2019.05.038.
32. Czerny M., Schmidli J., Bertoglio L., Carrel T., Chiesa R., Clough R.E., Grabenwöger M., Kari F.A., Mestres C.A., Rylski B., Schönhoff F., Tsagakis K., Wyss T.R. Clinical cases referring to diagnosis and management of patients with thoracic aortic pathologies involving the aortic arch: a companion document of the 2018 European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) expert consensus document addressing current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch. Eur J Vasc Endovasc Surg 2019; 57(3): 452–460, https://doi.org/10.1016/j.ejvs.2018.12.011.

Sirota D.A., Zhulkov M.O., Khvan D.S., Caus T., Kozlov B.N., Protopopov A.V., Makayev A.G., Fomichev A.V., Agayeva Kh.A., Sabetov A.K., Lukinov V.L., Edemsky A.G., Chernyavsky A.M. Hybrid Technologies for Reconstruction of Proximal Aortic Dissection. Sovremennye tehnologii v medicine 2023; 15(3): 42, https://doi.org/10.17691/stm2023.15.3.05