Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes
Keywords:Aortic arch, minimally invasive, frozen elephant trunk
Background: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes.
Methods: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C).
Results: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%.
Conclusion: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.
Byrne JG, Karavas AN, Cohn LH, Adams DH. 2000. Minimal access aortic root, valve and complex ascending aortic surgery. Current Cardiology Reports 2:549-557.
Cappabianca G, Roscitano C, Bichi S, et al. 2017. Whole body perfusion in patients undergoing frozen elephant trunk for type A acute aortic dissection. Perfusion 32:164-167.
Cohn L, Adams D, Couper G, et al. 1997. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 226:421-8.
Deschka H, Erler S, Machner M, et al. 2013. Surgery of the ascending aorta, root remodeling and aortic arch surgery with circulatory arrest through partial upper sternotomy: results of 50 consecutive cases. Eur J Cardiothoracic Surg 43:580-4.
El-Sayed Ahmad A, Risteski P, Papadopoulos N, et al. 2016. Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique. Eur J Cardiothorac Surg 50(1):140-4.
Goebel N, Bonte D, Salehi-Gilani S, et al. 2017. Minimally invasive access aortic arch surgery. Innovations (Phila). 12(5):351-355.
Gorlitzer M, Weiss G, Thalmann M, et al. 2007. Combined surgical and endovascular repair of complex aortic pathologies with a new hybrid prosthesis. 84:1971-6.
Lamelas J, Chen P, Loor G, LaPietra A. 2018. Successful use of sternal-sparing minimally invasive surgery of proximal ascending aortic pathology. Ann Thorac Surg 106:742-9.
Leshnower BG, Myung RJ, Kilgo PD, et al. 2010. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg 90:547-554.
Liu J, Sidtropoulos A, Konertz W. 1999. Minimally invasive aortic valve replacement (AVR) compared to standard AVR. Eur J Cardiothoracic Surg 16(suppl 2):S80-3.
Mächler H, Bergmann P, Anelli-Monti M, et al. 1999. Minimally invasive versus conventional aortic valve operations: a prospective study in 120 patients. Ann Thorac Surg 67:1001-5.
Risteski P, El-Sayed Ahmad A, Monsefi N, et al. 2017. Minimally invasive aortic arch surgery; early and late outcomes. Int J Surg 45:113-7.
Risteski P, Radwan M, Mitrev Z, Walther T. 2019. Minimal access transposition of arteria lusoria through an upper mini-sternotomy. Clin Surg 4:2681-2.
Svensson LG. 2002. Progress in ascending and aortic arch surgery: minimally invasive surgery, blood conservation, and neurologic deficit prevention. Ann Thorac Surg 74:S1786-8.
Svensson LG, Nadolny EM, Kimmel WA. 2001. Minimal access aortic surgery including re-operations. Eur J Cardiothorac Surg 19:30-33.
Shrestha M, Krueger H, Umminger J, et al. 2015. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg 4:148-153.
Tabata M, Khalpey Z, Aranki SF, et al. 2007. Minimally access surgery of ascending and proximal arch of the aorta: a 9-Year experience. Ann Thorac Surg 84:67-72.
Walther T, Falk V, Metz S, et al. 1999. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 67:1643-7.
Zierer A, Aybek T, Risteski P, et al. 2005. Moderate hypothermia (30°C) for surgery of acute type A aortic dissections. Thorac Cardiovasc Surg 53:74-9.
Zierer A, El-Sayed Ahmad A, Papadopoulos N, et al. 2012. Selective antegrade cerebral perfusion and mild (28-30°C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients. J Thorac Cardiovasc Surg 144:1042-1049.
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