OPTIONS IN AORTIC ARCH RECONSTRUCTION:

CONVENTIONAL vs. FROZEN ELEPHANT TRUNKRicardo R Dias

ricardo.dias@incor.usp.br

□ No disclosure

STS/EACTS Latin America Cardiovascular Surgery Conference 20172

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 20173

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

SURGERY should be considered

□ maximal diameter ≥ 55mm

□ symptons

□ signs of local compression

DECISION-MAKING about the procedure

(weigh perioperative risk)

□ partial or total arch replacement

□ hibrid approach - FET

□ arch vessel transposition and TEVAR

Specific strategies lowered the inherent risk of aortic arch surgery - ANEURYSM / DISSECTION

□ continuous antegrade cerebral perfusion

□ assessment of transcranial oxigen saturation

□ innovative arch prostheses

□ moderate (25º-28ºC) rather than deep hypothermia

□ the possibility of extensive repair of the aorta (ascending / arch / descending)

FET PROCEDURE

STS/EACTS Latin America Cardiovascular Surgery Conference 20174

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 20175

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

“...complex thoracic aortic pathology requires simplified solutions, or at least, as simple as possible...”

STS/EACTS Latin America Cardiovascular Surgery Conference 20176

STRATEGY - AORTIC ARCH OPERATION

Proximal Arch - Ascending disease

Distal Arch - Descending disease

TOTAL ARCH - ARCH DISEASE

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

□ location and / or extension of the disease

□ diagnosis: aneurysm or dissection

□ type of prosthesis available for use in your country

STS/EACTS Latin America Cardiovascular Surgery Conference 20177

RECONSTRUCTION OF THE ARCH

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 20178

55 patients

Hospital Mortality - 2%

CVA - 5%

Hemodialysis - 5%

8169 patients

7038 - antegrade cer perfusion

Hospital Mortality - 6% vs 7,1%

CVA - 6,7% vs 8,6%

Hemodialysis - 3,9% vs 3,8%

150 patients

Hospital Mortality - 4,6%

CVA - 4%

Hemodialysis - 4,6%

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 20179

803 patients

Hospital Mortality - 6,5%

CVA - 2%

Paraplegia - 2,4%

Hemodialysis - 3,4%

106 patients

Hospital Mortality - 6,6%

CVA - 0,9%

Paraplegia - 0,9%

Hemodialysis - 3,8%

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 2017 10

100 patients

Hospital Mortality - 7%

CVA - 9%

Paraplegia - 7%

Hemodialysis - 8%

509 patients

Hospital Mortality - 15,9%

CVA - 7,7%

Paraplegia - 7,5%

Hemodialysis - 4,1%

383 patients

Hospital Mortality - 16,5%

CVA - 2,2%

Paraplegia - 3,6%

Hemodialysis - 19,1%

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 201711

ACUTE TYPE A AORTIC DISSECTION - NEW PARADIGM ???

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 201712

ACUTE TYPE A AORTIC DISSECTION - NEW PARADIGM ???

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 201713

Aortic Disease 30ª death ranking State of Sao Paulo, 18.042 deaths (98-06)

□ TAD 9.465 deaths (Jan 1998 to Dez 2007)

- confirmed diagnosis after death - 8.167 patients (86,3%)

- 6.721 acute dissection (ICD I71.0) 71%

- 2.744 thoracic aortic aneurysm (ICD I71.1; I71.2; I71.5; I71.6) 29%

□ TAD 6.109 hospitalizations SUS

□ TAD 3.572 aortic surgeries (58,5% total patients)

HOSPITAL MORTALITY 1.298 pacientes (21,2%)

causes AMI Pneumonia CVA Gunshot DM Heart Failure Cardiomyopathy Car Acident Breast CA Prostate CA

AORTICDISEASE

Ranking 1º 2º 3º 5º 6º 8º 12º 14º 18º 23º 30º

nº de óbitos 177.484 111.427 80.952 76.691 75.428 64.479 40.251 35.962 28.496 26.941 18.042

Dias RR. Arq Bras Cardiol 2013;101(6):528-35

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 201714

São Paulo - over 20 million people city !

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

STS/EACTS Latin America Cardiovascular Surgery Conference 201715

Heart Institute - 1977 - 503 bedsOver 2.000 open cardiovascular surgeries / year

Clinical Hospital - 1944Over 2.000 bedsOver 15.000 employees

Sao Paulo Medical School - 1912

Total de operações = 1387

965

7567 28 42 15

195

Ascendente

Descendente

Complexo

TAAAArco

AAA

Outras69,6%

14%

1,1%2%

4,8%

5,4%

3%

STS/EACTS Latin America Cardiovascular Surgery Conference 201716

0

10

20

30

40

50

60

70

80

90

110

2002 2003 2004 2005 2006 2007 2008 2009

0102030405060708090

100110120130140150160170180190200

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

+24,6%

13,5%21%

17,5%12,7% 10%

19%12%

15% 15%9%

7,8%12,5%

-25,7%

+25,5%

+27,5%

+26,2%

-14,7%

+19,3%

+4,2%

-4,5%

+2,8%

+50,5%

-15,2%

9,6% 10,4%

-7,4%

Total de operações = 1387

AscendingDescendingFET or ET

ARCH

Others

TAAA

AAA

ANNUAL AORTIC PROCEDURES MORTALITY

PROCEDURES

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

TOTAL = 61 PATIENTS HOSPITAL MORTALITY = 10 PATIENTS (16,4%)

7% ( 4 pat) - Acute type A dissection

□ cause for first operation 69% (42 pat) - Chronic type A/B disssection

24% (15 pat) - Aneurysm

30% reoperations

36% associated procedures [7% RM + 17% TVAo + 13% composite mechanical graft (Bentall/Cabrol)]

□ Second-stage intervention

STS/EACTS Latin America Cardiovascular Surgery Conference 201717

FROZEN ELEPHANT TRUNK PROCEDURES 2009 - 2017

Endovascular TEVAR - 5 patients

Open thoracoabdominal repair - 4 patients (1 death)

OPTIONS IN AORTIC ARCH RECONSTRUCTION: CONVENTIONAL vs. FROZEN ELEPHANT TRUNK

Thank you !ricardo.dias@incor.usp.br