Comparison of the Proximalized Distal Aortic Arch Anastomosis Site

Summary

Here, we present a protocol for two approaches to total arch replacement with a proximal anastomosis in zones 0/1 or zone 2 for aortic arch replacement, along with differences in outcomes reported in the literature.

Abstract

Total arch repair (TAR) has traditionally been performed with a zone 3 distal anastomosis. In recent years, proximalization of the distal anastomosis has been utilized with proposed benefits including an easier distal anastomosis, reduced risk of bleeding, and lower rates of recurrent laryngeal nerve injury. While there have been several comparisons between more proximal distal anastomoses and the traditional zone 3 anastomosis, there have been limited comparisons between proximal anastomoses in zones 0-2.

TAR with a frozen elephant trunk (FET) in zone 0 or 1 generally requires debranching of the head vessels proximally or a combination of head vessel bypasses with deployment of the FET across the aortic arch. Select hybrid arch FET devices are available in trifurcated configurations specifically made for a zone 0 distal anastomosis. A zone 2 arch can often be performed with a branched or straight graft and with head vessel anastomoses in the aortic arch.

In four studies published to date comparing outcomes following proximal (zone 0/1) or more distal (zone 2) anastomoses, the majority of outcomes, including mortality, stroke, and aortic remodeling, were not significantly different. Rates of major bleeding were more common with a zone 2 distal anastomosis.

Proximalization of the distal anastomosis at the time of TAR carries several benefits. Rates of bleeding were lower with a more proximal anastomosis, suggesting improved safety with a zone 0 or 1 anastomosis, without added risk in other metrics.

Introduction

Acute type A aortic dissection (ATAAD) necessitates emergent surgical intervention to reduce the risk of morbidity and mortality¹. The hemiarch repair has long been the minimum intervention for ATAAD, resecting the primary entry tear and stabilizing the aortic arch. Extended arch or total arch repairs (TAR) have been utilized for specific indications such as arch tears, aneurysmal arches, or in patients with known connective tissue disease. Aortic arch interventions may be required in other settings as well, including aortic arch aneurysms, chronic dissections, and penetrating aortic ulcers. While more extensive interventions, extended arch rep....

Protocol

The protocol should be approved and performed following the institutional review board guidelines. Written consent must also be obtained from the patients prior to the surgical procedure. For this study, an ethical statement is not applicable to this article. No patient data has been utilized, and all references to the literature have been cited.

1. Zone 0 and 1 arch

NOTE: Proximalization of the TAR with FET requires anastomosis of the ascending aortic graft in either zone 0 or zone 1 (Figure 1, Figure 2A).

1. Cardiopulmonary by....

Results

This section reports outcomes from select studies in the literature comparing outcomes of TAR using a more proximal (zone 0/1) distal anastomosis or more distal (zone 2) anastomosis, often based on the Ishimura Zones. Studies were included if they were retrospective, prospective, or randomized controlled trial studies comparing outcomes of TAR. Case reports, previous reviews, or studies reporting outcomes on a single surgical approach were excluded. Characteristics of the included studies.......

Discussion

Extended arch repairs have become more frequently utilized for ATAAD, and the FET has allowed flexibility in the location of the distal anastomosis. The TAR FET procedure has expanded the versatility of the TAR procedure, allowing for proximalization of the distal anastomosis while still treating the entire aortic arch. Proximalization of the distal anastomosis to zones 0-2 are proposed to have several advantages, including an easier distal anastomosis, a more accessible anastomosis to address bleeding, and reduced risk .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3-0 Prolene sutures	Ethicon, New Jersey, USA	https://www.jnjmedtech.com/en-US/product/prolene-polypropylene-suture	This is just one example
4-0 Prolene sutures	Ethicon, New Jersey, USA	https://www.jnjmedtech.com/en-US/product/prolene-polypropylene-suture	This is just one example
Aortic cannula	Medtronic	https://www.medtronic.com/me-en/healthcare-professionals/products/cardiovascular/cannulae.html	This is just one example
E-vita Open Neo	Artivion, Georgia, United States	https://artivion.com/product/e-vita-open-neo/	Frozen elephant trunk device
Frozenix J Graft	Japan Lifeline, Tokyo, Japan.	https://www.j-graft.com/frozenix/	Frozen elephant trunk device
Silk tie	Ethicon, New Jersey, USA)	https://www.jnjmedtech.com/en-US/product/perma-hand-silk-suture	This is just one example
Thoraflex	Terumo Corporation, Tokyo, Japan.	https://terumoaortic.com/products/thoraflex-hybrid/	Frozen elephant trunk device
Venous Cannula	Medtronic	https://www.medtronic.com/me-en/healthcare-professionals/products/cardiovascular/cannulae.html	This is just one example