Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients Malakh Shrestha,

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TOTAL AORTIC ARCH REPLACEMENT WITH THORAFLEX HYBRID FROZEN ELEPHANT TRUNK PROSTHESIS: RESULTS OF FIRST 100 PATIENTS Malakh Shrestha, Heike Krueger, Tim.

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Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: Single-center results of the first 100 patients Malakh Shrestha, MBBS, Tim Kaufeld, MD, Erik Beckmann, MD, Felix Fleissner, MD, Julia Umminger, MD, Firas Abd Alhadi, MD, Dietmar Boethig, MD, Heike Krueger, RN, Axel Haverich, MD, Andreas Martens, MD The Journal of Thoracic and Cardiovascular Surgery Volume 152, Issue 1, Pages 148-159.e1 (July 2016) DOI: 10.1016/j.jtcvs.2016.02.077 Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Thoraflex Hybrid graft (Vascutek, Inchinnan, Scotland). A, Deployed graft, containing 3 side branches for supra-aortic vessels, 1 sidearm for cardiopulmonary bypass, a sewing collar, and a self-expanding stented portion with nitinol ring stents. B, Illustration showing the graft during implantation. After distal aortic repair, reperfusion of the lower body is commenced. Supra-aortic vessels are reimplanted during reperfusion. C, Three-dimensional computed tomography angiography after implantation of a Thoraflex Hybrid graft in a patient with acute aortic dissection. The segments for computed tomography angiography assessment are shown: Segment A, stented part of the aorta; Segment B, downstream segment up to the Celiac trunk; and Segment C, below the celiac trunk. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Kaplan-Meier curves for survival and freedom of aortic reoperation. A, Survival, total patient cohort. B, Survival, acute aortic dissection (AAD) versus chronic aortic dissection (CAD) versus aneurysm (An) group. C, Freedom from aortic reoperation, total group. D, Freedom from aortic reoperation, AAD versus CAD versus aneurysm group. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Changes of aortic diameters after frozen elephant trunk treatment with Thoraflex Hybrid graft (Vascutek, Inchinnan, Scotland). Aortic diameters according to measurements of the largest part of each segment in computed tomography angiography (CTA) during follow-up. Time points were defined as preoperative (pre), postoperative; that is, discharge CTA (post) or according to time after surgery (years). Segments A, B, and C of the descending aorta are classified as depicted in Figure 1 and shown in columns. Top row shows total aortic diameters. Middle row shows TL diameters. Bottom row shows FL diameters. Diameter changes over time were assessed by linear mixed models analysis. AAD, Acute aortic dissection; CAD, chronic aortic dissection; An, aneurysm; TL, true lumen; FL, false lumen. *P < .05, AAD versus CAD. #P < .05 versus An. +Significant increase during follow-up, (P < .05). −Significant decrease during follow-up (P < .05). The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Aortic remodeling after frozen elephant trunk treatment with Thoraflex Hybrid graft (Vascutek, Inchinnan, Scotland). Based on individual patient's changes of total aortic diameter, true lumen diameter, and false lumen diameter, aortic remodeling is assessed and defined for each disease and aortic segment as positive (pos), negative (neg), or stable. Segments A, B, and C of the descending aorta are classified as depicted in Figure 1 and shown in columns. Top row shows aortic remodeling in acute aortic dissection (AAD) cases, middle row shows chronic aortic dissection (CAD) cases, bottom row aneurysm cases. P value calculations give results from χ2 test within each segment/disease data set. Due to small numbers, computed tomography angiography from 2- to 5-year follow-up had to be summarized. Columns show absolute numbers of computed tomography angiography scans per patients assessed. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Kaplan-Meier curves of false lumen thrombosis rate in acute aortic dissection (AAD) and chronic aortic dissection (CAD) patients and endoleak rate in aneurysm patients after treatment with Thoraflex Hybrid graft (Vascutek, Inchinnan, Scotland). Segments A (Seg A), B (Seg B), and (Seg C) of the descending aorta are classified as depicted in Figure 1. False lumen thrombosis is defined as thrombosis of >80% or complete obliteration of the false lumen. A, False lumen thrombosis rate of stented Seg A. Kaplan-Meier curves end at 19 months, because every patient at risk reached the end point (false lumen thrombosis). B, False lumen thrombosis rate of downstream Seg B. C, False lumen thrombosis rate of downstream Seg C. D, Columns show relative incidence of type IB endoleaks after frozen elephant trunk treatment of aneurysm patients with the Thoraflex Hybrid graft. P value calculation gives result of χ2 test. Columns show absolute numbers of computed tomography angiography scans per patients assessed. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Synopsis showing study cohort and follow-up. FET, Frozen elephant trunk; ET, elephant trunk; CTA, computed tomography angiography; FU, follow-up. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Thoraflex Hybrid graft (Vascutek, Inchinnan, United Kingdom). The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159 The Journal of Thoracic and Cardiovascular Surgery 2016 152, 148-159.e1DOI: (10.1016/j.jtcvs.2016.02.077) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions