Scientific Papers

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk | Journal of Cardiothoracic Surgery


Patient characteristics are summarised in Table 1. The patients in this study were predominantly male (81.6%), aged 73.5 ± 8.3 years, with various comorbidities, including diabetes mellitus (28.6%) and hyperlipidaemia (53.1%), and with a history of cerebrovascular events (22.4%) and haemodialysis (8.2%). Aortic pathologies included distal arch degenerative aneurysms (30.6%, 15/49), degenerative aortic arch (36.7%, 18/49), chronic aortic dissection DeBakey 3b or 3bR (24.5%, 12/49), and type 1 (8.1%, 4/49). The average EuroSCORE II was 4.7 ± 2.5. The median EuroSCORE II was 4.4 [2.8–6.3]. The patency rate of the Left CCA-SCA bypass was 100%, and the rate of stenosis was approximately 15%, with a discrepancy between the right and left upper extremity blood pressure (right > left about 15–20 mmHg). During the follow-up, we did not observe any bypass failure. We observed one case of brachial plexus palsy after debranching. Left arm weakness was noted postoperatively for a month but was cured completely after rehabilitation.

Table 1 Baseline characteristics

Intraoperative data (Table 2) showed a median operation and cardiopulmonary bypass time of 272 [IQR, 250–328] and 203 [IQR, 182–242] min, respectively. Ascending aortic cannulation was performed in 79.2% of patients. However, 10.4% of the patients underwent right SCA cannulation, and 6.3% underwent femoral cannulation. The median length of the open stent graft was 60 mm [IQR, 60–90 mm]. The average lumen diameter was 27 mm. Furthermore, 18.2% of patients required concomitant procedures (coronary artery bypass graft, 4; aortic valve replacement, 3; pulmonary vein isolation, 1). The median duration from the first bypass to TAR was 9 [IQR, 7–28] days. The median lengths of intubation and intensive care unit (ICU) stay were 2.5 [IQR, 1.8–5.0] and 6 [IQR, 4.0–13.5] days, respectively.

Table 2 Operative characteristics and postoperative outcomes

Regarding postoperative outcomes (Table 2), there were two reported operative mortality. The cause of death for the first patient was a rupture of the arch aneurysm measuring > 6 cm after the left CCA–SCA bypass while waiting for second-stage TAR. Another patient developed aspiration pneumonia after TAR and underwent a tracheostomy. However, the patient died of multiple organ failure. The operative mortality rate was 4.1% (2/49). Five patients (10.2%, 5/49) developed stroke. All of them were developed after TAR. The average intubation length was 6.4 days, and the length of ICU stay was 16.2 days for those five patients. All patients were discharged from the hospital. Based on the Rankin scale, one patient had a score of 4+, two had a score of 3+, and two had a score of 2+. The most frequently observed radiological finding was a stroke in the right middle cerebral artery area. The relatively high stroke rate in our cohort led to the investigation of the factors associated with stroke. Logistic regression analysis identified atheroma of the ascending aorta as a risk factor for stroke. We did not observe any case of recurrent nerve injury; although some cases developed swallowing difficulty necessitating speech therapy, it was temporary, and the recurrent nerve was intact. No episodes of paraplegia were observed.

During follow-up, 15 patients (30.6%, 15/49) patients required further TEVAR to treat residual descending aortic aneurysms. No episodes of paraplegia occurred after additional TEVAR. Two (4.1%, 2/49) patients developed distal stent graft-induced new entry (dSINE) due to an open stent graft, requiring intimal tear closure by subsequent TEVAR. An open stent graft has a spring-back force that causes a tear around the distal edge of the open stent, known as dSINE. The mean duration from TAR to additional planned TEVAR was 32.7 days. However, for two patients undergoing TEVAR for dSINE, the duration was 6 months to 2 years, as TEVAR was an unplanned procedure for these two patients. The average level of the thoracic vertebrae at the distal edge of the endoprosthesis (TEVAR) was 8.2. During follow-up, the excluded aneurysm was remodelled or thrombosed, and chronic dissection cases showed a complete thrombosed false lumen in the extent of the aortic area covered by the stent graft down to the descending aorta, but the abdominal aorta was partially thrombosed in most cases. The degenerative aneurysm exhibited a stable sac size or a slight decrease in size.

Regarding follow-up outcomes, the estimated 5-year overall survival was 76.8% (Fig. 2A). Causes of death were pneumonia (n = 2), renal failure (n = 1), arrhythmia (n = 1), sepsis (n = 2), thoracic aneurysm rupture (n = 1), pseudoaneurysm rupture 1, lung = 1). The estimated 5-year aortic-related mortality rate was 2% (Fig. 2B). Accordingly, the estimated 5-year aortic event-free survival rate is 98%. The average observation period for overall survival and aortic-related mortality was 38.4 ± 22.5 months. The estimated 5-year overall cumulative aortic reintervention rate was 31.3% (Fig. 3A). The estimated cumulative rate of non-intended reintervention was 4.5% at 5 years (Fig. 3B). The average observation period for the overall reintervention rate was 23.8 ± 22.0 months.

Fig. 2
figure 2

Estimated overall survival (%) (A). Estimated cumulative aortic-related mortality (%) (B)

Fig. 3
figure 3

Estimated overall cumulative incidence of reintervention (%) (A). Unplanned reintervention (%) (B)



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