Incidence of spinal cord injury in patients with acute type A aortic dissection after expanding the landing zone of frozen elephant trunk: A retrospective study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Guangtian ^1,2 , YAN Xinjian ² , LIANG Qiuer ³ , WANG Chaojie ⁴ , PENG Jihai ⁵ , HE Jie ⁶ ,  FAN Xiaoping ^1,4,7 ,  ZHOU Chengbin ^1,2

1. School of Medicine, South China University of Technology, Guangzhou, 510006, P. R. China;
2. Department of Cardiovascular Surgery, Guangdong Provincial People’s Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P. R. China;
3. School of Traditional Chinese Medicine, Jinan University, Guangzhou, 510632, P. R. China;
4. Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, P. R. China;
5. Department of Rehabilitation, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080,P. R. China;
6. Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, P. R. China;
7. The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510405, P. R. China;

Corresponding author：

FAN Xiaoping, Email: fukui-hanson@hotmail.com; ZHOU Chengbin, Email: zcbwwww@163.com

Keywords：

Aortic dissection; frozen elephant trunk; spinal cord injury; landing zone of stent

DOI：

10.7507/1007-4848.202106104

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Objective To assess whether expanding the landing zone of frozen elephant trunk (FET) increases the risk of spinal cord injury in patients with acute type A aortic dissection. Methods Patients with acute type A aortic dissection who were treated in Guangdong Provincial People’s Hospital from 2017 to 2020 were collected. They were divided into two groups according to the landing zone of FET by the image diagnosis of postoperative chest X-ray or total aorta CT angiography, including a Th9 group which defined as below the eighth thoracic vertebral level, and a Th8 group which was defined as above or equal to the eighth thoracic vertebral level. Using the propensity score matching (PSM) method, the preoperative and intraoperative data of two groups were matched with a 1∶2 ratio. The prognosis of the two groups after PSM was analyzed. Results Before PSM, 573 patients were collected, including 58 patients in the Th9 group and 515 patients in the Th8 group. After PSM, 174 patients were collected, including 58 patients in the Th9 group (46 males and 12 females, with an average age of 47.91±9.92 years), and 116 patients in the Th8 group (93 males and 23 females, with an average age of 48.01±9.53 years). There were 8 patients of postoperative spinal cord injury in the two groups after PSM, including 5 (4.31%) patients in the Th8 group and 3 (5.17%) patients in the Th9 group (P=0.738). In the Th8 group, 2 patients had postoperative transient paresis and recovered spontaneously after symptomatic treatment, and 1 patient had postoperative paraplegia with cerebrospinal fluid drainage. After 3 days, the muscle strength of both lower limbs gradually recovered after treatment. There was no statistical difference in complications between the two groups (P＞0.05). Conclusion Expanding the landing zone of FET does not increase the risk of spinal cord injury in patients with acute type A aortic dissection. However, the sample size is limited, and in the future, multicenter large-scale sample size studies are still needed for verification

Citation： CHEN Guangtian, YAN Xinjian, LIANG Qiuer, WANG Chaojie, PENG Jihai, HE Jie, FAN Xiaoping, ZHOU Chengbin. Incidence of spinal cord injury in patients with acute type A aortic dissection after expanding the landing zone of frozen elephant trunk: A retrospective study in a single center. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(11): 1591-1597. doi: 10.7507/1007-4848.202106104 Copy

1.	Gudbjartsson T, Ahlsson A, Geirsson A, et al. Acute type A aortic dissection—A review. Scand Cardiovasc J, 2020, 54(1): 1-13.
2.	Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA, 2000, 283(7): 897-903.
3.	Howard DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation, 2013, 127(20): 2031-2037.
4.	Reutersberg B, Salvermoser M, Trenner M, et al. Hospital incidence and in-hospital mortality of surgically and interventionally treated aortic dissections: Secondary data analysis of the nationwide German diagnosis-related group statistics from 2006 to 2014. J Am Heart Assoc, 2019, 8(8): e011402.
5.	Ogino H. Acute type A aortic dissection: The role of frozen elephant trunk. Ann Cardiothorac Surg, 2020, 9(3): 233-235.
6.	Furutachi A, Takamatsu M, Nogami E, et al. Early and mid-term outcomes of total arch replacement with the frozen elephant trunk technique for type A acute aortic dissection. Interact Cardiovasc Thorac Surg, 2019, 29(5): 753-760.
7.	王超杰, 张文倩, 彭继海, 等. 长象鼻支架与急性A型主动脉夹层术后脊髓损伤风险的单中心回顾性队列研究. 中国胸心血管外科临床杂志, 2022, 29(11): 1450-1454.
8.	Yamane Y, Uchida N, Mochizuki S, et al. Early- and mid-term aortic remodelling after the frozen elephant trunk technique for retrograde type A acute aortic dissection using the new Japanese J Graft open stent graft. Interact Cardiovasc Thorac Surg, 2017, 25(5): 720-726.
9.	Kazui T, Washiyama N, Muhammad BA, et al. Extended total arch replacement for acute type A aortic dissection: Experience with seventy patients. J Thorac Cardiovasc Surg, 2000, 119(3): 558-565.
10.	Katayama A, Uchida N, Katayama K, et al. The frozen elephant trunk technique for acute type A aortic dissection: Results from 15 years of experience. Eur J Cardiothorac Surg, 2015, 47(2): 355-360.
11.	Watanuki H, Ogino H, Minatoya K, et al. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg, 2007, 84(5): 1585-1591.
12.	Dohle DS, Jakob H, Schucht R, et al. The impact of entries and exits on false lumen thrombosis and aortic remodelling. Eur J Cardiothorac Surg, 2017, 52(3): 508-515.
13.	Leshnower BG, Duwayri YM, Chen EP, et al. Aortic remodeling after endovascular repair of complicated acute type B aortic dissection. Ann Thorac Surg, 2017, 103(6): 1878-1885.
14.	Tokuda Y, Fujimoto K, Narita Y, et al. Spinal cord injury following aortic arch replacement. Surg Today, 2020, 50(2): 106-113.
15.	Chakos A, Jbara D, Yan TD, et al. Long-term survival and related outcomes for hybrid versus traditional arch repair—A meta-analysis. Ann Cardiothorac Surg, 2018, 7(3): 319-327.
16.	Leontyev S, Tsagakis K, Pacini D, et al. Impact of clinical factors and surgical techniques on early outcome of patients treated with frozen elephant trunk technique by using EVITA open stent-graft: Results of a multicentre study. Eur J Cardiothorac Surg, 2016, 49(2): 660-666.
17.	Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg, 2006, 131(2): 336-342.
18.	Pacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: A multicenter experience. Ann Thorac Surg, 2011, 92(5): 1663-1670.
19.	Hori D, Kusadokoro S, Adachi K, et al. Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(4): 328-334.
20.	Hohri Y, Yamasaki T, Matsuzaki Y, et al. Early and mid-term outcome of frozen elephant trunk using spinal cord protective perfusion strategy for acute type A aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(10): 1119-1127.
21.	Griepp EB, Di Luozzo G, Schray D, et al. The anatomy of the spinal cord collateral circulation. Ann Cardiothorac Surg, 2012, 1(3): 350-357.
22.	Etz CD, Kari FA, Mueller CS, et al. The collateral network concept: A reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg, 2011, 141(4): 1020-1028.
23.	David N, Roux N, Douvrin F, et al. Aortic aneurysm surgery: Long-term patency of the reimplanted intercostal arteries. Ann Vasc Surg, 2012, 26(6): 839-844.
24.	Hoffman A, Damberg ALM, Schälte G, et al. Thoracic stent graft sizing for frozen elephant trunk repair in acute type A dissection. J Thorac Cardiovasc Surg, 2013, 145(4): 964-969.
25.	Kozlov BN, Panfilov DS, Saushkin VV, et al. Distal aortic remodelling after the standard and the elongated frozen elephant trunk procedure. Interact Cardiovasc Thorac Surg, 2019, 29(1): 117-123.

1. Gudbjartsson T, Ahlsson A, Geirsson A, et al. Acute type A aortic dissection—A review. Scand Cardiovasc J, 2020, 54(1): 1-13.
2. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA, 2000, 283(7): 897-903.
3. Howard DP, Banerjee A, Fairhead JF, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation, 2013, 127(20): 2031-2037.
4. Reutersberg B, Salvermoser M, Trenner M, et al. Hospital incidence and in-hospital mortality of surgically and interventionally treated aortic dissections: Secondary data analysis of the nationwide German diagnosis-related group statistics from 2006 to 2014. J Am Heart Assoc, 2019, 8(8): e011402.
5. Ogino H. Acute type A aortic dissection: The role of frozen elephant trunk. Ann Cardiothorac Surg, 2020, 9(3): 233-235.
6. Furutachi A, Takamatsu M, Nogami E, et al. Early and mid-term outcomes of total arch replacement with the frozen elephant trunk technique for type A acute aortic dissection. Interact Cardiovasc Thorac Surg, 2019, 29(5): 753-760.
7. 王超杰, 张文倩, 彭继海, 等. 长象鼻支架与急性A型主动脉夹层术后脊髓损伤风险的单中心回顾性队列研究. 中国胸心血管外科临床杂志, 2022, 29(11): 1450-1454.
8. Yamane Y, Uchida N, Mochizuki S, et al. Early- and mid-term aortic remodelling after the frozen elephant trunk technique for retrograde type A acute aortic dissection using the new Japanese J Graft open stent graft. Interact Cardiovasc Thorac Surg, 2017, 25(5): 720-726.
9. Kazui T, Washiyama N, Muhammad BA, et al. Extended total arch replacement for acute type A aortic dissection: Experience with seventy patients. J Thorac Cardiovasc Surg, 2000, 119(3): 558-565.
10. Katayama A, Uchida N, Katayama K, et al. The frozen elephant trunk technique for acute type A aortic dissection: Results from 15 years of experience. Eur J Cardiothorac Surg, 2015, 47(2): 355-360.
11. Watanuki H, Ogino H, Minatoya K, et al. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg, 2007, 84(5): 1585-1591.
12. Dohle DS, Jakob H, Schucht R, et al. The impact of entries and exits on false lumen thrombosis and aortic remodelling. Eur J Cardiothorac Surg, 2017, 52(3): 508-515.
13. Leshnower BG, Duwayri YM, Chen EP, et al. Aortic remodeling after endovascular repair of complicated acute type B aortic dissection. Ann Thorac Surg, 2017, 103(6): 1878-1885.
14. Tokuda Y, Fujimoto K, Narita Y, et al. Spinal cord injury following aortic arch replacement. Surg Today, 2020, 50(2): 106-113.
15. Chakos A, Jbara D, Yan TD, et al. Long-term survival and related outcomes for hybrid versus traditional arch repair—A meta-analysis. Ann Cardiothorac Surg, 2018, 7(3): 319-327.
16. Leontyev S, Tsagakis K, Pacini D, et al. Impact of clinical factors and surgical techniques on early outcome of patients treated with frozen elephant trunk technique by using EVITA open stent-graft: Results of a multicentre study. Eur J Cardiothorac Surg, 2016, 49(2): 660-666.
17. Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg, 2006, 131(2): 336-342.
18. Pacini D, Tsagakis K, Jakob H, et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: A multicenter experience. Ann Thorac Surg, 2011, 92(5): 1663-1670.
19. Hori D, Kusadokoro S, Adachi K, et al. Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(4): 328-334.
20. Hohri Y, Yamasaki T, Matsuzaki Y, et al. Early and mid-term outcome of frozen elephant trunk using spinal cord protective perfusion strategy for acute type A aortic dissection. Gen Thorac Cardiovasc Surg, 2020, 68(10): 1119-1127.
21. Griepp EB, Di Luozzo G, Schray D, et al. The anatomy of the spinal cord collateral circulation. Ann Cardiothorac Surg, 2012, 1(3): 350-357.
22. Etz CD, Kari FA, Mueller CS, et al. The collateral network concept: A reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg, 2011, 141(4): 1020-1028.
23. David N, Roux N, Douvrin F, et al. Aortic aneurysm surgery: Long-term patency of the reimplanted intercostal arteries. Ann Vasc Surg, 2012, 26(6): 839-844.
24. Hoffman A, Damberg ALM, Schälte G, et al. Thoracic stent graft sizing for frozen elephant trunk repair in acute type A dissection. J Thorac Cardiovasc Surg, 2013, 145(4): 964-969.
25. Kozlov BN, Panfilov DS, Saushkin VV, et al. Distal aortic remodelling after the standard and the elongated frozen elephant trunk procedure. Interact Cardiovasc Thorac Surg, 2019, 29(1): 117-123.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Incidence of spinal cord injury in patients with acute type A aortic dissection after expanding the landing zone of frozen elephant trunk: A retrospective study in a single center

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