Treatment of acute type A aortic dissection with intraluminal sutureless prosthesis

One-stage aortic replacement for type A aortic dissection: using a Vasoring and a conventional elephant trunk graft

OBJECTIVES

We used a vascular ring connector (Vasoring) and a conventional elephant trunk graft for complete repair in open surgery for type A aortic dissection. This report described the immediate and mid-term results of this new technique.

METHODS

We used a rigid titanic ring as a stent in the vascular graft for rapid sutureless anastomosis in the reconstruction of type A aortic dissection.

RESULTS

A total of 65 consecutive patients with Stanford type A aortic dissection underwent open surgery performed by a single surgeon from November 2007 to February 2017. All patients underwent aortic reconstruction with vascular grafts and Vasorings (21 patients in the ascending aorta and 44 patients in the total aortic arch). For total aortic arch replacement, we implanted the conventional vascular graft in the proximal descending thoracic aorta as an elephant trunk graft. Concomitant procedures included the Bentall procedure (9 patients), the David operation (6 patients), coronary artery bypass grafting (9 patients), heart transplantation (1 patient), mitral valve replacement (2 patients) and endovascular aortic repair (1 patient). The mean duration of postoperative endotracheal intubation was 17.0 ± 11.8 h. The average blood loss was 520 ± 743 ml, and 25% of patients required no blood transfusion. The in-hospital mortality rate was 6%.

CONCLUSIONS

The combined use of the vascular ring connector and the conventional elephant trunk graft may reduce bleeding and pump time, stop the blood flow in the false lumen and allow the 1-stage total arch replacement to be performed safely. The conventional elephant trunk graft is free from stent graft-induced new entry.

Α systematic review and meta-analysis of the efficacy of aortic anastomotic devices

OBJECTIVE

One of the factors contributing to complications related to open repair of the aorta is the construction of a hand-sewn anastomosis. Aortic anastomotic devices (AADs), such as the intraluminal ringed graft (IRG), and the anastomotic stenting technique have been developed to perform a sutureless and less complicated anastomosis. This study performed a systematic review and meta-analysis of the literature reporting clinical use of AADs and aimed to assess, primarily, the effect of each device on 30-day overall and operation-related mortality and aortic cross-clamping time and, secondarily, the rate of successful two-sided application of the IRG device and the operation-related morbidity for each device.

METHODS

An electronic search was performed using MEDLINE, Scopus, ScienceDirect, and Cochrane Library by two independent authors. Our exclusion criteria included studies incorporating fewer than three patients and studies reporting results solely from animals or in vitro testing, results solely from end-to-side anastomosis, and results solely from endarterectomy procedures. The last search date was February 1, 2018.

RESULTS

A total of 41 studies were identified that reported outcomes for the use of three different device types: IRG, anastomotic stenting technique, and surgical staplers. The last two types were classified together as the non-IRG group. The meta-analysis included 27 studies with 50 cohorts incorporating 1260 patients. The median age of the incorporated patients was 61.4 years (range, 51-73 years), and 68.9% were male. The operations were performed for the treatment of acute aortic dissection in 82.3%. The pooled overall 30-day mortality rate varied by device type; IRG devices had a mean rate of all-cause mortality of 9.71%, whereas non-IRG devices were associated with a significantly (I² = 15.78%; P for Cochrane Q test < .19) lower rate of death (1.47%). The pooled mean aortic cross-clamping time was 35.83 minutes. Metaregression showed that the performance of two-sided anastomosis with the IRG device significantly decreased the aortic cross-clamping time. However, a successful two-sided ringed anastomosis was performed in approximately half of the cases.

CONCLUSIONS

Taking into account that the majority of operations were performed for the treatment of acute aortic dissection, AADs had a relatively low rate of 30-day mortality. Despite the observed heterogeneity in study protocols and the small sample size in the non-IRG group, the non-IRG group presented with the lowest 30-day mortality rate. Specific device-related complications between the different device types need further investigation.

Combined heart transplantation and total replacement of thoracic aorta in Marfan's syndrome with recurrent aortic dissection: a case report

It is extremely rare for a patient to need simultaneous heart transplantation (HTx) and replacement of the thoracic aorta. A 23-year-old woman with Marfan's syndrome underwent Bentall's operation and replacement of the ascending aorta (AsA) due to a type A aortic dissection (AD) in August 2001. In March 2005, she began to experience dyspnea on exertion and was found to have a huge pseudoaneurysm at the aortic root, which had caused dehiscence of the aortic conduit. In July 2009, she suffered acute chest pain followed by hypotension and cold sweating. The computed tomography (CT) scan showed a recurrent dissection with a long intimal tear extending from the arch to the mid-portion of the descending thoracic aorta (DTA). Due to technical difficulties in the repair of the aortic root, she was placed on the HTx waiting list. The next day, she received a donor heart and underwent combined HTx and total replacement of the thoracic aorta. Explantation of the heart improved the exposure of the DTA. With the use of a vascular ring connector (Vasoring), the operation was successfully performed without need for a blood transfusion. The patient was still well at 2 years after the operation. Simultaneous replacement of the heart and the whole segment of the thoracic aorta is technically possible in Marfan patients who are complicated with aortic dissection.

Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection

BACKGROUND

After surgery to repair a type A aortic dissection, most late complications and mortality result from descending aorta-related problems. This study was performed to determine the risk factors leading to descending aortic aneurysm formation and late mortality in patients undergoing the type A aortic dissection operation.

METHODS

The medical records of patients who survived the operation for type A aortic dissection between 1984 and 1998 were reviewed. There were 144 patients (95 men and 49 women), ranging in age from 24 to 78 years (mean age, 52 years). Most patients were acutely ill, 15 patients were in shock, and 54 patients had cardiac tamponade at the time of the surgical procedure. One hundred thirty-seven patients had ascending aortic replacement only, and of the other 6 patients 2 had hemiarch and 4 had total arch replacement using the elephant trunk technique. The aortic valve was replaced in 23 patients, resuspended in 100, and untouched in 21. Twenty-four risk factors were evaluated in statistical analyses for the prediction of descending aortic aneurysm formation and 3-year mortality. Risk factors were investigated using univariate and multiple logistic regression and survival analyses.

RESULTS

The 3-year, 5-year, and 8-year cumulative survival rates were 96.2%, 89.1%, and 80.0%, respectively. The 3-year, 5-year, and 8-year cumulative survival rates, free from descending aortic aneurysm formation or descending aorta operation, were 74.7%, 58.6%, and 43.0%, respectively. Multivariate analysis confirmed that patent false lumen and initial descending aortic diameter were statistically significant risk factors for descending aortic aneurysm formation.

CONCLUSIONS

The medium-term survival rate of patients who received operations for type A aortic dissection was satisfactory, despite the high incidence of descending aortic aneurysm formation. The intimal entry site over the aortic arch that was resected during the first operation could decrease the patency rate of a false lumen over the descending aorta. In the absence of a patent false lumen over the descending aorta, the chance of descending aortic aneurysm formation or operation is lessened, and the late survival rate is increased.

Acute Type A Aortic Dissection. Influence of Early Management on Results

One hundred and six patients were operated upon for acute type A aortic dissection in 7 years between February 1992 and May 1999. There were 102 males and 4 females, aged 18 to 83 years with a mean of 59 ± 14 years. All patients underwent surgery within 14 hours of diagnosis. The ascending aorta was replaced with a Dacron graft in 103 patients; in the other 3 cases, the repair extended to the aortic arch. The aortic valve was preserved by resuspension in all except 4 patients, 3 of whom had Marfan's syndrome. There were 9 (8.5%) deaths, all due to respiratory and multiorgan failure. Nine patients (8.5%) needed hemodialysis; only one of these required permanent dialysis. Ten patients (9.4%) had transient neurological disorders, 2 others (1.9%) suffered permanent hemiplegia. Three patients (2.8%) underwent reoperation for bleeding. Tracheostomy for prolonged respiratory assistance was required in 6 patients (5.7%), of whom 1 died from respiratory failure. Early surgical intervention could be performed with low morbidity and mortality.