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Akita S, Tokuda Y, Kato W, Tanaka K, Mutsuga M. Risk factors for proximal and distal aortic events after type A acute aortic dissection. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02077-z. [PMID: 39287769 DOI: 10.1007/s11748-024-02077-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVES Type A acute aortic dissection (TAAAD) is a life-threatening condition often requiring emergency surgery, with approximately 30% of patients needing reoperation. This study aimed to identify predictors of long-term aortic events from early postoperative computed tomography (CT) examinations. METHODS A total of 336 cases underwent TAAAD surgery at two institutions between 2002 and 2018. Of these, 302 patients received CT examinations immediately after initial TAAAD surgery. Predictors of aortic events were evaluated from these early postoperative CT exams. Aortic events were defined as any events involving aortic-related death, open surgery, reoperation, endovascular stenting, or thoracic aorta diameter enlargement to ≥ 55 mm. RESULTS Excluding 34 in-hospital deaths (10.1%; 34/336), the 1-, 5-, and 10-year actuarial survival rates after primary TAAAD surgery were 98.2%, 88.6%, and 81.7%, respectively. Over a mean follow-up period of 7.4 ± 5.1 years, 67 aortic events (proximal: 19, distal: 45, both: 3) were observed. Freedom from proximal aortic events was 98.6%, 93.9%, and 85.2% at 1, 5, and 10 years, respectively. Proximal anastomosis new entry was identified as a significant risk factor for aortic events, with a 92% vs. 42% incidence at 10 years (p < 0.001). Freedom from distal aortic events was 99.6%, 84.5%, and 67.2% at 1, 5, and 10 years, respectively. A false/true area ratio greater than 1 and distal anastomosis new entry were significant risk factors for aortic events (low-risk group: 83.3% vs. high-risk group: 42.3% at 10 years, p < 0.001). CONCLUSIONS Detailed analysis of early postoperative CT scans following primary TAAAD surgery may help identify predictors of subsequent aortic events, potentially improving long-term patient management and outcomes.
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Affiliation(s)
- Sho Akita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, 466-8560, Japan.
- Department of Cardiovascular Surgery, Nagoya Daini Redcross Hospital, 2-9, Myoken-cho, Showa-ku, Nagoya, Aichi, 466-8650, Japan.
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, 466-8560, Japan
| | - Wataru Kato
- Department of Cardiovascular Surgery, Nagoya Daini Redcross Hospital, 2-9, Myoken-cho, Showa-ku, Nagoya, Aichi, 466-8650, Japan
| | - Keisuke Tanaka
- Department of Cardiovascular Surgery, Nagoya Daini Redcross Hospital, 2-9, Myoken-cho, Showa-ku, Nagoya, Aichi, 466-8650, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya City, Aichi, 466-8560, Japan
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Vo TX, Rahmouni K, Visintini S, Guo MH, Ouzounian M, Chu MWA, Boodhwani M, Appoo JJ, Tucker K, Al-Atassi T. Computed Tomography Imaging Measurements as a Surrogate for Clinical Outcomes After Surgical Management of Acute Type A Aortic Dissection: A Systematic Review. J Am Heart Assoc 2024; 13:e034496. [PMID: 39248260 DOI: 10.1161/jaha.124.034496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/24/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Postoperative computed tomography imaging surveillance is an essential component of care after acute type A aortic dissection (ATAAD) repair. Prognostic imaging factors after ATAAD repair have not been systematically reviewed. METHODS AND RESULTS We performed a systematic review to summarize postoperative computed tomography measurements including aortic diameter, cross-sectional area, volume, growth rate, and false lumen thrombosis in addition mid- to long-term clinical outcomes after ATAAD repair. Searches were conducted in Medline, Embase, and CENTRAL in October 2022. Studies were included if they reported clinical outcomes such as mortality or aortic reintervention after 1 year and included aforementioned computed tomography findings. Studies of chronic aortic dissection and studies of exclusive patient populations such as those with connective tissue diseases were excluded. Risk of bias was assessed with the Newcastle-Ottawa Scale. Searches retrieved 6999 articles. Sixty-eight studies met inclusion criteria (7885 patients). Extended repairs were associated with improved false lumen thrombosis, decreased aortic growth rate, and decreased rates of reintervention but not improved survival. Growth rates of the aorta post-ATAAD repair were highest in the descending thoracic aorta. The most frequent prognostic imaging factors reported were a patent/partially thrombosed false lumen and postoperative aortic diameter >40 to 45 mm. CONCLUSIONS Established measurements of positive aortic remodeling, including complete false lumen thrombosis and stabilization of postoperative aortic diameter and growth are the most studied prognostic indicators for improved clinical outcomes after ATAAD repair. Growth rate of the aorta remains significant after ATAAD repair. Future studies should prospectively evaluate and compare prognostic factors for improved surveillance and management.
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Affiliation(s)
- Thin X Vo
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Kenza Rahmouni
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Sarah Visintini
- Berkman Library University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Ming H Guo
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery University of Toronto Toronto Ontario Canada
| | - Michael W A Chu
- Division of Cardiac Surgery Western University London Ontario Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Jehangir J Appoo
- Division of Cardiac Surgery University of Calgary Calgary Alberta Canada
| | - Katherine Tucker
- Division of Medical Sciences, Nuffield Department of Primary Care Health Sciences Oxford University Oxford UK
| | - Talal Al-Atassi
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
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Yaşar E, Duman ZM, Timur B, Bayram M, Kaplan MC, Kadiroğulları E. Fate of the Patent False Lumen of the Descending Aorta After Surgical Treatment for Acute Type 1 Aortic Dissection. Braz J Cardiovasc Surg 2023; 38:e20220257. [PMID: 37801681 PMCID: PMC10552773 DOI: 10.21470/1678-9741-2022-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 05/15/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the factors affecting false lumen patency in the descending thoracic aorta among patients who underwent surgery for acute type 1 aortic dissection. METHODS A total of 112 patients with acute type 1 aortic dissection, with the flap below the diaphragm level, underwent surgery between January 2010 and September 2019. Of these, 60 patients who were followed up for ≥ 12 months and whose computed tomography scans were available were included in this study. The patients were divided into two groups: group I, consists of patent false lumen (n=36), and group II, consists of thrombosed false lumen (n=24). Demographic data, operative techniques, postoperative descending aortic diameters, reintervention, and late mortality were compared between the two groups. RESULTS The mean follow-up period of all patients was 37.6±26.1 months (range: 12-104). The diameter increase in the proximal and distal descending aorta was significantly higher in the patent false lumen group (5.3±3.7 mm vs. 3.25±2.34 mm; P=0.015; 3.1±2.52 mm vs. 1.9±1.55 mm; P=0.038, respectively). No significant difference in terms of hypertension was found between the two groups during the follow-up period (21 patients, 58.3% vs. 8 patients, 33.3%; P=0.058). A total of 29 patients (48.3%) were found to be hypertensive in the postoperative period. CONCLUSION After surgical treatment for acute type 1 aortic dissection, patients should be monitored closely, regardless of whether the false lumen is patent or thrombosed. Mortality and reintervention can be seen in patients with patent false lumen during follow-up.
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Affiliation(s)
- Emre Yaşar
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy
Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Zihni Mert Duman
- Department of Cardiovascular Surgery, Cizre State Hospital,
Şırnak, Turkey
| | - Barış Timur
- Department of Cardiovascular Surgery, Istanbul Dr. Siyami Ersek
Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muhammed Bayram
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy
Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Can Kaplan
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy
Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ersin Kadiroğulları
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy
Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Nakai Y, Yamada T, Ogawa S, Kamiya S, Saitoh Y, Suda H. Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians. Asian Cardiovasc Thorac Ann 2022; 30:772-778. [PMID: 35234053 DOI: 10.1177/02184923221083369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians. METHODS From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians. RESULTS The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23). CONCLUSION The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.
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Affiliation(s)
- Yosuke Nakai
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Toshiyuki Yamada
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shinji Ogawa
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shinji Kamiya
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yuhei Saitoh
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Hisao Suda
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
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Santamaria V, Schirone L, Vinciguerra M, De Bellis A, Greco E. Predictors for outcome in type A aortic dissection: A focus on false lumen. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wu Q, Xiao J, Qiu Z, Yan L, Shen Y, He J, Chen LW. Long-term outcomes of treatment with different stent grafts in acute DeBakey type I aortic dissection. J Card Surg 2020; 35:3078-3087. [PMID: 33032378 DOI: 10.1111/jocs.14996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/14/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND We developed an integrated triple-branched stent to treat acute DeBakey type I aortic dissection (AD) and modified it to enhance its adaptability. However, whether the patients treated by the modified stent would achieve better long-term prognosis is unknown. METHODS This study enrolled 147 patients with acute DeBakey type I AD. The original integrated triple-branched stents were used in 57 patients (Group A) between July 2012 and August 2013, and the modified stents in 90 patients (Group B) between September 2013 and March 2015. Clinical characteristics, surgical data, postoperative complications, mortality, and follow-up data of the two groups were analyzed. RESULTS The two groups presented comparable early death rates (Group A = 7.0%, Group B = 5.9%; p = .719). The incidence of postoperative acute kidney injury (AKI) was lower in Group B (10.0%) versus Group A (24.6%) (p = .018). Compared with the original integrated triple-branched stent graft, the modified stent could reduce the risk of early postoperative AKI (OR [95% CI] = 0.36 [0.14, 0.94]). Early endoleak rates were significantly lower in Group B (1.0%) compared to Group A (9.4%) (p = .004). During follow-up, there were five deaths in Group A (9.4%) and six deaths in Group B (7.2%) (p = .646). Chronic kidney injury (7.5% vs. 3.6%; p = .311), delayed endoleak (11.3% vs. 4.8%; p = .157), and late reinterventions (7.5% vs. 2.4%; p = .155) in the two groups were similar. CONCLUSIONS In patients with acute DeBakey type I AD, the modified stent showed feasible and safe treatment outcomes and reduced early endoleak rates. However, the long-term effects were similar to the original treatment.
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Affiliation(s)
- Qingsong Wu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jun Xiao
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhihuang Qiu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Liangliang Yan
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yue Shen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jian He
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Ikeno Y, Yokawa K, Koda Y, Gotake Y, Henmi S, Nakai H, Yamanaka K, Inoue T, Tanaka H, Okita Y. The fate of the downstream aorta after open aortic repair for acute DeBakey type I aortic dissection: total arch replacement with elephant trunk technique versus non-total arch replacement†. Eur J Cardiothorac Surg 2020; 55:966-974. [PMID: 30481293 DOI: 10.1093/ejcts/ezy381] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/26/2018] [Accepted: 10/08/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the fate of the downstream aorta following open aortic repair for acute DeBakey type I aortic dissection comparing total arch replacement (TAR) with the elephant trunk (ET) technique versus non-total arch replacement (non-TAR). METHODS From October 1999 to December 2016, 267 patients underwent open repair for acute DeBakey type I aortic dissection. A tear-oriented strategy was mainly used to determine the extent of graft replacement. Hospital mortality was 10.0% (12/120 patients) in the TAR group and 17.0% (25/147 patients) in the non-TAR group (P = 0.070). Late outcomes were compared in 230 hospital survivors (TAR: n = 108 and non-TAR: n = 122). Mean follow-up was 6.5 ± 4.6 years. The aortic diameters were measured at 4 levels, across 6 time points using computed tomography. RESULTS Freedom from additional aortic surgery for distal dilation was significantly better in the TAR group than the non-TAR group (TAR: 97.5 ± 1.8% at 5 years and non-TAR: 88.2 ± 3.4% at 5 years, P = 0.045). Freedom from a distal aortic event was also significantly better in the TAR group compared with the non-TAR group (TAR: 97.2 ± 1.6% at 5 years and non-TAR: 80.7 ± 4.2% at 5 years, P = 0.013). In the non-TAR group, the aortic arch diameter significantly increased (P < 0.001). Significant aortic remodelling occurred at the proximal descending aorta in the TAR with ET group (P < 0.001). CONCLUSIONS The TAR with ET reduced the need for additional distal aortic repair compared to non-TAR. TAR with ET prevented unfavourable aortic growth in both the aortic arch and the proximal descending aorta.
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Affiliation(s)
- Yuki Ikeno
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yojiro Koda
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yasuko Gotake
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Soichiro Henmi
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Hidekazu Nakai
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Katsuhiro Yamanaka
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Japan
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Inoue Y, Matsuda H, Omura A, Seike Y, Uehara K, Sasaki H, Kobayashi J. What is the optimal surgical strategy for Stanford Type A acute aortic dissection in patients with a patent false lumen at the descending aorta? Eur J Cardiothorac Surg 2019; 54:933-939. [PMID: 29608664 DOI: 10.1093/ejcts/ezy125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 03/03/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Aggressive total arch replacement (TAR) to obtain thrombosis of the distal false lumen (FL) in patients with Stanford Type A acute aortic dissection, particularly with a patent FL at the descending aorta, is discussed. The aim of this study was to examine the efficacy of our strategy. METHODS In the last 20 years, we retrospectively reviewed the records of 518 patients with Type A acute aortic dissection who underwent an emergent surgery. Among them, 290 patients with a preoperative patent FL at the descending aorta were enrolled in this study. Patients were divided in 2 groups: the non-TAR group (n = 124; 68 ± 14 years) and the TAR group (n = 166; 61 ± 13 years). RESULTS In-hospital mortality was 11% (32/290) without significant difference between the 2 groups (the non-TAR group 13% vs the TAR group 10%, P = 0.45). The rates of FL thrombosis of the entire descending aorta were detected at 32% in the non-TAR group and 41% in the TAR group (P = 0.16). Freedom from distal aortic dilatation ≥50 mm was significantly higher in the TAR group (P = 0.03) than in the non-TAR group. Independent predictors of distal aortic dilatation >50 mm were patients in the non-TAR group (P = 0.01; hazard ratio 3.1, 95% confidence interval 1.28-8.05) and unachieved primary entry tear resection (P = 0.002; hazard ratio 6.2, 95% confidence interval 1.38-8.66). CONCLUSIONS Our surgical strategy with an aggressive entry resection with higher rate of TAR was acceptable. In patients with a patent FL at the descending aorta, TAR should be considered to prevent the future growth of the distal aorta.
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Affiliation(s)
- Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
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Target mortality for repair of acute type A dissection. J Thorac Cardiovasc Surg 2019; 157:e113-e115. [DOI: 10.1016/j.jtcvs.2018.09.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/17/2018] [Accepted: 09/18/2018] [Indexed: 11/23/2022]
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Hsu CP, Huang CY, Chen HT. Combined surgical and endovascular treatment with arch preservation of acute DeBakey type I aortic dissection. J Chin Med Assoc 2019; 82:209-214. [PMID: 30913117 DOI: 10.1097/jcma.0000000000000030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND DeBakey type I aortic dissection is a catastrophic event that presents a formidable challenge to cardiovascular surgeon. Here, we evaluate a new combined surgical and endovascular technique for acute condition. METHODS Between December 2011 and December 2015, 12 patients with type I aortic dissection concomitant involving supra-aortic vessels underwent ascending aortic replacement and simultaneous stent grafts inserted into the descending aorta, left subclavian, and left carotid arteries, and into the innominate artery when possible, without arch replacement. The stent grafts, Gore TAG thoracic endoprosthesis and Viabahn, were deployed under visual guidance through opened aortic arch into the true lumen, with the techniques of circulatory arrest, moderate hypothermia, and bilateral antegrade cerebral perfusion. RESULTS Operation was performed smoothly in all patients. There was one death, and the other 11 recovered without any neurological deficits. Follow-up computed tomography scans showed that the true lumen expanded and false lumen regressed in both arch and descending aortic segments in 1 year. The diameter did not increase in either arch or descending aortic segments. CONCLUSION Ascending aortic replacement and stent graft for supra-aortic arteries and the descending aorta without arch replacement are feasible options for type I aortic dissection with satisfactory short-term aortic remodeling.
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Affiliation(s)
- Chiao-Po Hsu
- Faculty of Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan, ROC
| | - Chun-Yang Huang
- Faculty of Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsiang-Ting Chen
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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11
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Zhang L, Yu C, Yang X, Sun X, Qiu J, Jiang W, Wang D. Hybrid and frozen elephant trunk for total arch replacement in DeBakey type I dissection. J Thorac Cardiovasc Surg 2019; 158:1285-1292. [PMID: 30824349 DOI: 10.1016/j.jtcvs.2019.01.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study objective was to determine whether hybrid aortic repair yields superior outcomes compared with the conventional surgical approach for DeBakey type I aortic dissection. METHODS A retrospective analysis of patients with DeBakey type I dissection admitted to Fuwai Hospital between January 2010 and December 2016 showed that 815 patients (86.9%) underwent open total arch replacement with frozen elephant trunk (frozen elephant trunk group) and 122 (13.1%) underwent hybrid aortic arch repair without deep hypothermic circulatory arrest (hybrid group). We selected 109 pairs of patients for propensity score matching. Outcomes included early postoperative death, a composite of complications, dissected aorta remodeling, long-term survival, and freedom from reoperation. RESULTS Early mortality and complication rates were lower in the hybrid group, but the difference was not statistically significant (9.2% vs 17.4%, P = .073; 15.6% vs 25.7%, P = .066). The rates of postoperative renal insufficiency was significantly lower in the hybrid group than in the frozen elephant trunk group (22.9% vs 38.5%, P = .013); liver insufficiency and paraplegia were significantly lower in the hybrid group than in the frozen elephant trunk group (20.2% vs 33.9%, P = .022; 0% vs 6.4%, P = .014). After matched, the 1-year, 3-year, and 5-year survivals were 87.6%, 86.3%, and 82.2%, respectively, in the hybrid group and 80.7%, 76.5%, and 74.6% (P = .071), respectively, in the frozen elephant trunk group. CONCLUSIONS Hybrid aortic arch repair is a viable alternative treatment for patients with DeBakey type I aortic dissection, which improves outcomes and promotes remodeling of the dissected thoracic aorta.
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Affiliation(s)
- Liang Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Cuntao Yu
- The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Xiubin Yang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiaogang Sun
- The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenxiang Jiang
- The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - De Wang
- The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Shen K, Zhou X, Tan L, Li F, Xiao J, Tang H. An innovative arch-first surgical procedure under moderate hypothermia for acute type A aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018. [PMID: 29532651 DOI: 10.23736/s0021-9509.18.10180-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND We hypothesized that the arch-first procedure without extra devices under moderate-to-mild systemic hypothermia during acute type A aortic dissection is safe and efficient and will improve patient outcome compared with the standard total arch replacement technique. METHODS From December 2014 to February 2017, 89 patients were enrolled in this study, 52 of whom underwent conventional deep hypothermic circulatory arrest (DHCA, 24.2±0.71 °C) using the antegrade cerebral perfusion surgical procedure (Group A) and 37 of whom underwent the "arch-first" technique with moderate (27.4±1.1 °C) systemic hypothermia during antegrade cerebral perfusion (Group B). The clinical data, surgical and postoperative data, complications, and mortality of the two groups were analyzed. RESULTS The cardiopulmonary bypass (171.3±40.0 min) and awakening time (7.0 hours) was significantly decreased in Group B. Two patients died 30 d after surgery (5.4%, two of 37) in Group B. The incidence of transient neurologic deficit (2.7%) and distal organ complications (5.4%) was lower in Group B. CONCLUSIONS In patients with acute type A aortic dissection involving the arch, the innovative arch-first surgical procedure could provide feasible and safe treatment outcomes, which brings us closer to the goal of performing surgery with moderate-to-mild systemic hypothermia with better cerebral, distal organ, and survival outcomes.
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Affiliation(s)
- Kangjun Shen
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xinmin Zhou
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ling Tan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feng Li
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jun Xiao
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hao Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China -
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Fleischman F, Elsayed RS, Cohen RG, Tatum JM, Kumar SR, Kazerouni K, Mack WJ, Barr ML, Cunningham MJ, Hackmann AE, Baker CJ, Starnes VA, Bowdish ME. Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection. Ann Thorac Surg 2017; 105:505-512. [PMID: 29103584 DOI: 10.1016/j.athoracsur.2017.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 05/27/2017] [Accepted: 07/10/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. METHODS Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. RESULTS Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). CONCLUSIONS A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.
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Affiliation(s)
- Fernando Fleischman
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ramsey S Elsayed
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Robbin G Cohen
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - James M Tatum
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - S Ram Kumar
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kayvan Kazerouni
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mark L Barr
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mark J Cunningham
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Amy E Hackmann
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Craig J Baker
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Vaughn A Starnes
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Michael E Bowdish
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Smith HN, Boodhwani M, Ouzounian M, Saczkowski R, Gregory AJ, Herget EJ, Appoo JJ. Classification and outcomes of extended arch repair for acute Type A aortic dissection: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2017; 24:450-459. [PMID: 28040765 DOI: 10.1093/icvts/ivw355] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 09/16/2016] [Indexed: 01/16/2023] Open
Abstract
Objectives Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation. Methods Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated. Results Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05). Conclusions Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.
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Affiliation(s)
- Holly N Smith
- Toronto Western Hospital EW 1-433, Toronto, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard Saczkowski
- Department of Anesthesiology, Hospital of the Sacred Heart of Montreal and the University of Montreal, Montreal, Quebec, Canada
| | | | - Eric J Herget
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Di Bartolomeo R, Leone A, Di Marco L, Pacini D. When and how to replace the aortic arch for type A dissection. Ann Cardiothorac Surg 2016; 5:383-8. [PMID: 27563552 DOI: 10.21037/acs.2016.07.07] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high. The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.
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Affiliation(s)
- Roberto Di Bartolomeo
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Kondoh H, Satoh H, Daimon T, Tauchi Y, Yamamoto J, Abe K, Matsuda H. Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians. J Thorac Cardiovasc Surg 2016; 152:439-46. [DOI: 10.1016/j.jtcvs.2016.03.093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/23/2016] [Accepted: 03/12/2016] [Indexed: 01/16/2023]
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Settepani F, Cappai A, Basciu A, Barbone A, Tarelli G. Outcome of open total arch replacement in the modern era. J Vasc Surg 2016; 63:537-45. [DOI: 10.1016/j.jvs.2015.10.061] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/05/2015] [Indexed: 11/24/2022]
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18
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Omura A, Miyahara S, Yamanaka K, Sakamoto T, Matsumori M, Okada K, Okita Y. Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement. J Thorac Cardiovasc Surg 2016; 151:341-8. [DOI: 10.1016/j.jtcvs.2015.03.068] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/08/2015] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
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19
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Lu Q, Feng J, Zhou J, Zhao Z, Li H, Teng Z, Jing Z. Endovascular repair by customized branched stent-graft: A promising treatment for chronic aortic dissection involving the arch branches. J Thorac Cardiovasc Surg 2015; 150:1631-8.e5. [DOI: 10.1016/j.jtcvs.2015.08.032] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/30/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
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20
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Hemiarch and Total Arch Surgery in Patients With Previous Repair of Acute Type I Aortic Dissection. Ann Thorac Surg 2015; 100:833-8. [DOI: 10.1016/j.athoracsur.2015.03.095] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/25/2015] [Accepted: 03/30/2015] [Indexed: 11/17/2022]
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21
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Zhu JM, Qi RD, Chen L, Liu W, Li CN, Fan ZM, Sun LZ. Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Preservation of autologous brachiocephalic vessels. J Thorac Cardiovasc Surg 2015; 150:101-5. [DOI: 10.1016/j.jtcvs.2015.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/16/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
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22
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Chen LW, Wu XJ, Dai XF, Lu L, Liao DS, Li C, Li QZ. Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique. J Cardiothorac Surg 2014; 9:135. [PMID: 25085259 PMCID: PMC4445643 DOI: 10.1186/s13019-014-0135-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 07/17/2014] [Indexed: 11/12/2022] Open
Abstract
Background In total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique. Methods and results Total arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients. Conclusions The modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it’s placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair.
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Affiliation(s)
- Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Xi-Jie Wu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Xiao-Fu Dai
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Lin Lu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Dong-Shan Liao
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Chao Li
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
| | - Qian-Zhen Li
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, 350001, China.
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Chen LW, Lu L, Dai XF, Wu XJ, Zhang GC, Yang GF, Dong Y. Total arch repair with open triple-branched stent graft placement for acute type A aortic dissection: experience with 122 patients. J Thorac Cardiovasc Surg 2013; 148:521-8. [PMID: 24280711 DOI: 10.1016/j.jtcvs.2013.10.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/20/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To summarize the clinical experiences and midterm follow-up results of total arch repair with open triple-branched stent graft placement for acute type A aortic dissection. METHODS From June 2008 to March 2013, 122 patients (95 men and 27 women; mean age, 50.9 ± 10.4 years) with acute type A aortic dissection underwent total arch repair with open placement of a triple-branched stent graft under hypothermic cardiopulmonary bypass and selective cerebral perfusion. During the follow-up period, enhanced computed tomography and echocardiography were performed at 3 months postoperatively and annually thereafter. RESULTS Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in 121 patients. The cardiopulmonary bypass time was 186.50 ± 38.23 minutes, and the selective antegrade cerebral perfusion time was 31.97 ± 10.08 minutes. The in-hospital mortality was 4.93%. No permanent neurologic dysfunction or paraplegia was observed. Three patients were lost to follow-up. The mean follow-up period was 30.24 ± 12.35 months. After hospital discharge, 3 patients died. On the 3-month postoperative scans, complete thrombus formation around the triple-branched stent graft was observed in 89.38% of the patients. Endoleaks were detected in 12 patients; 8 patients refused any management for the endoleaks, but they maintained a good quality of life. The other 4 patients were successfully treated by additional surgery. CONCLUSIONS Total arch repair with open triple-branched stent graft placement is an effective technique with satisfactory early and midterm results. This technique could be an attractive alternative to conventional total arch replacement.
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Affiliation(s)
- Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China.
| | - Lin Lu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiao-Fu Dai
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xi-Jie Wu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Gui-Can Zhang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Guo-Feng Yang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Di Eusanio M, Castrovinci S, Tian DH, Folesani G, Cefarelli M, Pantaleo A, Murana G, Berretta P, Yan TD, Bartolomeo RD. Antegrade stenting of the descending thoracic aorta during DeBakey type 1 acute aortic dissection repair. Eur J Cardiothorac Surg 2013; 45:967-75. [DOI: 10.1093/ejcts/ezt493] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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25
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Roselli EE. We should replace the aortic arch and more in DeBakey type I dissection - A perspective from the Cleveland Clinic. Ann Cardiothorac Surg 2013; 2:216-21. [PMID: 23977586 DOI: 10.3978/j.issn.2225-319x.2013.03.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/18/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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26
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Davies RA, Black D, Bannon PG, Bayfield MS, Hendel PN, Hughes CF, Wilson MK, Vallely MP. Outcomes of aortic arch replacement surgery after previous cardiac surgery. ANZ J Surg 2013; 83:827-32. [PMID: 23782742 DOI: 10.1111/ans.12299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic arch replacement is a potentially high-risk operation and in the re-operative setting has been found to be a risk factor for poor outcome, yet there is a dearth of published data specifically on this topic. The aim of the study was to review our unit's outcomes in this re-operative setting. METHOD Data were collated for all patients who underwent aortic arch replacement surgery after previous cardiac surgery from January 1988 to November 2011. The patients were divided based primarily on elective versus non-elective and also early (≤2005) and late (≥2006) series. RESULTS Twenty-seven eligible patients (22 male; median age: 53.0 years; elective: 14, non-elective: 13) were identified. There was a mean period of 14.5 years between the first operation and the subsequent aortic arch replacement. The overall 30-day mortality rate was 22.2% - 0% elective and 46.2% non-elective (P = 0.004). Overall permanent neurological dysfunction was 21.7% - 28.6% elective and 11.1% non-elective (P = 0.463). There were 11 early-series patients and 16 late-series patients. For early-series patients, 90.9% were non-elective versus 18.8% in the late-series patients. The 30-day mortality rate was 54.5% early series versus 0% late series. CONCLUSION Aortic arch replacement is high risk in the re-operative setting. These risks are even greater for non-elective procedures. This highlights the need for aggressive first-time surgery to reduce re-operative procedures and good long-term follow-up programmes to allow elective procedures if required.
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Affiliation(s)
- Reece A Davies
- Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia; The Baird Institute for Heart and Lung Surgical Research, Sydney, New South Wales, Australia
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Choi CH, Park CH, Jeon YB, Lee SY, Lee JI, Park KY. Early and Mid-term Changes of the Distal Aorta after Total Arch Replacement for Acute Type A Aortic Dissection. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:33-40. [PMID: 23423122 PMCID: PMC3573163 DOI: 10.5090/kjtcs.2013.46.1.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 08/22/2012] [Accepted: 08/24/2012] [Indexed: 11/29/2022]
Abstract
Background Total arch replacement (TAR) is being more widely performed due to recent advances in operative techniques and cerebral protective strategies. In this study, the authors reviewed the relationship between TAR and early- and mid-term changes of the false lumen after TAR in acute type A aortic dissection. Materials and Methods Twenty-six patients (aged, 54.7±13.3 years) who underwent TAR for acute type A dissection between June 2004 and February 2012 were reviewed. The relationship between the percentage change in the aortic diameter and the false lumen patency status was assessed by examining the early and late postoperative computed tomography imaging studies. Results There were two in-hospital mortalities, one late death, and three follow-up loses. The mean follow-up duration for the final 21 patients studied was 54±19.0 months (range, 20 to 82 months). The incidence of false lumen thrombosis within 2 weeks of surgery in the proximal, middle, and distal thoracic aorta, and the suprarenal and infrarenal abdominal aorta were 67%, 38%, 38%, 48%, and 33%, respectively, and 57%, 67%, 52%, 33%, and 33% for those examined at a mean of 49±18 months after surgery, respectively. The false lumen regressed in 11 patients (42.3%). The aortic diameters were larger in the patients with a patent false lumen than those with a thrombosed false lumen at all levels of the descending aorta (p<0.05). Conclusion TAR and a more complete primary tear-resection can be accomplished with a relatively low-risk of morbidity and mortality. Enlargement of the distal aorta significantly correlated with the false lumen patency status.
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Affiliation(s)
- Chang Hu Choi
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University, Korea
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Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol 2012; 58:2455-74. [PMID: 22133845 DOI: 10.1016/j.jacc.2011.06.067] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/07/2011] [Indexed: 01/11/2023]
Abstract
Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
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Chen LW, Wu XJ, Lu L, Zhang GC, Yang GF, Yang ZW, Dong Y, Cao H, Chen Q. Total Arch Repair for Acute Type A Aortic Dissection With 2 Modified Techniques: Open Single-Branched Stent Graft Placement and Reinforcement of the Dissected Arch Vessel Stump With Stent Graft. Circulation 2011; 123:2536-41. [PMID: 21576657 DOI: 10.1161/circulationaha.110.008656] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In total arch replacement for patients with acute type A aortic dissection, anastomoses of the graft to the left subclavian artery and descending aorta are often difficult, and the arch vessel anastomosis is frequently performed at the site of dissection. To make this procedure easier and safer, we developed 2 modified techniques: open single-branched stent graft placement into the left subclavian artery and the descending aorta and reinforcement of the dissected arch vessel stump with a stent graft neointima. The feasibility and initial clinical results of these 2 new techniques are reported.
Methods and Results—
Total arch repair with the 2 new techniques was performed in 26 patients with acute Stanford type A aortic dissection. Most patients had an uneventful postoperative course, and there were no surgical deaths. All implanted stent grafts were fully opened and not kinked, and there was no space or blood flow surrounding any of the stent grafts. The false lumen of the descending thoracic aorta closed with thrombus formation in 22 of 26 patients. Disappearance of the false lumen and recovery of the true lumen was observed in all of the dissected arch vessels.
Conclusions—
Open single-branched stent graft placement into the left subclavian artery and the descending aorta and reinforcement of the dissected arch vessel stump with a stent graft neointima are 2 simple and effective techniques that should make total arch repair an easier and safer procedure for acute type A aortic dissection.
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Affiliation(s)
- Liang-Wan Chen
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xi-Jie Wu
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Lin Lu
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Gui-Can Zhang
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Guo-Feng Yang
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhao-Wei Yang
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yi Dong
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Hua Cao
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Qiang Chen
- From the Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Marullo AG, Bichi S, Pennetta RA, Di Matteo G, Cricco AM, Specchia L, Castriota F, Esposito G. Hybrid Aortic Arch Debranching With Staged Endovascular Completion in DeBakey Type I Aortic Dissection. Ann Thorac Surg 2010; 90:1847-53. [PMID: 21095323 DOI: 10.1016/j.athoracsur.2010.07.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 07/23/2010] [Accepted: 07/26/2010] [Indexed: 10/18/2022]
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Ius F, Vendramin I, Mazzaro E, Piccoli G, Bassi F, Gasparini D, Livi U. Transluminal Stenting in Type A Acute Aortic Dissection: Does the Djumbodis System Have Any Impact on False Lumen Evolution? Ann Thorac Surg 2010; 90:1450-6. [DOI: 10.1016/j.athoracsur.2010.06.087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 06/13/2010] [Accepted: 06/14/2010] [Indexed: 11/27/2022]
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The Essen concept of surgical management of patients with acute aortic dissection. COR ET VASA 2010. [DOI: 10.33678/cor.2010.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sun LZ, Qi RD, Chang Q, Zhu JM, Liu YM, Yu CT, Lv B, Zheng J, Tian LX, Lu JG. Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Experience with 107 patients. J Thorac Cardiovasc Surg 2009; 138:1358-62. [DOI: 10.1016/j.jtcvs.2009.04.017] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 03/31/2009] [Accepted: 04/17/2009] [Indexed: 10/20/2022]
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Cho SH, Sung K, Park KH, Yang JH, Kim WS, Jun TG, Lee YT, Park PW. Midterm results of aortic arch replacement in a stanford type a aortic dissection with an intimal tear in the aortic arch. Korean Circ J 2009; 39:270-4. [PMID: 19949611 PMCID: PMC2771823 DOI: 10.4070/kcj.2009.39.7.270] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 12/08/2008] [Indexed: 12/03/2022] Open
Abstract
Background and Objectives Stanford type A aortic dissection is a potentially catastrophic event that requires surgical repair, on an emergency basis. The extent of arch repair that should be carried out during emergency surgery of this type is controversial. This study was designed to evaluate the results of arch replacement carried out during acute type A dissection. Subjects and Methods 28 patients with Stanford type A dissection and who underwent arch replacement between 1995 and 2006 were reviewed. Results Hospital mortality was 3.6% (1 patient), and transient neurocognitive dysfunction was observed in 5 patients. During the follow-up period (mean 26±20 months; range 1 to 66 months), 3 patients underwent reoperation due to descending thoracic or abdominal aortic aneurysm. There was no late death. Follow up computed tomography was performed in 15 patients and false lumen disappeared totally or partially in 10 patients (66.7%). Conclusion Arch replacement for acute Stanford type A dissection may decrease the risk of late complications related to false lumen and lead to an excellent midterm survival rate.
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Affiliation(s)
- Seong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hata H, Toda K, Shudo Y, Kainuma S, Yoshida K, Yamamoto K, Taniguchi K. Repair for acute type A aortic dissection with a long elephant trunk technique. J Thorac Cardiovasc Surg 2009; 137:777-8. [PMID: 19258117 DOI: 10.1016/j.jtcvs.2008.07.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Revised: 06/13/2008] [Accepted: 07/06/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Hiroki Hata
- Department of Cardiovascular Surgery and Clinical Engineering Section, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, Sakai, Japan
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Surgery for Marfan Patients With Acute Type A Dissection Using a Stented Elephant Trunk Procedure. Ann Thorac Surg 2008; 86:1821-5. [DOI: 10.1016/j.athoracsur.2008.08.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 08/10/2008] [Accepted: 08/11/2008] [Indexed: 11/19/2022]
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Song JM, Kim SD, Kim JH, Kim MJ, Kang DH, Seo JB, Lim TH, Lee JW, Song MG, Song JK. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007; 50:799-804. [PMID: 17707186 DOI: 10.1016/j.jacc.2007.03.064] [Citation(s) in RCA: 254] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Revised: 02/20/2007] [Accepted: 03/13/2007] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We sought to demonstrate the long-term natural course of descending aorta dilation after acute aortic dissection (AD) and identify early predictors for late aneurysmal change. BACKGROUND Aneurysmal dilation of the aorta is a critical late complication in AD patients. METHODS Contrast-enhanced computed tomography (CT) was performed during the acute phase in 100 AD patients, comprising 51 type 1 who underwent ascending aorta surgery and 49 type 3 AD patients. Clinical observation was conducted for 53 +/- 26 months, and CT was repeated for 31 +/- 27 months. RESULTS Aneurysm (diameter > or =60 mm) occurred in 14.4%, 8.2%, 4.1%, and 3.1% of patients at the upper descending thoracic aorta (UT), mid descending thoracic aorta (MT), lower descending thoracic aorta (LT) and abdominal aorta (AA), respectively. Of 53 patients in whom CT was repeated for > or =2 years, the rates of aorta diameter enlargement at the UT, MT, LT, and AA levels were 3.43 +/- 3.66 mm/year, 3.21 +/- 2.70 mm/year, 2.62 +/- 2.19 mm/year, and 1.93 +/- 3.13 mm/year, respectively (p < 0.01), and aneurysm developed in 15 (28%). The initial false lumen diameter at the UT, the aorta diameter at the MT, and Marfan syndrome were independent predictors of late aneurysm. A > or =22-mm initial false lumen diameter at the UT predicted late aneurysm with a sensitivity of 100% and a specificity of 76%. The patients with initial UT false lumen diameter > or =22-mm (n = 42) showed higher event rate (aneurysm or death) than others (n = 58) (p < 0.001). CONCLUSIONS The UT is the major site of late aneurysmal dilation. A large UT false lumen diameter on the initial CT portends late aneurysm and adverse outcome warranting early intervention.
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Affiliation(s)
- Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Gomes WJ. Invited commentary. Ann Thorac Surg 2005; 80:1302. [PMID: 16181858 DOI: 10.1016/j.athoracsur.2005.04.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 04/20/2005] [Accepted: 04/29/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP 04023-900, Brazil.
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