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Brown JA, Yousef S, Serna-Gallegos D, Sá MP, Agrawal N, Thoma F, Wang Y, Phillippi J, Sultan I. Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach. Perfusion 2024:2676591241259622. [PMID: 38863259 DOI: 10.1177/02676591241259622] [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: 06/13/2024]
Abstract
OBJECTIVE To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. METHODS This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. RESULTS A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24 h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. CONCLUSIONS Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nishant Agrawal
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abt BG, Bojko M, Elsayed RS, Han S, Wang A, Vu I, Wishart D, Fleischman F. Branch-first aortic arch replacement strategy decreases perioperative mortality. J Thorac Cardiovasc Surg 2024; 167:2005-2012.e1. [PMID: 37574006 DOI: 10.1016/j.jtcvs.2023.08.012] [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: 02/26/2023] [Revised: 07/21/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement. METHODS We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality. RESULTS A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007). CONCLUSIONS We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.
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Affiliation(s)
- Brittany G Abt
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif.
| | - Markian Bojko
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Ramsey S Elsayed
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Sukgu Han
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Alan Wang
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Isabelle Vu
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Danielle Wishart
- University of Southern California, Keck School of Medicine, Los Angeles, Calif
| | - Fernando Fleischman
- Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Vendramin I, Piani D, Lechiancole A, Sponga S, Di Nora C, Londero F, Muser D, Onorati F, Bortolotti U, Livi U. Hemiarch Versus Arch Replacement in Acute Type A Aortic Dissection: Is the Occam's Razor Principle Applicable? J Clin Med 2021; 11:jcm11010114. [PMID: 35011856 PMCID: PMC8745476 DOI: 10.3390/jcm11010114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/25/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIM OF THE STUDY In patients with acute Type A aortic dissection (A-AAD) whether repair should be limited to ascending aorta/hemiarch replacement or extended to include the aortic arch is still debated. We have analyzed our experience to compare outcomes of patients with A-AAD treated with these 2 different surgical strategies. METHODS From 2006 to 2020, a total of 213 patients have undergone repair of A-AAD at our Center; in 163 of them ascending aorta/hemiarch replacement (Group 1) and in 75 ascending aorta and arch replacement (Group 2) were performed. The primary endpoint was early survival and secondary endpoints late survival, freedom from late complications and reoperations. Patients were compared according to era of operation: 2006 to 2013 (Era 1) and 2014 to 2020 (Era 2). RESULTS Overall hospital mortality was 12% and 5% in Group 1 and 2; mortality remained stable in Era 1 and 2 for Group 1 (15%), while it decreased from 8% to 1% in Group 2 patients (p = 0.24). Actuarial survival at 5 and 10 years is 72 ± 4% and 49 ± 5% in Group 1 and 77 ± 6% and 66 ± 9% in Group 2 (p = 0.073). Actuarial freedom from reoperation in the entire series is 94 ± 2% and 92 ± 3% at 5 and 10 years. Freedom from reoperation at 5 and 10 years is 92 ± 2% and 89 ± 3% in Group 1 and 98 ± 1% at all intervals in Group 2 (p = 0.068). CONCLUSIONS An aggressive approach to A-AAD provides superior long-term results without increasing mortality. Furthermore, arch replacement during A-AAD repair represents a more stable solution with lower incidence of late aortic-related complications. Immediate aortic arch replacement should be considered in the treatment of A-AAD especially in experienced centers.
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Affiliation(s)
- Igor Vendramin
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
- Correspondence: ; Tel.: +39-432-552431; Fax: +39-432-552975
| | - Daniela Piani
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Andrea Lechiancole
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Concetta Di Nora
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Francesco Londero
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Daniele Muser
- Division of Cardiology, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy;
| | - Francesco Onorati
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Verona, 37100 Verona, Italy;
| | - Uberto Bortolotti
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
| | - Ugolino Livi
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, 33100 Udine, Italy; (D.P.); (A.L.); (S.S.); (C.D.N.); (F.L.); (U.B.); (U.L.)
- Division of Cardiac Surgery, Department of Medical Area (DAME), University of Udine, 33100 Udine, Italy
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Vendramin I, Lechiancole A, Piani D, Sponga S, Di Nora C, Muser D, Bortolotti U, Livi U. An Integrated Approach for Treatment of Acute Type A Aortic Dissection. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111155. [PMID: 34833373 PMCID: PMC8621250 DOI: 10.3390/medicina57111155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 06/13/2023]
Abstract
Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004-2010 (Era 1, n = 90), 2011-2016 (Era 2, n = 87), and 2017-2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes.
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Affiliation(s)
- Igor Vendramin
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Andrea Lechiancole
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Daniela Piani
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Sandro Sponga
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Concetta Di Nora
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Daniele Muser
- Cardiothoracic Department, Division of Cardiology, University Hospital of Udine, 33100 Udine, Italy;
| | - Uberto Bortolotti
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
| | - Ugolino Livi
- Cardiothoracic Department, Division of Cardiac Surgery, University Hospital of Udine, 33100 Udine, Italy; (A.L.); (D.P.); (S.S.); (C.D.N.); (U.B.); (U.L.)
- Department of Medical Area (DAME), Division of Cardiac Surgery, University of Udine, 33100 Udine, Italy
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Sicim H, Demirdas E, Bolcal C. Direct bilateral carotid artery cannulation can be better strategy for acute aortic dissection involving both carotid arteries. J Card Surg 2021; 36:3977-3980. [PMID: 34338328 DOI: 10.1111/jocs.15872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/30/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022]
Abstract
Although acute aortic dissections with bilateral carotid artery involvement are rare, they have serious morbidity and mortality rates. The most important strategy in cases with carotid involvement is to provide adequate cerebral perfusion during cardiopulmonary bypass. In this case, we presented, aortic dissection with bilateral carotid involvement was detected in the patient who was admitted to the emergency department with severe chest pain, vision loss, and left arm monoplegia, and the decision for surgery was made urgently. Selective cerebral perfusion was provided throughout the operation with direct bilateral carotid cannulation, in terms of being the fastest method and providing adequate cerebral flow. During the discharge period, full recovery was achieved in neurological deficits without any sequelae. We think that the technique we have applied in such a difficult and complicated case is the best strategy because it is fast and effective.
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Affiliation(s)
- Hüseyin Sicim
- Department of Cardiovascular Surgery, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ertan Demirdas
- Department of Cardiovascular Surgery, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Cengiz Bolcal
- Department of Cardiovascular Surgery, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Sun X, Zhao Q, Huo Y, Zhou J, Zhao F, Liu Y, Du Y, He S, Liu C, Jiang D, Sun W. Short-term outcomes of modified Y-graft technique in acute type a aortic dissection using the femoral artery bypass and one minute systemic circulatory arrest technique. J Cardiothorac Surg 2020; 15:106. [PMID: 32434594 PMCID: PMC7240991 DOI: 10.1186/s13019-020-01156-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Aortic arch replacement in acute type A aortic dissection patients remains the most challenging cardiovascular operation. Herein, we described our modified Y-graft technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) technique, and assessed the short-term outcomes of the patients. Methods Between February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients underwent FAB while 28 patients underwent both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previously reported studies. Results In the FAB group, two patients died due to pulmonary infection (30-day survival rate, 91.3%), and two patients were paralyzed from the waist down. Hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received respiratory support for more than 2-days and eight patients (34.8%) for more than 5-days. These follow-up results were comparable or better than the patients with traditional Y-graft technique. Furthermore, compared to the FAB group, the morbidity due to neurological dysfunction and acute renal failure was significantly reduced in the FAB+OSCA group. Moreover, the respiratory support, length of postoperative stay and ICU stay were shortened. Conclusions This study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients showed less surgical complications and favorable short-term outcomes after this surgery.
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Affiliation(s)
- Xiangfei Sun
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021, China.,Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Qi Zhao
- Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021, China.,Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yufeng Huo
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Jinfeng Zhou
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Fen Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Yimin Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Yonghai Du
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Songxiong He
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Chao Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Detian Jiang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Wenyu Sun
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China.
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Orlov CP, Orlov OI, Shah VN, Kilcoyne M, Buckley M, Sicouri S, Plestis KA. Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft. Semin Thorac Cardiovasc Surg 2020; 32:683-691. [PMID: 32360886 DOI: 10.1053/j.semtcvs.2020.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/23/2020] [Indexed: 11/11/2022]
Abstract
This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18-22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32-82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79-94%) were alive at 1 year, 78% at 5 years (95%CI: 66-86%), and 73% at 10 years (95%CI: 59-82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes.
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Affiliation(s)
- Cinthia P Orlov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Oleg I Orlov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Vishal N Shah
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania; Lankenau Heart Institute, Department of Cardiothoracic Surgery, Wynnewood, Pennsylvania
| | - Maxwell Kilcoyne
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Meghan Buckley
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Serge Sicouri
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
| | - Konstadinos A Plestis
- Lankenau Heart Institute, Department of Cardiothoracic Surgery, Wynnewood, Pennsylvania
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Olai H, Thornéus G, Watson H, Macleod M, Rhodes J, Friberg H, Nielsen N, Cronberg T, Deierborg T. Meta-analysis of targeted temperature management in animal models of cardiac arrest. Intensive Care Med Exp 2020; 8:3. [PMID: 31953652 PMCID: PMC6969098 DOI: 10.1186/s40635-019-0291-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/29/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) of 32 to 34 °C has been the standard treatment for out-of-hospital cardiac arrest since clinical trials in 2002 indicated benefit on survival and neurological outcome. In 2013, a clinical trial showed no difference in outcome between TTM of 33 °C and TTM of 36 °C. In this meta-analysis, we investigate the evidence for TTM in animal models of cardiac arrest. METHODS We searched PubMed and EMBASE for adult animal studies using TTM as a treatment in different models of cardiac arrest or global brain ischemia which reported neurobehavioural outcome, brain histology or mortality. We used a random effects model to calculate estimates of efficacy and assessed risk of bias using an adapted eight-item version of the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES) quality checklist. We also used a scoring system based on the recommendations of the Stroke Treatment Academic Industry Roundtable (STAIR), to assess the scope of testing in the field. Included studies which investigated a post-ischemic induction of TTM had their treatment regimens characterized with regard to depth, duration and time to treatment and scored against the modified STAIR criteria. RESULTS The initial and updated search generated 17809 studies after duplicate removal. One hundred eighty-one studies met the inclusion criteria, including data from 1,787, 6,495 and 2,945 animals for neurobehavioural, histological and mortality outcomes, respectively. TTM was favoured compared to control for all outcomes. TTM was beneficial using short and prolonged cooling, deep and moderate temperature reduction, and early and delayed time to treatment. Median [IQR] study quality was 4 [3 to 6]. Eighteen studies checked seven or more of the eight CAMARADES quality items. There was no clear correlation between study quality and efficacy for any outcome. STAIR analysis identified 102 studies investigating post-ischemic induction of TTM, comprising 147 different treatment regimens of TTM. Only 2 and 8 out of 147 regimens investigated comorbid and gyrencephalic animals, respectively. CONCLUSIONS TTM is beneficial under most experimental conditions in animal models of cardiac arrest or global brain ischemia. However, research on gyrencephalic species and especially comorbid animals is uncommon and a possible translational gap. Also, low study quality suggests risk of bias within studies. Future animal research should focus on mimicking the clinical scenario and employ similar rigour in trial design to that of modern clinical trials.
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Affiliation(s)
- Hilmer Olai
- Department of Experimental Medical Science, Experimental Neuroinflammation Laboratory, Lund University, Lund, Sweden
| | - Gustav Thornéus
- Department of Experimental Medical Science, Experimental Neuroinflammation Laboratory, Lund University, Lund, Sweden
| | - Hannah Watson
- Department of Anaesthesia, Western General Hospital, NHS Lothian, Edinburgh, UK
- Department of Critical Care, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jonathan Rhodes
- Department of Anaesthesia, Critical care and Pain Medicine/NHS Lothian, University of Edinburgh, Edinburgh, UK
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesia & Intensive care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive care, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Tomas Deierborg
- Department of Experimental Medical Science, Experimental Neuroinflammation Laboratory, Lund University, Lund, Sweden.
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Srivastava S, Bhan A. Aortic arch aneurysms and dissection-open repair is the gold standard. Indian J Thorac Cardiovasc Surg 2019; 35:136-155. [PMID: 33061079 DOI: 10.1007/s12055-019-00819-w] [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: 12/09/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 10/26/2022] Open
Abstract
The aortic arch repair is one of the most complex surgeries and carries a high risk of complications as well as mortality. Since 1975, when the arch repair was first done by Randall B. Griepp using hypothermic circulatory arrest, many new technologies were introduced. But even with the use of antegrade and retrograde perfusion techniques and improvement of surgical techniques and grafts, the rate of mortality, cerebral, spinal, and visceral damage was much higher as compared to any other cardiac surgeries. With further developments aimed at less invasive approaches, thoracic endovascular aortic repair (TEVAR) along with de-branching of supra-aortic vessels or the frozen elephant trunk was introduced. Here, in this article, we review the myriad of approaches to the aortic arch and have come to a conclusion that while traditional open surgery is considered as the gold standard for treatment of extensive aortic arch pathologies, one school of thought suggests hybrid techniques such as the frozen elephant trunk and aortic arch vessel de-branching as more appropriate procedures for high-risk patients, where co-morbidities may contraindicate cardiopulmonary bypass and longer operative times required for traditional repair. No randomized trials are present to compare between open and hybrid or endovascular procedure in normal or high-risk patients. The meta-analysis of most of the studies defines open surgery as the gold standard for arch pathology because the hybrid procedures did not provide any proven survival benefits or decrease in stroke rate and spinal ischemia when compared to open surgery in early, mid, or long-term results.
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Affiliation(s)
- Swarnika Srivastava
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India.,Noida, India
| | - Anil Bhan
- Department of cardiothoracic surgery, Medanta The Medicity hospital, Gurugram, India
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Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques. Asian J Surg 2019; 42:482-487. [DOI: 10.1016/j.asjsur.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022] Open
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Yoshitake A, Okamoto K, Yamazaki M, Kimura N, Hirano A, Iida Y, Abe T, Shimizu H. Comparison of aortic arch repair using the endovascular technique, total arch replacement and staged surgery†. Eur J Cardiothorac Surg 2017; 51:1142-1148. [DOI: 10.1093/ejcts/ezx028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 01/10/2017] [Indexed: 11/12/2022] Open
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Shelstad RC, Reeves JG, Yamanaka K, Reece TB. Total Aortic Arch Replacement: Advantages of Varied Techniques. Semin Cardiothorac Vasc Anesth 2016; 20:307-313. [PMID: 27765887 DOI: 10.1177/1089253216672849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique-each having its own advantages. In addition, thoracic aortic aneurysms involving the arch and descending aorta pose a substantial surgical challenge and often require hybrid or nonclamp technique with staged operative interventions. Hybrid and endovascular (thoracic endovascular aortic repair) techniques for the descending aorta are evolving and require consideration in operative planning. Areas of controversy include management of the subclavian artery, extent of distal arch replacement, elephant trunk and hybrid frozen elephant trunk techniques, and use and timing of staged approaches. Aortic arch replacement remains a complex, potentially difficult procedure. Better understanding of the potential open approaches to arch replacement will optimize the potential outcomes for patients. Aortic arch pathology is best served by tailoring the procedure to the patient-specific anatomy and pathology.
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Centofanti P, Barbero C, D'Agata F, Caglio MM, Caroppo P, Cicerale A, Attisani M, La Torre M, Milan A, Contristano ML, Carlini E, Izzo G, Mortara P, Veglio F, Rinaldi M. Neurologic and cognitive outcomes after aortic arch operation with hypothermic circulatory arrest. Surgery 2016; 160:796-804. [DOI: 10.1016/j.surg.2016.02.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/04/2016] [Accepted: 02/04/2016] [Indexed: 11/17/2022]
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Kayatta MO, Chen EP. Optimal temperature management in aortic arch operations. Gen Thorac Cardiovasc Surg 2016; 64:639-650. [PMID: 27501694 DOI: 10.1007/s11748-016-0699-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/26/2016] [Indexed: 01/26/2023]
Abstract
Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.
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Affiliation(s)
- Michael O Kayatta
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
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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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Preventza O, Garcia A, Cooley DA, Haywood-Watson RJ, Simpson K, Bakaeen FG, Cornwell LD, Omer S, de la Cruz KI, Price MD, Rosengart TK, LeMaire SA, Coselli JS. Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair. J Thorac Cardiovasc Surg 2015; 150:1591-8; discussion 1598-600. [DOI: 10.1016/j.jtcvs.2015.08.117] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/11/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
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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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Riambau V. Application of the Bolton Relay Device for Thoracic Endografting In or Near the Aortic Arch. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2015; 3:16-24. [PMID: 26798752 DOI: 10.12945/j.aorta.2015.14-050] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/05/2015] [Indexed: 11/18/2022]
Abstract
Endovascular correction of aortic arch pathology remains a challenge, with a variety of techniques proposed over the years to minimize complications and enhance the probability of a successful result. A variety of approaches have been developed in order to deal with the aortic arch pathology and its idiosyncrasies. We review potential interventional techniques for the repair of aortic arch pathologies, beginning with conventional aortic arch surgery, followed by hybrid treatments and those along the endovascular spectrum (parallel and fenestrated endografts, scalloped endografts, and ascending and new branched endografts). We finish with an overview of all the Bolton Medical (Barcelona, Spain and Sunrise, FL, USA) thoracic platforms. Endovascular techniques show acceptable results in selected cases. Both proximal Bolton Relay configurations (with and without a bare stent) offer conformability and accuracy on deployment with very low rates of stroke. Fenestrated and scalloped designs are also useful for selected cases. Ascending and branched Bolton devices are very promising platforms for a serious, full endovascular approach to the aorta.
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Affiliation(s)
- Vincent Riambau
- Vascular Surgery Division, Thorax Institute, Hospital Clinic of Barcelona, Barcelona, Spain
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Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: Safe and effective. J Thorac Cardiovasc Surg 2014; 148:888-98; discussion 898-900. [DOI: 10.1016/j.jtcvs.2014.05.027] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/02/2014] [Accepted: 05/12/2014] [Indexed: 11/20/2022]
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Yang SM, Xu P, Li CX, Huang Q, Gao HB, Li ZF, Chang Q. A modified total arch replacement combined with a stented elephant trunk implantation for acute type A dissection under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. J Cardiothorac Surg 2014; 9:140. [PMID: 25174987 PMCID: PMC4203861 DOI: 10.1186/s13019-014-0140-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 08/04/2014] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Since the optimal management of patients with acute aortic dissection is unclear, this study analyzed total arch replacement combined with stented elephant trunk implantation in the treatment of acute type A aortic dissection. METHODS Between February 2008 and February 2013, 86 consecutive patients admitted to our hospital for acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under deep hypothermic circulatory arrest. The Bentall, David, and Wheat procedure was performed on 46, 12 and two patients, respectively. Ascending aorta replacement was performed on 26 patients, while two patients in Bentall group and 7 in ascending aorta replacement group underwent coronary artery bypass grafting as a concomitant procedure. RESULTS Sixty-nine patients were male and 17 patients were female, with an average age of 45.2 ± 2.3 years. The in-hospital mortality rate was 5.8%. Two patients presented with persisting paraplegia. The cardiopulmonary bypass time was 186.3 ± 45.2 minutes and the myocardium ischemia time was 102.6 ± 28.1 minutes. Selective antegrade cerebral perfusion time was 29.4 ± 10.3 minutes. Low-body circulatory arrest time was 18.5 ± 8.4 minutes. Mechanical ventilation time was 80.7 ± 11.3 hours. ICU and hospital stays were 5.3 ± 4.8 and 16.8 ± 5.5 days, respectively. Seven patients underwent reoperation for bleeding. During a mean follow-up of 28.5 months, two patients died and 2 patients were lost to follow-up. Obliteration of the false lumen around the stented graft and at the diaphragmatic level occurred in 97.1% (68 of 70) and 70% (49 of 70) of the patients. CONCLUSIONS Modified total arch replacement combined with stented elephant trunk implantation using selective antegrade cerebral perfusion is a safe and effective alternative for patients with acute type A dissection and produces satisfactory clinical outcomes in our center.
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Affiliation(s)
- Su-Min Yang
- Department of Cardiovascular Surgery, the Affiliated Hospital of Medical College, Qingdao University, Qingdao 266003, Shandong, China.
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Bashir M, Fok M, Shaw M, Field M, Kuduvalli M, Desmond M, Harrington D, Rashid A, Oo A. Liverpool Aortic Surgery Symposium V: New Frontiers in Aortic Disease and Surgery. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2014; 2:100-9. [PMID: 26798724 DOI: 10.12945/j.aorta.2014.13-051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 04/09/2014] [Indexed: 11/18/2022]
Abstract
Aortic aneurysm disease is a complex condition that requires a multidisciplinary approach in management. The innovation and collaboration among vascular surgery, cardiothoracic surgery, interventional radiology, and other related specialties is essential for progress in the management of aortic aneurysms. The Fifth Liverpool Aortic Surgery Symposium that was held in May 2013 aimed at bringing national and international experts from across the United Kingdom and the globe to deliver their thoughts, applications, and advances in aortic and vascular surgery. In this report, we present a selected short synopsis of the key topics presented at this symposium.
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Affiliation(s)
- Mohamad Bashir
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Fok
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Shaw
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Field
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Michael Desmond
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Abbas Rashid
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Aung Oo
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Chiesa R, Bertoglio L, Rinaldi E, Tshomba Y. Hybrid repair of aortic arch pathology. Multimed Man Cardiothorac Surg 2014; 2014:mmu003. [PMID: 24876520 DOI: 10.1093/mmcts/mmu003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.
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Affiliation(s)
- Roberto Chiesa
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Luca Bertoglio
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Enrico Rinaldi
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Yamume Tshomba
- 'Vita-Salute' University, Scientific Institute H. San Raffaele, Milan, Italy
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Leshnower BG, Kilgo PD, Chen EP. Total arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2014; 147:1488-92. [DOI: 10.1016/j.jtcvs.2014.01.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 12/15/2013] [Accepted: 01/30/2014] [Indexed: 11/27/2022]
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Pacini D, Pantaleo A, Di Marco L, Leone A, Barberio G, Murana G, Castrovinci S, Sottili S, Di Bartolomeo R. Visceral organ protection in aortic arch surgery: safety of moderate hypothermia. Eur J Cardiothorac Surg 2014; 46:438-43. [DOI: 10.1093/ejcts/ezt665] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tsagakis K, Dohle D, Benedik J, Lieder H, Jakob H. Overall Essen's experience with the E-vita open hybrid stent graft system and evolution of the surgical technique. Ann Cardiothorac Surg 2013; 2:612-20. [PMID: 24109569 DOI: 10.3978/j.issn.2225-319x.2013.09.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 09/23/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND The hybrid stent graft prosthesis E-vita open was designed and introduced by us in 2005 to avoid a two-stage surgical approach in the surgical treatment of complex thoracic aortic disease. Experience in ascending aortic and arch replacement with simultaneous stent grafting of the descending aorta was accumulated over the past 8 years. Facilitation of surgical technique by moving the distal suture line from Zone 3 into Zone 2 took place in 2009. We report our mid-term single-center experience comparing both surgical periods. METHODS Between January 2005 and July 2013 a total of 132 patients (mean age 59±11 years) underwent one stage surgery for acute (AAD, n=74), chronic aortic dissection (CAD, n=35) or an extensive thoracic aortic aneurysm (TAA, n=23). Patients were separated in two groups according to distal anastomosis level in Zone 2 (Z2, 41/132) and Zone 3 (Z3, 91/132). Outcome, ischemic and operative times as well as adverse events were monitored during follow up. RESULTS Overall in-hospital mortality was 13% (17/132) without difference between the groups. However, Zone 2 anastomosis resulted in reduction of cardioplegic arrest (117±39 vs. 147±35 minutes; P<0.001), selective cerebral perfusion (52±15 vs. 68±18 minutes; P<0.001) and visceral ischemic time (51±19 vs. 72±23 minutes; P<0.001). The incidence of postoperative temporary hemodialysis decreased from 40% to 20% in Z2 (P=0.028), postoperative re-exploration rate from 15% to 2% (P=0.037). No difference was found in dissection with complete false lumen thrombosis in 83% (90/109) within 10 days, as well as in TAA, where 100% aneurysm exclusion was observed. Three-year survival, freedom from thoracoabdominal aortic surgery and endovascular repair was 93%, 88%, 88%, respectively. Overall 5-year survival was 76% in AAD, 85% in CAD and 79% in TAA patients. CONCLUSIONS The dimension of surgery could be successfully reduced, indicated by significantly shortened ischemic times and postoperative complications. Durable one-stage repair of complex thoracic aortic disease could be achieved in the majority of cases with acceptable mortality. Distal reintervention is infrequent but associated with low risk when indicated.
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Affiliation(s)
- Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Germany
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Griepp RB, Griepp EB. Perfusion and cannulation strategies for neurological protection in aortic arch surgery. Ann Cardiothorac Surg 2013; 2:159-62. [PMID: 23977576 DOI: 10.3978/j.issn.2225-319x.2013.03.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 03/21/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Randall B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York City, New York, USA
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Czerny M, König T, Reineke D, Sodeck GH, Rieger M, Schoenhoff F, Basciani R, Jenni H, Schmidli J, Carrel TP. Total surgical aortic arch replacement as a safe strategy to treat complex multisegmental proximal thoracic aortic pathology. Interact Cardiovasc Thorac Surg 2013; 17:532-6. [PMID: 23788196 DOI: 10.1093/icvts/ivt260] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To analyse the results after elective open total aortic arch replacement. METHODS We analysed 39 patients (median age 63 years, median logistic EuroSCORE 18.4) who underwent elective open total arch replacement between 2005 and 2012. RESULTS In-hospital mortality was 5.1% (n = 2) and perioperative neurological injury was 12.8% (n = 5). The indication for surgery was degenerative aneurysmal disease in 59% (n = 23) and late aneurysmal formation following previous surgery of type A aortic dissection in 35.9% (n = 14); 5.1% (n = 2) were due to anastomotical aneurysms after prior ascending repair. Fifty-nine percent (n = 23) of the patients had already undergone previous proximal thoracic aortic surgery. In 30.8% (n = 12) of them, a conventional elephant trunk was added to total arch replacement, in 28.2% (n = 11), root replacement was additionally performed. Median hypothermic circulatory arrest time was 42 min (21-54 min). Selective antegrade cerebral perfusion was used in 95% (n = 37) of patients. Median follow-up was 11 months [interquartile range (IQR) 1-20 months]. There was no late death and no need for reoperation during this period. CONCLUSIONS Open total aortic arch replacement shows very satisfying results. The number of patients undergoing total arch replacement as a redo procedure and as a part of a complex multisegmental aortic pathology is high. Future strategies will have to emphasize neurological protection in extensive simultaneous replacement of the aortic arch and adjacent segments.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland.
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Alameddine AK, Alimov VK, Flack JE. Alternative perfusion technique without axillary artery cannulation during combined aortic root and total arch replacement. J Card Surg 2013; 28:427-9. [PMID: 23692659 DOI: 10.1111/jocs.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report describes an effective cerebral perfusion method using an additional 4th side limb graft sewn to a trifurcated graft in patients undergoing redo aortic root reconstruction combined with total aortic arch replacement. This method is useful in cases where the origin of the innominate artery is unsuitable for clamping or when axillary perfusion is not employed, and assures continuous brain protection and minimizes circulatory arrest time.
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Affiliation(s)
- Abdallah K Alameddine
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, Massachusetts 01107, USA
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Hagl C, Pichlmaier M, Khaladj N. Elephant trunks in aortic surgery: fresh and frozen. J Thorac Cardiovasc Surg 2013; 145:S98-102. [PMID: 23410783 DOI: 10.1016/j.jtcvs.2012.11.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
Abstract
Aneurysmal diseases are often silent but can cause potentially life-threatening complications in cases of dissection or rupture. Surgical strategies depend on the involved part of the aorta and frequently require extracorporeal circulation and circulatory arrest. From data available from the Centers for Disease Control and Prevention, aneurysm disease is the 18th most common cause of death in all individuals, and the incidence is certain to increase as our population ages. This article discusses different treatment options introduced in the past few decades to address multifocal pathologic conditions of the thoracic aorta. These include the conventional elephant trunk procedure introduced by Hans Borst in 1983, with several modifications, and also hybrid procedures combining open surgical and endovascular techniques: the so-called frozen elephant trunk. Advantages and drawbacks of both techniques will be discussed based on personal and practical perspectives, with specific mention of the elephant trunk procedure in acute aortic dissections.
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Affiliation(s)
- Christian Hagl
- Department of Cardiac Surgery, University Hospital Munich, Munich, Germany.
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Griepp RB, Di Luozzo G. Hypothermia for aortic surgery. J Thorac Cardiovasc Surg 2013; 145:S56-8. [PMID: 23410782 DOI: 10.1016/j.jtcvs.2012.11.072] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/16/2012] [Accepted: 11/28/2012] [Indexed: 12/13/2022]
Abstract
Hypothermic circulatory arrest has been used during aortic arch repairs with acceptable neurologic outcomes. Through the years, we have studied the effects of deep hypothermia on brain metabolism and perfusion both in a pig model and in surgical patients. Hypothermic circulatory arrest has also been used as a method of organ protection in the repair of thoracoabdominal aortic aneurysms. We summarize the clinical and laboratory studies to support the routine use of hypothermic circulatory arrest in clinical practice.
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Affiliation(s)
- Randall B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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Uchida N, Katayama K, Takahashi S, Sueda T. Modified arch-first technique performed on a beating heart for an arch aneurysm with atheromatous plaques. Ann Vasc Dis 2013; 6:226-9. [PMID: 23825510 DOI: 10.3400/avd.hdi.12.00072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 02/14/2013] [Indexed: 11/13/2022] Open
Abstract
A shaggy aorta with unstable atheromatous plaques has a high risk of neurologic complications in cases of arch aneurysm. We report the use of a modified arch-first technique involving arch replacement for a beating heart after reconstruction of supra-aortic vessels while maintaining normal blood pressure. The procedure was performed in a patient who had an arch aneurysm, complicated by an aberrant right subclavian artery (ARSA) and a shaggy aorta ascending to the aortic arch. This modified arch-first technique is an alternative surgical approach that is used for arch aneurysms involving a shaggy aorta, in order to prevent embolic debris-related complications.
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Affiliation(s)
- Naomichi Uchida
- Division of Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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34
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Di Luozzo G. Visceral and spinal cord protection during thoracoabdominal aortic aneurysm repair: Clinical and laboratory update. J Thorac Cardiovasc Surg 2013; 145:S135-8. [DOI: 10.1016/j.jtcvs.2012.11.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 10/12/2012] [Accepted: 11/28/2012] [Indexed: 11/28/2022]
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35
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Yokoi Y, Azuma T, Yamazaki K. Advantage of a precurved fenestrated endograft for aortic arch disease: Simplified arch aneurysm treatment in Japan 2010 and 2011. J Thorac Cardiovasc Surg 2013; 145:S103-9. [DOI: 10.1016/j.jtcvs.2012.11.058] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 09/13/2012] [Accepted: 11/28/2012] [Indexed: 11/29/2022]
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36
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Aortic arch replacement for degenerative aneurysms: advances during the last decade. Gen Thorac Cardiovasc Surg 2012; 61:191-6. [DOI: 10.1007/s11748-012-0166-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Indexed: 10/27/2022]
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Qi R, Sun L, Zhu J, Liu Y, Zheng J, Li C, Chang Q. Total arch replacement in patients with aortic dissection with an isolated left vertebral artery. Ann Thorac Surg 2012; 95:36-40. [PMID: 23040824 DOI: 10.1016/j.athoracsur.2012.07.078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 07/21/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The presence of an isolated left vertebral artery requires changes in the aortic arch reconstruction techniques and cerebral protection methods in patients with total arch replacement. The best method for surgical repair of the isolated left vertebral artery is controversial. We retrospectively reviewed our experience of total arch replacement in patients with aortic dissection with this vessel anomaly. METHODS Between August 2003 and December 2008, 21 patients with aortic dissection (type A dissection, n = 20; type B dissection, n = 1) with an isolated left vertebral artery underwent total arch replacement under hypothermic cardiopulmonary bypass combined with selective cerebral perfusion. Concomitant stented elephant trunk was implanted in 20 patients. RESULTS There was no in-hospital death. Injury to the spinal cord occurred in 2 patients with chronic dissection using stented elephant trunk implantation. One had weakness in the left lower extremity, and the other patient had paraparesis: both recovered during the follow-up period. One patient experienced transient neurologic deficit, and acute renal failure was observed in 1 patient: both recovered completely before hospital discharge. CONCLUSIONS Acceptable results were obtained in patients with aortic dissection with an isolated left vertebral artery. Although there was no clear evidence that the spinal cord injury was related to the isolated left vertebral artery using stented elephant trunk implantation, the isolated left vertebral artery was constructed as soon as possible in patients with this vessel anomaly.
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Affiliation(s)
- RuiDong Qi
- Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Di Luozzo G, Griepp RB. Cerebral Protection for Aortic Arch Surgery: Deep Hypothermia. Semin Thorac Cardiovasc Surg 2012; 24:127-30. [DOI: 10.1053/j.semtcvs.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/11/2022]
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Selective cerebral perfusion for thoracic aortic surgery: Association with neurocognitive outcome. J Thorac Cardiovasc Surg 2012; 143:1205-12. [DOI: 10.1016/j.jtcvs.2012.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 11/18/2011] [Accepted: 01/04/2012] [Indexed: 11/16/2022]
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Lu S, Lai H, Wang C, Sun X, Hong T, Song K, Yuan Z, Liu X. Surgical treatment for retrograde type A aortic dissection after endovascular stent graft placement for type B dissection. Interact Cardiovasc Thorac Surg 2012; 14:538-42. [PMID: 22361126 DOI: 10.1093/icvts/ivs043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Retrograde type A aortic dissection (RTAD) is a life-threatening and underestimated complication of endovascular stent graft placement for type B dissection. Here, we retrospectively investigated our experience of surgical treatment for RTAD after endovascular stent graft placement for type B dissection. Between June 2006 and September 2011, nine patients with RTAD were transferred to our department for surgery. Total arch replacement was performed in six patients and three patients underwent subtotal arch replacement. Associated procedures consisted of ascending aorta replacement in nine patients, coronary artery bypass grafting in one patient and aortic valve plasty in two patients. All operations were performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Cardiopulmonary bypass time was 158.33 ± 29.18 min. The myocardial ischaemic time was 78.11 ± 28.30 min. The antegrade cerebral perfusion time was 38.67 ± 12.34 min. The mean ventilation time was 45.63 ± 24.74 h. A tracheotomy was necessary in one patient. The ICU time was 7.00 ± 6.80 days and the in-hospital duration was 25.33 ± 11.95 days. There was no in-hospital mortality. The mean follow-up was 34.79 ± 19.37 months and eight patients are still alive. One patient was lost to follow-up. Surgical treatment for RTAD is a safe alternative and the results are encouraging.
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Affiliation(s)
- Shuyang Lu
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
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41
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Moderate Hypothermie in der Aortenbogenchirurgie: eine Gefahr für das Rückenmark? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-011-0893-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nakamura K, Nakamura E, Yano M, Niina K, Kojima K, Onitsuka T. Factors influencing permanent neurologic dysfunction and mortality after total arch replacement with separate arch vessel grafting using selective cerebral perfusion. Ann Thorac Cardiovasc Surg 2011; 17:39-44. [PMID: 21587127 DOI: 10.5761/atcs.oa.09.01514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 01/06/2010] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The present study was undertaken to identify risk factors for permanent neurological dysfunction (PND) and in-hospital mortality after total aortic arch replacement (TAR) with separate arch vessel grafting using selective cerebral perfusion (SCP) and hypothermic circulatory arrest. METHODS Between 1998 and 2008, we preformed a TAR on 143 consecutive patients in two centers by identical methods. Of these, 19 (13.3%) were emergency operations, and 46 (32.2%) were open stent-graft placements. Statistical analysis was performed to determine risk factors for PND and mortality, and furthermore, the survival rate was analyzed. RESULTS The in-hospital mortality rate was 4.9%, with chronic renal failure (p = 0.0013, odds ratio 10.0) as a significant risk factor. Nine patients (6.3%) had PND, with significant risk factors identified as (1) the presence of an old cerebral or silent lacunar infarction on preoperative imaging methods (p = 0.0458, odds ratio 8.0) and (2) duration of SCP (p = 0.0026, odds ratio 1.036). Long-term survival was the same in patients with or without PND. CONCLUSION The enhanced vulnerability of the brain in patients with a pre-existing old cerebral infarction or silent lacunar infarction is reflected by a high incidence of PND. Chronic renal failure had an impact on in-hospital mortality.
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Affiliation(s)
- Kunihide Nakamura
- The Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, 2-1-1 Shin-Koji, Nobeoka, Miyazaki, Japan.
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Kulik A, Castner CF, Kouchoukos NT. Outcomes After Total Aortic Arch Replacement With Right Axillary Artery Cannulation and a Presewn Multibranched Graft. Ann Thorac Surg 2011; 92:889-97. [DOI: 10.1016/j.athoracsur.2011.04.067] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 04/12/2011] [Accepted: 04/15/2011] [Indexed: 10/17/2022]
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Davies RA, Black D, Jeremy RW, Bannon PG, Bayfield MS, Hendel PN, Hughes CF, Wilson MK, Vallely MP. Evolution in the techniques and outcomes of aortic arch surgery: a 22 year single centre experience. Heart Lung Circ 2011; 20:704-11. [PMID: 21872527 DOI: 10.1016/j.hlc.2011.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 07/22/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Aortic arch replacement is a complicated and high risk procedure. There have been many advances over recent years. We review the changes in our unit's techniques and outcomes over the past 22 years. METHODS Data were collated from databases and medical records for all patients who underwent aortic arch replacement surgery from January 1989 to December 2010. The patients were divided into two groups - Group A (1989-2005) and Group B (2006-2010). Data were analysed to compare early and late series patients' outcomes. Logistic regression was used to identify variables that predicted mortality. RESULTS Seventy-five eligible patients (56 males; mean age: 57.5 years; Group A: 40, Group B 35) were identified. There were great changes in the technique and the methods of cerebral protection. The overall mortality rate was 30.7% - Group A: 50% and Group B: 8.6% (p<0.001). Overall permanent neurological dysfunction was 23.7% - Group A: 40% and Group B: 11.8% (p=0.012). Cardiovascular disease and circulatory arrest time were significant predictors of mortality. CONCLUSIONS Increased experience and volume and advances in techniques over 22 years have resulted in major improvements in outcomes for patients having aortic arch replacement, allowing the procedure to be performed with greatly improved outcomes.
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Affiliation(s)
- Reece A Davies
- Faculty of Medicine, The University of Sydney, Sydney, Australia
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45
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Bonnichsen CR, Sundt TM, Anavekar NS, Foley TA, Morris MF, Martinez MW, Williamson EE, Glockner JF, Araoz PA. Aneurysms of the ascending aorta and arch: the role of imaging in diagnosis and surgical management. Expert Rev Cardiovasc Ther 2011; 9:45-61. [PMID: 21166528 DOI: 10.1586/erc.10.168] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture occurred. Better imaging techniques and an increase in the use of cross-sectional imaging has led to an increase in the diagnosis of aortic aneurysms, which has allowed for elective treatment prior to the development of a complication. The location, size and etiology of an aneurysm all impact the clinical outcomes and these factors are used to determine the appropriate timing of surgical replacement. Surgeons often rely on the information obtained from preoperative imaging to determine when to intervene and what type of procedure will be necessary, making it important for the radiologist to understand these issues in order to provide the necessary information. Postoperative imaging after surgical replacement of the aorta is also important, as there are some common findings that occur in this patient population that can impact how they are treated. The purpose of this article is to review the etiology and associated findings of aneurysms of the ascending aorta and arch, with a focus on how computed tomography angiography and magnetic resonance angiography findings are used to determine the appropriate timing for elective replacement and the type of surgical procedure, as well as the role of follow-up imaging. This will include a review of the most commonly performed types of surgical procedures, to provide an understanding of how the findings of preoperative imaging studies impact what the surgeon does in the operating room, as well as the expected findings of postoperative imaging studies.
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Affiliation(s)
- Crystal R Bonnichsen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic and Mayo Foundation, 200 1st Street SW, Rochester, MN 55905, USA
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Noninvasive cerebral oxygenation may predict outcome in patients undergoing aortic arch surgery. J Thorac Cardiovasc Surg 2011; 141:815-21. [DOI: 10.1016/j.jtcvs.2010.05.017] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 05/05/2010] [Accepted: 05/16/2010] [Indexed: 11/15/2022]
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LeMaire SA, Price MD, Parenti JL, Johnson ML, Lay AD, Preventza O, Huh J, Coselli JS. Early Outcomes After Aortic Arch Replacement by Using the Y-Graft Technique. Ann Thorac Surg 2011; 91:700-7; discussion 707-8. [DOI: 10.1016/j.athoracsur.2010.11.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 11/07/2010] [Accepted: 11/08/2010] [Indexed: 11/16/2022]
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48
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Di Bartolomeo R, Pilato E, Pacini D, Savini C, Di Eusanio M. Cerebral protection during surgery of the aortic arch. Multimed Man Cardiothorac Surg 2011; 2011:mmcts.2010.004457. [PMID: 24414117 DOI: 10.1510/mmcts.2010.004457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Brain injury represents a primary concern during aortic arch surgery. Valid surgical techniques and reliable methods of brain protection are required to obtain a favorable outcome after such a complex surgery. Our aim was to review available methods of brain protection including deep hypothermia and circulatory arrest, retrograde cerebral perfusion and antegrade cerebral perfusion.
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Affiliation(s)
- Roberto Di Bartolomeo
- Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40124 Bologna, Italy
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Bischoff MS, Brenner RM, Scheumann J, Bodian CA, Griepp RB, Lansman SL, Spielvogel D. Long-term outcome after aortic arch replacement with a trifurcated graft. J Thorac Cardiovasc Surg 2010; 140:S71-6; discussion S86-91. [DOI: 10.1016/j.jtcvs.2010.07.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/12/2010] [Indexed: 11/28/2022]
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50
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Xydas S, Wei B, Takayama H, Russo M, Bacchetta M, Smith CR, Stewart A. Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction. J Thorac Cardiovasc Surg 2010; 139:717-22; discussion 722. [DOI: 10.1016/j.jtcvs.2009.10.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Revised: 09/28/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
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