1
|
Mylonas SN, Mammadov R, Dorweiler B. Complementary Thoracic Endovascular Aortic Repair (TEVAR) after Frozen Elephant Trunk for Residual Type A Aortic Dissection: Perioperative and Mid-Term Outcomes. J Clin Med 2024; 13:3007. [PMID: 38792548 PMCID: PMC11122292 DOI: 10.3390/jcm13103007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/06/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Objectives: The aim of this retrospective study was to evaluate the results of complementary TEVAR following the frozen elephant trunk (FET) procedure for patients with residual type A aortic dissection (rTAAD) in terms of technical feasibility, safety and mid-term outcomes. Methods: This was a retrospective single-centre analysis of patients who received TEVAR after FET for rTAAD from January 2012 up to December 2021. The primary endpoint was technical success. Safety parameters included 30-day/in-hospital morbidity and mortality. Furthermore, mid-term clinical and morphological outcomes were evaluated. Results: Among 587 TEVAR procedures, 60 patients (11 with connective tissue disorders) who received TEVAR after FET for rTAAD were identified. The median interval between FET and TEVAR was 28.5 months. Indications for TEVAR after FET were true lumen collapse distal to FET prosthesis (n = 7), dSINE (n = 2), planned completion (n = 13) and aortic diameter progression (n = 38). In forty-seven patients, TEVAR was performed in an elective setting; eight and six patients were operated on in an urgent or emergency setting, respectively. All TEVAR procedures were successfully completed. The 30-day mortality and spinal cord ischemia rates were 1.7%. During a median follow-up of 37 months, two further patients died. Nine patients had to undergo a further aortic intervention: fenestrated stent-graft (n = 3) or open repair of the infrarenal abdominal aorta (n = 6). Conclusions: Complementary TEVAR following FET for rTAAD showed excellent technical success and low perioperative risk, supporting the feasibility and safety of this strategy. Despite the favourable mid-term survival, certain patients might require a further aortic procedure.
Collapse
Affiliation(s)
- Spyridon N. Mylonas
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (R.M.); (B.D.)
| | | | | |
Collapse
|
2
|
Özçınar E, Yazıcıoğlu L, Dikmen N, Durmaz O, Guven A, Cahit Sarıcaoğlu M, Akca F, Ada A. Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:236-242. [PMID: 38933306 PMCID: PMC11197407 DOI: 10.5606/tgkdc.dergisi.2024.26062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 06/28/2024]
Abstract
In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.
Collapse
Affiliation(s)
- Evren Özçınar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Levent Yazıcıoğlu
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Oguzhan Durmaz
- Department of Cardiovascular Surgery, Perfusion Unit, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Aysegul Guven
- Department of Anesthesiology and Reanimation, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Mehmet Cahit Sarıcaoğlu
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Fatma Akca
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Altan Ada
- Department of Cardiovascular Surgery, Perfusion Unit, Ankara University Faculty of Medicine, Ankara, Türkiye
| |
Collapse
|
3
|
Geragotellis A, Jubouri M, Al-Tawil M, Mohammed I, Bashir M, Hosseini S. The Fate of Conventional Elephant Trunk in the Frozen Elephant Trunk Era. AORTA (STAMFORD, CONN.) 2023; 11:174-190. [PMID: 38754437 PMCID: PMC11219132 DOI: 10.1055/s-0044-1786352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/08/2023] [Indexed: 05/18/2024]
Abstract
Conventional elephant trunk (cET) and frozen elephant trunk (FET) are two distinct approaches to the surgical treatment of thoracic aortic aneurysms and dissections. With the advent and growing uptake of endovascular technologies, FET is becoming increasingly popular for its potential to be performed as a single-stage operation with better aortic remodeling and less risk of graft kinking than the traditional two-stage cET procedure. However, FET has been associated with a higher risk of spinal cord ischemia and its use in patients with connective tissue disorder remains controversial. The current review aimed to reflect on recent evidence surrounding the application of cET and FET to different types of aortic pathology in both acute and elective settings. Another scope of this review was to compare the characteristics of the currently available FET commercial devices on the global market. Our findings highlight that when the pathology is confined to the proximal descending aorta, such as in Dsine, intervention is often single-staged and false lumen (FL) thrombosis is achieved with good effect. FET remains limited by spinal cord injury and applicability in patients with connective tissue disorder, although some groups have started to circumvent associated complications, likely due to growing surgical expertise. Many other aortic diseases do require second-stage intervention, and even in these cases, there appears to be lower in-hospital mortality when using FET over cET. This is possibly due to the higher rate of endovascular completion facilitated by the completed landing zones created during FET. FET is trending toward becoming the universal treatment modality for extending repair to the descending aorta.
Collapse
Affiliation(s)
| | | | | | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Department of Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, United Kingdom
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
4
|
Zea-Vera R, Green SY, Amarasekara HS, Orozco-Sevilla V, Preventza O, LeMaire SA, Coselli JS. Contemporary Midterm Outcomes After Primary Repair of Chronic Type A Aortic Dissection. Ann Thorac Surg 2023; 116:459-466. [PMID: 36528124 DOI: 10.1016/j.athoracsur.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/21/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Without surgical repair, acute type A aortic dissection (TAAD) is usually fatal. However, some patients survive without an early operation and progress to the chronic phase. Contemporary outcomes of primary surgical repair of chronic TAAD are unclear, so we evaluated them at our single-practice service. METHODS During 1990 to 2021, 205 patients underwent repair of TAAD in the chronic phase (>60 days after onset). The 2 relevant DeBakey classifications were nearly equally represented: type I, 52% (n = 107), and type II, 48% (n = 98). The median interval between dissection onset and repair was 7 months (interquartile range, 3-25 months). Kaplan-Meier and competing-risk analyses provided time-dependent outcomes. RESULTS At the time of intervention, most patients (40%) had chronic symptoms. Type I patients were younger than type II patients; however, comorbidities were similar. Most patients (n = 183 [87%]) underwent hemiarch or total arch repair, although total arch replacement was more common in type I dissection (P < .001). There were 15 operative deaths (7%), and 7 strokes (3%) persisted to the time of death or discharge. No patient had persistent paraplegia. Median follow-up was 5 years (interquartile range, 2-11 years). The 5-year reoperation-free survival was 61% (95% CI, 54%-68%), and the incidence of reoperation was 3% (95% CI, 0.4%-5%). Patients with type I and type II dissection did not differ significantly in survival (P = .2). CONCLUSIONS Durable repair can be achieved with reasonable operative risk. Treatment is individualized and is associated with low rates of persistent neurologic complications. Despite differing operative approaches by DeBakey type, early and late outcomes were similar.
Collapse
Affiliation(s)
- Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
5
|
Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene. Life (Basel) 2022; 12:life12101511. [DOI: 10.3390/life12101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.
Collapse
|
6
|
Right Heart Failure as an Atypical Presentation of Chronic Type A Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A case report and mini-review of literature. J Crit Care Med (Targu Mures) 2022; 8:204-213. [PMID: 36062037 PMCID: PMC9396954 DOI: 10.2478/jccm-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment. Case presentation A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained. Conclusion This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.
Collapse
|
7
|
Pavlou A, Cardenas Ramos L, Vanek M, Regelmann DJ. A Case of Chronic Aortic Dissection With Hemopericardium and Tamponade. Cureus 2022; 14:e23924. [PMID: 35530841 PMCID: PMC9076048 DOI: 10.7759/cureus.23924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/14/2022] Open
Abstract
Type A aortic dissection involves the separation of the wall of the ascending aorta into a true lumen and a false lumen. The finding of an aortic dissection in a patient experiencing mild to moderate symptoms for several weeks may be surprising for clinicians, given the severity of the underlying process. Here, we present an 88-year-old patient who was admitted to our hospital due to orthopnea and leg swelling for the past two to three weeks and was found to have a chronic dissection of the ascending aorta, complicated by hemopericardium and tamponade. The existing literature very rarely reports chronic type A aortic dissection with tamponade on presentation.
Collapse
|
8
|
Shetty V, Shetty DP, Rao PV, Hosabettu PK, Subramanian S, Vikneswaran G, Narayan P. Determinant of outcome in late presenting type A aortic dissection. J Card Surg 2022; 37:1654-1660. [DOI: 10.1111/jocs.16401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Varun Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Parachuri Venkat Rao
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Praveen Kumar Hosabettu
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Sendur Subramanian
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Gunaseelan Vikneswaran
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Pradeep Narayan
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| |
Collapse
|
9
|
Vasudevan TM, Sivakumaran Y. “More or less”: management of type A aortic dissections in the endovascular era. Indian J Thorac Cardiovasc Surg 2022; 38:193-197. [PMID: 35463709 PMCID: PMC8980979 DOI: 10.1007/s12055-021-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/17/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022] Open
Abstract
The management of type A aortic dissection presents a major therapeutic challenge in modern surgical practice. Whilst the traditional dictum, to provide timely surgical intervention with the minimum treatment needed to repair the ascending aorta as well as the primary tear, may be a reasonable strategy in older patients, a tailored approach is desired for younger patients to manage the immediate life-threatening condition, as well as for the management of lifelong complications of the residual dissected aorta. Endovascular technology continues to advance, providing an adjunctive role to open cardiac repair presently to manage downstream aortic pathology, with the aim of striving towards a complete endovascular solution for type A aortic dissections.
Collapse
Affiliation(s)
| | - Yogeesan Sivakumaran
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, QLD Australia
| |
Collapse
|
10
|
Wu J, Xie E, Qiu J, Huang Y, Jiang W, Zafar MA, Zhang L, Yu C. Subacute/chronic type A aortic dissection: a retrospective cohort study. Eur J Cardiothorac Surg 2021; 57:388-396. [PMID: 31317195 DOI: 10.1093/ejcts/ezz209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Our goal was to outline the clinical presentations, surgical treatment and outcomes of subacute/chronic type A aortic dissection (TAAD). METHODS A total of 1092 patients with TAAD were enrolled retrospectively and divided into 2 groups based on acuity of TAAD (181 subacute/chronic vs 911 acute cases of TAAD). Early and late outcomes were investigated and compared using propensity score matching. RESULTS The top 3 symptoms for subacute/chronic TAAD were chest tightness (80/181, 44.2%), mild pain (65/181, 35.9%) and sweating (58/181, 32.0). Fifteen (15/181, 8.3%) patients were symptom-free. Typical symptoms of acute TAAD were less common in patients with subacute/chronic TAAD such as intense/sharp pain (48/181, 26.5%), tear-like pain (35/181, 19.3%) and radiating pain (30/181, 16.6%). Patients with subacute/chronic TAAD had better early and late survival rates, with an early mortality rate of 6.1% (11/181) compared to 11.6% (106/911) of those with acute TAAD (P = 0.038). Before propensity score matching, survival at 1, 3 and 5 years was 93.1% [95% confidence interval (CI) 89.4-96.9%], 88.4% (95% CI 83.1-93.9%) and 86.4% (95% CI 80.1-93.1%) for subacute/chronic TAAD and 86.9% (95% CI 84.7-89.2%), 82.6% (95% CI 79.9-85.3%) and 79.0% (95% CI 75.5-82.7%) for acute TAAD, respectively (P = 0.039). The propensity score matching analysis substantiated the foregoing results. CONCLUSIONS Subacute/chronic TAAD was clearly distinct from acute TAAD in terms of clinical presentations and had better early and late survival rates. Current surgical strategies for acute TAAD are applicable to subacute/chronic TAAD with excellent outcomes.
Collapse
Affiliation(s)
- Jinlin Wu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China.,Aortic Institute at Yale-New Haven Hospital, New Haven, CT, USA
| | - Enzehua Xie
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Yan Huang
- Beijing University of Chinese Medicine, Beijing, China
| | - Wenxiang Jiang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | | | - Liang Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China
| |
Collapse
|
11
|
Orozco-Sevilla V, Coselli JS. Surgical strategies in the management of chronic dissection of the thoracoabdominal aorta. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:302-315. [PMID: 33565747 DOI: 10.23736/s0021-9509.21.11806-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Most operations for dissection of the thoracoabdominal aorta take place in the chronic phase of the disease, because the acutely dissected distal aorta is almost always initially treated non-surgically with aggressive pharmacological anti-impulse therapy. Identifying patients who are no longer responding to medical treatment is the first step in preventing further disease progression and rupture. Symptomatic aneurysms should be promptly repaired. Asymptomatic patients are followed until significant aortic dilation occurs and reaches a threshold of intervention: current guidelines endorse repair once a diameter of 5.5 cm is reached. In patients with heritable thoracic aortic disease (such as Marfan Syndrome), the threshold of intervention is often lowered. Aortic replacement typically centers on the dilatated segment. For all extents of repair, we use passive mild hypothermia, sequential aortic cross-clamping, aggressive reimplantation of intercostal and lumbar arteries, and cold renal perfusion whenever possible. For Crawford extents I and II thoracoabdominal aneurysm repair, we routinely use cerebrospinal fluid drainage, left heart bypass, and selective visceral perfusion. A four-branched graft approach to thoracoabdominal aortic aneurysm repair is frequently used in patients with chronic aortic dissection; this approach facilitates visceral artery perfusion during repair, expedites the distal anastomosis, and prevents subsequent visceral patch aneurysms. Lifelong imaging surveillance is necessary, because the distal aorta often continues to expand; residual aortic dissection commonly remains after repair and may necessitate further repair.
Collapse
Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA - .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health - Baylor St. Luke's Medical Center, Houston, TX, USA
| |
Collapse
|
12
|
Kassab K, Jolly N, Vij A. Middle-Aged Man With Unstable Angina and an Inaccessible Right Coronary Artery. Cureus 2020; 12:e11156. [PMID: 33251064 PMCID: PMC7686933 DOI: 10.7759/cureus.11156] [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] [Indexed: 11/18/2022] Open
Abstract
Acute myocardial ischemia and infarction from retrograde dissection of the aortic root into the coronary ostia is a potentially fatal condition. Unrecognized type A aortic dissection at the time of angiography for acute coronary syndrome (ACS) carries a high burden of morbidity and mortality. Cardiac computed tomography angiography (CCTA) has emerged as one of the instrumental tools in the diagnosis of retrograde coronary involvement from type A aortic dissections. We present a case of ACS secondary to retrograde aortic dissection extending into the right coronary artery (RCA) suspected during coronary angiography and confirmed by CCTA. The patient was managed surgically with aortic root replacement and coronary artery bypass grafting.
Collapse
Affiliation(s)
- Kameel Kassab
- Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Neeraj Jolly
- Cardiology, Rush University Medical Center, Chicago, USA
| | - Aviral Vij
- Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA
| |
Collapse
|
13
|
Chen Y, Ma WG, Li JR, Zheng J, Liu YM, Zhu JM, Sun LZ. Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome? Ann Cardiothorac Surg 2020; 9:197-208. [PMID: 32551252 DOI: 10.21037/acs.2020.03.10] [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] [Indexed: 01/16/2023]
Abstract
Background Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS. Methods The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed. Results Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death. Conclusions This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.
Collapse
Affiliation(s)
- Yu Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Jian-Rong Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing 100037, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing 100037, China
| |
Collapse
|
14
|
Moeller E, Nores M, Stamou SC. Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 7:155-162. [PMID: 32272487 PMCID: PMC7145439 DOI: 10.1055/s-0039-3401810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.
Collapse
Affiliation(s)
- Ellie Moeller
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Marcos Nores
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| |
Collapse
|
15
|
Peterss S, Hagl C, Pichlmaier M. Chronic aortic dissection type A: simply an overlooked acute event? Eur J Cardiothorac Surg 2020; 57:397-398. [PMID: 31364697 DOI: 10.1093/ejcts/ezz218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | | |
Collapse
|
16
|
Maffè S, Nicali R, Dellavesa P, Paffoni P, Bergamasco L, Parravicini U. An atypical case of Stanford type-A chronic aortic dissection managed conservatively. Echocardiography 2019; 36:1936-1940. [PMID: 31573719 DOI: 10.1111/echo.14493] [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: 09/04/2019] [Accepted: 09/11/2019] [Indexed: 11/28/2022] Open
Abstract
Stanford type-A aortic dissection is a clinical emergency; mortality is high, and surgery is urgently required in most cases. Chronic forms of type-A dissection are rare and have a poor prognosis if not treated surgically. We present an unusual case of chronic type-A aortic dissection, with silent onset, in an oncologic patient without risk factors, which was managed conservatively and remained substantially stable during follow-up.
Collapse
Affiliation(s)
- Stefano Maffè
- Division of Cardiology, SS Trinita' Borgomanero Hospital, ASL No, Novara, Italy
| | - Roberta Nicali
- Division of Respiratory Medicine, Medical Department, University of Piemonte Orientale, AOU Maggiore della Carità di Novara, Novara, Italy
| | | | - Paola Paffoni
- Division of Cardiology, SS Trinita' Borgomanero Hospital, ASL No, Novara, Italy
| | - Luca Bergamasco
- Division of Cardiology, SS Trinita' Borgomanero Hospital, ASL No, Novara, Italy
| | - Umberto Parravicini
- Division of Cardiology, SS Trinita' Borgomanero Hospital, ASL No, Novara, Italy
| |
Collapse
|
17
|
Gudbjartsson T, Ahlsson A, Geirsson A, Gunn J, Hjortdal V, Jeppsson A, Mennander A, Zindovic I, Olsson C. Acute type A aortic dissection - a review. SCAND CARDIOVASC J 2019; 54:1-13. [PMID: 31542960 DOI: 10.1080/14017431.2019.1660401] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.
Collapse
Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anders Ahlsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jarmo Gunn
- Department of Cardiothoracic Surgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ari Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland
| | - Igor Zindovic
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Department of Cardiothoracic Surgery, Lund, Sweden
| | - Christian Olsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
18
|
Chronic Type A Aortic Dissection: Rare Presentation of Incidental Pericardial Effusion. Case Rep Cardiol 2019; 2019:3562871. [PMID: 31192016 PMCID: PMC6525833 DOI: 10.1155/2019/3562871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/08/2019] [Accepted: 04/02/2019] [Indexed: 01/16/2023] Open
Abstract
Aortic dissection is the most devastating sequelae of aortopathy other than aortic rupture. However, aortic dissection can be asymptomatic in the acute phase with delayed symptomatic presentation or incidental diagnosis upon chest imaging. We report a case of a 63-year-old male who was diagnosed with pericardial effusion upon preoperative workup for elective cholecystectomy. Further investigations confirmed hemorrhagic pericardial effusion secondary to a chronic dissecting ascending aortic aneurysm. The patient condition was successfully managed with open surgical repair with an uneventful postoperative course. This case demonstrates an extremely rare presentation of incidental hemorrhagic pericardial effusion caused by a chronic dissecting ascending aortic aneurysm.
Collapse
|
19
|
Nishida H, Ota T. Commentary: Ongoing challenges for optimal strategy of aortic arch surgery. J Thorac Cardiovasc Surg 2019; 159:390-391. [PMID: 30902469 DOI: 10.1016/j.jtcvs.2019.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Hidefumi Nishida
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill
| | - Takeyoshi Ota
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill.
| |
Collapse
|
20
|
Ertugay S, Apaydın A, Baysal B. Kronik tip a aort diseksiyonunun cerrahi tedavisi: Erken dönem sonuçlar. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.418028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
21
|
Bhardwaj R, Mahajan K, Sondhi S. Chronic painless stanford type a aortic dissection involving whole of the aorta in an elderly female. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2019. [DOI: 10.4103/jpcs.jpcs_14_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
22
|
Zhong YL, Qi RD, Ma WG, Ge YP, Qiao ZY, Li CN, Zhu JM, Sun LZ. Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection. J Thorac Dis 2018; 10:5376-5383. [PMID: 30416785 DOI: 10.21037/jtd.2018.08.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD). Methods From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up. Results In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%. Conclusions Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.
Collapse
Affiliation(s)
- Yong-Liang Zhong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Rui-Dong Qi
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| |
Collapse
|
23
|
Distinguishing acute from chronic aortic dissections using CT imaging features. Int J Cardiovasc Imaging 2018; 34:1831-1840. [PMID: 29915877 DOI: 10.1007/s10554-018-1398-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/13/2018] [Indexed: 10/14/2022]
Abstract
The aim was to compare computed tomography (CT) features in acute and chronic aortic dissections (AADs and CADs) and determine if a certain combination of imaging features was reliably predictive of the acute versus chronic nature of disease in individual patients. Consecutive patients with aortic dissection and a chest CT scan were identified, and 120 CT scans corresponding to 105 patients were reviewed for a variety of imaging features. Statistical tests assessed for differences in the frequency of these features. A predictive model was created and tested on an additional 120 CT scans from 115 patients. Statistically significant features of AAD included periaortic confluent soft tissue opacity, curved dissection flap, and highly mobile dissection flap, and features of CAD included thick dissection flap, false lumen (FL) outer wall calcification, FL thrombus, dilated FL, and tear edges curling into the FL. The model predicted the chronicity of a dissection with an area under the curve of 0.98 (CI 0.98-1.00). AADs and CADs demonstrated significantly different CT imaging features.
Collapse
|
24
|
Tinelli G, Ferraresi M, Watkins AC, Soler R, Fadel E, Fabre D, Haulon S. Frozen elephant trunk and arch endografts for chronic thoracoabdominal aortic dissections. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:775-783. [PMID: 29786413 DOI: 10.23736/s0021-9509.18.10579-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic aortic dissecting aneurysms (TAAD) presenting after acute Stanford type A or B dissection includes both arch and/or thoracoabdominal aortic aneurysms (TAAA). Approximately 60% of patients who survive surgical treatment of acute type A aortic dissections will require another aortic procedure. Similarly, more than 70% of patients with chronic type B aortic dissections will experience false lumen dilation at 5-year follow-up, often requiring intervention. Open or hybrid aortic repairs of complex TAAD involving the arch and the TAAA are very demanding procedures for both patients and clinicians. Open surgery remains the first line therapy in fit patients. Recent development of branched arch devices has offered an alternative option for high-risk patients. Technical challenges associated with the endovascular management of these complex aneurysms include proximal sealing zone often located in the aortic arch or the ascending aorta, narrow true lumen working space, and aortic branch perfusion by either the true or false lumen, or both. Recent studies have reported encouraging results with endovascular treatment of these complex dissecting aneurysms, especially following open ascending aortic repair. The aim of this review was to describe the available strategies for arch repair in the setting of a chronic TAAD and to determine the subset of patients that can benefit from of a totally endovascular approach.
Collapse
Affiliation(s)
- Giovanni Tinelli
- Unit of Vascular Surgery, Center for Cardiovascular and Thoracic Surgery, Policlinico A. Gemelli University Foundation, Rome, Italy
| | - Marco Ferraresi
- Unit of Vascular Surgery, Center for Cardiovascular and Thoracic Surgery, Policlinico A. Gemelli University Foundation, Rome, Italy
| | - A Claire Watkins
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France.,Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Elie Fadel
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France -
| |
Collapse
|
25
|
Liu YY, Li HY, Jiang WJ, Guan XL, Wang XL, Liu O, Zhu JM, Sun LZ, Zhang HJ. Treatment of patients with aortic disease during pregnancy and after delivery. J Int Med Res 2017; 45:1359-1368. [PMID: 28587539 PMCID: PMC5625542 DOI: 10.1177/0300060517711088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective This study aimed to review treatment of patients with aortic disease during pregnancy and after delivery in Beijing Anzhen Hospital. Methods A retrospective study was conducted using data from 12 patients with aortic disease during pregnancy and after delivery in our institution from May 2005 to December 2014. Patients were provided different treatments based on the type of aortic disease and clinical characteristics. Results The mean age was 29.83 ± 4.17 years, mean height was 171.7 ± 8.22 cm, mean weight was 68.55 ± 10.62 kg, and mean body mass index was 23.18 ± 2.93 kg/m2. Two patients with Stanford type A aortic dissection died of renal failure after surgery. All of the other patients were discharged. Six foetuses survived. One patient continued her pregnancy after an aortic operation. The gestational age of the remaining five patients was less than 28 weeks at the time of the operation and all foetuses of these five patients died. Conclusions A suitable treatment strategy for aortic disease during pregnancy and after delivery should be chosen based on an individual’s comprehensive clinical condition. Foetal management should be chosen based on gestational age and severity of aortic disease.
Collapse
Affiliation(s)
- Yu-Yong Liu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Hai-Yang Li
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Wen-Jian Jiang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Xin-Liang Guan
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Xiao-Long Wang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Ou Liu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Jun-Ming Zhu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Li-Zhong Sun
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Hong-Jia Zhang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.,3 Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,4 Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,5 Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| |
Collapse
|
26
|
Girardi LN. Endovascular Repair of Type A Dissection: Just Because We Can, Does That Mean We Should? Semin Thorac Cardiovasc Surg 2017; 28:318-319. [PMID: 28043437 DOI: 10.1053/j.semtcvs.2016.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, M-404, New York, NY 10065.
| |
Collapse
|
27
|
Peterss S, Mansour AM, Ross JA, Vaitkeviciute I, Charilaou P, Dumfarth J, Fang H, Ziganshin BA, Rizzo JA, Adeniran AJ, Elefteriades JA. Changing Pathology of the Thoracic Aorta From Acute to Chronic Dissection. J Am Coll Cardiol 2016; 68:1054-65. [DOI: 10.1016/j.jacc.2016.05.091] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/25/2016] [Accepted: 05/24/2016] [Indexed: 01/16/2023]
|
28
|
Cabasa A, Pochettino A. Surgical management and outcomes of type A dissection-the Mayo Clinic experience. Ann Cardiothorac Surg 2016; 5:296-309. [PMID: 27563542 DOI: 10.21037/acs.2016.06.01] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes. METHODS All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method. RESULTS Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support post-operatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study. DISCUSSION TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.
Collapse
Affiliation(s)
- Alduz Cabasa
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Pochettino
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
29
|
Hynes CF, Greenberg MD, Sarin S, Trachiotis GD. Chronic Type A Aortic Dissection: Two Cases and a Review of Current Management Strategies. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 4:16-21. [PMID: 27766269 DOI: 10.12945/j.aorta.2015.15.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 10/20/2015] [Indexed: 01/16/2023]
Abstract
Stanford Type A aortic dissection is a rapidly progressing disease process that is often fatal without emergent surgical repair. A small proportion of Type A dissections go undiagnosed in the acute phase and are found upon delayed presentation of symptoms or incidentally. These chronic lesions may have a distinct natural history that may have a better prognosis and could potentially be managed differently then those presenting acutely. The method of repair depends on location and extent of the false lumen, as well as involvement of critical structures and branch arteries. Surgical repair techniques similar to those employed for acute dissection management are currently first-line therapy for chronic cases that involve the aortic valve, sinuses of Valsalva, coronary arteries, and supra-aortic branch arteries. In patients with high-risk for surgery, endovascular repairs have been successful, and active development of delivery systems and grafts will continue to enhance outcomes. We present two cases of chronic Type A aortic dissection and review the current literature.
Collapse
Affiliation(s)
- Conor F Hynes
- Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington District of Columbia, USA
| | - Michael D Greenberg
- Division of Cardiology, Veterans Affairs Medical Center, Washington District of Columbia, USA
| | - Shawn Sarin
- Department Interventional Vascular Radiology, The George Washington University, Washington District of Columbia, USA
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington District of Columbia, USA; Division of Cardiothoracic Surgery, The George Washington University, Washington District of Columbia, USA
| |
Collapse
|
30
|
Katada Y, Kondo S, Tsuboi E, Rokkaku K, Irie Y, Yokoyama H. Endovascular Total Arch Repair Using In Situ Fenestration for Arch Aneurysm and Chronic Type A Dissection. Ann Thorac Surg 2016; 101:625-30. [DOI: 10.1016/j.athoracsur.2015.07.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/24/2015] [Accepted: 07/09/2015] [Indexed: 11/15/2022]
|
31
|
Gennari M, Annoni A, Agrifoglio M. Undiagnosed Stanford type A aortic dissection: a rare survival report. Int J Cardiovasc Imaging 2016; 32:659-60. [PMID: 26757707 DOI: 10.1007/s10554-015-0823-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
Acute aortic dissection is a life-threatening conditions with a high mortality rate within the first 24 h since presentation, if left untreated. Nevertheless the setting may be chronic and stable. We present a rare case of a misdiagnosed and unoperated Stanford type A aortic dissection in a 78-year old woman with stable computed tomography features at the second year of clinical follow-up.
Collapse
Affiliation(s)
- Marco Gennari
- Department of Cardiovascular Disease, Cardiac Surgery Unit II, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138, Milan, Italy.
| | - Andrea Annoni
- Cardiovascular Imaging Department, Centro Cardiologico Monzino, Via Parea 4, 20138, Milan, Italy
| | - Marco Agrifoglio
- Department of Cardiovascular Disease, Cardiac Surgery Unit II, Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20138, Milan, Italy
| |
Collapse
|
32
|
Martín M, García Iglesias D, Rozado J, Padrón RR, García-Campos A, Morís C, Alvarez Cabo R. Type A Aortic Dissection: The Controversy of the Root Replacement. Ann Thorac Surg 2015; 100:1136-7. [PMID: 26354662 DOI: 10.1016/j.athoracsur.2015.03.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 03/22/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Affiliation(s)
- María Martín
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain.
| | - Daniel García Iglesias
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - José Rozado
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Remigio R Padrón
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Ana García-Campos
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - César Morís
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Rubén Alvarez Cabo
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| |
Collapse
|
33
|
Huang B, Yang Y, Lu H, Zhao Z, Zhang S, Hui R, Fan X. Impact of d-Dimer Levels on Admission on Inhospital and Long-Term Outcome in Patients With Type A Acute Aortic Dissection. Am J Cardiol 2015; 115:1595-600. [PMID: 25863830 DOI: 10.1016/j.amjcard.2015.02.067] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 01/16/2023]
Abstract
Limited studies with relatively small sample sizes have reported that elevated d-dimer levels on admission were associated with increased risk of short-term mortality in patients with type A acute aortic dissection (AAD). However, there were unavailable data regarding the impact of admission d-dimer levels on long-term outcomes. Our present study aimed to evaluate the association of admission d-dimer levels with both inhospital and long-term all-cause mortality in patients with type A AAD. A total of 212 consecutive patients with type A AAD were enrolled. d-Dimer levels were measured on admission, and patients were followed up prospectively. The primary end points were inhospital and long-term all-cause mortality. The median length of follow-up was 18.8 months (interquartile range 6.7 to 24.4 months). The inhospital and long-term all-cause mortality rates were 12.7% and 12.4%, respectively. Compared with the survivors, the nonsurvivors had significantly higher d-dimer levels (p <0.001). When divided into 4 groups according to admission d-dimer quartiles, patients in Q4 (>6.10 μg/ml) had the highest inhospital and long-term mortality among groups. After multivariate adjustment, the d-dimer level in Q4 (>6.10 μg/ml) was an independent risk factor for inhospital mortality (hazard ratio [HR] 6.12, 95% confidence interval 1.35 to 27.89, p = 0.019) in addition to surgical treatment; however, this was not an independent predictor for long-term mortality. In conclusion, our study with a relatively large sample size suggested that elevated admission d-dimer levels (>6.10 μg/ml) might be a predictor for increased risk of inhospital mortality, and urgent-emergent surgery might be needed in patients with elevated d-dimer levels on admission. However, d-dimer levels at admission failed to predict long-term mortality.
Collapse
Affiliation(s)
- Bi Huang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanmin Yang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haisong Lu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenhua Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rutai Hui
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohan Fan
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
34
|
Invited commentary. Ann Thorac Surg 2015; 99:94. [PMID: 25555937 DOI: 10.1016/j.athoracsur.2014.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 07/31/2014] [Accepted: 08/07/2014] [Indexed: 11/20/2022]
|