1
|
Haider Jeoffrey SM, Zafar MA, Velasco J, Khattak A, Ellauzi H, Nasir A, Kalyanasundaram A, Ziganshin BA, Elefteriades JA. Midterm follow-up of composite graft replacement of the aortic root (30-year experience)-remarkably safe, effective, and durable. JTCVS OPEN 2024; 17:1-13. [PMID: 38420531 PMCID: PMC10897671 DOI: 10.1016/j.xjon.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 03/02/2024]
Abstract
Objectives Contemporary operative choices for aortic root disease include aortic root replacement (ARR) and a variety of valve-sparing and aortic root-repair procedures. We evaluate ultra-long-term outcomes of ARR, focusing on survival, freedom from late reoperation, and adverse events. Methods Prospectively kept records were used to accomplish long-term follow-up of patients who underwent ARR (4-pronged Yale survival assessment paradigm). Results Between 1990 and 2020, 564 patients underwent ARR (mean 56 years, 84% male). A modified Cabrol procedure (Dacron coronary graft) was employed in 9.0% (51/564) and concomitant coronary artery bypass grafting in 9.4% (53/564). There were 12.8% (72/564) urgent/emergent and 7.4% (42/564) redo procedures. Operative mortality occurred in 12 patients (2.1%) overall, or 1.4% (8/554) of nondissection and 1.3% (6/468) of elective first-time operations. Six of the 12 deaths presented with acute type A dissection, urgent operation, or reoperative states. Operative mortality dropped to 0.6% during the past 10 years. In total, 11 patients developed endocarditis. Stroke occurred in 11 of 564 patients (2.0%), 4 of whom had presented with type A dissection. Late events included bleeding in 2.8% (16/564), thromboembolism in 1.4% (8/564), and reoperation of the root in 5 of 564 (0.9%) at 15 years and more distal aortic segments in 16/564 (2.8%). Survival was no different from age/sex-matched controls. Conclusions This ultra-long-term experience finds ARR to be extraordinarily safe, effective, and durable, with minimal long-term bleeding, thromboembolism, or graft failure. This experience provides a standard of durability for ARR against which ultra-long-term outcomes with alternate procedures (valve-sparing, Ross, other) may be compared.
Collapse
Affiliation(s)
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Juan Velasco
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Ahad Khattak
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Hesham Ellauzi
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Afsheen Nasir
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Asanish Kalyanasundaram
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| |
Collapse
|
2
|
Ohira S, Pan S, Levine A, Aggarwal-Gupta C, Lanier GM, Gass AL, Spielvogel D, Kai M. Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support. Perfusion 2023; 38:473-476. [PMID: 34958280 DOI: 10.1177/02676591211064721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.
Collapse
Affiliation(s)
- Suguru Ohira
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Stephen Pan
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Avi Levine
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Chhaya Aggarwal-Gupta
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Alan L Gass
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - David Spielvogel
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Masashi Kai
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| |
Collapse
|
3
|
Ceulemans A, Derwael R, Vandenbrande J, Buyck K, Gruyters I, Van Tornout M, Murkin JM, Starinieri P, Yilmaz A, Stessel B. Incidence, predictors and vascular sequelae of distal limb ischemia in minimally invasive cardiac surgery with femoral artery cannulation: an observational cohort study. Heart Vessels 2023; 38:964-974. [PMID: 36723766 DOI: 10.1007/s00380-023-02241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
Literature regarding monitoring and consequences of distal limb ischemia due to femoral artery cannulation for Minimally Invasive Cardiac Surgery (MICS) remains limited. The primary objective was to determine its incidence, defined as a ≥ 15% difference in regional Oxygen Saturation (rSO2) lasting ≥ four consecutive minutes between the cannulated and non-cannulated limb. The secondary objectives included: determination of distal limb ischemia, defined as a Tissue Oxygenation Index (TOI) < 50% in the cannulated limb, identification of predictors for distal limb ischemia, determination of a possible association of NIRS-diagnosed ischemia with acute kidney injury, and the need for vascular surgery up to six months after cardiac surgery. A prospective, observational cohort study with blinded rSO2-measurements to prevent intraoperative clinical decision-making. A single-center, community-hospital, clinical study. All consecutive patients ≥ 18 years old, and scheduled for predefined MICS. Patients underwent MICS with bilateral calf muscle rSO2-measurements conducted by Near-Infrared Spectroscopy (NIRS). In total 75/280 patients (26.79%) experienced distal limb ischemia according to the primary objective, while 18/280 patients (6.42%) experienced distal limb ischemia according to the secondary objective. Multivariate logistic regression showed younger age to be an independent predictor for distal limb ischemia (p = 0.003). None of the patients who suffered intraoperative ischemia required vascular surgery within the follow-up period. The incidence of NIRS-diagnosed ischemia varied from 6.4% to 26.8% depending on the used criteria. Short and long-term vascular sequelae, however, are limited and not intraoperative ischemia related. The added value of intraoperative distal limb NIRS monitoring for vascular reasons seems limited. Future research on femoral artery cannulation in MICS should shift focus to other outcome parameters such as acute kidney injury, postoperative pain or paresthesias.
Collapse
Affiliation(s)
- Angelique Ceulemans
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Ruben Derwael
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Jeroen Vandenbrande
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Katelijne Buyck
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Ine Gruyters
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Michiel Van Tornout
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - John M Murkin
- Department of Anesthesiology and Perioperative Medicine, University Hospitals-LHSC, University of Western Ontario, London, ON, Canada
| | | | - Alaaddin Yilmaz
- Department of Cardiac Surgery, Jessa Hospital, Hasselt, Belgium
| | - Björn Stessel
- Department of Anesthesiology and Critical Care, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| |
Collapse
|
4
|
Choudhary SK, Reddy PR. Cannulation strategies in aortic surgery: techniques and decision making. Indian J Thorac Cardiovasc Surg 2022; 38:132-145. [PMID: 35463714 PMCID: PMC8980986 DOI: 10.1007/s12055-021-01191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022] Open
Abstract
Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.
Collapse
Affiliation(s)
- Shiv K. Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
| | - Pradeep R. Reddy
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
| |
Collapse
|
5
|
Ramaprabhu K, Saran N, Dearani J, Lahr B, Schaff H, Greason K, Yalamuri S, Mangukia C, Stulak J, Bagameri G, Crestanello J, Pochettino A. Cannulation strategies for acute type A dissection—role of central cannulation. Eur J Cardiothorac Surg 2022; 62:6561483. [DOI: 10.1093/ejcts/ezac207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/22/2022] [Accepted: 03/23/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
OBJECTIVES
The purpose of this study was to assess the safety and efficacy of direct cannulation of the ascending aorta in comparison with cannulating peripheral arteries.
METHODS
We retrospectively analysed type A dissection patients [n = 107; median (interquartile range [IQR]) age, 64 [53–73] years] from January 2008 to March 2018. The cohort was divided into 2 groups: direct ascending aorta cannulation (group A, n = 47; median [IQR] age, 69 [54–74] years; 34% female) and non-aortic cannulation (group B, n = 60; median [IQR] age, 62 [52–72] years; 20% female). Postoperative outcomes and long-term survival were compared.
RESULTS
Baseline characteristics were not significantly different between the 2 groups, except for higher creatinine in group B (median 0.9 vs 1.1, P = 0.028) and higher prevalence of dyslipidaemia in group A (58.7% vs 38.3%, P = 0.037). Overall early mortality was 12.1% (n = 13); 12.8% (n = 6) in group A and 11.7% (n = 7) in group B (P = 0.863). The incidence of stroke was 10.6% (n = 5) in group A and 6.7% (n = 4) in group B (P = 0.463). After adjusting for CPB and circulatory arrest times, there was no group difference in the length of ICU (P = 0.257) or hospital stay (P = 0.118), all-cause reoperation (P = 0.709), peak postoperative creatinine (P = 0.426) and lactate values (n = 60; P = 0.862). Overall survival at 1, 3 and 5 years was 84%, 78% and 73%, respectively, with no difference between the 2 groups after adjustment (P = 0.629).
CONCLUSIONS
Direct cannulation of the ascending aorta is a safe cannulation strategy for type A dissection repair, offering the opportunity for rapid arterial cannulation and antegrade perfusion.
Collapse
Affiliation(s)
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brian Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Suraj Yalamuri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chirantan Mangukia
- Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Juan Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
6
|
Bastopcu M, Senay S, Güllü AÜ, Kocyigit M, Alhan C. Percutaneous cannulation for cardiopulmonary bypass in robotic mitral valve surgery with zero groin complications. J Card Surg 2021; 37:280-284. [PMID: 34665477 DOI: 10.1111/jocs.16090] [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: 07/17/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Robotic valve surgery utilizes the femoral vessels to set up cardiopulmonary bypass (CPB) which translates to groin wound and lower extremity vascular complications. A less invasive technique is a totally percutaneous bypass using vascular closure devices (VCDs) with concerns for lower limb ischemia and arterial stenosis. Since April 2018, we have adopted the standard use of total percutaneous CPB in our robotic mitral cases. We report our institutional results with this technique. METHODS All consecutive patients who underwent robotic mitral valve surgery between April 2018 and December 2020 in our institution were included in our study. Hospital database data on demographics, operative variables, and surgical outcomes were recorded and analyzed. RESULTS Robotic mitral valve surgeries were performed on 32 consecutive patients (mean age 57.2 ± 14.8) between April 2018 and December 2020. None of our patients developed an infection at any site. Seroma, hematoma, or pseudoaneurysm were not observed at puncture sites. Surgical repair of the femoral vessels or an additional VCD was not necessary for any of our patients. Patients were followed up for a mean duration of 23.5 months. Our patients did not present with a late wound infection, a seroma, or a pseudoaneurysm, nor had complaints of limb ischemia or claudication. CONCLUSION Total percutaneous bypass is the least invasive method of establishing extracorporeal circulation for cardiac surgery and can be performed with excellent results. The benefits of robotic surgery can be expanded with better results in groin cannulation by the adoption of total percutaneous CPB.
Collapse
Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Tatvan State Hospital, Bitlis, Turkey
| | - Sahin Senay
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Ahmet Ü Güllü
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Muharrem Kocyigit
- Department of Anesthesiology, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| |
Collapse
|
7
|
Frozen Elephant Trunk Technique in Acute Type A Aortic Dissection: Is It for All? MEDICINA-LITHUANIA 2021; 57:medicina57090894. [PMID: 34577818 PMCID: PMC8467885 DOI: 10.3390/medicina57090894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 02/05/2023]
Abstract
Acute type A aortic dissection (ATAAD) is an indisputable emergency with very poor outcomes without surgical treatment. Although the aortic arch is often involved in the aortic dissection, its optimal management during surgical therapy remains uncertain. A conservative tear-oriented approach has traditionally been adopted, limiting the procedure to the ascending aorta (or hemiarch) replacement. However, dilation of the residual dissected aorta and subsequent rupture may occur, requiring further intervention in the future. In the last two decades, the frozen elephant trunk (FET) technique has become a valid and attractive option to treat aortic disease when the arch and the thoracic aorta are involved, both in elective and in emergency settings. Here, we report a review of the contemporary literature regarding the short- and long-term outcomes of the FET technique in ATAAD repair.
Collapse
|
8
|
Sirin G. Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021; 13:309-324. [PMID: 34589167 PMCID: PMC8436682 DOI: 10.4330/wjc.v13.i8.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/27/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023] Open
Abstract
Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.
Collapse
Affiliation(s)
- Gokce Sirin
- Department of Cardiovascular Surgery, Biruni University, Istanbul 34010, Turkey
- Department of Cardiovascular Surgery, Camlica Medicana Hospital, Istanbul 34692, Turkey.
| |
Collapse
|
9
|
Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021. [DOI: 10.4330/wjc.v13.i8.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
10
|
Deng L, Qin H, Guan Z, Mu Q, Xia Q, Wang M, Huang WH, Gu K. Computational numerical analysis of different cannulation methods during cardiopulmonary bypass of type A aortic dissection model based on computational fluid dynamics. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:667. [PMID: 33987365 PMCID: PMC8106110 DOI: 10.21037/atm-21-605] [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] [Indexed: 11/06/2022]
Abstract
Background The aim of the present study was to use a numerical simulation based on computational fluid dynamics (CFD) to analyze the difference of different cannulation methods on hemodynamics characteristic in a type A aortic dissection (TAAD) model. Methods A finite-element analysis based on the CFD model of a TAAD patient was used, and axillary artery cannulation (AAC), innominate artery cannulation (IAC), and femoral artery cannulation (FAC) were analyzed under different situations, including a cardiac output (CO) of 2.5 L/min and cardiopulmonary bypass (CPB) of 2.5 L/min (partial CPB before cross-clamping aorta, defined as condition A), and a CO of 0 L/min and CPB of 5 L/min (aortic cross-clamping phase, defined as condition B). The insertion of an 8-mm cannula into the different models was simulated. Hemodynamic characteristics, including wall shear stress, wall stress, blood flow, and velocity were analyzed. Results In condition A, the total flow of branches of the aortic arch was 2,009.5 mL/min (AAC), 1,855.47 mL/min (IAC), and 1,648.03 mL/min (FAC). All cannulation methods improved left renal blood perfusion. However, in relation to blood flow in the right renal artery, FAC showed the highest blood flow (105 mL/min). The results in condition B were similar to those of condition A. The velocity, shear stress, and stress of entry tear via AAC and IAC decreased in condition B compared with condition A. The velocity, shear stress, stress of tear via AAC was lower than that of IAC. Conclusions Different cannulation modes have an effect on the hemodynamic characteristic of the tear, but this effect is related to different states of CPB. AAC was found to superior to IAC, especially in reducing velocity, stress, and shear stress of site of tear. However, IAC and AAC are more conductive to blood supply than FAC in branch vessels of the aortic arch without being affected by the CPB state.
Collapse
Affiliation(s)
- Li Deng
- Affiliated Gaozhou Hospital of Guangdong Medical University, Gaozhou, China.,Clinical Research Center of Digital Medicine and 3D Printing, Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hao Qin
- Clinical Research Center of Digital Medicine and 3D Printing, Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Zhiyuan Guan
- Peking University Third Hospital, Beijing, China
| | - Qingchun Mu
- Clinical Research Center of Digital Medicine and 3D Printing, Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Qingping Xia
- Clinical Research Center of Digital Medicine and 3D Printing, Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Maosheng Wang
- Clinical Research Center of Digital Medicine and 3D Printing, Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Wen-Hua Huang
- Orthopaedic Center, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang, China.,Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, Guangdong Provincial Key Laboratory of Medical Biomechanics, National Key Discipline of Human Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Kaiyun Gu
- National Clinical Research Center for Child Health, The Children's Hospital Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
11
|
Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, Han H. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13:2551-2562. [PMID: 34012600 PMCID: PMC8107572 DOI: 10.21037/jtd-21-411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.
Collapse
Affiliation(s)
- Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Yong Cao
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Baodong Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongyun Qiu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maosheng Wang
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, The General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
12
|
Kawashima T, Okamoto K, Wada T, Shuto T, Umeno T, Miyamoto S. Femoral artery anatomy is a risk factor for limb ischemia in minimally invasive cardiac surgery. Gen Thorac Cardiovasc Surg 2020; 69:246-253. [PMID: 32671552 DOI: 10.1007/s11748-020-01442-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In minimally invasive cardiac surgery (MICS), femoral artery cannulation during cardiopulmonary bypass (CPB) can cause limb ischemia. This study evaluated the association between femoral artery anatomy and the risk of limb ischemia in MICS. METHODS Eighty-one patients who underwent MICS with CPB using single femoral artery cannulation between 2010 and 2018 were included. The patients were stratified by their femoral artery diameter and anatomy of ectopic side branch, i.e., medial or lateral femoral circumflex arteries: Type A, deep femoral artery (DFA) ≥ superficial femoral artery (SFA); type B, DFA < SFA with an ectopic side branch of the common femoral artery (CFA); type C, DFA < SFA with an ectopic side branch at the CFA bifurcation; and type D, DFA < SFA without an ectopic side branch. The ratio of the postoperative creatine kinase concentration and the cross-sectional area of the femoral muscles (CK/MA) was used as a surrogate marker of limb ischemia. Predictors of high CK/MA were evaluated. RESULTS No critical limb ischemia was observed in this study. The median postoperative creatine kinase and CK/MA were 1954 (1305-2872) IU/l and 15.2 (9.2-19.8) IU/l/cm2. Multivariable logistic regression found that anatomical type D (odds ratio 4.19, 95% confidence interval: (1.26-14.0); p = 0.020) and prolonged CPB time (OR 1.01, 95% CI (1.00-1.02); p = 0.045) were independent risk factors of high CK/MA. CONCLUSION Anatomical type D and prolonged CPB time were associated with risk of limb ischemia in MICS.
Collapse
Affiliation(s)
- Takayuki Kawashima
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan.
| | - Keitaro Okamoto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Takashi Shuto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tadashi Umeno
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| |
Collapse
|
13
|
Stein LH, Elefteriades JA. Commentary: Like the children of Lake Wobegon: All aortic cannulation strategies are above average. JTCVS Tech 2020; 2:8-9. [PMID: 34317733 PMCID: PMC8299039 DOI: 10.1016/j.xjtc.2020.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Louis H. Stein
- Division of Cardiothoracic Surgery, Department of Surgery, Albany Medical College, Albany, NY
- Address for reprints: Louis H. Stein, MD, PhD, Division of Cardiothoracic Surgery, Albany Medical Center, Surgeons Pavilion, 3rd Floor, 50 New Scotland Ave, Albany, NY 12208.
| | | |
Collapse
|
14
|
Ohno N, Minatoya K. sArterial cannulation to establish cardiopulmonary bypass during surgery for acute aortic dissection. Surg Today 2019; 50:1353-1359. [PMID: 31773278 DOI: 10.1007/s00595-019-01921-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/16/2019] [Indexed: 12/19/2022]
Abstract
A cannulation strategy in surgery for Stanford type A acute aortic dissection (AAAD) is integral for patient survival. Femoral cannulation has been the standard option for cannulation; however, there is increasing evidence that retrograde perfusion with femoral cannulation is associated with worse clinical outcomes, and new cannulation sites have been introduced in surgery for AAAD. Although axillary artery cannulation and central cannulation via the ascending aorta have become more popular than femoral access in recent years, adverse events have been reported and shifting cannulation sites during surgery are recommended by some surgeons. Therefore, it is beneficial for surgeons to broaden their knowledge about cannulation technology for AAAD. In this review, we discuss the various methods of cannulation for AAAD.
Collapse
Affiliation(s)
- Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 6068507, Japan.
| |
Collapse
|
15
|
Wang F, Su H, Wang X, Wu Q, Zhou Y, Xu H, Zhang R. Pituitrin use is associated with an increased risk of inguinal hematomas and pseudoaneurysms in patients undergoing femoral artery puncture. J Int Med Res 2019; 47:2976-2986. [PMID: 31119963 PMCID: PMC6683930 DOI: 10.1177/0300060519849785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective Femoral artery puncture (FAP) is an effective method for interventional percutaneous vascular procedures. However, FAP leads to complications including hematomas and pseudoaneurysms. This study was performed to determine whether pituitrin infusion or vascular closure devices (VCDs) increase the risk of complications after FAP. Methods This single-center retrospective study included 3641 patients who underwent FAP. The patients were divided into two groups: a groin complication group (including hematomas and pseudoaneurysms) and a no-groin complication group. Results In the multivariate analysis, perioperative pituitrin infusion and the use of VCDs were strongly associated with inguinal hematomas and pseudoaneurysms. The complication rate was obviously higher in patients who underwent bronchial artery embolization (BAE). Because high dosages of pituitrin and VCDs were used in patients undergoing BAE, postoperative hematoma development occurred significantly earlier in these patients. Hematomas occurred within 14 days of the operation in all patients who underwent BAE. Conclusion Perioperative pituitrin infusion and the use of VCDs are associated with an increased risk of complications after FAP, including hematomas and pseudoaneurysms. Notably, patients who underwent BAE, who are subject to higher pituitrin and VCD use, showed a higher complication rate. The incidence of complications was highest within 2 weeks postoperatively.
Collapse
Affiliation(s)
- Fang Wang
- 1 Department of Nursing, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Hua Su
- 2 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Xiaoxia Wang
- 1 Department of Nursing, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Qionghui Wu
- 1 Department of Nursing, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Yong Zhou
- 2 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Hangdi Xu
- 2 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Ruifeng Zhang
- 2 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| |
Collapse
|
16
|
Gryaznov AA, Ma WG, Erben Y, Zafar MA, Velasquez CA, Saeyeldin A, Ziganshin BA, Elefteriades JA. Intraoperative descending aortic dissection during aortic root replacement: successful management. J Thorac Dis 2018; 10:3065-3069. [PMID: 29997974 DOI: 10.21037/jtd.2018.05.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anton A Gryaznov
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgery, Saint Mary's Hospital, Waterbury, CT, USA
| | - Wei-Guo Ma
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China
| | - Young Erben
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Camilo A Velasquez
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Ayman Saeyeldin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
17
|
Innominate Versus Axillary Artery Cannulation for the Hemiarch Repair. J Surg Res 2018; 232:234-239. [PMID: 30463723 DOI: 10.1016/j.jss.2018.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Innominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing selective antegrade cerebral perfusion during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide less resistance to high flow during bypass and selective antegrade cerebral perfusion. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss. METHODS This was a single-center retrospective analysis of 206 patients who underwent hemiarch replacement between 2009 and 2017. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary and innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp time, circulatory arrest (CA) time, postoperative transfusions, intensive care unit length of stay, development of any neurological complications, end-organ failure, and mortality. Subgroup analysis was performed for elective and emergent cases. RESULTS Axillary and innominate artery cannulation accounted for 37% (n = 77) and 67% (n = 129) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of renal disease in the axillary group (16% versus 6%, P = 0.05). More emergent cases were performed in the axillary group (61% versus 17%, P < 0.001). Innominate cases had shorter CPB times (189 versus 150 min, P < 0.001) and CA (22.5 versus 11 min, P < 0.001) times overall. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference in operative times. Less transfusions were given in the innominate group including units of red blood cells (2 [0-6] versus 0 [0-2], P < 0.001), units of platelets (2 [1-3] versus 1 [0-2], P = 0.001), and units of plasma (6 [2-9] versus 2 [0-4], P < 0.001). A similar trend was observed in the elective subgroup. No difference in transfusions was observed in the emergent subgroup. There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups. CONCLUSIONS Alternate cannulation strategies for open arch anastomoses are evolving with a trend toward using the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.
Collapse
|
18
|
Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
Collapse
Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| |
Collapse
|
19
|
Preventza O, Price MD, Spiliotopoulos K, Amarasekara HS, Cornwell LD, Omer S, de la Cruz KI, Zhang Q, Green SY, LeMaire SA, Rosengart TK, Coselli JS. In elective arch surgery with circulatory arrest, does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation. J Thorac Cardiovasc Surg 2018; 155:1953-1960.e4. [DOI: 10.1016/j.jtcvs.2017.11.095] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 11/14/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
|
20
|
Left Axillary Artery Cannulation Facilitates Reoperative Total Aortic Arch Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:70-73. [PMID: 29432362 DOI: 10.1097/imi.0000000000000459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Total aortic arch replacement remains a technically formidable procedure, particularly in patients with previous proximal aortic dissection repair. Our case discussion highlights a useful strategy for extracorporeal support and circulation management to facilitate total arch reconstruction in the reoperative setting, based on cannulation of the left axillary artery. Our preference is to use a left axillary artery approach to initiate cardiopulmonary bypass and to ultimately revascularize the left arm via an extra-anatomic graft. Our technique, as described, affords the option to initiate cardiopulmonary bypass before sternal re-entry, it reduces the risk of embolic complications and possible stroke, and it directly facilitates simple extra-anatomic debranching of the left subclavian artery, resulting in easier arch and great vessel reconstruction within the chest.
Collapse
|
21
|
Hemli JM, Gu B, Scheinerman SJ, Brinster DR. Left Axillary Artery Cannulation Facilitates Reoperative Total Aortic Arch Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan M. Hemli
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY USA
| | - Bo Gu
- Department of Cardiothoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY USA
| | - S. Jacob Scheinerman
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY USA
| | - Derek R. Brinster
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY USA
| |
Collapse
|
22
|
Carino D, Mori M, Pang PYK, Singh M, Elkinany S, Tranquilli M, Ziganshin BA, Elefteriades JA. Direct axillary cannulation with open Seldinger-guided technique: is it safe? Eur J Cardiothorac Surg 2017; 53:1279-1281. [DOI: 10.1093/ejcts/ezx394] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/17/2017] [Indexed: 12/29/2022] Open
Affiliation(s)
- Davide Carino
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Makoto Mori
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Philip Y K Pang
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mrinal Singh
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Sherif Elkinany
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
- Department of Surgical Diseases # 2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
23
|
Velasquez CA, Zafar MA, Saeyeldin A, Bin Mahmood SU, Brownstein AJ, Erben Y, Ziganshin BA, Elefteriades JA. Two-Stage Elephant Trunk approach for open management of distal aortic arch and descending aortic pathology in patients with Marfan syndrome. Ann Cardiothorac Surg 2017; 6:712-720. [PMID: 29270386 DOI: 10.21037/acs.2017.11.11] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Camilo A Velasquez
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Ayman Saeyeldin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Syed Usman Bin Mahmood
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Brownstein
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Young Erben
- Section of Vascular and Endovascular Surgery, Yale-New Haven Hospital, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
24
|
Zhang Y, Fan F, Zeng G, Zhou L, Zhang Y, Zhang J, Jiao H, Zhang T, Su D, Yang C, Wang X, Xiao K, Li H, Zhong Z. Temporal analysis of blood-brain barrier disruption and cerebrospinal fluid matrix metalloproteinases in rhesus monkeys subjected to transient ischemic stroke. J Cereb Blood Flow Metab 2017; 37:2963-2974. [PMID: 27885100 PMCID: PMC5536803 DOI: 10.1177/0271678x16680221] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Blood-brain barrier (BBB) disruption plays an important role in pathophysiological progress of ischemic stroke. However, our knowledge of the dynamic change of BBB permeability and its mechanism remains limited. In the current study, we used a non-human primate (NHP) MCAO model and a serial CSF sampling method that allowed us to determine the dynamic change of BBB permeability by calculating the CSF/serum albumin ratio (AR). We showed that AR increased rapidly and significantly after ischemia, and the fold increase of AR is highly correlated with the infarction size during the subacute phase. Moreover, we determined the temporal change of MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, MMP-13, TIMP-1, and TIMP-2 in CSF and serum. Each MMP and TIMP showed different change patterns when comparing their values in CSF and serum. Based on the longitudinal dataset, we showed that the fold increase of MMP-9 in serum and CSF are both correlated to infarction size. Among the measured MMPs and TIMPs, only MMP-2, MMP-13, and TIMP-2 in CSF correlated with AR to some extent. Our data suggest there is no single MMP or TIMP fully responsible for BBB breakdown, which is regulated by a much more complicated signal network and further investigations of the mechanisms are needed.
Collapse
Affiliation(s)
- Yingqian Zhang
- 1 Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Fan
- 2 Department of Neurointervention, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guojun Zeng
- 3 Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Linlin Zhou
- 4 Department of Medical Microbiology, West China School of Preclinical and Forensic Medicine, Sichuan University, China
| | - Yinbing Zhang
- 5 Sichuan Kangcheng Biotech Co., Inc., Chengdu, China
| | - Jie Zhang
- 5 Sichuan Kangcheng Biotech Co., Inc., Chengdu, China
| | - He Jiao
- 6 Department of Interventional therapy, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Zhang
- 1 Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Su
- 1 Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Yang
- 7 Key Laboratory of Green Chemistry & Technology of Ministry of Education, College of Chemistry, Sichuan University, Chengdu, China
| | - Xin Wang
- 5 Sichuan Kangcheng Biotech Co., Inc., Chengdu, China
| | - Kai Xiao
- 5 Sichuan Kangcheng Biotech Co., Inc., Chengdu, China
| | - Hongxia Li
- 8 National Chengdu Center for Safety Evaluation of Drugs, State Key Lab of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Zhihui Zhong
- 1 Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.,5 Sichuan Kangcheng Biotech Co., Inc., Chengdu, China
| |
Collapse
|
25
|
Patient management in aortic arch surgery†. Eur J Cardiothorac Surg 2017; 51:i4-i14. [DOI: 10.1093/ejcts/ezw337] [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: 05/22/2016] [Revised: 08/23/2016] [Accepted: 09/02/2016] [Indexed: 12/31/2022] Open
|
26
|
Mok SCM, Ma WG, Mansour A, Charilaou P, Chou AS, Peterss S, Tranquilli M, Ziganshin BA, Elefteriades JA. Twenty-five year outcomes following composite graft aortic root replacement. J Card Surg 2016; 32:99-109. [PMID: 27966257 DOI: 10.1111/jocs.12875] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Operative choices for aortic root disease include traditional root replacement with a composite valved graft as well as various valve-sparing and root repair procedures. OBJECTIVES To report our experience with traditional composite graft aortic root replacement by a single surgeon over a 25-year period in 449 patients, focusing on long-term survival and freedom from late reoperation and adverse events. METHODS The coronary button technique was used in all patients. Mean age was 56.1 ± 14.0 years (range 14-87) with 83% males (373/449). Valve prosthesis was mechanical in 343 (76%) and bioprosthetic in 106 (24%). A modified Cabrol procedure (Dacron coronary graft) was employed in 10% (45/449) and concomitant coronary artery bypass graft in 10.9% (49/449). There were 15.8% (71/449) urgent/emergent and 8.2% (37/449) redo procedures. Survival follow-up was 100%. Mean follow-up was 7.0 ± 5.1 years (range 0.1-24.8). RESULTS Operative mortality occurred in 14 patients (3.1%) and was 2.2% (9/418) in non-dissection and 1.9% (7/361) in elective first-time operations. Stroke and re-exploration for bleeding occurred in nine (2.0%) and 20 (4.5%) patients, respectively. Major late events included bleeding in 2.5% (11/435) and thromboembolism in 1.1% (5/435). At 5, 10, and 20 years, freedom from major events and reoperations on the root were 97.8, 95.4, and 94.39%, and 99.0, 99.0, and 97.9%, respectively. Survival in patients aged <60 years was 92.0, 90.1, and 79.8% at five, 10, and 20 years versus 88.4, 67.9, and 42.6% in patients aged ≥60 years (p = 0.001). Compared with age- and gender-matched controls, survival was not significantly different (p = 0.20). CONCLUSIONS Composite graft aortic root replacement is associated with low operative risk, excellent long-term survival, and low incidence of reoperation and late events.
Collapse
Affiliation(s)
- Salvior C M Mok
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Wei-Guo Ma
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Ahmed Mansour
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Paris Charilaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Alan S Chou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Sven Peterss
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
27
|
Abe T, Usui A. The cannulation strategy in surgery for acute type A dissection. Gen Thorac Cardiovasc Surg 2016; 65:1-9. [PMID: 27650659 PMCID: PMC5214928 DOI: 10.1007/s11748-016-0711-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/07/2016] [Indexed: 01/09/2023]
Abstract
The rates of mortality and morbidity remain high in surgery for acute type A dissection. There is controversy regarding the best cannulation strategy for achieving good clinical results. Each cannulation technique has different anatomical characteristics and a different flow pattern inside the aorta during cardiopulmonary bypass. Some adverse, clinically important outcomes may be related to events at this time. Femoral artery cannulation, axillary artery cannulation, and central aortic cannulation are the three major cannulation strategies that are adopted in many centers in the world. Accumulating results from comparative studies between right axillary artery cannulation and femoral artery cannulation show that right axillary artery cannulation is associated with better clinical outcomes. However, all of the studies have been retrospective, and few studies have compared the results of other combinations of cannulation strategies. Observational studies using newer monitoring techniques clearly show that no perfusion strategy is perfect or free from complications. In summary, the evidence is insufficient to make a strong recommendation regarding cannulation strategies. Based on the fairly consistent results of retrospective studies, more surgeons are tending to switch from a retrograde perfusion strategy to adopt an antegrade perfusion strategy. Regardless of the routine cannulation strategy that is adopted, careful monitoring and a swift response to adverse events are necessary. The further accumulation of evidence is warranted.
Collapse
Affiliation(s)
- Tomonobu Abe
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| |
Collapse
|
28
|
Peterss S, Charilaou P, Dumfarth J, Li Y, Bhandari R, Tranquilli M, Rizzo JA, Ziganshin BA, Elefteriades JA. Aortic valve disease with ascending aortic aneurysm: Impact of concomitant root-sparing (supracoronary) aortic replacement in nonsyndromic patients. J Thorac Cardiovasc Surg 2016; 152:791-798.e1. [PMID: 27318616 DOI: 10.1016/j.jtcvs.2016.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 04/23/2016] [Accepted: 05/17/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The purpose of the study was to assess the anticipated incremental risk of a concomitant aortic resection performed with an aortic valve replacement. METHODS Patients who underwent aortic valve replacement with root-sparing ascending replacement were compared with those who underwent isolated aortic valve replacement using propensity score matching (81 pairs; mean age, 63 ± 11 years [root-sparing ascending replacement] vs 64 ± 14 years). To evaluate the impact of the technique at distal site, 71 pairs of those undergoing root-sparing ascending replacement also were matched by propensity score according to distal anastomosis performed clamped and open under deep hypothermic circulatory arrest. RESULTS Operative mortality was equal between the root-sparing ascending replacement and isolated aortic valve replacement groups. No significant difference was found regarding postoperative morbidities, such as bleeding, renal failure, stroke, and length of stay, except prolonged ventilation was found after root-sparing procedures (P = .028). Survival estimation showed no difference between the groups. Comparing the patients undergoing root-sparing ascending replacement with clamped and opened distal anastomosis revealed a prolonged ventilation requirement (7% vs 3%; P = not significant) in the open group. Operative mortality was 0% in both groups, and midterm survival was comparable. CONCLUSIONS The concomitant replacement of the aorta in root-sparing fashion is associated with an excellent operative outcome and adds no additional risk to aortic valve replacement in elective and non-high-risk patients. If the distal anastomosis is performed in an open fashion, while the operative mortality is still very low, morbidities are slightly higher, but midterm survival remains comparable.
Collapse
Affiliation(s)
- Sven Peterss
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiac Surgery, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - Paris Charilaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Julia Dumfarth
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Yupeng Li
- Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, NY
| | - Rohan Bhandari
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A Rizzo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, NY
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
| |
Collapse
|
29
|
Hughes GC. Invited Commentary. Ann Thorac Surg 2016; 101:2235-6. [PMID: 27211935 DOI: 10.1016/j.athoracsur.2016.01.051] [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: 01/11/2016] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 10/21/2022]
Affiliation(s)
- G Chad Hughes
- Duke Center for Aortic Disease, Duke Center for Structural Heart Disease, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Box 3051 DUMC, Durham, NC27710.
| |
Collapse
|
30
|
Liu LY, Callahan B, Peterss S, Dumfarth J, Tranquilli M, Ziganshin BA, Elefteriades JA. Neuromonitoring Using Motor and Somatosensory Evoked Potentials in Aortic Surgery. J Card Surg 2016; 31:383-9. [PMID: 27193893 DOI: 10.1111/jocs.12739] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) are established methods of neuromonitoring aimed at preventing paraplegia after descending or thoracoabdominal aortic repair. However, their predictive impact remains controversial. The aim of this study was to evaluate our single-center experience using this monitoring technique. METHODS Between 2009 and 2014, 78 patients (mean age 66 ± 12, 53% male) underwent either descending or thoracoabdominal aortic repairs. Of these, 60% had an aortic aneurysm, 30% dissection, and 10% other etiologies. Intraoperatively, MEPs and SSEPs were monitored and, if necessary, clinical parameters (blood pressure, hematocrit, oxygenation) were adjusted in response to neuromonitoring signals. This analysis is focused on the neurological outcome (paraplegia, stroke) after the use of intraoperative neuromonitoring. RESULTS Thirty-day mortality was 10 (12.8%). All patients with continuously stable signals or signals that returned after signal loss developed no spinal cord injury, whereas two out of six of the evaluable patients with signal loss (without return) during the procedure suffered from postoperative paraplegia (one transient and one permanent). Sensitivity and specificity of use of MEP and SSEP were 100% and 94.20% regarding paraplegia, respectively. CONCLUSIONS (1) Preservation of signals or return of signals is an excellent prognostic indicator for spinal cord function. (2) Intraoperative modifications in direct response to the signal change may have averted permanent paralysis in the patients with signal loss without neurologic injury. We have found MEP and SSEP neuromonitoring to be instrumental in the prevention of paraplegia. doi: 10.1111/jocs.12739 (J Card Surg 2016;31:383-389).
Collapse
Affiliation(s)
- Lucy Y Liu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | | | - Sven Peterss
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - Julia Dumfarth
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.,Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|