Residual Arch Tears and Major Adverse Events After Acute DeBakey Type I Aortic Dissection Repair

Major adverse outcomes in patients with acute type A aortic dissection undergoing total arch replacement with frozen elephant trunk procedure

BACKGROUND

The objective of this investigation was to identify the risk factors linked to major adverse outcomes (MAO) subsequent to total arch replacement with frozen elephant trunk procedure (TAR+FET) surgery among patients diagnosed with acute type A aortic dissection (ATAAD). Additionally, the study aimed to elucidate the influence of these adverse outcomes on the long-term prognosis of the patients.

METHOD

670 ATAAD patients received the TAR+FET procedure. Multivariable logistic regression was used to investigate the risk factors associated with in-hospital MAO. Additionally, long-term survival outcomes were assessed through follow-up observations of all patients.

RESULTS

The overall in-hospital mortality was 4.33%. Among 670 patients, 169 patients (25.22%) developed postoperative MAO. Multivariate analysis showed that in-hospital MAO was positively associated with age (OR = 1.025, 95%CI: 1.005-1.045, P = 0.014), lower limb symptoms (OR = 2.562, 95%CI: 1.407-4.666, P = 0.002), involvement of coronary artery (OR = 2.027, 95%CI: 1.312-3.130, P = 0.001), involvement of left renal artery (OR = 1.998, 95%CI: 1.359-2.938, P < 0.001), CPB time (OR = 1.011, 95%CI: 1.007-1.015, P < 0.001) and WBC counts (OR = 1.045, 95%CI: 1.007-1.083, P = 0.019). MAO group showed a worse long-term prognosis than those non-MAO group (P = 0.002).

CONCLUSIONS

While TAR+FET can be an effective treatment option for ATAAD patients, careful patient selection and management are essential in minimizing the risk of MAO and ensuring long-term success.

Hemolytic Anemia After an Aortic Dissection Treated With a Valve-Sparing Aortic Root Replacement

A 46-year-old man with a personal history of a repaired aortic dissection was admitted because of hemolytic anemia. The transesophageal echocardiogram displayed an accelerated flow and a residual intimal flap in the proximal descending aorta. A total arch replacement was performed, the flap was removed, and his hemolytic anemia was resolved. (Level of Difficulty: Advanced.).

Early Results of a Novel Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With Distal Anastomosis Line Beyond Aortic Arch Zone Zero

Introduction

Acute aortic dissection type A (AADA) is associated with high perioperative morbidity and mortality. A novel non-covered hybrid prosthesis (Ascyrus Medical Dissection Stent (AMDS) Hybrid Prosthesis, Cryolife/Jotec, Hechingen, Germany) can be easily implanted to stabilize the true lumen (TL), improve remodeling, and preserve organ perfusion. Although developed for implantation in aortic zone 0, occasionally, partial replacement of the aortic arch and further distal implantation of AMDS may appear favorable. Implantation of AMDS with anastomosis line beyond zone 0 has not been described yet.

Materials and Methods

Between 08/2019 and 12/2020, a total of n = 97 patients were treated due to AADA at a single University hospital. Of those, n = 28 received an AMDS hybrid prosthesis, of whom in eight patients, due to intraoperative finding the distal anastomosis line was placed distal to the brachiocephalic trunk. Three patients had AMDS implantation in zone I and four were treated by implantation of the prostheses in zone II, and one patient had the implantation performed in zone III. Clinical outcome and the development of a proportional area of TL and false lumen (FL) at defined levels of the thoracic aorta were analyzed.

Results

None of the surviving patients (87.5%) showed signs of clinical malperfusion (i.e., stroke, spinal cord injury, and need for dialysis). A postoperative CT scan showed an open TL in all patients. The proportion of TL with respect to total aortic diameter (TL+FL) was postoperatively significantly higher in zone III (p = 0.016) and at the level of T11 (p = 0.009). The mean area of TL+FL was comparable between pre- and postoperative CT-scan (p = n.s.). One patient with preoperative resuscitation died of multiple organ failure on extracorporeal life support on postoperative day 3.

Conclusion

Implantation of AMDS can be safely performed in patients who need partial replacement of the aortic arch beyond zone 0. The advantages of the AMDS can be combined with those of the total arch repair (remodeling of the arch and prevention of TL collapse) without the possible disadvantages (risk of spinal cord injury).

Influence of residual primary entry following the tear-oriented strategy for acute type A aortic dissection

OBJECTIVES

Although a tear-oriented strategy has contributed to improving short-term surgical outcomes of acute type A aortic dissection (ATAAD), long-term clinical influences of residual entry tear in the downstream aorta have not been fully investigated. The goal of this study was to assess the long-term surgical outcomes of ATAAD with or without a residual entry tear in the downstream aorta.

METHODS

Medical records of 1107 patients with ATAAD who underwent emergency surgery between 1990 and 2018 were retrospectively reviewed. A tear-oriented paradigm was adopted for the baseline strategy. The 837 patients in whom the entry tears were resected comprised the resected group, and the 270 patients with a residual entry tear comprised the residual group. Of these patients, 252 in each group were analysed using propensity score matching, and long-term outcomes were compared with or without residual entry.

RESULTS

Hospital deaths were lower in the resected group (3.2% vs 8.3%; P = 0.020). The survival rate was not significantly different between the groups: It was 83.8% and 68.5% in the resected group and 80.2% and 66.5% in the residual group at 5 and 10 years, respectively (P = 0.600). However, residual entry in the downstream aorta affected the distal aortic event-free survival rate (90.4% and 80.6% in the resected group and 82.3% and 67.4% in the residual group at 5 and 10 years, respectively; P = 0.003). Furthermore, multivariable risk analysis of 1107 patients confirmed that a residual entry in the downstream aorta was a risk factor for distal aortic events.

CONCLUSIONS

The tear-oriented strategy remains the gold standard for high-risk patients; however, the extensive operation might be considered for stable patients to reduce long-term aortic events.

Postoperative Maximal Aortic Diameter is a Significant Predictor of Dilation of the Residual Dissected Aorta after Aortic Replacement for Acute Debakey Type I Aortic Dissection

BACKGROUND

This study investigated the impact of aortic diameter on late aortic dilation of the residual dissected aorta after tear-oriented aortic replacement for acute DeBakey type I aortic dissection.

METHODS

Of 133 patients who underwent aortic replacement for acute DeBakey type I/II aortic dissection between 2008 and 2019, 45 patients with a residual dissected aorta after surgery for acute DeBakey type I aortic dissection and who underwent computed tomography at predischarge and after 1 year were retrospectively assessed. The aortic diameter and false lumen area were measured at 3 levels: the maximal aortic site, seventh thoracic vertebra, and celiac axis. Multivariable Cox regression analysis was employed to identify the predictors of late aortic dilation, defined as an aortic growth rate of ≥5 mm/year or a maximal aortic diameter of ≥55 mm.

RESULTS

During a median follow-up of 75 [range: 13-152] months, 6 patients (5 men; mean age: 57 ± 14 years) experienced aortic dilation. All 6 patients had the maximal aortic diameter between the distal aortic arch and seventh thoracic vertebra level at the last computed tomography. Multivariable Cox regression analysis showed that the predischarge maximal aortic diameter was an independent determinant of late aortic dilation (hazard ratio: 2.28/mm, 95% confidence interval: 1.10-5.86).

CONCLUSIONS

Predischarge maximal aortic diameter is a significant predictor of late aortic dilation in patients with a residual dissected aorta after tear-oriented surgical repair of acute DeBakey type I aortic dissection.

Modified "in situ" arch replacement with an integrative frozen elephant trunk device for acute type A aortic dissection

Background

Total arch replacement (TAR) and frozen elephant trunk (FET) has been proposed as the primary arch repair method for acute type A aortic dissection (aTAAD). We introduce a modified “in situ” arch replacement with an integrative FET device for aTAAD.

Methods

From January 2018 to December 2019, 507 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy; among them, 57 patients with modified island total arch replacement (MiTAR) and 138 patients with TAR were enrolled. Marfan syndrome, primary intimal tears located in the large curve of aortic arch +/− or supra-arch vessels and dilated aortic arch (≥45 mm) were contraindications for MiTAR. MiTAR involves two steps: first, insert a FET device into the descending aorta during the hypothermic circulation arrest period; second, anastomose the remaining “island” arch with the prosthetic vessel and the proximal part of the FET.

Results

MiTAR patients were older than those receiving TAR (52.1 vs. 48.9 years; P=0.078), but their baseline demographics and manifestations of organ ischaemia were nearly the same. The times of cardiopulmonary bypass (CPB), aortic clamp and hypothermic circulation arrest were significantly shorter with MiTAR (209.3 vs. 267.1 minutes, P=0.000; 147.9 vs. 190.0 minutes, P=0.000; 34.0 vs. 39.4 minutes, P=0.003, respectively). The volumes of intraoperative transfusions of red blood cells (RBCs), fresh frozen plasma (FFP), platelets and cryoprecipitates were significantly lower in MiTAR (5.9 vs. 8.5 units, P=0.000; 758.3 vs. 930.4, P=0.000; 12.5 vs. 17.5 mL, P=0.000; 9.4 vs. 16.6 units, P=0.000). The 30-day mortality was 7.0% (4/57) for MiTAR and 11.6% (16/138) for TAR. One patient died and no patient received reintervention during the follow-up period, while the size of several levels of aorta showed a decreasing trend.

Conclusions

MiTAR is a simplified approach to TAR that reduces the surgical trauma while achieving aortic reshaping effects.

CT Angiography Findings Predictive of Kidney Injury in Chronic Aortic Dissection

OBJECTIVE. The purpose of this study was to compare the volume alteration and effective renal plasma flow of kidneys supplied by false lumens (FLs) with those of kidneys supplied by true lumens (TLs), to show the discrepancy in perfusion between the two lumens. We sought to corroborate malperfusion of FL-supplied kidneys with imaging characteristics observed on CT angiography. MATERIALS AND METHODS. A retrospective analysis was conducted using prospectively collected data for 87 patients with a diagnosis of residual chronic aortic dissection between 2005 and 2013 who had one kidney perfused by a TL and the other kidney perfused by a FL. RESULTS. Overall, at follow-up, FL-supplied kidneys had a mean (± SD) effective renal plasma flow (117.5 ± 42.6 vs 146.6 ± 41.0 mL/min; p = 0.004) and volume (131.1 ± 37.1 vs 146.5 ± 33.3 cm³; p = 0.004) that were lower than those of TL-supplied kidneys. Multivariate analysis revealed the presence of a proximal major inlet (odds ratio, 0.306; 95% CI, 0.103-0.910; p = 0.033) and large FL area (odds ratio, 0.104; CI, 0.012-0.880; p = 0.038) as factors protecting against malperfusion of FL-supplied kidneys. In patients with dissected renal arteries, the FL-supplied kidney had low effective renal plasma flow (mean, 88.5 ± 26.8 vs 149.6 ± 43.5 mL/min; p = 0.004) and diminished volume (mean, 120.4 ± 30.4 vs 152.3 ± 24.6 cm³; p = 0.001). CONCLUSION. In the present study, kidneys perfused by FLs showed decreased volume and reduced effective renal plasma flow during follow-up, particularly those kidneys with dissected renal arteries, a small FL area at the renal level, and lack of a proximal major inlet. Further studies are warranted to identify the clinical relevance of malperfusion in FL-supplied kidneys.

Impact of Supraaortic Intimal Tears on Aortic Diameter Changes After Nontotal Arch Replacement

BACKGROUND

This study evaluated the impact of the intimal tear location on aortic dilation and reintervention after nontotal arch replacement (non-TAR) for acute type I aortic dissection.

METHODS

Between 2009 and 2017, 92 patients who underwent non-TAR for acute type I aortic dissection were enrolled. Intimal tears were analyzed at the supraaortic (SA) segment; segment 1, proximal descending thoracic aorta (DTA); segment 2, distal DTA; and segment 3, abdominal aorta. Aortic diameter was measured at the pulmonary artery bifurcation, celiac axis, maximal abdominal aorta, and maximal thoracoabdominal aorta using serial follow-up computed tomographic scans. The Fisher exact or χ² test, independent t or Mann-Whitney U test, and log-rank test were used in the statistical analyses.

RESULTS

The significant factors for increasing aortic diameter were the first location of intimal tear in the SA segment and segments 1 and 2. In the adjusted analysis, the first location of intimal tear in the SA segment and segment 1 was statistically significant. In the additional adjusted analysis, a segment 1 tear without SA tear was the only significant factor for increasing aortic diameter. The 5-year freedom from reintervention rate was significantly higher in patients with no intimal tear than in those with a segment 1 intimal tear with/without SA tear.

CONCLUSIONS

We confirmed that SA and proximal DTA intimal tears are associated with subsequent aortic dilation and reintervention. These proximal aortic intimal tears might warrant aggressive surgical treatment at the initial operation or close postoperative follow-up.

Locational impact of luminal communication on aortic diameter changes and reintervention in acute type I aortic dissection

OBJECTIVES

The aim of this study is to evaluate the locational impact of a luminal communication on aortic diameter changes and reintervention after surgical repair of acute type I aortic dissection.

METHODS

Between 2009 and 2017, 304 patients underwent operation for acute type I aortic dissection. Among them, 93 patients were enrolled. The luminal communications were analysed in segment 1 (the proximal descending thoracic aorta), segment 2 (the distal descending thoracic aorta) and segment 3 (the abdominal aorta). The aortic diameter was measured at the pulmonary artery bifurcation, coeliac axis, maximal abdominal aorta and maximal thoraco-abdominal aorta using serial follow-up computed tomography scans. The linear mixed model was used, and the rate of freedom from reintervention was analysed.

RESULTS

In the adjusted analysis, the initial diameter of the maximal abdominal aorta and the first luminal communication in segment 1 was statistically significant. However, the slope value of the maximal abdominal aorta was smaller than that of the first luminal communication in segment 1 (0.024 vs 0.198). The 3-year freedom from reintervention rate was significantly higher in patients without a luminal communication than in those with an initial luminal communication in segment 1 (96% vs 47%, log rank, P = 0.003).

CONCLUSIONS

A luminal communication at the proximal descending thoracic aorta (segment 1) is a significant factor for an increasing aortic diameter and reintervention after surgical repair of acute type I aortic dissection.