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Ohira S, Kai M, Goldberg JB, Malekan R, Gregory V, Pena CDL, Aoki K, Egawa S, Lansman SL, Spielvogel D. Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach. Ann Thorac Surg 2024; 117:753-760. [PMID: 38081500 DOI: 10.1016/j.athoracsur.2023.11.028] [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: 02/17/2023] [Revised: 10/12/2023] [Accepted: 11/20/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. METHODS A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. RESULTS The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. CONCLUSIONS Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Vasiliki Gregory
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Corazon de la Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kosuke Aoki
- Department of Neurosurgery and Biochemistry, University of Miami, Miami, Florida
| | - Satoshi Egawa
- Department of Neurology, Colombia University Irving Medical Center, New York, New York
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
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Ohira S, Gregory V, Goldberg JB, Malekan R, Laskowski I, De La Pena C, Lansman SL, Spielvogel D, Kai M. Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair. JTCVS Tech 2023; 21:7-17. [PMID: 37854804 PMCID: PMC10580043 DOI: 10.1016/j.xjtc.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 10/20/2023] Open
Abstract
Objective With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair. Methods From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N = 19, and proximal-first technique, N = 26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch. Results The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P < .001). Cardiopulmonary bypass (230 vs 177.5 minutes, P < .001), myocardial ischemic (124 vs 91 minutes, P < .001), and lower-body circulatory arrest (87 vs 28 minutes, P < .001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P = .048), platelets (arch-first, 4 units vs proximal-first, 2 units, P = .003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P = .024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P = .001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P = .739). Distal intervention was successfully performed in 5 patients (endovascular, N = 3, and open repair, N = 2). Conclusions Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | | | - Joshua B. Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Igor Laskowski
- New York Medical College, Valhalla, NY
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Steven L. Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
- New York Medical College, Valhalla, NY
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Ohira S, Malekan R, Kai M, Goldberg JB, Laskowski I, De La Pena C, Mason I, Lansman SL, Spielvogel D. Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don't Despair the Repair. Ann Thorac Surg 2023; 116:43-50. [PMID: 36653324 DOI: 10.1016/j.athoracsur.2022.10.021] [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: 07/14/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair. METHODS From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis. RESULTS Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y. CONCLUSIONS Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York.
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Igor Laskowski
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - Ian Mason
- New York Medical College, Valhalla, New York
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
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Ohira S, Dhand A, Hirani R, Martinez S, Lanier GM, Levine A, Pan S, Aggarwal-Gupta C, Gass AL, Wolfe K, Spielvogel D, Kai M. Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation. Clin Transplant 2023; 37:e14871. [PMID: 36468757 DOI: 10.1111/ctr.14871] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/14/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Abhay Dhand
- New York Medical College, Valhalla, New York, USA.,Transplant Infectious Disease, Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Rahim Hirani
- New York Medical College, Valhalla, New York, USA
| | | | - Gregg M Lanier
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Avi Levine
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Stephen Pan
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Chhaya Aggarwal-Gupta
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Alan L Gass
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Kevin Wolfe
- Division of Data Compliance, Transplant Services, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
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Orozco-Sevilla V, LeMaire SA. Is Direct Cannulation the Right Approach to the Right Axillary Artery? Ann Thorac Surg 2022; 114:1347-1348. [PMID: 35346635 DOI: 10.1016/j.athoracsur.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390 Houston, TX 77030; Texas Heart Institute, Houston, Texas; Department of Cardiovascular Surgery, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390 Houston, TX 77030; Texas Heart Institute, Houston, Texas; Department of Cardiovascular Surgery, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas.
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