Single Stage Hybrid Repair for DeBakey Type I Aortic Dissection in High Risk Patients

The creation and validation of predictive models to assess the risk of unfavorable outcomes following hybrid total arch repair for Stanford type A aortic dissection

BACKGROUND

The objective of this study was to develop and validate a nomogram for the individualized prediction of adverse events in patients with Stanford type A aortic dissection (TAAD) undergoing hybrid total aortic arch repair.

METHODS

From April 2019 to April 2022, we conducted a comprehensive review of the medical records of Stanford type A aortic dissection patients who underwent hybrid total aortic arch repair surgery at our hospital. Patients were separated into two groups based on whether or not a composite adverse event occurred following surgery. Using univariate and multivariate analyses of logistic regression, the prediction model was created. Construct risk prediction models utilizing nomograms and evaluate their precision, discrimination, and clinical utility.

RESULTS

Age, platelets, serum blood urea nitrogen, and ascending aortic diameter were the variables included in the nomogram by univariate and multivariate analysis. The risk model performed well in internal validation, with an area under the curve (AUC) of 0.829. The calibration curve demonstrated good agreement between predicted and actual probabilities (Hosmer-Lemeshow test, P = 0.22). Clinical decision analysis curves demonstrate predictive nomograms' clinical utility.

CONCLUSION

This study created and validated a nomogram for predicting the risk of composite endpoint events in TAAD patients undergoing hybrid total aortic arch repair. The nomogram can help determine the severity of a patient's condition and provide a more personalized diagnosis and treatment.

Early and Midterm Outcomes of Type II Hybrid Arch Repair for Complex Aortic Arch Pathology

Background

The hybrid arch repair (HAR) is an appealing surgical option in the management of aortic arch diseases. The aim is to evaluate the short and mid-term outcomes of type II HAR involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment in diverse arch pathologies.

Methods

200 patients with various diffuse aortic pathologies involving the arch were enrolled between 2016 and 2019. Complex arch diseases included acute type A dissection (n = 129, 64.5%), acute type B dissection (n = 16, 8.0%), aortic arch aneurysm (n = 42, 21.0%) and penetrating arch ulcer (n = 13, 6.5%). Mortality, morbidity, survival and re-intervention were analyzed.

Results

The overall 30-day mortality rate was 8.0% (16/200). Stroke was present in 3.5% (7/200) of the general cohort and spinal cord injury was occurred in 3.0% (6/200). Multivariable logistic analysis showed that cardiac malperfusion and CPB time were the risk factors associated with 30-day mortality. The mean follow-up duration was 25.9 months (range 1–57.2 months), and the 3-year survival rate was 83.1%. On Cox regression analysis, age, diabetes, cardiac malperfusion and CPB time predicted short and mid-term overall mortality. A total of 3 patients required reintervention during the follow-up due to the thrombosis of epiaortic artificial vessels (n = 1), anastomotic leak at the site of the proximal ascending aorta (n = 1) and the type I endoleak (n = 1).

Conclusions

Type II HAR was performed with satisfactory early and mid-term outcomes in complex aortic arch pathologies.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Midterm Outcomes of One-Stage Hybrid Aortic Arch Repair for Stanford Type A Aortic Dissection: A Single Center's Experience

This study sought to identify the midterm outcomes of one-stage hybrid aortic arch repair (HAAR) in patients with Stanford type A aortic dissection (TAAD). Between January 2010 and December 2015, 75 consecutive patients with TAAD involving the aortic arch who underwent one-stage type Ⅱ HAAR at our institution were identified. During this period, 496 consecutive patients with TAAD underwent traditional total aortic arch replacement (TAR) with frozen elephant trunk. The preoperative, perioperative and postoperative data of all patients were compared. A propensity score-matching analysis was applied to adjust for baseline risk factors. 571 patients were included for analysis (428 men; mean age, 48.9±11.1 years). For all patients, the mean follow-up time was 41.1±22.1 months, in-hospital mortality was 4.7% and the 5-year survival rate was 89.5%. Midterm outcomes between the propensity-matched groups were compared (59 HAAR vs TAR pairs). HAAR group showed shorter cardiopulmonary bypass time (105-159 min vs 158-230 min, p < 0.001), aortic cross-clamping time, postoperative ventilation time and intensive care unit stays (33-108 h vs 45-131 h, p = 0.010) than the TAR group. There were no significant differences in in-hospital mortality, rate of stroke and rate of paraplegia between the two groups, however, better 5-year survival rate was found in HAAR group (94.9% vs 75.8%, Log-rank p = 0.005). As compared to propensity matched cohort of TAR patients, HAAR shows good midterm outcomes for patients with TAAD. Further randomized study was needed to clarify the optimal management strategy of TAAD.

Total Arch Replacement With Frozen Elephant Trunk Using a NEW “Brain-Heart-First” Strategy for Acute DeBakey Type I Aortic Dissection Can Be Performed Under Mild Hypothermia (≥30°C) With Satisfactory Outcomes

Background

Total arch replacement (TAR) with Frozen elephant trunk (FET) treatment of acute DeBakey type I aortic dissection (ADIAD) is complicated, carries a high complication/mortality risk and remains controversial on the optimal hypothermic level, cerebral perfusion and visceral organ protection strategy. We developed a new strategy named “Brain-Heart-first” in which the surgical procedures and the management of cardiac perfusion/cerebral protection during Cardiopulmonary bypass (CPB) were redesigned, and TAR with FET technique can be performed under mild hypothermia with satisfactory outcomes.

Objective

Our aims were to describe a new surgical strategy under mild hypothermia (≥30°C) for the treatment of ADIAD and to report the operative outcomes of 215 patients.

Methods

We conducted a retrospective analysis of 215 consecutive cases of ADIAD treated with our new strategy.

Results

The durations of CPB, aortic cross-clamping, antegrade cerebral perfusion, operation, mechanical ventilation support, and Intensive Care Unit stay were 139.7 ± 52.3 min, 55.6 ± 27.4 min, 14.1 ± 3.1 min, 6.0 ± 1.7 h, 40.0 h and 4.0 d, respectively. The 30-day mortality was 9.8%, with cerebral stroke occurring in nine patients (4.2%), paraplegia in one patient (0.5%) and postoperative renal injury requiring dialysis in 21 patients (9.8%). The blood transfusion of red blood cells and fresh frozen plasma during surgery and the first 24 h after surgery was 4.0 u and 200.0 ml, respectively.

Conclusions

The Brain-Heart-first strategy can be widely used with low technical and resource requirements and provides a safe alternative for conventional TAR with FET technique in ADIAD patients with satisfactory operative results.

Age-dependent differences in the prognostic relevance of body composition-related variables in type A aortic dissection patients

Background

The current research is allocated to appraise the association between the parameters of body composition and findings in type A aortic dissection (TAAD) cases in diverse age groups.

Methods

Data from consecutive TAAD patients undergoing implantation of modified triple-branched stent-graft from January 2017 and December 2019 were prospectively collected and analyzed. A regression model of Cox proportional hazard was employed to assess correlations among body composition-related variables (body mass index [BMI], lean body mass [LBM], body surface area [BSA], and LBM index) as well as cumulative mortality.

Results

Overall, 258 patients (53.9 ± 11.1 years old; 72.9% male) were separated into young (n = 110) and elderly (n = 148) age groups based upon whether they were younger or older than 50 years of age. Of these patients, 247 survivors were included in subsequent analyses over an average 26.8 ± 11.6 month follow-up duration. Multivariate analyses in the elderly group instead of young group indicated that increased BMI (p = 0.042), BMI ≤ 18.5 kg/m² (p = 0.025), and lower LBM index values (p = 0.019) were significant predictors of increased total all-cause cumulative mortality. BMI was considerably positively correlated with estimated all-cause cumulative mortality in elderly but not young TAAD cases.

Conclusion

Briefly, these results suggest that BMI and LBM indices are only significant predictors of TAAD patient all-cause mortality in elderly patient cohorts, whereas they do not offer significant prognostic value for younger patients. As such, these age differences must be taken into consideration when conducting stratified risk assessments based upon TAAD patient body composition characteristics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01742-1.

Comparison of Prognosis Between Hybrid Debranching Surgery and Total Open Arch Replacement With Frozen Elephant Trunk for Type A Acute Aortic Syndrome Patients

Background: It is unclear whether the total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery have a difference in the prognosis of patients with type A acute aortic syndrome (AAS). We attempted to compare the short-term and long-term prognosis of total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery in patients with type A acute aortic syndrome (AAS).

Methods: From January 2014 to September 2020, a total of 518 patients who underwent TAR with FET surgery and 31 patients who underwent hybrid surgery were included. We analyzed the post-operative mortality and morbidity of complications of the two surgical methods, and we determined 67 patients for subgroup analysis through a 1:2 propensity score match (PSM). We identified risk factors for patient mortality and post-operative neurological complications through multivariate regression analysis.

Results: Compared with the TAR with FET group, hybrid surgery could reduce aortic cross-clamp time, reduce intraoperative blood loss and prevent some patients from cardiopulmonary bypass. There was no significant difference in 30-day mortality between the TAR with FET group and the hybrid surgery group (10.6 vs. 9.7%). However, hybrid surgery had increased the incidence of permanent neurological complications in patients (95%CI: 4.7–35.7%, P = 0.001), especially post-operative cerebral infarction (P < 0.001). During the average follow-up period of 31.6 months, there was no significant difference in the 1-year survival rate and 3-year survival rate between the TAR with FET group and the hybrid surgery group (P = 0.811), but hybrid surgery increased the incidence of long-term neurological complications (P < 0.001). In multivariate regression analysis, surgical methods were not a risk factor for post-operative deaths, but hybrid surgery was a risk factor for post-operative neurological complications (P < 0.001).

Conclusions: Hybrid surgery is an acceptable treatment for AAS, and its post-operative mortality is similar to FET. But hybrid surgery may increase the risk of permanent neurological complications after surgery, and this risk must be carefully considered when choosing hybrid surgery.

Type II hybrid arch repair versus total arch replacement with frozen elephant trunk: a propensity score-matched analysis

 

OBJECTIVES

The aim of this study was to evaluate the objective outcomes of type II hybrid arch repair (HAR) and total arch replacement with frozen elephant trunk (TAR with FET).

METHODS

Data from 528 patients who underwent aortic arch repair from January 2017 to June 2019 were collected, which consisted of 175 type II HAR and 353 TAR with FET. The propensity score-matched analysis identified a subgroup of 90 pairs. Perioperative data and mid-term follow-up results were assessed.

RESULTS

There was no significant difference in the composite adverse events (type II HAR, 20.6%, 36/175 vs TAR with FET, 17.8%, 63/353, P = 0.450). Multivariable logistic analysis of the 528 patients showed that the procedure type (type II HAR or TAR with FET) was not associated with composite adverse events, 30-day mortality or stroke. The 3-year survival rates were 84.8% in the type II HAR group and 90.1% in the TAR with FET group (P = 0.12). The 3-year reintervention-free rates in the type II HAR and TAR with FET groups were 98.7% and 96.5% (P = 0.22), respectively. After matching, no significant difference was found in the incidence of composite adverse events or the 3-year survival and reintervention-free rates.

CONCLUSIONS

No significant clinical differences were found in the early and mid-term outcomes of type II HAR and TAR with FET. The long-term outcomes remain to be investigated. Careful patient selection for individualized approaches is the key to taking full advantage of the 2 surgical procedures.

Early outcomes of hybrid type II arch repair versus total arch replacement with frozen elephant trunk in acute DeBakey type I aortic dissection: a propensity score-matched analysis

OBJECTIVES

The aim was to evaluate the short-term outcomes of hybrid type II arch repair (HAR) and total arch replacement with frozen elephant trunk (TAR with FET) for acute DeBakey type I aortic dissection patients.

METHODS

From January 2017 to June 2019, the clinical data of acute DeBakey type I aortic dissection patients in a single centre were retrospectively reviewed; there were 92 cases of HAR and 268 cases of TAR with FET, with 56 pairs by propensity score matching.

RESULTS

After matching, the composite end points including 30-day mortality, stroke, paraplegia, renal failure, hepatic failure, reintubation or tracheotomy and low cardiac output syndrome were comparable (21.4%, 12/56 in the HAR group vs 21.4%, 12/56 in the TAR with FET group, P = 1.000). The rate of acute kidney injury (AKI) was significantly lower in the HAR group (58.9%, 33/56 vs 80.4%, 45/56, P = 0.031). The distribution of AKI stage according to the Kidney Disease Improving Global Outcomes criteria was different (P = 0.039), with more patients suffering from high-grade AKI in the TAR with FET group. Multivariable logistic analysis showed that the procedure type (HAR or TAR with FET) was not an independent predictor of composite adverse events or stroke. HAR was identified as a protective factor against AKI (odds ratio 0.485, 95% confidence interval 0.287-0.822; P = 0.007).

CONCLUSIONS

In the treatment of acute DeBakey type I aortic dissection, no significant differences were found in early outcomes between the 2 groups, but HAR was associated with a significantly lower incidence of AKI.

Clinical features and surgical outcomes of type A intramural hematoma

Background

Data on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes.

Methods

From February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test.

Results

Except 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively.

Conclusions

Our strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.