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Barnes JA, Wanken ZJ, Columbo JA, Kuwayama DP, Fillinger MF, Suckow BD. Procedure-Associated Costs and Mid-Term Outcomes of Endovascular Zone 0 and Zone 1 Aortic Arch Repair. Ann Vasc Surg 2021; 81:98-104. [PMID: 34780945 DOI: 10.1016/j.avsg.2021.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/24/2021] [Accepted: 10/01/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch pathology provides a less-invasive treatment option for high-risk patients ineligible for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the mid-term outcomes after Zone 0 and Zone 1 TEVAR and describe the associated technical costs, revenues, and net margins at a single tertiary medical center. METHODS We examined all patients who underwent TEVAR between April 2011 and August 2019 via retrospective chart review. Patients were categorized by proximal endograft extent to identify Zone 0 or Zone 1 repairs. Procedural characteristics and outcomes were described. Technical costs, revenues, and margins were obtained from the hospital finance department. RESULTS We identified 10 patients (6 Zone 0, 4 Zone 1) who were denied open arch reconstruction. Patients were predominantly female (n = 8; 80%) and the mean age was 72.8 ± 5.5 years. TEVAR was performed in 5 asymptomatic patients, urgently in 3 symptomatic patients, and emergently in 2 ruptured patients. TEVAR plus extra-anatomic bypass was performed in 4 patients. Another 4 patients also received parallel stent-grafting while 1 patient received a branched thoracic endograft and yet another an in-situ laser fenestration followed by branch stent grafting. Within the 30-day postoperative period, 1 patient experienced stroke and 1 patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean 19.3 months). Mean total technical cost associated with all procedures or repair stages was $105,164 ± $59,338 while mean net technical margin was -$25,055 ± $18,746. The net technical margin was negative for 9 patients. CONCLUSIONS Endovascular repair of the proximal aortic arch is associated with good mid-term outcomes in patients considered too high-risk for open repair. However, reimbursement does not adequately cover treatment cost, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to both optimize aortic arch TEVAR delivery as well as advocate for reimbursement commensurate with associated costs.
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Affiliation(s)
| | - Zachary J Wanken
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David P Kuwayama
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark F Fillinger
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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2
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Di Marco L, Berardi M, Murana G, Leone A, Botta L, Amodio C, Bacchi Reggiani ML, Di Bartolomeo R, Pacini D. Early outcome and mid-term survival after open arch repair using selective antegrade cerebral perfusion. Asian Cardiovasc Thorac Ann 2021; 30:2184923211028782. [PMID: 34229481 DOI: 10.1177/02184923211028782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The introduction of selective antegrade cerebral perfusion technique as method of cerebral protection improved the outcome of open arch surgery. The aim of this study was to report early outcomes using this technique. METHODS Between 1997 and 2017, data were collected retrospectively for all patients who underwent surgical replacement of the aortic arch using selective antegrade cerebral perfusion (n = 938). To confirm the effectiveness of this cerebral protection method, early outcome and results were evaluated. RESULTS The incidence of postoperative permanent neurological dysfunction was 6.4%. Overall hospital mortality was 11.9% (n = 112). On multivariable analysis, age >75 years, female gender, euroscore at increment of 1 point, chronic renal failure, extension of thoracic aorta replacement and CPB time emerged as independent risk factors for hospital mortality. The mid-term survival at 1, 5, 10 and 15 years was 92%, 78%, 60% and 49%, respectively. The competing risk analysis for permanent neurological dysfunction and aortic reoperations was performed excluding the patients who died during the hospital stay. The cumulative incidence of permanent neurological dysfunction and aortic reoperations was 2% at 3 years, 3% at 5 years, 6% at 10 years, 12% at 3 years, 15% at 5 years and 19% at 10 years, respectively. CONCLUSIONS From the early 90s to the present day, the selective antegrade cerebral perfusion has confirmed to be a useful and "safe" method of brain protection in aortic arch surgery in terms of postoperative neurological complications.
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Affiliation(s)
- Luca Di Marco
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marianna Berardi
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giacomo Murana
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Leone
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Botta
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ciro Amodio
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Saito Y, Yamamoto H, Fukuda I, Miyata H, Minakawa M, Motomura N. The results of aortic arch replacement using antegrade cerebral perfusion in haemodialysis patients: analysis of the Japan cardiovascular surgery database. Eur J Cardiothorac Surg 2021; 61:162-169. [PMID: 34148088 DOI: 10.1093/ejcts/ezab252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database. METHODS A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014-2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model. RESULTS The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22-8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00-4.10, P = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified. CONCLUSIONS The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality.
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Affiliation(s)
- Yoshiaki Saito
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Ikuo Fukuda
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Masahito Minakawa
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
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Ohira S, Malekan R, Kai M, Goldberg JB, Spencer PJ, Lansman SL, Spielvogel D. Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion. Ann Thorac Surg 2021; 113:569-576. [PMID: 33857494 DOI: 10.1016/j.athoracsur.2021.03.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/23/2021] [Accepted: 03/29/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study reviews the outcomes of our reoperative total arch repair (TAR) technique using a trifurcated graft and selective antegrade cerebral perfusion (SACP). METHODS Fifty patients underwent reoperative TAR from January 2005 to September 2020, with either a one-stage (N=9), or two-stage repair (N=41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk via a partial transverse incision distally in the old-graft or in the aorta just distal to the old graft. RESULTS The median age was 63 years. Chronic dissection was the most frequent indication (88%) and 98% had undergone a previous proximal aortic repair at a median interval of 3.0 years. The median cardiopulmonary bypass, myocardial ischemic, SACP, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5 °C, and 20.0 °C. Operative mortality was 2% and the incidence of stroke, and spinal cord injury (SCI) were 2%, and 0%. Stage II repair was performed in 37 patients (open: 33 patients, endovascular: 4 patients), with two mortalities and no SCI. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4 ±4.9%, and 89.8 ±5.0%. CONCLUSIONS We report a reoperative TAR technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Philip J Spencer
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
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5
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Sun X, Zhao Q, Huo Y, Zhou J, Zhao F, Liu Y, Du Y, He S, Liu C, Jiang D, Sun W. Short-term outcomes of modified Y-graft technique in acute type a aortic dissection using the femoral artery bypass and one minute systemic circulatory arrest technique. J Cardiothorac Surg 2020; 15:106. [PMID: 32434594 PMCID: PMC7240991 DOI: 10.1186/s13019-020-01156-5] [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: 02/24/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Aortic arch replacement in acute type A aortic dissection patients remains the most challenging cardiovascular operation. Herein, we described our modified Y-graft technique using the Femoral Artery Bypass (FAB) and the One Minute Systemic Circulatory Arrest (OSCA) technique, and assessed the short-term outcomes of the patients. Methods Between February 2015 and November 2017, 51 patients with acute type A aortic dissection underwent aortic arch replacement. Among them, 23 patients underwent FAB while 28 patients underwent both FAB and OSCA. The intraoperative data and postoperative follow-up data were recorded. The follow-up data of patients with traditional Y-graft technique were collected from previously reported studies. Results In the FAB group, two patients died due to pulmonary infection (30-day survival rate, 91.3%), and two patients were paralyzed from the waist down. Hemodialysis was performed for five patients (21.7%) before hospital discharge. Fifteen patients (65.2%) received respiratory support for more than 2-days and eight patients (34.8%) for more than 5-days. These follow-up results were comparable or better than the patients with traditional Y-graft technique. Furthermore, compared to the FAB group, the morbidity due to neurological dysfunction and acute renal failure was significantly reduced in the FAB+OSCA group. Moreover, the respiratory support, length of postoperative stay and ICU stay were shortened. Conclusions This study clarified the feasibility of FAB and OSCA technique in modifying Y-graft technique. The acute type A aortic dissection patients showed less surgical complications and favorable short-term outcomes after this surgery.
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Affiliation(s)
- Xiangfei Sun
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021, China.,Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Qi Zhao
- Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021, China.,Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yufeng Huo
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Jinfeng Zhou
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Fen Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Yimin Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Yonghai Du
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Songxiong He
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Chao Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Detian Jiang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China
| | - Wenyu Sun
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266011, Shandong, People's Republic of China.
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6
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Orlov CP, Orlov OI, Shah VN, Kilcoyne M, Buckley M, Sicouri S, Plestis KA. Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft. Semin Thorac Cardiovasc Surg 2020; 32:683-691. [PMID: 32360886 DOI: 10.1053/j.semtcvs.2020.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/23/2020] [Indexed: 11/11/2022]
Abstract
This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18-22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32-82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79-94%) were alive at 1 year, 78% at 5 years (95%CI: 66-86%), and 73% at 10 years (95%CI: 59-82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes.
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Affiliation(s)
- Cinthia P Orlov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Oleg I Orlov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Vishal N Shah
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania; Lankenau Heart Institute, Department of Cardiothoracic Surgery, Wynnewood, Pennsylvania
| | - Maxwell Kilcoyne
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Meghan Buckley
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Serge Sicouri
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
| | - Konstadinos A Plestis
- Lankenau Heart Institute, Department of Cardiothoracic Surgery, Wynnewood, Pennsylvania
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7
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Dagenais F. Commentary: Have we finally settled the debate of unilateral versus bilateral antegrade cerebral perfusion for brain protection during type A repair? J Thorac Cardiovasc Surg 2019; 160:626-627. [PMID: 31562016 DOI: 10.1016/j.jtcvs.2019.07.118] [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: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Francois Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiology et Pneumologie de Québec, Québec, Québec, Canada.
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8
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Total arch replacement using a 4-branched graft with antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2019; 157:1370-1378. [DOI: 10.1016/j.jtcvs.2018.09.112] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 09/09/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022]
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Preventza O, Tan CW, Orozco-Sevilla V, Euhus CJ, Coselli JS. Zone zero hybrid arch exclusion versus open total arch replacement. Ann Cardiothorac Surg 2018; 7:372-379. [PMID: 30155416 DOI: 10.21037/acs.2018.04.03] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Open total aortic arch replacement is one of the most technically demanding operations in cardiothoracic surgery, requiring operator expertise and intraoperative and postoperative teamwork. Despite current advancements in the field of open aortic surgery with regard to intraoperative brain protection and postoperative care, the morbidity and mortality associated with open total arch operations varies. Endovascular and hybrid procedures involving the use of zone 0 as a landing zone allow fair comparison between open total arch and hybrid operations. Hybrid procedures involving all of the other landing zones [1-4] should not be compared with open total arch replacement, as the extent of the pathology is different.
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Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Corinne W Tan
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Caleb J Euhus
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
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10
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Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2017; 154:1831-1839.e1. [DOI: 10.1016/j.jtcvs.2017.08.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 07/09/2017] [Accepted: 08/01/2017] [Indexed: 01/15/2023]
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Hori D, Okamura H, Yamamoto T, Nishi S, Yuri K, Kimura N, Yamaguchi A, Adachi H. Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†. Interact Cardiovasc Thorac Surg 2017; 24:944-950. [PMID: 28329032 DOI: 10.1093/icvts/ivx031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/03/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. METHODS Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. RESULTS Seventy percent ( n = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P < 0.001). Intensive care unit stay (1 vs 3 days, P < 0.001), hospital stay (11 vs 17 days, P < 0.001) and surgical time (208 vs 390 min, P < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P = 0.40). Mid-term survival ( P < 0.001) and freedom from reintervention ( P = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n = 58) demonstrated that survival was better in the open surgery group ( P = 0.011); no significant difference was seen in the reintervention rate ( P = 0.28). CONCLUSIONS Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takahiro Yamamoto
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Satoshi Nishi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koichi Yuri
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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13
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Shelstad RC, Reeves JG, Yamanaka K, Reece TB. Total Aortic Arch Replacement: Advantages of Varied Techniques. Semin Cardiothorac Vasc Anesth 2016; 20:307-313. [PMID: 27765887 DOI: 10.1177/1089253216672849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the "Spielvogel" trifurcated graft technique-each having its own advantages. In addition, thoracic aortic aneurysms involving the arch and descending aorta pose a substantial surgical challenge and often require hybrid or nonclamp technique with staged operative interventions. Hybrid and endovascular (thoracic endovascular aortic repair) techniques for the descending aorta are evolving and require consideration in operative planning. Areas of controversy include management of the subclavian artery, extent of distal arch replacement, elephant trunk and hybrid frozen elephant trunk techniques, and use and timing of staged approaches. Aortic arch replacement remains a complex, potentially difficult procedure. Better understanding of the potential open approaches to arch replacement will optimize the potential outcomes for patients. Aortic arch pathology is best served by tailoring the procedure to the patient-specific anatomy and pathology.
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14
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Der Aortenbogen – was ist bei der endovaskulären Versorgung zu beachten? GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00772-016-0164-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Aneurismas del arco aórtico. Generalidades: epidemiología, manifestaciones clínicas y diagnóstico. Indicaciones de cirugía. Cirugía abierta. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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16
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Matalanis G, Perera NK, Galvin SD. Aortic arch replacement without circulatory arrest or deep hypothermia: The “branch-first” technique. J Thorac Cardiovasc Surg 2015; 149:S76-82. [DOI: 10.1016/j.jtcvs.2014.07.100] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/03/2014] [Accepted: 07/21/2014] [Indexed: 11/30/2022]
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Di Eusanio M, Berretta P, Cefarelli M, Castrovinci S, Folesani G, Alfonsi J, Pantaleo A, Murana G, Di Bartolomeo R. Long-term outcomes after aortic arch surgery: results of a study involving 623 patients. Eur J Cardiothorac Surg 2014; 48:483-90. [DOI: 10.1093/ejcts/ezu468] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/04/2014] [Indexed: 11/12/2022] Open
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18
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Endovascular treatment of thoracic aortic aneurysms with a short proximal landing zone using scalloped endografts. J Vasc Surg 2014; 60:1499-506. [DOI: 10.1016/j.jvs.2014.08.062] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/07/2014] [Indexed: 11/18/2022]
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19
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Midterm Outcomes of Carotid-to-Carotid Bypass for Hybrid Treatment of Aortic Arch Disease. Ann Vasc Surg 2014; 28:860-5. [DOI: 10.1016/j.avsg.2013.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/11/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022]
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20
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Matalanis G, Galvin SD. "Branch-first" continuous perfusion aortic arch replacement and its role in intra-operative cerebral protection. Ann Cardiothorac Surg 2013; 2:194-201. [PMID: 23977582 DOI: 10.3978/j.issn.2225-319x.2013.02.01] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/18/2013] [Indexed: 11/14/2022]
Affiliation(s)
- George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Heidelberg, Australia
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21
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Numata S, Tsutsumi Y, Monta O, Yamazaki S, Seo H, Yoshida S, Samura T, Ohashi H. Mid-Long-Term Results After Aortic Arch Repair Using a Four-Branched Graft With Antegrade Selective Cerebral Perfusion. J Card Surg 2013; 28:537-42. [DOI: 10.1111/jocs.12166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Satoshi Numata
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Yasushi Tsutsumi
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Osamu Monta
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Sachiko Yamazaki
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Hiroyuki Seo
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Shohei Yoshida
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Takaaki Samura
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
| | - Hirokazu Ohashi
- Department of Cardiovascular Surgery; Fukui Cardiovascular Center; Fukui Japan
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22
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Davies RA, Black D, Bannon PG, Bayfield MS, Hendel PN, Hughes CF, Wilson MK, Vallely MP. Outcomes of aortic arch replacement surgery after previous cardiac surgery. ANZ J Surg 2013; 83:827-32. [PMID: 23782742 DOI: 10.1111/ans.12299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic arch replacement is a potentially high-risk operation and in the re-operative setting has been found to be a risk factor for poor outcome, yet there is a dearth of published data specifically on this topic. The aim of the study was to review our unit's outcomes in this re-operative setting. METHOD Data were collated for all patients who underwent aortic arch replacement surgery after previous cardiac surgery from January 1988 to November 2011. The patients were divided based primarily on elective versus non-elective and also early (≤2005) and late (≥2006) series. RESULTS Twenty-seven eligible patients (22 male; median age: 53.0 years; elective: 14, non-elective: 13) were identified. There was a mean period of 14.5 years between the first operation and the subsequent aortic arch replacement. The overall 30-day mortality rate was 22.2% - 0% elective and 46.2% non-elective (P = 0.004). Overall permanent neurological dysfunction was 21.7% - 28.6% elective and 11.1% non-elective (P = 0.463). There were 11 early-series patients and 16 late-series patients. For early-series patients, 90.9% were non-elective versus 18.8% in the late-series patients. The 30-day mortality rate was 54.5% early series versus 0% late series. CONCLUSION Aortic arch replacement is high risk in the re-operative setting. These risks are even greater for non-elective procedures. This highlights the need for aggressive first-time surgery to reduce re-operative procedures and good long-term follow-up programmes to allow elective procedures if required.
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Affiliation(s)
- Reece A Davies
- Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia; The Baird Institute for Heart and Lung Surgical Research, Sydney, New South Wales, Australia
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23
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Alameddine AK, Alimov VK, Flack JE. Alternative perfusion technique without axillary artery cannulation during combined aortic root and total arch replacement. J Card Surg 2013; 28:427-9. [PMID: 23692659 DOI: 10.1111/jocs.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report describes an effective cerebral perfusion method using an additional 4th side limb graft sewn to a trifurcated graft in patients undergoing redo aortic root reconstruction combined with total aortic arch replacement. This method is useful in cases where the origin of the innominate artery is unsuitable for clamping or when axillary perfusion is not employed, and assures continuous brain protection and minimizes circulatory arrest time.
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Affiliation(s)
- Abdallah K Alameddine
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, Massachusetts 01107, USA
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24
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Nakamura K, Nagahama H, Nakamura E, Yano M, Matsuyama M, Nishimura M, Yokota A, Ishii H. Predictors of early and late outcome after total arch replacement for atherosclerotic aortic arch aneurysm. Gen Thorac Cardiovasc Surg 2013; 62:31-7. [DOI: 10.1007/s11748-013-0264-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 05/10/2013] [Indexed: 11/28/2022]
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25
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Moz M, Misfeld M, Leontyev S, Borger MA, Davierwala P, Mohr FW. Aortic arch reoperation in a single centre: early and late results in 57 consecutive patients†. Eur J Cardiothorac Surg 2013; 44:e82-6. [DOI: 10.1093/ejcts/ezt205] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Kouchoukos NT. Total aortic arch replacement in 2013: where do we go from here? Eur J Cardiothorac Surg 2013; 43:1084-6. [DOI: 10.1093/ejcts/ezt133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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27
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Yuri K, Yokoi Y, Yamaguchi A, Hori D, Adachi K, Adachi H. Usefulness of fenestrated stent grafts for thoracic aortic aneurysms. Eur J Cardiothorac Surg 2013; 44:760-7. [DOI: 10.1093/ejcts/ezt127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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28
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Qi R, Sun L, Zhu J, Liu Y, Zheng J, Li C, Chang Q. Total arch replacement in patients with aortic dissection with an isolated left vertebral artery. Ann Thorac Surg 2012; 95:36-40. [PMID: 23040824 DOI: 10.1016/j.athoracsur.2012.07.078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 07/21/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The presence of an isolated left vertebral artery requires changes in the aortic arch reconstruction techniques and cerebral protection methods in patients with total arch replacement. The best method for surgical repair of the isolated left vertebral artery is controversial. We retrospectively reviewed our experience of total arch replacement in patients with aortic dissection with this vessel anomaly. METHODS Between August 2003 and December 2008, 21 patients with aortic dissection (type A dissection, n = 20; type B dissection, n = 1) with an isolated left vertebral artery underwent total arch replacement under hypothermic cardiopulmonary bypass combined with selective cerebral perfusion. Concomitant stented elephant trunk was implanted in 20 patients. RESULTS There was no in-hospital death. Injury to the spinal cord occurred in 2 patients with chronic dissection using stented elephant trunk implantation. One had weakness in the left lower extremity, and the other patient had paraparesis: both recovered during the follow-up period. One patient experienced transient neurologic deficit, and acute renal failure was observed in 1 patient: both recovered completely before hospital discharge. CONCLUSIONS Acceptable results were obtained in patients with aortic dissection with an isolated left vertebral artery. Although there was no clear evidence that the spinal cord injury was related to the isolated left vertebral artery using stented elephant trunk implantation, the isolated left vertebral artery was constructed as soon as possible in patients with this vessel anomaly.
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Affiliation(s)
- RuiDong Qi
- Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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29
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Thomas M, Li Z, Cook DJ, Greason KL, Sundt TM. Contemporary results of open aortic arch surgery. J Thorac Cardiovasc Surg 2012; 144:838-44. [DOI: 10.1016/j.jtcvs.2011.09.069] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/13/2011] [Accepted: 09/21/2011] [Indexed: 10/14/2022]
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Krüger T, Conzelmann LO, Bonser RS, Borger MA, Czerny M, Wildhirt S, Carrel T, Mohr FW, Schlensak C, Weigang E. Acute aortic dissection type A. Br J Surg 2012; 99:1331-44. [DOI: 10.1002/bjs.8840] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges.
Methods
Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described.
Results
Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options.
Conclusion
AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.
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Affiliation(s)
- T Krüger
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - L O Conzelmann
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
| | - R S Bonser
- Department of Cardiac Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust and University of Birmingham, Birmingham, UK
| | - M A Borger
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - M Czerny
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - S Wildhirt
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - T Carrel
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - F W Mohr
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - C Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - E Weigang
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
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31
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Di Luozzo G, Griepp RB. Cerebral Protection for Aortic Arch Surgery: Deep Hypothermia. Semin Thorac Cardiovasc Surg 2012; 24:127-30. [DOI: 10.1053/j.semtcvs.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/11/2022]
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Abstract
A critical consideration in the operative strategy for aortic arch replacement, how best to protect the brain while providing surgical access to the cerebral vessels, involves two key aspects: minimizing cerebral ischaemia and preventing cerebral embolization of air and atheromatous debris. We describe a technique, using a trifurcated branched graft, that combines hypothermic circulatory arrest, selective antegrade perfusion and axillary artery cannulation.
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Affiliation(s)
- David Spielvogel
- New York Medical College, Section of Cardiothoracic Surgery, Westchester Medical Center, Macy Pavilion 114W, Valhalla, NY 10595, USA
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33
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Davies RA, Black D, Jeremy RW, Bannon PG, Bayfield MS, Hendel PN, Hughes CF, Wilson MK, Vallely MP. Evolution in the Techniques and Outcomes of Aortic Arch Surgery: A 22 Year Single Centre Experience. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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34
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Grimm M, Bonaros N, Schachner T. Evolving knowledge about age and hypothermic circulatory arrest in aortic surgery. Circulation 2011; 124:1401-3. [PMID: 21947932 DOI: 10.1161/circulationaha.111.052340] [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] [Indexed: 11/16/2022]
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35
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Davies RA, Black D, Jeremy RW, Bannon PG, Bayfield MS, Hendel PN, Hughes CF, Wilson MK, Vallely MP. Evolution in the techniques and outcomes of aortic arch surgery: a 22 year single centre experience. Heart Lung Circ 2011; 20:704-11. [PMID: 21872527 DOI: 10.1016/j.hlc.2011.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 07/22/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Aortic arch replacement is a complicated and high risk procedure. There have been many advances over recent years. We review the changes in our unit's techniques and outcomes over the past 22 years. METHODS Data were collated from databases and medical records for all patients who underwent aortic arch replacement surgery from January 1989 to December 2010. The patients were divided into two groups - Group A (1989-2005) and Group B (2006-2010). Data were analysed to compare early and late series patients' outcomes. Logistic regression was used to identify variables that predicted mortality. RESULTS Seventy-five eligible patients (56 males; mean age: 57.5 years; Group A: 40, Group B 35) were identified. There were great changes in the technique and the methods of cerebral protection. The overall mortality rate was 30.7% - Group A: 50% and Group B: 8.6% (p<0.001). Overall permanent neurological dysfunction was 23.7% - Group A: 40% and Group B: 11.8% (p=0.012). Cardiovascular disease and circulatory arrest time were significant predictors of mortality. CONCLUSIONS Increased experience and volume and advances in techniques over 22 years have resulted in major improvements in outcomes for patients having aortic arch replacement, allowing the procedure to be performed with greatly improved outcomes.
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Affiliation(s)
- Reece A Davies
- Faculty of Medicine, The University of Sydney, Sydney, Australia
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