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Brown JA, Yousef S, Serna-Gallegos D, Sá MP, Agrawal N, Thoma F, Wang Y, Phillippi J, Sultan I. Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach. Perfusion 2024:2676591241259622. [PMID: 38863259 DOI: 10.1177/02676591241259622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
OBJECTIVE To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. METHODS This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. RESULTS A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24 h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. CONCLUSIONS Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nishant Agrawal
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Elbatarny M, Trimarchi S, Korach A, Di Eusanio M, Pacini D, Bekeredjian R, Myrmel T, Bavaria JE, Desai ND, Sultan I, Brinster DR, Pai CW, Eagle KA, Patel HJ, Peterson MD. Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data. Ann Thorac Surg 2024; 117:1128-1134. [PMID: 38458510 DOI: 10.1016/j.athoracsur.2024.02.026] [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: 10/16/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD). METHODS The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral. RESULTS The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia. CONCLUSIONS Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.
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Affiliation(s)
- Malak Elbatarny
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Santi Trimarchi
- Division of Cardiac Surgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Amit Korach
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Marco Di Eusanio
- Cardiac Surgery Unit, University of Medicine of Ancona, Ancona, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, University Hospital S. Orsola, Bologna, Italy
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Truls Myrmel
- Department of Clinical Medicine, Tromso University Hospital, Tromso, Norway
| | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek R Brinster
- Department of Cardiothoracic Surgery, Northwell Health, New York City, New York
| | - Chih-Wen Pai
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Kim A Eagle
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Mark D Peterson
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.
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Samadzadeh Tabrizi N, Sá MP, Jacquemyn X, Yousef S, Brown JA, Serna-Gallegos D, Sultan I. Central versus peripheral cannulation for acute type A aortic dissection: A meta-analysis of over 14,000 patients. Am J Surg 2024:115780. [PMID: 38825544 DOI: 10.1016/j.amjsurg.2024.115780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/08/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE The optimal cannulation strategy for patients with acute type A aortic dissections (ATAAD) is unclear. METHODS A systematic search was performed to identify all studies comparing aortic and non-aortic cannulation in patients undergoing ATAAD repair. The primary endpoint was overall survival. The secondary endpoints were operative mortality, postoperative stroke, renal failure, renal replacement therapy, paraplegia, and mesenteric ischemia. Pooled meta-analyses with aggregated and reconstructed time-to-event data were performed. RESULTS Twenty-three studies were included (aortic: 3904; non-aortic: 10,719). Ten-year overall survival was 61.1 % and 58.4 % for aortic and non-aortic cannulation, respectively (HR 1.07; 95 % CI 0.92-1.25; p = 0.38). No statistically significant difference was observed for operative mortality (p = 0.10), stroke (p = 0.89), renal failure (p = 0.83), or renal replacement therapy (p = 0.77). CONCLUSION Patients undergoing surgery for ATAAD can undergo aortic cannulation with similar outcomes to those who undergo non-aortic cannulation.
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Affiliation(s)
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pennsylvania, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
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Ede J, Teurneau-Hermansson K, Ramgren B, Moseby-Knappe M, Åström DO, Larsson M, Sjögren J, Wierup P, Nozohoor S, Zindovic I. Retrograde cerebral perfusion reduces embolic and watershed lesions after acute type a aortic dissection repair with deep hypothermic circulatory arrest. J Cardiothorac Surg 2024; 19:302. [PMID: 38811972 PMCID: PMC11134620 DOI: 10.1186/s13019-024-02814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/25/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection. METHODS Single-center, retrospective, observational study including all patients undergoing acute type A aortic dissection repair with deep hypothermic circulatory arrest between January 1998 and December 2022 with or without the adjunct of retrograde cerebral perfusion. 515 patients were included: 257 patients with hypothermic circulatory arrest only and 258 patients with hypothermic circulatory arrest and retrograde cerebral perfusion. The primary endpoints were clinical neurological injury, embolic lesions, and watershed lesions. Multivariable logistic regression was performed to identify independent predictors of the primary outcomes. Survival analysis was performed using Kaplan-Meier estimates. RESULTS Clinical neurological injury and embolic lesions were less frequent in patients with retrograde cerebral perfusion (20.2% vs. 28.4%, p = 0.041 and 13.7% vs. 23.4%, p = 0.010, respectively), but there was no significant difference in the occurrence of watershed lesions (3.0% vs. 6.1%, p = 0.156). However, after multivariable logistic regression, retrograde cerebral perfusion was associated with a significant reduction of clinical neurological injury (OR: 0.60; 95% CI 0.36-0.995, p = 0.049), embolic lesions (OR: 0.55; 95% CI 0.31-0.97, p = 0.041), and watershed lesions (OR: 0.25; 95%CI 0.07-0.80, p = 0.027). There was no significant difference in 30-day mortality (12.8% vs. 11.7%, p = ns) or long-term survival between groups. CONCLUSION In this study, we showed that the addition of retrograde cerebral perfusion during hypothermic circulatory arrest in the setting of acute type A aortic dissection repair reduced the risk of clinical neurological injury, embolic lesions, and watershed lesions.
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Affiliation(s)
- Jacob Ede
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Karl Teurneau-Hermansson
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Birgitta Ramgren
- Department of Clinical Sciences Lund, Department of Radiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Department of Neurology and Rehabilitation, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Oudin Åström
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Division of Sustainable Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mårten Larsson
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Per Wierup
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
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Zhu Z, Wu L, Yuan Y. Is axillary artery cannulation necessary in type II hybrid aortic arch repair for acute type A aortic dissection? Perfusion 2024:2676591241252721. [PMID: 38703049 DOI: 10.1177/02676591241252721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Axillary artery cannulation (AAC) has been widely employed in total arch replacement surgeries using the frozen elephant trunk (FET) technique for acute type A aortic dissection (ATAAD), showing better clinical results than femoral artery cannulation (FAC). Nevertheless, in type II hybrid arch repair (HAR), FAC is crucial for lower body perfusion. Hence, it is unclear whether AAC remains necessary or if AAC represents a more advantageous method for initiating cardiopulmonary bypass. METHODS We conducted a study involving patients diagnosed with ATAAD who underwent type II HAR from August 2021 to December 2022. Demographic baseline and intraoperative data were collected, and the postoperative outcomes of patients receiving FAC only were compared with those receiving AAC. RESULTS There were no significant differences in baseline demographics between patients who underwent FAC alone (n = 46) and those who underwent AAC (n = 39). Patients who underwent AAC showed a lower incidence of transient neurological dysfunction (TND) post-surgery compared to those who underwent FAC (12.8% vs 32.6%, p = .032). There were no significant differences between the groups in terms of postoperative mortality within 30 days, permanent neurological dysfunction (PND), length of stay in the intensive care unit (ICU) and postoperative ward, duration of mechanical ventilation, and other complications. CONCLUSIONS Axillary artery cannulation may decrease the incidence of postoperative transient neurological dysfunction (TND) in type II HAR for ATAAD. Nonetheless, studies with larger sample sizes are necessary.
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Affiliation(s)
- Zhonglai Zhu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Long Wu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhong Yuan
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Brown JA, Yousef S, Garvey J, Ogami T, Serna-Gallegos D, Sá MP, Thoma F, Zhu J, Phillippi J, Sultan I. Reinterventions After Repair of Acute Type A Aortic Dissection: Incidence, Outcomes, and Risk Factors. Ann Thorac Surg 2024; 117:915-921. [PMID: 38036024 DOI: 10.1016/j.athoracsur.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD). METHODS This was an observational study of aortic operations from 2010 to 2021. All patients with ATAAD undergoing open aortic arch reconstruction were included. Patients were dichotomized by the need for reintervention, which included reinterventions proximal to or distal to the index aortic repair. Propensity matching was used to determine the impact of reintervention on long-term outcomes. The cumulative incidence function for reintervention was estimated, and multivariable Fine-Gray analysis was performed to identify variables associated with reintervention, with death treated as a competing event. RESULTS We identified 601 patients undergoing surgery for ATAAD. An aortic reintervention was required in 71 (11.8%), comprising a proximal reintervention in 12 patients, a distal reintervention in 56, and both in 3. The cumulative incidence of reintervention was 11.6% (95% CI, 8.9%-14.6%) at 5 years and was 16.0% (95% CI, 12.2%-20.3%) at 10 years, with a median time to reintervention of 4.0 years (interquartile range, 0.9-7.5 years). Multivariable analysis using the Fine-Gray method showed no operative variables were associated with reinterventions. Among the 71 reinterventions, there were 4 (5.6%) operative deaths. After propensity matching, there was no difference in Kaplan-Meier survival estimates across each group (P = .138 by log-rank statistics). CONCLUSIONS The cumulative incidence of aortic reintervention after ATAAD repair was reasonably low (16% at 10 years), reinterventions were relatively safe (6% operative mortality), and reinterventions did not significantly impact long-term survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph Garvey
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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7
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Naito N, Takagi H. Meta-analysis of central and peripheral cannulation for type A aortic dissection. Perfusion 2024:2676591241238865. [PMID: 38472159 DOI: 10.1177/02676591241238865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND Acute type A aortic dissection necessitates rapid and effective arterial cannulation techniques for optimal outcomes. This meta-analysis compares the safety and effectiveness of direct aortic cannulation (AoC) with peripheral cannulation (PC) via the femoral or axillary arteries in aortic surgery for acute type A aortic dissection. METHODS A systematic review following PRISMA guidelines identified 10 retrospective studies encompassing 2518 patients (961 AoC, 1557 PC). Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative complications including stroke and acute kidney injury. RESULTS Short-term mortality did not significantly differ between AoC and PC (OR [95% CI] = 0.78 [0.61-1.01], p = .06). Likewise, postoperative stroke (OR [95% CI] = 0.86 [0.63-1.17], p = .33) nor acute kidney injury (OR [95% CI] = 1.11 [0.89-1.37], p = .35) showed no significant differences. AoC exhibited shorter operation time whereas there were no significant differences in aortic cross clamp time and cardiopulmonary bypass time between both groups. Our meta-regression analysis, considering the distal extent of aortic replacement, indicated that variations in aortic replacement rates did not significantly impact the observed outcomes. CONCLUSION AoC is a viable alternative to PC for acute type A aortic dissection. While both approaches offer comparable outcomes, AoC's advantage in shorter operation time warrants thoughtful consideration in clinical practice.
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Affiliation(s)
- Noritsugu Naito
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
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Yousef S, Brown JA, Serna-Gallegos D, Navid F, Zhu J, Thoma FW, Bianco V, Aranda-Michel E, Diaz-Castrillon CE, Sultan I. Central versus peripheral cannulation for acute type A aortic dissection. J Thorac Cardiovasc Surg 2024; 167:588-595. [PMID: 35989125 DOI: 10.1016/j.jtcvs.2022.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/28/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study sought to evaluate the impact of central aortic versus peripheral cannulation on outcomes after acute type A aortic dissection repair. METHODS This was an observational study using an institutional database of acute type A aortic dissection repairs from 2007 to 2021. Patients were stratified according to central, subclavian, or femoral cannulation. Kaplan-Meier survival estimation and multivariable Cox regression were performed. RESULTS The study population consisted of 577 patients who underwent acute type A aortic dissection repair. Of these, central cannulation was used in 490 patients (84.9%), subclavian cannulation was used in 54 patients (9.4%), and femoral cannulation was used in 33 patients (5.7%). Rates of peripheral vascular disease, aortic insufficiency moderate or greater, and cerebral malperfusion differed significantly among the groups, but baseline characteristics were otherwise comparable (P > .05). Operative mortality was lowest in the central cannulation group (9.8%), but this did not differ significantly among the groups. Kaplan-Meier survival estimates were similar among the groups. On multivariable Cox regression, cannulation strategy was not significantly associated with long-term survival. CONCLUSIONS Acute type A aortic dissection repair can be safely performed through central aortic cannulation, with outcomes comparable to those obtained with subclavian or femoral cannulation.
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Affiliation(s)
- Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Yamana F, Kuratani T, Domae K, Sakamoto T, Hata M, Shirakawa Y, Masai T, Sawa Y. The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection. J Endovasc Ther 2023:15266028231214206. [PMID: 38050851 DOI: 10.1177/15266028231214206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD). METHODS We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed. RESULTS There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications. CONCLUSION Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase. CLINICAL IMPACT This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.
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Affiliation(s)
- Fumio Yamana
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Keitaro Domae
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Tomohiko Sakamoto
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Masatoshi Hata
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yukitoshi Shirakawa
- Department of Cardiovascular Surgery, Osaka General Medical Center, Osaka, Japan
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
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Pedersen MW, Kragholm K, Oksjoki R, Møller JE, Gundlund A, Fosbøl E, Nielsen DG, Køber L, Torp-Pedersen C, Søgaard P, Andersen NH. Characteristics and Outcomes in Patients With Acute Aortic Dissection: A Nationwide Registry Study. Ann Thorac Surg 2023; 116:1177-1184. [PMID: 37419172 DOI: 10.1016/j.athoracsur.2023.06.019] [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: 11/28/2022] [Revised: 05/03/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND We aimed to describe characteristics and outcomes in a nationwide population of patients with acute type A and type B aortic dissection. METHODS All patients in Denmark with a first-time diagnosis of acute aortic dissection between 2006 and 2015 were identified by national registries. The main outcomes were in-hospital mortality and long-term survival in hospital survivors. RESULTS The study population comprised 1157 (68%) patients with type A aortic dissection and 556 (32%) patients with type B aortic dissection, median age of 66 (57-74) years and 70 (61-79) years, respectively. Men accounted for 64%. Median follow-up was 8.9 (6.8-11.5) years. Of patients with type A aortic dissection, 74% were managed surgically, whereas 22% of the patients with type B aortic dissection were managed with surgery or endovascular technique. In-hospital mortality was 27% for type A aortic dissection overall (surgery, 18%; no surgery, 52%) and 16% for type B aortic dissection (surgery or endovascular treatment, 13%; conservative treatment, 17%; P < .001, type A vs type B). Of patients discharged alive, survival was persistently better for type A aortic dissection than for type B aortic dissection (P < .001). Unadjusted 1- and 3-year survival of patients with type A aortic dissection discharged alive was 96% and 91%, respectively, for surgically managed and 88% and 78% without surgery. For type B aortic dissection, the numbers were 89% and 83% for endovascular/surgically managed and 89% and 77% for conservatively managed. CONCLUSIONS We found higher in-hospital mortality for type A and type B aortic dissection than is reported from referral center registries. Type A aortic dissection had the highest mortality rate during the acute phase, whereas for patients who were discharged alive, the mortality rate was higher for patients with type B aortic dissection.
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Affiliation(s)
- Maria W Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark.
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Riina Oksjoki
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Cardiology, Lillebælt Hospital, Vejle, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anna Gundlund
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dorte G Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Copenhagen K, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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11
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Trimarchi S, Mandigers TJ, Bissacco D, Nienaber C, Isselbacher EM, Evangelista A, Suzuki T, Bossone E, Pape LA, Januzzi JL, Harris KM, O'Gara PT, Gilon D, Hutchison S, Patel HJ, Woznicki EM, Montgomery D, Kline-Rogers E, Eagle KA. Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00608-6. [PMID: 37453718 DOI: 10.1016/j.jtcvs.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
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Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
| | - Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniele Bissacco
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Nienaber
- Department of Cardiology, Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, Imperial College, London, United Kingdom
| | - Eric M Isselbacher
- Cardiology Department, Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
| | - Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Linda A Pape
- Department of Medicine, University of Massachusetts Hospital, Worcester, Mass
| | - James L Januzzi
- Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Mass; Cardiology Division, Massachusetts General Hospital, Boston, Mass
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Patrick T O'Gara
- Department of Cardiology, Brigham & Women's Hospital, Boston, Mass
| | - Dan Gilon
- Department of Non-invasive Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Stuart Hutchison
- Department of Cardiac Sciences, University of Calgary Medical Centre, Calgary, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | | | | | - Kim A Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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12
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Arnaoutakis GJ, Ogami T, Patel HJ, Pai CW, Woznicki EM, Brinster DR, Leshnower BG, Serna-Gallegos D, Bekeredjian R, Sundt TM, Shaffer AW, Peterson MD, Geuzebroek GSC, Eagle KA, Trimarchi S, Sultan I. Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection. Ann Thorac Surg 2023; 115:879-885. [PMID: 36370884 DOI: 10.1016/j.athoracsur.2022.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/27/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. METHODS Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. RESULTS A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). CONCLUSIONS AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.
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Affiliation(s)
- George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Michigan
| | - Chih-Wen Pai
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Elise M Woznicki
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Derek R Brinster
- Department of Cardiac Surgery, Northwell Health, New York, New York
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raffi Bekeredjian
- Department of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew W Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Mark D Peterson
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, Toronto, Canada
| | - Guillaume S C Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim A Eagle
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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13
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Alhussaini M, Falasa MP, Jeng EI, Martin T, Becker TK, Arnaoutakis GJ, Fillion A, Neal D, Beaver TM. Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 165:1275-1280. [PMID: 33934896 DOI: 10.1016/j.jtcvs.2021.03.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Deep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center. METHODS Between January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05). RESULTS Major adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1). CONCLUSIONS DHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.
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Affiliation(s)
| | - Matheus P Falasa
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Eric I Jeng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Amber Fillion
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
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14
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Tenorio ER, Vacirca A, Mesnard T, Sulzer T, Baghbani-Oskouei A, Mirza AK, Huang Y, Oderich GS. Technical tips and clinical experience with the Cook Triple inner arch branch stent-graft. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:9-17. [PMID: 36598743 DOI: 10.23736/s0021-9509.22.12569-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Open surgical repair remains the gold standard for treatment for aortic arch diseases, but these operations can be associated with wide heterogeneity in outcomes and significant morbidity and mortality, particularly in elderly patients with severe comorbidities or those who had prior arch procedures via median sternotomy. Endovascular repair has been introduced as a less invasive alternative to reduce morbidity and mortality associated with open surgical repair. The technique evolved with new device designs using up to three inner branches for incorporation of the supra-aortic trunks. This manuscript summarizes technical tips and clinical experience with the triple inner arch branch stent graft for total endovascular repair of aortic arch pathologies.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Vacirca
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Thomas Mesnard
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Titia Sulzer
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ying Huang
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA -
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15
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Abstract
Acute aortic dissection is a highly morbid condition with high mortality that requires emergent surgical evaluation and repair. The intraoperative management of acute aortic dissection requires the anesthesiologist to do far more than administer anesthesia and begins before the patient arrives at the operative theater. High-fidelity communication with the surgeon, knowledge of the surgical plan, knowledge of the anatomy of the dissection, and a nuanced understanding of aortic dissection pathophysiology are all critical aspects of anesthetic management.
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Affiliation(s)
- D Keegan Stombaugh
- Department of Anesthesiology, Division of Cardiovascular Anesthesia, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA; Department of Anesthesiology, Division of Critical Care Medicine, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA
| | - Venkat Reddy Mangunta
- Department of Anesthesiology, Division of Cardiovascular Anesthesia, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA; Department of Anesthesiology, Division of Critical Care Medicine, University of Virginia, School of Medicine, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA.
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16
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Hauck SR, Kern M, Dachs TM, Haider L, Stelzmüller ME, Ehrlich M, Loewe C, Funovics MA. Applicability of endovascular branched and fenestrated aortic arch repair devices to treat residual type A dissection after ascending replacement. J Vasc Surg 2022; 76:1440-1448. [PMID: 36028159 DOI: 10.1016/j.jvs.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Endovascular repair of post-type-A aortic dissection after open ascending replacement (PTAD) has recently been shown as safe and feasible, but with limited anatomic applicability since only one stent graft was evaluated. We assessed anatomic and clinical applicability of six commercially available branched/fenestrated stent grafts for endovascular repair of PTAD. METHODS On postoperative CT-scans of 101 patients, we measured aortic diameter at: sino-tubular junction, supra-aortic vessels (SAV), and descending aorta, as well as the distances between these landmarks along the outer curvature of the arch and the diameters of the SAV. Anatomical applicability was evaluated according to the instructions-for-use, clinical applicability with regard to supra-aortic and iliac arteries. Assessed devices were: Cook aortic double branch; Terumo double branch; Najuta fenestrated; Endospan Nexus; Medtronic Mona LSA; and Gore TAG thoracic branch. RESULTS Single devices were anatomically and clinically applicable between 19/101 (Mona LSA) and 83/101 (Najuta) cases. Reasons for rejection varied considerably across devices. With all devices available, anatomical applicability was 97/101 and clinical applicability 95/101. Combinations of a fenestrated and a branched device showed the most favorable clinical applicability for a pair of two devices, ranging from 86/101 to 94/101. CONCLUSIONS Anatomical and clinical applicability of endovascular devices for the repair of PTAD is high for fenestrated and branched devices, and very high for the combination of fenestrated and branched devices. Manufacturers should amend specific device requirements for PTAD. Surgeons should emphasize the need for a sufficiently long and straight graft as a potential landing zone.
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Affiliation(s)
- Sven R Hauck
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Maximilian Kern
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lukas Haider
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Marek Ehrlich
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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17
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Nazir S, Ariss RW, Minhas AMK, Issa R, Michos ED, Birnbaum Y, Moukarbel GV, Ramanathan PK, Jneid H. Demographic and Regional Trends of Mortality in Patients With Aortic Dissection in the United States, 1999 to 2019. J Am Heart Assoc 2022; 11:e024533. [PMID: 35301872 PMCID: PMC9075427 DOI: 10.1161/jaha.121.024533] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Aortic dissection (AoD) is associated with high morbidity and mortality. However, the burden of AoD mortality is not well characterized, and contemporary data and mortality trends in different demographic and geographic subgroups have not been described. Methods and Results Trends in AoD mortality were assessed using a cross‐sectional analysis of the Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research database. Crude and age‐adjusted mortality rates (AAMR) per 1 million people with associated annual percent changes were determined. Joinpoint regression was used to assess trends in the overall sample and different demographic (sex, race and ethnicity, age) and geographic subgroups. Between 1999 and 2019, a total of 86 855 AoD deaths occurred within the United States. In the overall population, AAMR was 21.1 per 1 million in 1999 and 21.3 in 2019. After an initial decline in mortality, AAMR increased from 2012 to 2019, with an associated annual change of 2.5% (95% CI, 1.8–3.3). Men, older adults (aged ≥85 years), and non‐Hispanic Black or African American individuals had higher mortality rates than women, younger individuals, and other racial and ethnic individuals, respectively. Despite lower AAMRs throughout the study period, women experienced greater increases in AAMR from 2012 to 2019 compared with men. Similarly, non‐Hispanic Black or African American individuals had a pronounced increase in AAMR from 2012 to 2019. Conclusions Despite an initial decline in AoD mortality, the mortality rate has been increasing from 2012 to 2019, with pronounced increases among women and non‐Hispanic Black or African American individuals.
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Affiliation(s)
- Salik Nazir
- Division of Cardiovascular Medicine University of Toledo Medical Center Toledo OH.,Section of Cardiology ProMedica Toledo Hospital Toledo OH
| | - Robert W Ariss
- Division of Cardiovascular Medicine University of Toledo Medical Center Toledo OH.,Section of Cardiology ProMedica Toledo Hospital Toledo OH
| | | | - Rochell Issa
- Division of Cardiovascular Medicine University of Toledo Medical Center Toledo OH.,Section of Cardiology ProMedica Toledo Hospital Toledo OH
| | - Erin D Michos
- Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | | | - George V Moukarbel
- Division of Cardiovascular Medicine University of Toledo Medical Center Toledo OH
| | | | - Hani Jneid
- Section of Cardiology Baylor College of Medicine Houston TX
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18
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Chang Y, Lin H, Qian X, Guo H, Yu C, Sun X, Wei B, Ma Q, Wei Y, Shi Y. Comparison of Single Axillary vs. Dual Arterial Cannulation for Acute Type a Aortic Dissection: A Propensity Score Matching Analysis. Front Cardiovasc Med 2022; 9:809493. [PMID: 35282342 PMCID: PMC8904879 DOI: 10.3389/fcvm.2022.809493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
Background The optimal arterial cannulation site for acute aortic dissection repair is unclear, especially for complex arch surgery. Axillary artery cannulation is widely accepted but adding femoral artery cannulation to it was considered to potentially improve perfusion and early outcomes. To clarify this point, a comparison of perioperative outcomes for these two different cannulation strategies was conducted regarding the pathological features of dissection. Methods From January 2010 to December 2019, 927 consecutive patients underwent a total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data, including detailed pathological features, were retrospectively collected and analyzed. Propensity score matching and multivariate logistic regression analysis were used for adjusting confounders that are potentially related to the outcome. Results A total of 523 patients (56.3%) accepted a dual arterial cannulation (DAC group), and 406 patients (43.7%) received a single axillary artery cannulation (SAC group). In total, 388 pairs of patients were well-matched. Whether before or after adjusting the preoperative characteristics by matching, there were no significant differences in operative mortality (6.7 vs. 5.4%, P = 0.420 before matching; 5.4 vs. 5.4%, P = 1 after matching), stroke (6.7 vs. 5.4%, P = 0.420 before matching; 6.4 vs. 5.2%, P = 0.435 after matching), spinal cord injury (5 vs. 5.7%, P = 0.640 before matching; 5.4 vs. 5.7%, P = 1. After matching), and acute renal failure requiring dialysis (13.8 vs. 9.6%, P =0.050 before matching; 12.6 vs. 9.5%, P = 0.174) between the two groups. Dual arterial cannulation was not an independent protective factor of operative mortality (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.55–1.86), stroke (OR 1.17, 95% CI 0.65–2.11), spinal cord injury (OR 1.17, 95% CI 0.65–2.11), and acute renal failure requiring continuous renal replacement therapy (CRRT) (OR 1.24, 95% CI 0.78–1.97) after adjusting for confounding factors by multivariable logistic regression analysis. In the subgroup analysis, no advantage of dual arterial cannulation was found for a particular population. Conclusions Single axillary artery cannulation was competent in the complex arch repair for acute aortic dissection, presenting with a satisfactory result as dual arterial cannulation. Adding femoral artery cannulation was necessary when a sufficient flow volume could not be achieved by axillary artery cannulation or when a lower limb malperfusion existed.
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Affiliation(s)
- Yi Chang
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongyuan Lin
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Bo Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Qiong Ma
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yizhen Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yi Shi
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
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19
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Liu S, Qiu J, Qiu J, Jiang W, Gao W, Wei B, Yu C. Midterm Outcomes of One-Stage Hybrid Aortic Arch Repair for Stanford Type A Aortic Dissection: A Single Center's Experience. Semin Thorac Cardiovasc Surg 2022; 35:311-321. [PMID: 35276357 DOI: 10.1053/j.semtcvs.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Shen Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China; Department of Cardiovascular Surgery, Peking University International Hospital, Peking University Health Science Center, Beijing, PR China
| | - Jiawei Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Wenxiang Jiang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Wei Gao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Bo Wei
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China.
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20
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Gulati A, Leach J, Wang Z, Xuan Y, Hope MD, Saloner DA, Ge L, Tseng EE. Ascending thoracic aortic aneurysm growth is minimal at sizes that do not meet criteria for surgical repair. Quant Imaging Med Surg 2022; 12:333-340. [PMID: 34993082 DOI: 10.21037/qims-21-55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Historic studies of nonsyndromic ascending thoracic aortic aneurysms (aTAAs) reported that the typical aTAA growth rate was approximately 0.6 mm/year, but data were limited due to relatively few studies using computed tomography (CT) imaging. Our purpose was to reevaluate the annual growth rate of nonsyndromic aTAAs that do not meet criteria for surgical repair in veterans in the contemporary era, using modern CT imaging suitable for highly accurate and reproducible aneurysm measurement. METHODS Nonsurgical patients (diameter <5.5 cm) undergoing aneurysm surveillance at a Veterans Affairs Medical Center with repeat CT imaging performed 3 to 5 years apart were identified. Maximum diameter was determined by a single radiologist using multiplanar reformat-based measurements. Average rate of aneurysm growth was evaluated based on longest available follow-up. RESULTS Sixty-seven patients were included. Average follow-up time was 4.06±0.83 years. Patients were exclusively male, with average age of 68.1±6.0 years, and the majority had a history of smoking (n=52, 78%), hypertension (n=52, 78%), and dyslipidemia (n=48, 72%). Average baseline aneurysm diameter was 44.0±3.2 mm and average growth rate was 0.11±0.31 mm/year, with no difference in growth rate between patients with initial diameter ≤45 vs. >45 mm. Only 3 patients experienced clinically significant changes in diameter with magnitude greater than 5% of baseline. CONCLUSIONS In this veteran population, most patients did not experience significant annual aneurysm growth over up to 5 years of follow-up, regardless of initial diameter. Thus, in the modern era, aTAAs may not grow as quickly as previously described, which will be important in determining appropriate intervals for aneurysm surveillance based upon risk-benefit ratio.
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Affiliation(s)
- Arushi Gulati
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Joseph Leach
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Zhongjie Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Yue Xuan
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Michael D Hope
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - David A Saloner
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
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21
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Dang Van S, Laribi J, Pinaud F, Binuani P, Willoteaux S, Baufreton C, Fouquet O. Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:67-75. [PMID: 34619800 PMCID: PMC8526144 DOI: 10.1055/s-0041-1725074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background
Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery.
Methods
One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up.
Results
Patients from ARR group were younger than those from SCR group (
p
< 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6–8.3) and 6.15 (IR: 2.8–10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%,
p
= 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% (
p
= 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups (
p
= 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies (
p
= 0.58). Reoperation on the distal aorta (
p
= 0.012) and patent radiologic false lumen of the descending aorta (
p
= 0.043) were independent risk factors of late death.
Conclusion
SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.
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Affiliation(s)
- Simon Dang Van
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Jihed Laribi
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Frédéric Pinaud
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Patrice Binuani
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Serge Willoteaux
- Department of Radiology, University Hospital of Angers, Angers, France
| | - Christophe Baufreton
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
| | - Olivier Fouquet
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France.,Mitovasc Institute INSERM U1083 UMR-CNRS 6214, University Hospital of Angers, Angers, France
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22
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Wang L, Li Y, Dun Y, Sun X. Risk factor analysis of clinical outcomes of total aortic arch replacement and frozen elephant trunk with aortic balloon occlusion. J Cardiothorac Surg 2021; 16:256. [PMID: 34496891 PMCID: PMC8425170 DOI: 10.1186/s13019-021-01643-3] [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: 06/07/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded. Results The 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions The ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01643-3.
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Affiliation(s)
- Luchen Wang
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Yunfeng Li
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Yaojun Dun
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Xiaogang Sun
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China.
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23
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Stanford type A acute aortic dissection with proximal intimo-intimal intussusception: a case report and literature review. J Cardiothorac Surg 2021; 16:201. [PMID: 34321028 PMCID: PMC8317293 DOI: 10.1186/s13019-021-01581-0] [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: 04/21/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background Acute aortic circumferential dissection with proximal intimo-intimal intussusception is a rare and potentially lethal occurrence. We here report a case and review previous works to better understand this particular condition and help surgeons to determine accurate diagnosis and optimal intervention strategies by intraoperative transesophageal echocardiography (TEE). Case presentation We report a case of a 46-year-old male who complained of sudden substernal chest pain. Stanford type A acute aortic dissection with proximal intimo-intimal intussusception was confirmed by contrast-enhanced computed tomography (CECT), transthoracic echocardiography (TTE), and TEE. We found the intimal flap prolapsed into the left ventricle outflow tract (LVOT), which caused severe aortic regurgitation (AR) and obstructed the ostia of the coronary arteries. Given the preexisting aneurysmal dilatation of aortic sinus and severity of aortic root and arch dissection, Bentall procedure and Sun’s procedure were performed for our patient. Conclusions Intraoperative TEE used by anesthesiologists here played an increasingly valuable role in the determination of acute aortic dissection. Hence, it is necessary that TEE screening is routinely performed in patients with acute aortic dissection to provide valuable information for facilitating surgical strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01581-0.
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24
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Wang L, Cheng Z, Li Y, Li J, Guo H, Liang S, Sun X. Improvement of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk Surgery With Aortic Balloon Occlusion. Front Cardiovasc Med 2021; 8:691615. [PMID: 34381824 PMCID: PMC8350051 DOI: 10.3389/fcvm.2021.691615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/21/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) surgery provides improved long-term results, but the surgery itself is associated with higher risks compared with isolated proximal reconstructions. We applied an aortic balloon occlusion (ABO) technique to reduce the circulatory arrest (CA) time and improve other clinical outcomes. Methods: All patients who underwent TAR with FET surgery (130 with ABO technique, 230 with the conventional approach) in Fuwai Hospital from August 2017 to February 2019 were reviewed in this retrospective observational cohort study. Intra- and early-postoperative results and clinical characteristics were analyzed. Results: After 1:1 propensity score matching (130 cases in each group), the 30-day mortality of the ABO group and the conventional group were 4.6% and 10.8% (p = 0.063), respectively. Although the reduction in complications was not statistically significant, the complication rate in the ABO group was relatively low, having fewer cases of postoperative renal (23.1 vs. 38.5%, p = 0.007) and hepatic (12.3 vs. 30.0%, p < 0.001) injury, lower postoperative wake-up time (15.2 ± 23.6 h vs. 20.1 ± 26.5 h, respectively, p < 0.001), reduced chest tube output (176.03 ± 143.73 ml vs. 213.29 ± 130.12 ml, respectively, p = 0.003), lower red blood cell transfusion volume (4.98 ± 6.53 u vs. 7.28 ± 10.41 u, respectively, p = 0.008), and no fatal events. Conclusions: The ABO technique is a simple method that can reduce the CA time and improve the recovery stage following TAR with FET surgery. The technique represents a practical strategy to treat patients with high operative risks due to its lower complication rate compared with the conventional approach.
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Affiliation(s)
- Luchen Wang
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zeyi Cheng
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yunfeng Li
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Qilu Hospital, Shandong University, Jinan, China
| | - Junpeng Li
- Huamei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Hongwei Guo
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shenghua Liang
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Aortic and Vascular Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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25
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Falasa MP, Arnaoutakis GJ, Janelle GM, Beaver TM. Neuromonitoring and neuroprotection advances for aortic arch surgery. JTCVS Tech 2021; 7:11-19. [PMID: 34318192 PMCID: PMC8312079 DOI: 10.1016/j.xjtc.2020.12.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Matt P. Falasa
- Department of Surgery, University of Florida, Gainesville, Fla
| | - George J. Arnaoutakis
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Greg M. Janelle
- Department of Anesthesiology, University of Florida, Gainesville, Fla
| | - Thomas M. Beaver
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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26
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Huckaby LV, Sultan I, Trimarchi S, Leshnower B, Chen EP, Brinster DR, Myrmel T, Estrera AL, Montgomery DG, Korach A, Eckstein HH, Coselli JS, Ota T, Kaiser CA, Eagle KA, Patel HJ, Gleason TG. Sex-Based Aortic Dissection Outcomes From the International Registry of Acute Aortic Dissection. Ann Thorac Surg 2021; 113:498-505. [PMID: 34090668 DOI: 10.1016/j.athoracsur.2021.03.100] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era. METHODS The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex. RESULTS Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes. CONCLUSIONS In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.
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Affiliation(s)
- Lauren V Huckaby
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Santi Trimarchi
- Fondazione IRCCS, Cà Granda Ospedale Maggiore Policlinico Milan, University of Milan, Milan, Italy
| | | | - Edward P Chen
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Truls Myrmel
- The Arctic University of Norway, Breivika, Norwa
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27
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Endovascular Treatment of Post Type A Chronic Aortic Arch Dissection With a Branched Endograft: Early Results From a Retrospective International Multicenter Study. Ann Surg 2021; 273:997-1003. [PMID: 30973389 DOI: 10.1097/sla.0000000000003310] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.
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28
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Nagata T, Iwakoshi S, Yamada T, Johno H. Seven arterial aneurysms with an acute type A aortic dissection. J Card Surg 2021; 36:2543-2545. [PMID: 33768572 DOI: 10.1111/jocs.15510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple arterial aneurysms are often seen in the elderly and are caused mainly by atherosclerosis.
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Affiliation(s)
- Tomoki Nagata
- Department of Cardiovascular Surgery, Takaishi Fujii Cardiovascular Hospital, Osaka, Japan
| | | | - Takashi Yamada
- Department of Cardiology, Takaishi Fujii Cardiovascular Hospital, Osaka, Japan
| | - Hiroyuki Johno
- Department of Cardiovascular Surgery, Takaishi Fujii Cardiovascular Hospital, Osaka, Japan
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29
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Demal TJ, Bax L, Brickwedel J, Kölbel T, Vettorazzi E, Sitzmann F, Reichenspurner H, Detter C. Outcome of the frozen elephant trunk procedure as a redo operation. Interact Cardiovasc Thorac Surg 2021; 33:85-92. [PMID: 33667306 DOI: 10.1093/icvts/ivab059] [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] [Received: 08/27/2020] [Revised: 12/01/2020] [Accepted: 01/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. METHODS One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. RESULTS A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19-35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23-3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. CONCLUSIONS Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.
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Affiliation(s)
- Till Joscha Demal
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Sitzmann
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Centre Hamburg, University Heart & Vascular Centre Hamburg, Hamburg, Germany
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Impact of time between diagnosis to treatment in Acute Type A Aortic Dissection. Sci Rep 2021; 11:3519. [PMID: 33568755 PMCID: PMC7876041 DOI: 10.1038/s41598-021-83180-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/27/2021] [Indexed: 01/03/2023] Open
Abstract
There is a paucity of data describing the effect of time interval between diagnosis and surgery for Acute Type A Aortic Dissection. We describe our 8-year experience and investigate the impact of time interval between symptom onset, diagnosis and surgery on outcomes. Retrospective single-center study utilizing our Society of Thoracic Surgeons registry and patient records. Subjects were grouped by time interval between radiographic diagnosis and surgical treatment: Group A (0-4 h), Group B (4.1-8 h), Group C (8.1-12 h), and Group D (12.1 + h). Data were analyzed to identify factors associated with mortality and outcomes. 164 patients were included. Overall mortality was 21.3%. Group C had the greatest intervals between symptom onset to diagnosis to surgery, and also the highest mortality (66.7%). Preoperative tamponade, cardiac arrest, malperfusion, elevated creatinine, cardiopulmonary bypass time, and blood transfusions were associated with increased mortality, while distance of referring hospital was not. Time intervals between symptom onset, diagnosis and surgery have a significant effect on mortality. Surgery performed 8-12 h after diagnosis carries the highest mortality, which may be exacerbated by longer interval since symptom onset. Time-dependent effects should be considered when determining optimal strategy especially if inter-facility transfer is necessary.
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Yang B. Commentary: Individualize the strategy of cerebral protection in aortic arch surgery. JTCVS Tech 2021; 7:20-21. [PMID: 34318193 PMCID: PMC8311544 DOI: 10.1016/j.xjtc.2021.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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Antegrade cerebral perfusion: A review of its current application. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:1-4. [PMID: 33768974 PMCID: PMC7970089 DOI: 10.5606/tgkdc.dergisi.2021.21255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/25/2020] [Indexed: 01/14/2023]
Abstract
The technique of antegrade cerebral perfusion has been adopted by many aortic surgery centers as the routine method of brain protection with some variations in its implementation. These variations stem from the issues with regard to the perfusion pressure, flow, temperature, pH management, hematocrit value, cannulation sites, and unilateral versus bilateral application. In this review, the prespecified issues were discussed and some recommendations about the implementation of antegrade cerebral perfusion were given.
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Munir W, Chong JH, Harky A, Bashir M, Adams B. Type A aortic dissection: involvement of carotid artery and impact on cerebral malperfusion. Asian Cardiovasc Thorac Ann 2020; 29:635-642. [PMID: 33375820 DOI: 10.1177/0218492320984329] [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] [Indexed: 01/16/2023]
Abstract
Acute type A aortic dissection is a surgical emergency and management of such pathology can be complex with poor outcomes when there is organ malperfusion. Carotid artery involvement is present in 30% of patients diagnosed with acute type A aortic dissection, and given its emergency and complex nature, there is much controversy regarding the approach, extent of treatment, and timing of the intervention. It is clear that the occurrence of cerebral malperfusion adds an extra layer of complexity to the decision-making framework for treatment. Standardization and validation of the optimal management approach is required, and this should ideally be addressed with large-scale studies. Nonetheless, current literature supports the need for rapid recognition and diagnosis of acute type A aortic dissection with cerebral malperfusion, immediate and extensive surgical repair, and the appropriate use of cerebral perfusion techniques. This paper aims to discuss the current evidence regarding the impact of carotid artery involvement in both the management and outcomes of acute type A aortic dissection.
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Affiliation(s)
- Wahaj Munir
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jun Heng Chong
- GKT School of Medical Education, King's College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Benjamin Adams
- Aortovascular Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
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Jiang D, Huo Y, Liu Y, Wang Y, Zhou J, Sun X, Zhao F, Du Y, He S, Liu C, Sun W. One minute of circulatory arrest for acute type A aortic dissection --------- a simple operation for acute type A aortic dissection (AAAD). J Cardiothorac Surg 2020; 15:328. [PMID: 33183318 PMCID: PMC7661205 DOI: 10.1186/s13019-020-01370-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Sun’s procedure is currently recognized as the standard procedure for acute type A aortic dissection (AAAD). But the operation istoo difficult for beginners. We hope to reduce the difficulty and complications of this operation. Methods The aortic arch was immediately cross-clamped after the stented graft was inserted into the distal aorta. Thereafter, the lower-body perfusion was restored. Then, anastomosis was performed between the proximal stent graft and the distal 4-branched Dacron graft. The other arteries were anastomosed to the arched branch of the 4-branched graft. Results The cardiopulmonary bypass (CPB) time was (207 ± 52) min, and the aortic cross-clamp time was (114 ± 39) min. The circulatory arrest time was (38 ± 16) sec. One patient (4%) died. The incidence of complications was stroke (4%), renal dysfunction requiring dialysis (4%), prolonged intubation(12%). Conclusions The time of circulatory arrest in this operation is less than 1 min, which can avoid the complications caused by DHCA and decrease risk of bleeding and complexity by shifting anastomosis more proximally. The effect of our operation is similar to and even better than that of Sun’s procedure. It does not even require relatively advanced skill, much experience and excellent psychological quality, especially suitable for beginners.
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Affiliation(s)
- Detian Jiang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Yufeng Huo
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Yimin Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Yan Wang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Jinfeng Zhou
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Xiangfei Sun
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Fen Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Yonghai Du
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Songxiong He
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Chao Liu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China
| | - Wenyu Sun
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Qingdao, 266000, China.
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35
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Huang LC, Xu QC, Chen DZ, Dai XF, Chen LW. Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair. J Cardiothorac Surg 2020; 15:326. [PMID: 33172480 PMCID: PMC7654610 DOI: 10.1186/s13019-020-01371-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background The optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection. Methods We performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated. Results Femoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure. Conclusion Femoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.
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Affiliation(s)
- Ling-Chen Huang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Qi-Chen Xu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Dao-Zhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Xiao-Fu Dai
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
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Trimarchi S, Grassi V, Lomazzi C, Domanin M, Bissacco D, Bellosta R, Piffaretti G. Endovascular type A aortic repair-When? J Card Surg 2020; 36:1742-1744. [PMID: 33029800 DOI: 10.1111/jocs.15103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/10/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Santi Trimarchi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan School of Medicine, Milan, Italy
| | - Viviana Grassi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Chiara Lomazzi
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Maurizio Domanin
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan School of Medicine, Milan, Italy
| | - Daniele Bissacco
- Department of Surgery, Vascular Surgery, Ospedale Maggiore Policlinico, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Cardiovascular Department, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
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Xue Y, Zhou Q, Pan J, Cao H, Fan F, Zhu X, Wang D. "Double Jacket Wrapping" Root Reconstruction for Acute Type A Aortic Dissection. Ann Thorac Surg 2020; 110:1060-1062. [PMID: 32360872 DOI: 10.1016/j.athoracsur.2020.03.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/02/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
This report describes a simple and effective method of aortic root repair and reconstruction in acute type A aortic dissection to reduce the risks of hemorrhage and late aortic root new intimal tear and dilation. "Double jacket wrapping" (DJW) has 2 steps: the first jacket is used for aortic root "sandwich" repair, with a patch between the outer and inner layers; and the second jacket is wrapped outside the reconstructed root at the level of the supracoronary ostium. Compared with aortic root replacement, the DJW method may avoid prosthetic valve-related complications and decrease the complexity of valve-sparing root replacement; thus, DJW is a method worthy of wide use.
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Affiliation(s)
- Yunxing Xue
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Fudong Fan
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiyu Zhu
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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38
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Li Y, Yan S, Lou S, Sun X. The strategy of cardiopulmonary bypass for total aortic arch replacement and the frozen elephant trunk technique with aortic balloon occlusion. J Int Med Res 2020; 48:300060520905410. [PMID: 32357091 PMCID: PMC7218955 DOI: 10.1177/0300060520905410] [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] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the use of the aortic balloon occlusion technique to assist total aortic arch replacement (TAR) with frozen elephant trunk (FET) to shorten the lower body circulatory arrest (CA) time and raise the nadir temperature during cardiopulmonary bypass. Methods This retrospective study reviewed consecutive patients that underwent aortic balloon occlusion to assist TAR with FET and patients that received conventional TAR with FET procedures. Preoperative characteristics, perioperative characteristics and postoperative outcomes were compared between the two groups. Results The study included130 patients treated with aortic balloon occlusion and 230 patients treated with conventional TAR with FET. The 30-day mortality rate was similar between the aortic balloon occlusion and conventional groups (4.62% versus 7.83%, respectively). Multivariate analysis showed that aortic balloon occlusion reduced the incidence of acute kidney injury, hepatic injury and red blood cell transfusion. The application of aortic balloon occlusion reduced the mean ± SD CA time from 17.24 ± 4.36 min to 6.33 ± 5.74 min, with the target nadir nasal temperature being increased from 25°C to 28°C. Conclusion The aortic balloon occlusion technique achieved significant improvements in reducing complications, but this did not translate into lower 30-day mortality.
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Affiliation(s)
- Yunfeng Li
- Aortic and Vascular Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujie Yan
- Department of Adult Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Adult Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Aortic and Vascular Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lomazzi C, Trimarchi S, Pyeritz RE, Bekeredjian R, Erlich MP, Braverman AC, Pacini D, Shermerhorn M, Myrmel T, Eagle KA. Lesson learned from the International Registry of Acute Aortic Dissection (IRAD). ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01452-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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40
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Fatima J, Tenorio ER, Oderich GS. Anatomical aspects and feasibility of endovascular repair for chronic post-dissection arch and thoracoabdominal aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:385-391. [PMID: 32337942 DOI: 10.23736/s0021-9509.20.11405-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aortic dissection is a complex pathology that carries significant morbidity and mortality if not treated in a timely fashion. While the open repair remains the gold standard treatment for patients with acute type A dissection, ascending aortic replacement is associated with high incidence of arch and descending thoracic aorta residual false lumen patency and aneurysmal degeneration. Multiple approaches have been used over the decades to address aneurysmal degeneration in the arch and thoracoabdominal aorta. This article summarizes anatomical requirements for total endovascular repair of aortic arch and TAAAs using fenestrated and branched endografts.
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Affiliation(s)
- Javairiah Fatima
- Department of Vascular Surgery, MedStar Heart and Vascular Institute, Washington DC, USA -
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Norton EL, Makkinejad A, Le T, Wu X, Yang B. Intrathoracic right subclavian artery cannulation in aortic arch surgery. JTCVS Tech 2020; 2:1-5. [PMID: 34317731 PMCID: PMC8299036 DOI: 10.1016/j.xjtc.2020.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Alex Makkinejad
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Tan Le
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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Hui DS. Commentary: Moving the goalposts. J Thorac Cardiovasc Surg 2020; 160:1431-1432. [PMID: 32113715 DOI: 10.1016/j.jtcvs.2020.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex.
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Commentary: Progressive aortic valve regurgitation after replacement of the dissected ascending aorta: An unsolved dilemma. J Thorac Cardiovasc Surg 2020; 160:1432-1433. [PMID: 32113719 DOI: 10.1016/j.jtcvs.2020.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
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Abe T, Yamamoto H, Miyata H, Motomura N, Tokuda Y, Tanemoto K, Usui A, Takamoto S. Patient trends and outcomes of surgery for type A acute aortic dissection in Japan: an analysis of more than 10 000 patients from the Japan Cardiovascular Surgery Database. Eur J Cardiothorac Surg 2019; 57:660-667. [DOI: 10.1093/ejcts/ezz323] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
To evaluate the background trends and surgical outcomes for more than 10 000 patients with acute type A dissection in Japan in a recent 8-year period.
METHODS
Data on replacement of the ascending aorta and/or aortic arch for acute type A dissection were collected from the Japan Cardiovascular Surgery Database from 2008 to 2015. Linear-by-linear association tests or Cuzick’s test for trend was used to evaluate group trends over time. The results were calculated for ascending or hemiarch replacement and arch replacement. A multivariable logistic regression model was used to calculate the risk-adjusted operative mortality rate.
RESULTS
A total of 11 843 patients were included. The overall 30-day mortality and operative mortality rates were 7.6% and 9.5%, respectively. The number of surgically treated cases increased from 2436 patients in 2008–2009 to 3533 in 2014–2015, a 45.0% increase. A trend analysis revealed significant changes in patient characteristics with time, including increasing age and rate of preoperative renal failure. Despite worsening risk factors, the unadjusted operative mortality rate with arch replacement showed a significant downward trend (P = 0.01; test of trend). The risk-adjusted mortality rate showed a downward trend both in ascending aorta or hemiarch replacement and arch replacement, although the trend was not statistically significant (P > 0.05).
CONCLUSIONS
Unadjusted and adjusted operative deaths have shown a decreasing trend, although patients undergoing surgery for acute type A dissection have demonstrated worsening of risk factors, such as age and renal failure. The number of surgeries performed for acute type A dissection significantly increased throughout the study period in Japan.
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Affiliation(s)
- Tomonobu Abe
- Division of Cardiovascular Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Noboru Motomura
- Division of Cardiovascular Surgery, Department of Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Akihiro Usui
- Department of Cardiac Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Shinichi Takamoto
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
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Ohno N, Minatoya K. sArterial cannulation to establish cardiopulmonary bypass during surgery for acute aortic dissection. Surg Today 2019; 50:1353-1359. [PMID: 31773278 DOI: 10.1007/s00595-019-01921-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/16/2019] [Indexed: 12/19/2022]
Abstract
A cannulation strategy in surgery for Stanford type A acute aortic dissection (AAAD) is integral for patient survival. Femoral cannulation has been the standard option for cannulation; however, there is increasing evidence that retrograde perfusion with femoral cannulation is associated with worse clinical outcomes, and new cannulation sites have been introduced in surgery for AAAD. Although axillary artery cannulation and central cannulation via the ascending aorta have become more popular than femoral access in recent years, adverse events have been reported and shifting cannulation sites during surgery are recommended by some surgeons. Therefore, it is beneficial for surgeons to broaden their knowledge about cannulation technology for AAAD. In this review, we discuss the various methods of cannulation for AAAD.
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Affiliation(s)
- Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 6068507, Japan.
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Norton EL, Wu X, Kim KM, Patel HJ, Deeb GM, Yang B. Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2019; 160:617-625.e5. [PMID: 31587891 DOI: 10.1016/j.jtcvs.2019.07.108] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/21/2019] [Accepted: 07/12/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair. METHODS From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database. RESULTS The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46. CONCLUSIONS In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.
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Affiliation(s)
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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Kreibich M, Chen Z, Rylski B, Bavaria JE, Brown CR, Branchetti E, Vallabhajosyula P, Szeto WY, Desai ND. Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection. J Thorac Cardiovasc Surg 2019; 158:27-34.e9. [DOI: 10.1016/j.jtcvs.2018.11.100] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 11/19/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022]
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Pacini D, Murana G, Di Marco L, Di Bartolomeo R. Aortic remodeling in acute type A aortic dissection after frozen elephant trunk implantation. Indian J Thorac Cardiovasc Surg 2019; 35:112-117. [PMID: 33061075 DOI: 10.1007/s12055-018-0679-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/26/2018] [Accepted: 04/01/2018] [Indexed: 01/22/2023] Open
Abstract
Survivors at first intervention after acute type A aortic dissection often necessitate additional interventions to avoid dilation and rupture of the remaining thoraco-abdominal aorta. During the first-stage arch procedure, the attempt to treat the descending thoracic aorta with a stent graft could attenuate this phenomenon and reduce the need for further open or endovascular reinterventions. In this short review article, the frozen elephant trunk technique was tested as influencing factor of aortic remodeling during follow-up analysis. Late results from the identified studies suggested promising rates of false lumen thrombosis of the descending thoracic aorta (78-100%), suggesting that aortic remodeling is highly probable with this approach. However, a longer surveillance of the aortic diameters is still necessary to confirm this initial hypothesis.
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Affiliation(s)
- Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Lin CY, Tseng CN, Lee HA, Ho HT, Tsai FC. Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience. PLoS One 2019; 14:e0211900. [PMID: 30726302 PMCID: PMC6364944 DOI: 10.1371/journal.pone.0211900] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/22/2019] [Indexed: 02/05/2023] Open
Abstract
Background Repair of acute type A aortic dissection (ATAAD) is a complex and emergent cardiovascular surgery that is associated with high perioperative morbidity and mortality. Each cannulation strategy has different benefits and drawbacks during cardiopulmonary bypass. Using a retrospective study design, we aimed to clarify the safety and efficacy of right axillary artery cannulation in combination with femoral artery cannulation compared to single arterial cannulation for ATAAD repair. Methods From January 2007 to July 2017, 476 adult patients underwent ATAAD repair at a single institution. Patients were classified into groups according to their cannulation strategy: the double arterial cannulation (DAC) group (n = 377; 79.2%) or single arterial cannulation (SAC) group (n = 99; 20.8%). Preoperative demographics, surgical information, and postoperative recovery were compared between both groups. Survival and freedom from reoperation rates were analyzed using the Kaplan-Meier actuarial method. Results Demographics, comorbidities, and surgical procedures were generally homogenous between the two groups, except for sex, age, and rate of extensive aortic repair. Patients who underwent DAC had lower in-hospital mortality (13.5% vs. 25.3%; P = 0.005) and lower incidence of malperfusion-related complications (18.8% vs. 30.3%; P = 0.011) than those who underwent SAC. During multivariate analysis, SAC was identified as an in-hospital mortality predictor (odds ratio, 2.81; 95% confidence interval, 1.52–5.17; P = 0.001), as were preoperative ventilator support, intraoperative extracorporeal membrane oxygenation installation, and postoperative malperfusion-related complications. Three-year cumulative survival and freedom from reoperation rates were 74.8% and 85.3% for the DAC group and 62.6% and 81.1% for the SAC group, respectively (P = 0.010 and 0.430, respectively). Conclusions With acceptable short- and mid-term outcomes, DAC is effective and safe for establishing cardiopulmonary bypass during ATAAD repair.
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Affiliation(s)
- Chun-Yu Lin
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- * E-mail:
| | - Chi-Nan Tseng
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsiu-An Lee
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Heng-Tsan Ho
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Feng-Chun Tsai
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
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Tian DH, Weller J, Hasmat S, Preventza O, Forrest P, Kiat H, Yan TD. Temperature Selection in Antegrade Cerebral Perfusion for Aortic Arch Surgery: A Meta-Analysis. Ann Thorac Surg 2019; 108:283-291. [PMID: 30682350 DOI: 10.1016/j.athoracsur.2018.12.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 11/11/2018] [Accepted: 12/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The increasing use of antegrade cerebral perfusion (ACP) during aortic arch surgery has corresponded with a trend toward warmer target temperatures for hypothermic circulatory arrest. This meta-analysis examined the clinical outcomes using colder or warmer circulatory arrest targets with ACP. METHODS Electronic searches were performed using four databases from their inception to February 2017. Comparative studies of adult patients who underwent aortic arch operations using ACP at different circulatory arrest temperatures were included. Data were extracted by 2 independent researchers and analyzed according to predefined end points using a random-effects model. RESULTS The literature search identified 18 comparative studies, with 1,215 patients in the "cold" cohort and 1,417 in the "warm" cohort. Mean hypothermic circulatory arrest temperatures were 20.3°C and 26.5°C in the cold and warm groups, respectively. A trend existed for increased permanent neurologic deficit overall when colder targets were used (odds ratio, 1.45; 95% confidence interval, 0.98 to 2.13; p = 0.06); this became significant when adjusted estimates were aggregated (odds ratio, 1.65; 95% confidence interval, 1.06 to 2.55; p = 0.03). No difference in the mortality rate was seen when adjusted effects were aggregated. Temporary neurologic deficit, postoperative dialysis, ventilator time, and intensive care unit stay were significantly reduced in the warm cohort overall. No significant differences in reexploration for bleeding were found. CONCLUSIONS ACP with warmer circulatory arrest temperatures may reduce the incidence of permanent neurologic deficit as well as potentially other clinical outcomes. Further studies are required to determine the safe circulatory arrest durations for visceral organs at warmer temperatures.
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Affiliation(s)
- David H Tian
- Collaborative Research (CORE) Group, Macquarie University, Sydney, New South Wales, Australia; Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| | - Justin Weller
- Collaborative Research (CORE) Group, Macquarie University, Sydney, New South Wales, Australia
| | - Shaheen Hasmat
- Collaborative Research (CORE) Group, Macquarie University, Sydney, New South Wales, Australia
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Paul Forrest
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Hosen Kiat
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Tristan D Yan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, New South Wales, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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