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Liu H, Sun BQ, Qian SC, Sun MY, Shao YF, Ding Y, Li H, Zhang HJ. Contemporary use and outcome of Cabrol shunt in type A aortic dissection surgery: insight from China 5A study. Open Heart 2023; 10:e002465. [PMID: 38070883 PMCID: PMC10729034 DOI: 10.1136/openhrt-2023-002465] [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: 08/21/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE Cabrol shunt has been introduced for surgical repair of type A aortic dissection (TAAD) without robust evidence supporting its routine preventive use. METHODS Adult patients with TAAD from China 5A study were included if surgically repaired between 2016 and 2022. Primary outcome was operative mortality according to Society of Thoracic Surgeons criterion. Overall, we compared clinical outcomes in patients with and without Cabrol shunt, and subgroup analysis were further examined between Cabrol shunt and outcome among patients with or without root replacement. RESULTS 3283 patients were finally identified for analysis, with median age of 51 (IQR 41-59) years, 2389 men, and 2201 treated with Cabrol shunt technique. Cabrol shunt-treated patients were more severely ill before surgery than those without Cabrol shunt. Overall, the rate of operative mortality was 6.6% (146/2201 in Cabrol shunt group and 71/1082 in non-Cabrol shunt group), with no association between Cabrol shunt and operative mortality (OR 1.012 (95% CI 0.754 to 1.357); p=0.938). Stratified by root replacement, Cabrol shunt was associated with similar risk of operative mortality either in patients without root replacement (OR 1.054 (0.747 to 1.487); p=0.764) or in patients with root replacement (OR 1.194 (0.563 to 2.536); p=0.644) (P interaction=0.765). Results were similar in multiple sensitivity analysis. CONCLUSION Cabrol shunt was not associated with either a greatly lowered or an increased risk of operative mortality, regardless of aortic root replacement. Our study did not support the use of Cabrol shunt as a routine preventive strategy in the treatment of TAAD. TRIAL REGISTRATION NUMBER NCT04398992.
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Affiliation(s)
- Hong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bing-Qi Sun
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences, Tianjin, China
| | - Si-Chong Qian
- Department of Cardiovascular Surgery, Capital Medical University, Beijing, China
| | - Ming-Yu Sun
- Department of Cardiovascular Surgery, Capital Medical University, Beijing, China
| | - Yong-Feng Shao
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Ding
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hui Li
- Capital Medical University Affiliated Anzhen Hospital, Chaoyang-qu, Beijing, China
| | - Hong-Jia Zhang
- Department of Cardiovascular Surgery, Capital Medical University, Beijing, China
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Shimamoto T, Komiya T, Matsuo T. Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection. Asian Cardiovasc Thorac Ann 2023; 31:759-767. [PMID: 37731318 DOI: 10.1177/02184923231203753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The management of anastomosis and hemostasis of the dissected aorta remains challenging. This study aims to establish an optimal surgical strategy for type A acute aortic dissection by reviewing single-center data using the turn-up anastomosis technique. METHODS Between 2003 and 2015, 264 consecutive patients with type A acute aortic dissection who underwent emergency surgery within 14 days of symptom onset were enrolled. RESULTS The mean age of the patients was 67.7 ± 13.4 years, and 129 were males. The operative time and surgical bleeding were 390.9 ± 144.5 min and 2983.8 ± 3026.5 mL, respectively. In-hospital mortality was observed in 25 patients (9.4%), and 3 (1.1%) experienced uncontrolled bleeding (from the aortic root in two patients and coagulopathy due to dabigatran in one patient). Immediate reopening for bleeding was performed in 20 patients, and bleeding from the aortic anastomosis was observed at three proximal and two distal sites. Proximal re-dissection was observed in 18 patients; in all of which, glue was used, although two re-ruptures of the aortic root were observed among those without glue use. The rates of freedom from all-cause death, aortic death, and aortic events at postoperative 5 years were 78.5 ± 2.7%, 86.8 ± 2.1%, and 74.4 ± 2.9%, respectively. When these values were stratified according to the operative extent, no significant differences were observed. CONCLUSIONS Turn-up anastomosis facilitates short circulatory arrest, short operative time, and stable hemostasis, with few anastomotic complications during surgery for type A acute aortic dissection.
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Affiliation(s)
- Takeshi Shimamoto
- Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital, Shizuoka, Japan
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Takehiko Matsuo
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
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Raghuram A, Kalyanasundaram A, Babcock M, Zafar MA, Ziganshin B, Elefteriades J. Long-term follow-up of Cabrol fistula for uncontrollable bleeding: A life-saving procedure. JTCVS Tech 2023; 21:1-6. [PMID: 37854823 PMCID: PMC10580030 DOI: 10.1016/j.xjtc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 10/20/2023] Open
Abstract
Objective Surgeons shy away from using the Cabrol fistula (perigraft space to right atrium [RA] shunt) due to unfamiliarity, concern for persistent left-to-right shunting, and fear of "painting-over" anastomotic defects that will result in later problems. We review nearly 2 decades of experience with application of the Cabrol fistula in a large thoracic aortic practice, with emphasis on precise surgical techniques, early and late outcomes, and detailed radiographic analysis. Methods Operative records of all procedures in which the Cabrol fistula was used were retrieved and analyzed, with precise review of the details of construction of each Cabrol fistula and clinical and radiologic (echocardiographic and computed tomographic) patient follow-up. Results The Cabrol fistula successfully controlled the bleeding in all cases. There were no late false aneurysms at any anastomotic sites. There was no continued flow through any fistula. Good perioperative and long-term survival was achieved in these complex cases that found themselves at a very dangerous crux before application of the Cabrol fistula. Conclusions The Cabrol fistula is an important tool for the thoracic aortic surgeon to have in the toolbox. We found the Cabrol fistula to be extremely effective at controlling bleeding, with no late persistent fistula flow and no late false aneurysm formation. Without the fistula, outcome in these patients would likely have been lethal. We recommend the Cabrol fistula technique strongly for life-saving application in rare cases of bleeding uncontrollable by conventional methods.
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Affiliation(s)
- Akshay Raghuram
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Asanish Kalyanasundaram
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Maryann Babcock
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
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Salagaev GI, Lysenko AV, Lednev PV, Belov YV. [Hemostatic measures in reconstructive aortic root surgery]. Khirurgiia (Mosk) 2021:83-87. [PMID: 34786920 DOI: 10.17116/hirurgia202111183] [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: 11/18/2022]
Abstract
Bleeding is a significant cause of complications and mortality in surgery for ascending aorta and aortic root disease. This is especially true after complex reconstructions associated with hypothermic circulatory arrest and long-standing cardiopulmonary bypass. The review is devoted to modern methods of hemostasis in reconstructive aortic root surgery.
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Affiliation(s)
- G I Salagaev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - A V Lysenko
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - P V Lednev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - Yu V Belov
- Petrovsky National Research Center of Surgery, Moscow, Russia.,Sechenov First Moscow State Medical University, Moscow, Russia
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Wang M, Jia S, Pu X, Sun L, Gong M, Zhang H. Mid-term Patency of the Great Saphenous Bypass to Aorta vs. Non-aortic Arteries in Stanford Type A Aortic Dissection Surgery With Concomitant CABG. Front Cardiovasc Med 2021; 8:743562. [PMID: 34765655 PMCID: PMC8576286 DOI: 10.3389/fcvm.2021.743562] [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: 07/18/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Stanford type A aortic dissection (STAAD) is often associated with coronary artery problems requiring coronary artery bypass grafting (CABG). However, the prognosis of different proximal graft locations remains unclear. Methods: From May 2015 to April 2020, 62 patients with acute STAAD who underwent aortic surgery concomitant with CABG were enrolled in our study. Aortic bypass was defined as connecting the proximal end of the vein bridge to the artificial aorta (SVG-AO); non-aortic bypass was defined as connecting the proximal end of the vein bridge to a non-aorta vessel, including left subclavian artery, left common carotid artery, and right brachiocephalic artery (non-SVG-AO). We compared early- and mid-term results between patients in the above two groups. Early results included death and bleeding, and mid-term results graft patency, aortic-related events, and bleeding. Grafts were evaluated by post-operative coronary computed tomography angiography. According to the Fitzgibbon classification, grade A (graft stenosis <50%) is considered a patent graft. Univariate and multivariate analyses were performed to assess differences between aortic and non-aortic bypass in STAAD. Results: SVG-AO and non-SVG-AO were performed in 15 and 47 patients, respectively. There was no significant difference in death (log-rank test, p = 0.426) or bleeding (p = 0.766) between the two groups in the short term. One year of follow-up was completed in 37 patients (eight in the SVG-AO group and 29 in the non-SVG-AO group), among which 14/15 (93.3%) grafts were patent in the SVG-AO group and 32/33 (97.0%) grafts in the non-SVG-AO at 1 week, without a significant difference (p = 0.532). At 3 months, 12/13 (92.3%) grafts were patent in the SVG-AO group and 16/32 (50.0%) grafts in the non-SVG-AO, with a significant difference (p = 0.015), and 12/13 (92.3%) grafts in the SVG-AO group and 15/32 (46.9%) grafts in the non-SVG-AO group were patents, with a significant difference. Multivariate analysis showed proximal aortic bypass and dual anticoagulation to be protective factors for the 1-year patency of grafts. Conclusion: In patients requiring aortic dissection surgery with concomitant CABG, no differencess' between SVG-AO and SVG-non-AO in early outcomes were detected, but SVG-AO may have higher mid-term patency.
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Affiliation(s)
- Maozhou Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Songhao Jia
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Pu
- Department of Interventional Therapy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Jung JC, Park KH. Coronary artery disease in aortic aneurysm and dissection. Indian J Thorac Cardiovasc Surg 2021; 38:115-121. [PMID: 35463718 PMCID: PMC8980968 DOI: 10.1007/s12055-021-01265-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/17/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
Coexisting coronary artery disease is a significant risk factor of untoward outcomes after surgical and endovascular aortic repair. This article reviewed the data, consensus, and remaining controversy about the diagnosis and management of coexisting coronary artery disease in the patients who require intervention for aortic aneurysm and dissection. It can be summarized as follows: (1) the current guidelines generally recommend the same diagnostic algorithm, including indications of coronary artery angiography, as one for non-surgical patients; (2) they also recommend the same indications of coronary revascularization; and (3) there are minor, but important, remaining issues regarding the details of management and surgical techniques most of which are still at the discretion of individual surgeons and institutions. Because it is not likely to get large-scale investigational data about these issues, the collection of individual experiences should be promoted in future scientific meetings to build up the consensus.
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Affiliation(s)
- Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
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Branch stent-grafting for endovascular repair of chronic aortic arch dissection. J Thorac Cardiovasc Surg 2021; 162:12-22.e1. [DOI: 10.1016/j.jtcvs.2019.10.184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/27/2022]
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Lin TW, Tsai MT, Wu HY, Luo CY. Dissection for dissection: Limited for deliberate Cabrol fistula or extended for optimal exposure? J Thorac Cardiovasc Surg 2020; 159:e106-e107. [DOI: 10.1016/j.jtcvs.2019.07.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
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Zhang H, Chen LW. Reply from the authors: Response to the question of extended dissection rendering modified Cabrol fistula impossible. J Thorac Cardiovasc Surg 2019; 159:e108. [PMID: 31562013 DOI: 10.1016/j.jtcvs.2019.07.057] [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: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Hui Zhang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Lin TW, Tsai MT, Wu HY. "Mantle-style" modification of Cabrol shunt for hemostasis after extended aortic reconstruction in acute type A aortic dissection. Gen Thorac Cardiovasc Surg 2019; 67:1001-1005. [PMID: 31152378 DOI: 10.1007/s11748-019-01151-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/26/2019] [Indexed: 11/30/2022]
Abstract
Cabrol shunt and several of its modifications have been used as adjunctive procedures to control inaccessible bleeding occurring after aortic root surgeries. Nevertheless, the hemostatic effect of the shunt is suboptimal when the reconstructive procedure extends to the aortic arch and coronary arteries. We propose a "Mantle-style" modified Cabrol shunt to facilitate hemostasis of the exsanguination from the neo-root after aortic root replacement with concomitant arch and coronary reconstruction.
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Affiliation(s)
- Ting-Wei Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan City, 70428, Taiwan. .,Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City, 82445, Taiwan.
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan City, 70428, Taiwan
| | - Hsuan-Yin Wu
- Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City, 82445, Taiwan
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Commentary: To wrap or not to wrap-Have we now come full circle? J Thorac Cardiovasc Surg 2019; 158:1315-1316. [PMID: 30770112 DOI: 10.1016/j.jtcvs.2019.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 11/20/2022]
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