Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection?

Contemporary use and outcome of Cabrol shunt in type A aortic dissection surgery: insight from China 5A study

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.

Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection

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.

Long-term follow-up of Cabrol fistula for uncontrollable bleeding: A life-saving procedure

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.

[Hemostatic measures in reconstructive aortic root surgery]

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.

Mid-term Patency of the Great Saphenous Bypass to Aorta vs. Non-aortic Arteries in Stanford Type A Aortic Dissection Surgery With Concomitant CABG

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.

Coronary artery disease in aortic aneurysm and dissection

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.

"Mantle-style" modification of Cabrol shunt for hemostasis after extended aortic reconstruction in acute type A aortic dissection

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.