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Salem R, Van Linden A, Hlavicka J, Karimian-Tabrizi A, Ischewski I, Walther T, Holubec T. Trilateral versus Bilateral Antegrade Cerebral Perfusion in Frozen Elephant Trunk: A Propensity Score Analysis. Thorac Cardiovasc Surg 2024. [PMID: 38092063 DOI: 10.1055/a-2228-7189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Spinal cord injury (SCI) with subsequent paraplegia and/or stroke after arch repair with frozen elephant trunk (FET) remain the most devastating complications. In this study, we aim to examine the impact of different cerebral perfusion strategies on the neurological outcome comparing bilateral antegrade cerebral perfusion (bACP) and trilateral antegrade cerebral perfusion (tACP). METHODS Between 2009 and 2021, 88 patients underwent total arch replacement using a hybrid prosthesis in FET technique for acute (40.4%) and chronic (59.6%) aortic pathologies. After excluding 14 patients who underwent FET with unilateral ACP the remaining 74 patients were divided into two groups. Propensity score matching was performed based on pre- and perioperative patient characteristics resulting in 22 patients in each group. The primary endpoint was a combination of major cerebral event and SCI. Secondary end point was all-cause mortality. RESULTS Major cerebral events occurred in 9% of the patients in bACP versus 13.6% in tACP group (p = 0.63). No postoperative SCI was observed in patients with bACP and only one patient suffered SCI with tACP (p = 0.31). There was no significant difference in 30-day mortality between the two groups (22.7% in bACP vs. 13.6% in tACP; p = 0.43). CONCLUSION In patients undergoing total aortic arch repair using FET technique, both perfusion strategies (bilateral and trilateral ACP) are safe and effective. The rates of neurological complications as well as mortalities are acceptably low in both groups. Further studies with larger patient cohorts are warranted.
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Affiliation(s)
- Razan Salem
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Arnaud Van Linden
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Jan Hlavicka
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Afsaneh Karimian-Tabrizi
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Ina Ischewski
- Department of Cardiovascular Perfusion, Life Systems, Mönchengladbach, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Tomas Holubec
- Department of Cardiac Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
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Gerritse M, van Brakel TJ, van Houte J, van Hoeven M, Overdevest E, Soliman-Hamad M. Optimal antegrade cerebral perfusion flow in patients undergoing surgery for acute type A aortic dissection: A retrospective single-center analysis. Perfusion 2023:2676591231222136. [PMID: 38082542 DOI: 10.1177/02676591231222136] [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: 12/22/2023]
Abstract
BACKGROUND Systemic hypothermia with bilateral antegrade selective cerebral perfusion (ASCP) is the preferred cerebral protective strategy for type A aortic dissection surgery. The optimal ASCP flow rate remains uncertain and the target flow cannot always be reached due to pressure limitations. The aim of this study was to assess the correlation between ASCP flow and regional cerebral oxygen saturation (rSO2). METHODS A retrospective analysis was performed on 140 patients with acute type A aortic dissection who underwent surgery with moderate hypothermic circulatory arrest and bilateral ASCP between 2015 and 2021. Pearson correlation analysis was performed between ASCP flow and rSO2. RESULTS The median circulatory arrest duration was 46.5 (IQR:37.0-61.0) minutes. There was no significant correlation between ASCP flow and rSO2 for both the right (r = -.02, p = .851), and the left hemisphere (r = - .04, p = .618). The rSO2 values for ten patients who received > 10 mL/kg/min flow did not differ significantly from 130 patients who received 10 mL/kg/min or less for both the left hemisphere (p = .135), and the right hemisphere (p = .318). The ASCP flow was 5.1 (IQR:5.0- 6.5) mL/kg/min in five patients with, and 7.2 (IQR:5.8-8.3) mL/kg/min in 135 patients without a watershed infarction (p = .098). CONCLUSIONS There was no correlation between ASCP flow rate and rSO2 in patients with acute type A aortic dissection. Furthermore, ASCP flow below 10 mL/kg/min was not associated with a reduction in rSO2. Definitive associations between ASCP flow and neurological outcome after type A aortic dissection surgery need further investigation.
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Affiliation(s)
- Matthijs Gerritse
- Department of Extracorporeal Circulation, Catharina Hospital, Eindhoven, The Netherlands
| | - Thomas J van Brakel
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Joris van Houte
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Marloes van Hoeven
- Department of Extracorporeal Circulation, Catharina Hospital, Eindhoven, The Netherlands
| | - Eddy Overdevest
- Department of Extracorporeal Circulation, Catharina Hospital, Eindhoven, The Netherlands
| | - Mohamed Soliman-Hamad
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
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Evaluation of Different Cannulation Strategies for Aortic Arch Surgery Using a Cardiovascular Numerical Simulator. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010060. [PMID: 36671632 PMCID: PMC9854437 DOI: 10.3390/bioengineering10010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023]
Abstract
Aortic disease has a significant impact on quality of life. The involvement of the aortic arch requires the preservation of blood supply to the brain during surgery. Deep hypothermic circulatory arrest is an established technique for this purpose, although neurological injury remains high. Additional techniques have been used to reduce risk, although controversy still remains. A three-way cannulation approach, including both carotid arteries and the femoral artery or the ascending aorta, has been used successfully for aortic arch replacement and redo procedures. We developed circuits of the circulation to simulate blood flow during this type of cannulation set up. The CARDIOSIM© cardiovascular simulation platform was used to analyse the effect on haemodynamic and energetic parameters and the benefit derived in terms of organ perfusion pressure and flow. Our simulation approach based on lumped-parameter modelling, pressure-volume analysis and modified time-varying elastance provides a theoretical background to a three-way cannulation strategy for aortic arch surgery with correlation to the observed clinical practice.
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Okada K. Total arch replacement: When and how? Asian Cardiovasc Thorac Ann 2023; 31:42-47. [PMID: 35509182 DOI: 10.1177/02184923211073374] [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: 11/17/2022]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high hospital mortality rate. Open aortic surgery for ATAAD is always required to save the patient, particularly elderly patients. Tear-oriented surgery is recommended as the frontline treatment for ATAAD, and hemiarch replacement (HAR) is sufficient because the primary entry is often observed in the ascending aorta (60%-70%). However, HAR has some drawbacks, such as new creation of an anastomotic entry and unfavorable distal aortic remodeling during long-term follow-up. Although total arch replacement (TAR) is a demanding procedure, it is another useful option for ATAAD. Proper patient selection for TAR is controversial. Standardized procedure for TAR, including the optimal brain protection methods and the use of excellent sealed vascular prosthetic grafts, has been established over the past decades. Therefore, TAR is increasingly being selected for HAR in patients who are young or have enlarged aortic arch, severely dissected supra-aortic arch vessels, or hereditary thoracic aortic disorders. The emerging technology of commercially available frozen elephant trunk accelerated the application of TAR, facilitates distal anastomosis, and improves distal aortic remodeling. Although further evidence is required, TAR could be the best choice for HAR for selected patients. Currently, appropriate selection of the surgical technique is important to maximize the benefits of open surgery for ATAAD.
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Affiliation(s)
- Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Werner P, Stelzmüller ME, Mahr S, Ehrlich M. The 10 Commandments of Open Aortic Arch Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:259-265. [PMID: 35916005 PMCID: PMC9403391 DOI: 10.1177/15569845221112636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
| | | | - Stephane Mahr
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiac Surgery, 27271Medical University of Vienna, Austria
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Capoccia M, Nienaber CA, Mireskandari M, Sabetai M, Young C, Cheshire NJ, Rosendahl UP. Alternative Approach for Cerebral Protection during Complex Aortic Arch and Redo Surgery. J Cardiovasc Dev Dis 2021; 8:jcdd8080086. [PMID: 34436228 PMCID: PMC8396903 DOI: 10.3390/jcdd8080086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/22/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022] Open
Abstract
Total arch replacement remains a very demanding surgical procedure. It can be associated with reasonable long-term outcomes but carries serious perioperative complications. Aortic arch surgery has progressed in recent years to a wider adoption of reproducible and reliable techniques. Conventional open, surgical aortic arch replacement is currently offered to the majority of patients, although hybrid and wholly endovascular techniques are gaining popularity. With regards to open arch replacement, the nuances of surgical technique, the mode of cannulation and the optimal cerebral protection protocols remain a matter of debate. We propose an alternative cannulation approach facilitated by the cooperation between cardiac and vascular surgeons. A three-way arterial cannulation including both carotid arteries and the femoral artery (or ascending aorta) is the key feature of this approach. A case series of complex patients is presented to show both the feasibility and relative safety of a standardised new approach with a 100% technical success rate and a 16% 30-day mortality. The three-way cannulation approach may have a role to play for complex and extensive procedures requiring prolonged cerebral protection. We believe that a shared skill set from cardiac and vascular specialists is essential for the safe management and successful outcomes using this adaptive technique.
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Affiliation(s)
- Massimo Capoccia
- Aortic Centre, Royal Brompton Hospital, London SW3 6NP, UK; (C.A.N.); (M.M.); (N.J.C.); (U.P.R.)
- Correspondence:
| | - Christoph A. Nienaber
- Aortic Centre, Royal Brompton Hospital, London SW3 6NP, UK; (C.A.N.); (M.M.); (N.J.C.); (U.P.R.)
| | - Maziar Mireskandari
- Aortic Centre, Royal Brompton Hospital, London SW3 6NP, UK; (C.A.N.); (M.M.); (N.J.C.); (U.P.R.)
| | - Michael Sabetai
- Cardiac Surgery, Guy’s & St. Thomas’ Hospital, London SE1 9RS, UK; (M.S.); (C.Y.)
| | - Christopher Young
- Cardiac Surgery, Guy’s & St. Thomas’ Hospital, London SE1 9RS, UK; (M.S.); (C.Y.)
| | - Nicholas J. Cheshire
- Aortic Centre, Royal Brompton Hospital, London SW3 6NP, UK; (C.A.N.); (M.M.); (N.J.C.); (U.P.R.)
| | - Ulrich P. Rosendahl
- Aortic Centre, Royal Brompton Hospital, London SW3 6NP, UK; (C.A.N.); (M.M.); (N.J.C.); (U.P.R.)
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Kikuchi Y, Kikuchi Y, Kamiya H. A simplified isolation technique for atherosclerotic aortic arch aneurysms surgery. J Surg Case Rep 2021; 2021:rjab082. [PMID: 33897995 PMCID: PMC8055174 DOI: 10.1093/jscr/rjab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
The isolation technique is a useful adjunct that prevents atherosclerotic embolism in the brain when the aneurysm is filled with a massive hematoma or 'shaggy aorta'. But the technique is not widespread because of the difficulty in performing the cannulation. We modified this technique by simplifying the cannulation procedure using a puncture method with aortic root cannulas.
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Affiliation(s)
- Yuta Kikuchi
- Department of Cardiovascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yoichi Kikuchi
- Department of Cardiovascular Surgery, National Hospital Organization Obihiro Hospital, Obihiro, Hokkaido, Japan
| | - Hiroyuki Kamiya
- Department of Cardiovascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Sun S, Chien CY, Fan YF, Wu SJ, Li JY, Tan YH, Hsu KH. Retrograde cerebral perfusion for surgery of type A aortic dissection. Asian J Surg 2021; 44:1529-1534. [PMID: 33888364 DOI: 10.1016/j.asjsur.2021.03.047] [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: 12/16/2020] [Revised: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. METHODS From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29-88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. RESULTS The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). CONCLUSIONS Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (<65 years old) without pre-operative shock got better surgical outcome and long-term survival. RCP could provide acceptable cerebral protection during aortic surgery for the TAAD patients. Old age, pre-operative shock, CRI and past history of CAD are independent risk factors for long-term survival.
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Affiliation(s)
- Shen Sun
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chen-Yen Chien
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ya-Fen Fan
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shye-Jao Wu
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan.
| | - Jiun-Yi Li
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yu-Hern Tan
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
| | - Kung-Hong Hsu
- Division of Cardiovascular Surgery, Departments of Surgery, MacKay Memorial Hospital, Taipei, Taiwan
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Dong SB, Zhang K, Zhu K, Wang LF, Zheng J, Li JR, Liu YM, Sun LZ, Pan XD. Mild hypothermic circulatory arrest with selective cerebral perfusion in open arch surgery. J Thorac Dis 2021; 13:1151-1161. [PMID: 33717588 PMCID: PMC7947532 DOI: 10.21037/jtd-20-3550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background This study aimed to evaluate whether the use of mild hypothermic circulatory arrest (HCA) with selective cerebral perfusion (SCP) in open arch procedure provides comparable perioperative results to moderate HCA for patients with dissected or degenerative arch pathologies. Methods Between January 2017 and September 2020, a total of 88 consecutive patients (mean age 47±11 years, 71 males) underwent open arch repair under a single surgeon at our institution with mild or moderate systemic hypothermia assisted by unilateral or bilateral SCP. Patients were divided into groups according to the nasopharyngeal temperature at the beginning of HCA: a moderate HCA group (n=47, 53.4%) and a mild HCA group (n=41, 46.6%). The postoperative mortality, morbidity, and visceral organ functions between these groups were analyzed retrospectively. Results Compared to the moderate HCA group, the mild HCA group had a significantly higher core temperature (nasopharynx: 24.4±0.8 vs. 28.5±2, P<0.001; bladder 25.9±0.9 vs. 30±1.2, P<0.001), and the incidence of major adverse events (MAE) in this group was markedly lower (21.3% vs. 4.9%, P=0.031). No differences were identified between the two groups refer to in-hospital mortality, permanent neurological deficit (PND), temporary neurological deficit (TND), and paraplegia (8.5% vs. 2.4%, P=0.366; 8.5% vs. 0, P=0.120; 6.4% vs. 7.3%, P=1.0; 4.3% vs. 2.4%, P=1.0, respectively). In the moderate HCA group, 6 patients (12.8%) developed acute renal failure needing replacement therapy, which did not occur in the mild HCA group (P=0.028). The duration of ventilator support and intensive care unit stay was shorter in the mild HCA group, as well as a decreased volume of drainage during the first 24 h and reduced platelet transfusion. Conclusions The preliminary results of the mild HCA group with SCP applied in open arch repair, mainly in total arch replacement (TAR) and stented elephant trunk (SET) implantation for aortic dissection, were satisfactory. Furthermore, comparable inferior outcomes were obtained with mild HCA compared with that of the conventional moderate HCA strategy. These encouraging surgical and postoperative results favor this more aggressive hypothermia strategy in open arch repair.
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Affiliation(s)
- Song-Bo Dong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Kai Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Kai Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Long-Fei Wang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jian-Rong Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Xu-Dong Pan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
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Peterson MD, Garg V, Mazer CD, Chu MWA, Bozinovski J, Dagenais F, MacArthur RGG, Ouzounian M, Quan A, Jüni P, Bhatt DL, Marotta TR, Dickson J, Teoh H, Zuo F, Smith EE, Verma S. A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery. J Thorac Cardiovasc Surg 2020; 164:1426-1438.e2. [PMID: 33431219 DOI: 10.1016/j.jtcvs.2020.10.152] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 10/13/2020] [Accepted: 10/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. OBJECTIVE To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. METHODS This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. RESULTS One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. CONCLUSIONS diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.
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Affiliation(s)
- Mark D Peterson
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vinay Garg
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
| | - Michael W A Chu
- Division of Cardiac Surgery, Lawson Health Research Institute, Western University, London, Ontario, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - François Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Roderick G G MacArthur
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Maral Ouzounian
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Peter Jüni
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Thomas R Marotta
- Department of Medicine, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Diagnostic and Therapeutic Neuroradiology, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medical Imaging, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Dickson
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Eric E Smith
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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11
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Wai Sang SL, Beute TJ, Timek T. A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction. JTCVS Tech 2020; 2:10-15. [PMID: 34317734 PMCID: PMC8298922 DOI: 10.1016/j.xjtc.2020.03.012] [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: 02/09/2020] [Revised: 02/09/2020] [Accepted: 03/13/2020] [Indexed: 01/16/2023] Open
Abstract
Objective We describe a novel and safe technique using a 12F-14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction. Methods Between January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C-26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10-15 mL/kg/min. Data were collected by retrospective chart review. Results Thirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury. Conclusions Direct IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.
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Affiliation(s)
- Stephane Leung Wai Sang
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.,Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Tyler J Beute
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Tomasz Timek
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.,Michigan State University College of Human Medicine, Grand Rapids, Mich
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Mauduit M, Anselmi A, Tomasi J, Belhaj Soulami R, Roisné A, Flecher E, Rouze S, Verhoye JP. Early and late outcomes of aortic surgery under hypothermic circulatory arrest in the elderly: a single center study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:733-741. [PMID: 31599143 DOI: 10.23736/s0021-9509.19.10874-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the progressive aging of the population, aortic surgeons are caring for an increasing number of elderly patients. The objective of this study was to analyze early and late outcomes of aortic surgery with hypothermic circulatory arrest in patients aged 70 and above at our institution. METHODS We performed a retrospective cohort study including every patient aged 70 years or older who underwent aortic surgery with hypothermic circulatory arrest between January 1995 and June 2016 at our institution. Operative results were compared with the contemporary younger counterparts aged <70 years. In-hospital mortality and postoperative stroke were primary outcomes of interest. The main secondary outcomes included acute renal failure, reoperation for bleeding, and spinal cord injury. RESULTS In the study population, the in-hospital mortality was 16.8% (21/125). Ten (8.0%) patients presented postoperative stroke, and 6 had temporary neurologic disturbance (4.8%). Spinal cord injury occurred in 1 (0.8%) patient. For elective interventions and type A aortic dissections, the in-hospital mortality and stroke rates were 4.6% (3/65) and 7.7% (5/65), 26.8% (11/41) and 12.2% (5/41), respectively. The proportion of non-elective interventions, including type A aortic dissection, and the type of neuroprotective strategy were similar in septuagenarians and younger patients. Patients aged ≥70 had significant shorter cardiopulmonary bypass, myocardial ischemia, and circulatory arrest durations, compared to their younger counterparts. The in-hospital mortality of septuagenarians and younger patients were similar for elective surgery (4.6% vs. 4.7%, P=0.900) and aortic dissections (26.8% vs. 15.1%, P=0.107). There was no statistically significant difference between the two age groups regarding postoperative stroke, spinal cord injury, renal failure requiring dialysis or reintervention for bleeding. Estimated 1-, 3-, and 5-year survival was 78.0%, 70.6%, and 65.7%, respectively. The 5-year survival for elective surgery was 74.9% and 56.0% for non-elective procedures. CONCLUSIONS Aortic surgery with circulatory arrest in the elderly demonstrated favorable early and late results when compared with younger individuals, with an acceptable operative risk even under emergency conditions, and should not be denied only because of the chronological age of the patients.
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Affiliation(s)
- Marion Mauduit
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France -
| | - Amedeo Anselmi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Reda Belhaj Soulami
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Antoine Roisné
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Simon Rouze
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
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Kondo N, Tamura K, Hiraoka A, Totsugawa T, Chikazawa G, Sakaguchi T, Yoshitaka H. Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80. Gen Thorac Cardiovasc Surg 2019; 67:765-772. [PMID: 30888589 DOI: 10.1007/s11748-019-01111-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/04/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES While reports which focus on the outcomes of conservative treatments for acute type A aortic dissection in patients over the age of 80 are worth considering, recently many studies have reported improved outcomes of surgical treatment. Accordingly, we analyzed the outcomes of surgical and conservative treatments for acute type A aortic dissection with patent false lumen in patients over the age of 80. METHODS We retrospectively investigated 70 patients over 80 years in age out of 248 consecutive patients with acute type A aortic dissection between January, 2010, and May, 2015. Of the 70 patients, 44 underwent surgical treatments (ascending replacement in 33 and total arch replacement in 11) and 23 patients underwent conservative medical treatments. RESULTS In the surgical treatment, the 30-day mortality rate was 14% (6/44) and the rate of morbidity was 34%. And 17 patients (39%) were discharged home without ambulatory assistance. The actuarial survival rates in the surgical treatment group were 83% and 60% at 1 and 3 years, respectively. The in-hospital death rate of conservative medical treatment was 43% (10/23). Only 26% of the patients having had conservative treatment were discharged home without ambulatory assistance. The actuarial survival rate in the conservative medical group was 8.7% at 1 year. CONCLUSION Surgical outcomes of acute type A aortic dissection with patent false lumen were satisfactory in patients aged over 80 in this study by meticulously determining operative indications, depending on the background of each patient.
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Affiliation(s)
- Nobuo Kondo
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan.
| | - Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
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14
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Yamauchi T, Kubota S, Hasegawa K, Ueda H. Clinical results and medical costs of thoracic endovascular aortic repair in patients over 80 years of age. J Artif Organs 2018; 22:61-67. [DOI: 10.1007/s10047-018-1073-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/02/2018] [Indexed: 11/24/2022]
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Abstract
Conventional arch replacement can be carried out in a great majority of patients. Hybrid procedures are often as invasive and technically difficult as conventional ones. Moreover, their immediate results are, in many reported experiences, not better and their long-term results less favourable than the ones observed with conventional methods. So, yes, the open conventional arch replacement is still "the gold standard".
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Early results of total arch replacement under partial sternotomy. Gen Thorac Cardiovasc Surg 2018; 66:327-333. [PMID: 29600320 DOI: 10.1007/s11748-018-0913-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Partial sternotomy with limited skin incision has been utilized for cardiac surgery. We, therefore, started to apply the partial sternotomy for total arch replacement since 2013 in selected cases. The aim of this study reported the results of our early experiences. METHODS Between July 2013 and December 2015, we retrospectively reviewed 15 cases (median age 72, range 67-84, 15 male) who underwent total arch replacement thorough partial sternotomy. All procedures were performed under hypothermic circulatory arrest with selective cerebral perfusion. RESULTS Median skin incision was 9 cm (range 7-15 cm, 5.3% of height) and partial sternotomy consisted of 14 upper and 1 lower partial sternotomy (L shape 8 and T shape 7 cases). Median operation time, cardiopulmonary bypass time, ischemic heart time, selective cerebral perfusion time and hypothermic circulatory arrest time were 485 [360-770], 223 [1174-270], 146 [100-163], 154 [116-189], and 69 [45-90] minutes, respectively. Median duration of mechanical ventilator dependent time was 12 h [5-38]. Median length of ICU stay and hospital stay were 3 [1-7], and 18 [13-76] days, respectively. Thirty days and in-hospital mortality were 0% without any neurological complications. There are two aorta-related reoperation due to graft inducing hemolytic anemia and no aorta-related death during follow-up (median 954, range 702-1462 days). CONCLUSION The early results of total arch replacement through partial sternotomy were satisfactory. The partial sternotomy could be a good option for total arch replacement in selected patients.
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Lau C, Gaudino M, Iannacone EM, Gambardella I, Munjal M, Ohmes LB, Degner BC, Girardi LN. Retrograde Cerebral Perfusion Is Effective for Prolonged Circulatory Arrest in Arch Aneurysm Repair. Ann Thorac Surg 2018; 105:491-497. [DOI: 10.1016/j.athoracsur.2017.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/05/2017] [Accepted: 07/10/2017] [Indexed: 11/17/2022]
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19
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Aortic arch aneurysm surgery: what is the gold standard temperature in the absence of randomized data? Gen Thorac Cardiovasc Surg 2017; 67:127-131. [DOI: 10.1007/s11748-017-0867-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/12/2017] [Indexed: 11/26/2022]
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20
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Risteski P, El-Sayed Ahmad A, Monsefi N, Papadopoulos N, Radacki I, Herrmann E, Moritz A, Zierer A. Minimally invasive aortic arch surgery: Early and late outcomes. Int J Surg 2017; 45:113-117. [DOI: 10.1016/j.ijsu.2017.07.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/02/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
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21
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Silva Guisasola J, Alvarez-Cabo R, Hernández-Vaquero D, Méndez RD. Ascending aorta reinterventions. J Thorac Dis 2017; 9:S448-S453. [PMID: 28616341 DOI: 10.21037/jtd.2017.05.01] [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: 11/06/2022]
Abstract
Ascending aorta reinterventions present a challenge for surgeons as the technical difficulties of the procedure and the complex strategic approach can complicate successful treatment. These patients should be treated by surgical teams with ample experience in aortic diseases as they can be at high risk of mortality. The number of interventions on the ascending aorta and aortic arch and the use of biological conducts (lung autograft, homograft, etc.) have increased in recent years; therefore, the number of reinterventions can also be expected to increase, representing 10% of aortic surgical procedures. This article reviews the current status of ascending aorta reinterventions, analyzing the principal aspects of indication and surgical strategy, as well as the results published in the largest studies.
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Affiliation(s)
- Jacobo Silva Guisasola
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rubén Alvarez-Cabo
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Rocío Díaz Méndez
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
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Garg V, Peterson MD, Chu MWA, Ouzounian M, MacArthur RGG, Bozinovski J, El-Hamamsy I, Victor Chu F, Garg A, Hall J, Thorpe KE, Dhingra N, Teoh H, Marotta TR, Latter DA, Quan A, Mamdani M, Juni P, David Mazer C, Verma S. Axillary versus innominate artery cannulation for antegrade cerebral perfusion in aortic surgery: design of the Aortic Surgery Cerebral Protection Evaluation (ACE) CardioLink-3 randomised trial. BMJ Open 2017; 7:e014491. [PMID: 28601820 PMCID: PMC5623414 DOI: 10.1136/bmjopen-2016-014491] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Neurological injury remains the major cause of morbidity and mortality following open aortic arch repair. Systemic hypothermia along with antegrade cerebral perfusion (ACP) is the accepted cerebral protection approach, with axillary artery cannulation being the most common technique used to establish ACP. More recently, innominate artery cannulation has been shown to be a safe and efficacious method for establishing ACP. Inasmuch as there is a lack of high-quality data comparing axillary and innominate artery ACP, we have designed a randomised, multi-centre clinical trial to compare both cerebral perfusion strategies with regards to brain morphological injury using diffusion-weighted MRI (DW-MRI). METHODS AND ANALYSIS 110 patients undergoing elective aortic surgery with repair of the proximal arch requiring an open distal anastamosis will be randomised to either the innominate artery or the axillary artery cannulation strategy for establishing unilateral ACP during systemic circulatory arrest with moderate levels of hypothermia. The primary safety endpoint of this trial is the proportion of patients with new radiologically significant ischaemic lesions found on postoperative DW-MRI compared with preoperative DW-MRI. The primary efficacy endpoint of this trial is the difference in total operative time between the innominate artery and the axillary artery cannulation group. ETHICS AND DISSEMINATION The study protocol and consent forms have been approved by the participating local research ethics boards. Publication of the study results is anticipated in 2018 or 2019. If this study shows that the innominate artery cannulation technique is non-inferior to the axillary artery cannulation technique with regards to brain morphological injury, it will establish the innominate artery cannulation technique as a safe and potentially more efficient method of antegrade cerebral perfusion in aortic surgery. TRIAL REGISTRATION NUMBER NCT02554032.
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Affiliation(s)
- Vinay Garg
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael WA Chu
- Division of Cardiac Surgery, London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | - Maral Ouzounian
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Roderick GG MacArthur
- Division of Cardiac Surgery, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - F Victor Chu
- Division of Cardiac Surgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Ankit Garg
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Judith Hall
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Dhingra
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Department of Diagnostic and Therapeutic Neuroradiology, Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David A Latter
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART), St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter Juni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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Liu H, Chang Q, Zhang H, Yu C. Predictors of Adverse Outcome and Transient Neurological Dysfunction Following Aortic Arch Replacement in 626 Consecutive Patients in China. Heart Lung Circ 2017; 26:172-178. [DOI: 10.1016/j.hlc.2016.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 01/28/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
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Martinelli GL, Cotroneo A, Caimmi PP, Musica G, Barillà D, Stelian E, Romano A, Novelli E, Renzi L, Diena M. Safe Reentry for False Aneurysm Operations in High-Risk Patients. Ann Thorac Surg 2016; 103:1907-1913. [PMID: 27916243 DOI: 10.1016/j.athoracsur.2016.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. METHODS We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. RESULTS We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. CONCLUSIONS The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.
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Affiliation(s)
- Gian Luca Martinelli
- Department of Cardiac Surgery, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy.
| | - Attilio Cotroneo
- Department of Cardiac Surgery, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Philippe Primo Caimmi
- Department of Cardiac Surgery, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Gabriele Musica
- Department of Cardiac Surgery, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - David Barillà
- Vascular Surgery Department, Ospedali Riuniti Bianchi Melacrino Morelli, Reggio Calabria
| | - Edmond Stelian
- Department of Cardiac Anesthesiology, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Angelo Romano
- Department of Cardiac Anesthesiology, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Eugenio Novelli
- Department of Biostatistics and Clinical Research, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Luca Renzi
- Unit of Cardiopulmonary Circulatory Support, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
| | - Marco Diena
- Department of Cardiac Surgery, Clinica San Gaudenzio-Gruppo Policlinico di Monza, Novara, Italy
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Keenan JE, Benrashid E, Kale E, Nicoara A, Husain AM, Hughes GC. Neurophysiological Intraoperative Monitoring During Aortic Arch Surgery. Semin Cardiothorac Vasc Anesth 2016; 20:273-282. [PMID: 27708177 DOI: 10.1177/1089253216672441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Circulatory management during replacement of the aortic arch is complex and involves a period of circulatory arrest to provide a bloodless field during arch vessel anastomosis. To guard against ischemic brain injury, tissue metabolic demand is reduced by systemically cooling the patient prior to circulatory arrest. Neurophysiological intraoperative monitoring (NIOM) is often used during the course of these procedures to provide contemporaneous assessment of brain status to help direct circulatory management decisions and detect brain ischemia. In this review, we discuss the characteristics of electrocerebral activity through the process of cooling, circulatory arrest, and rewarming as depicted through commonly used NIOM modalities, including electroencephalography and peripheral nerve somatosensory-evoked potentials. Attention is directed toward the role NIOM has traditionally played during deep hypothermic circulatory arrest, where it is used to define the point of electrocerebral inactivity or maximal cerebral metabolic suppression prior to initiating circulatory arrest while also discussing the evolving utility of NIOM when systemic circulatory arrest is initiated at more moderate degrees of hypothermia in conjunction with regional brain perfusion. The use of cerebral tissue oximetry by near-infrared spectroscopy as an alternative NIOM modality during surgery of the aortic arch is addressed as well. Finally, special considerations for NIOM and the detection of spinal cord ischemia during hybrid aortic arch repair and emerging operative techniques are also discussed.
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Affiliation(s)
- Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Emily Kale
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Aatif M Husain
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement. J Thorac Cardiovasc Surg 2016; 152:1559-1569.e2. [PMID: 27692949 DOI: 10.1016/j.jtcvs.2016.08.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/27/2016] [Accepted: 08/11/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Moderate (MHCA) versus deep (DHCA) hypothermia for circulatory arrest in aortic arch surgery has been purported to reduce coagulopathy and bleeding complications, although there are limited data supporting this claim. This study aimed to compare bleeding-related events after aortic hemiarch replacement with MHCA versus DHCA. METHODS Patients who underwent hemiarch replacement at a single institution from July 2005 to August 2014 were stratified into DHCA and MHCA groups (minimum systemic temperature ≤20°C and >20°C, respectively) and compared. Then, 1:1 propensity matching was performed to adjust for baseline differences. RESULTS During the study period, 571 patients underwent hemiarch replacement: 401 (70.2%) with DHCA and 170 (29.8%) with MHCA. After propensity matching, 155 patients remained in each group. There were no significant differences between matched groups with regard to the proportion transfused with red blood cells, plasma, platelet concentrates, or cryoprecipitate on the operative day, the rate of reoperation for bleeding, or postoperative hematologic laboratory values. Among patients who received plasma, the median transfusion volume was statistically greater in the DHCA group (6 vs 5 units, P = .01). MHCA also resulted in a slight reduction in median volume of blood returned via cell saver (500 vs 472 mL, P < .01) and 12-hour postoperative chest tube output (440 vs 350, P < .01). Thirty-day mortality and morbidity did not differ significantly between groups. CONCLUSIONS MHCA compared with DHCA during hermiarch replacement may slightly reduce perioperative blood-loss and plasma transfusion requirement, although these differences do not translate into reduced reoperation for bleeding or postoperative mortality and morbidity.
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Kayatta MO, Chen EP. Optimal temperature management in aortic arch operations. Gen Thorac Cardiovasc Surg 2016; 64:639-650. [PMID: 27501694 DOI: 10.1007/s11748-016-0699-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/26/2016] [Indexed: 01/26/2023]
Abstract
Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.
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Affiliation(s)
- Michael O Kayatta
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA.
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Abstract
Children and particularly neonates present unique challenges during CPB. Patient age, size, underlying anatomy and surgical strategy influence the perfusion techniques and the construction of the CPB circuit. The normal changes in physiology in the first weeks of life impact upon surgical technique and outcome of repair. Limited surgical access necessitates alternative cannulation strategies. Deep hypothermia, low flow CPB and circulatory arrest are frequently used. An understanding of the related pathophysiology is therefore required to make the correct choices and to optimise patient outcome.
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Affiliation(s)
- T J Jones
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK.
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Durandy Y. Rationale for Implementation of Warm Cardiac Surgery in Pediatrics. Front Pediatr 2016; 4:43. [PMID: 27200324 PMCID: PMC4858514 DOI: 10.3389/fped.2016.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 02/03/2023] Open
Abstract
Cardiac surgery was developed thanks to the introduction of hypothermia and cardiopulmonary bypass in the early 1950s. The deep hypothermia protective effect has been essential to circulatory arrest complex cases repair. During the early times of open-heart surgery, a major concern was to decrease mortality and to improve short-term outcomes. Both mortality and morbidity dramatically decreased over a few decades. As a consequence, the drawbacks of deep hypothermia, with or without circulatory arrest, became more and more apparent. The limitation of hypothermia was particularly evident for the brain and regional perfusion was introduced as a response to this problem. Despite a gain in popularity, the results of regional perfusion were not fully convincing. In the 1990s, warm surgery was introduced in adults and proved to be safe and reliable. This option eliminates the deleterious effect of ischemia-reperfusion injuries through a continuous, systemic coronary perfusion with warm oxygenated blood. Intermittent warm blood cardioplegia was introduced later, with impressive results. We were convinced by the easiness, safety, and efficiency of warm surgery and shifted to warm pediatric surgery in a two-step program. This article outlines the limitations of hypothermic protection and the basic reasons that led us to implement pediatric warm surgery. After tens of thousands of cases performed across several centers, this reproducible technique proved a valuable alternative to hypothermic surgery.
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Affiliation(s)
- Yves Durandy
- Perfusion Department, CCML, Le Plessis Robinson, France
- Intensive Care Department, CCML, Le Plessis Robinson, France
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Cole D, Seller A, Peng YG. Descending Aortic Stent Graft Collapse During Frozen Elephant Trunk Repair: Detection Using Invasive Blood Pressure Monitoring and Intraoperative Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2016; 30:1344-9. [PMID: 27021175 DOI: 10.1053/j.jvca.2015.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Devon Cole
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Aaron Seller
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Yong G Peng
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL.
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Linardi D, Faggian G, Rungatscher A. Temperature Management During Circulatory Arrest in Cardiac Surgery. Ther Hypothermia Temp Manag 2016; 6:9-16. [DOI: 10.1089/ther.2015.0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniele Linardi
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Alessio Rungatscher
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
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Settepani F, Cappai A, Basciu A, Barbone A, Tarelli G. Outcome of open total arch replacement in the modern era. J Vasc Surg 2016; 63:537-45. [DOI: 10.1016/j.jvs.2015.10.061] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/05/2015] [Indexed: 11/24/2022]
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How to Perfuse: Concepts of Cerebral Protection during Arch Replacement. BIOMED RESEARCH INTERNATIONAL 2015; 2015:981813. [PMID: 26713319 PMCID: PMC4680049 DOI: 10.1155/2015/981813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/19/2015] [Indexed: 11/17/2022]
Abstract
Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data.
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Electroencephalography During Hemiarch Replacement With Moderate Hypothermic Circulatory Arrest. Ann Thorac Surg 2015; 101:631-7. [PMID: 26482779 DOI: 10.1016/j.athoracsur.2015.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 07/28/2015] [Accepted: 08/07/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study aimed to characterize intraoperative electroencephalography (EEG) during moderate hypothermic circulatory arrest (MHCA) with selective antegrade cerebral perfusion (SACP), which has not been described previously. METHODS This was a single-institution retrospective study of patients undergoing aortic hemiarch replacement using MHCA (temperatures <28°C at circulatory arrest [CA]) and unilateral SACP with EEG monitoring from July 1, 2013 to November 1, 2014. The EEG pattern was determined before and immediately after CA, as well as after establishment of SACP. Patient and procedural characteristics and outcomes were determined and compared after stratification by the presence of ischemic EEG changes. RESULTS The study included 71 patients. Before CA, 47 patients (66%) demonstrated a continuous EEG pattern, with or without periodic complexes, and 24 (34%) had a burst suppression EEG pattern. Immediately after CA, abrupt loss of electrocerebral activity occurred in 32 patients (45%), suggestive of cerebral ischemia. Establishment of unilateral SACP rapidly restored electrocerebral activity in all but 2 patients. One patient had persistent loss of left-sided activity, which resolved after transition to bilateral SACP. Another patient had persistent global loss of activity and was placed back on cardiopulmonary bypass for further cooling before reinitiation of CA. No significant differences in characteristics or outcomes were assessed between patients with and without loss of EEG activity. CONCLUSIONS Nearly half of patients undergoing hemiarch replacement with MHCA/SACP experience abrupt loss of electrocerebral activity after CA is initiated. Although unilateral SACP usually restores prearrest electrocerebral activity, intraoperative EEG may be particularly valuable for the identification of patients with persistent cerebral ischemia even after SACP.
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Ikonomidis JS. Bleeding and cerebral injury following aortic arch repair: Two chinks in the armor. J Thorac Cardiovasc Surg 2015; 151:296-7. [PMID: 26434702 DOI: 10.1016/j.jtcvs.2015.08.113] [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: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
Affiliation(s)
- John S Ikonomidis
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
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Seco M, Edelman JJB, Van Boxtel B, Forrest P, Byrom MJ, Wilson MK, Fraser J, Bannon PG, Vallely MP. Neurologic injury and protection in adult cardiac and aortic surgery. J Cardiothorac Vasc Anesth 2015; 29:185-95. [PMID: 25620144 DOI: 10.1053/j.jvca.2014.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Van Boxtel
- Columbia University Medical Center-New York Presbyterian Hospital, New York, New York
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Byrom
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Aneurismas del arco aórtico. Generalidades: epidemiología, manifestaciones clínicas y diagnóstico. Indicaciones de cirugía. Cirugía abierta. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: Analysis based on the Japan Adult Cardiovascular Surgery Database. J Thorac Cardiovasc Surg 2015; 149:S65-73. [DOI: 10.1016/j.jtcvs.2014.08.070] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/14/2014] [Accepted: 08/20/2014] [Indexed: 11/24/2022]
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Di Bartolomeo R, Di Marco L, Cefarelli M, Leone A, Pantaleo A, Di Eusanio M, Barberio G, Pacini D. The Bologna experience with the Thoraflex™ hybrid frozen elephant trunk device. Future Cardiol 2015; 11:39-43. [DOI: 10.2217/fca.14.56] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Background: We present our initial experience with the frozen elephant trunk using a Thoraflex™ hybrid device for the treatment of the complex thoracic aorta lesions. Materials & methods: Between March 2013 and March 2014, ten patients underwent thoracic aorta surgery using the frozen elephant trunk approach with the Thoraflex hybrid device. Indications for surgery were: residual type A chronic dissection (eight patients), degenerative aneurysm (one patient) and type B chronic aortic dissection (one patient). Selective antegrade cerebral perfusion and moderate hypothermia were used in all cases. Results: In-hospital mortality was 0% and no patients presented with paraplegia, paraparesis or major neurological events. One patient experienced transient ischemic attack. Two patients underwent reoperation for bleeding. All postoperative angiography CT scans confirmed the desired results. Conclusion: Our initial experience demonstrated excellent early results. The Thoraflex hybrid prosthesis with the four-branched arch graft increases the spectrum of techniques available for the surgeon in the treatment of complex diseases of the thoracic aorta.
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Affiliation(s)
- Roberto Di Bartolomeo
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Luca Di Marco
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Mariano Cefarelli
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Alessandro Leone
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Antonio Pantaleo
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Marco Di Eusanio
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Giuseppe Barberio
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
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Current status of cerebral protection for aortic arch surgery. J Thorac Cardiovasc Surg 2014; 148:2466-2467. [PMID: 25451498 DOI: 10.1016/j.jtcvs.2014.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 11/21/2022]
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Schäfers HJ. Hypothermer Kreislaufstillstand beim Aortenbogenersatz. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-014-1100-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Garg V, Tsirigotis DN, Dickson J, Dalamagas C, Latter DA, Verma S, Peterson MD. Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery. J Thorac Cardiovasc Surg 2014; 148:2920-4. [PMID: 25172323 DOI: 10.1016/j.jtcvs.2014.07.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 06/27/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate a novel, reproducible, and effective method of direct innominate artery cannulation using a 14 F pediatric venous cannula to establish antegrade cerebral protection (ACP) in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. METHODS We reviewed prospectively gathered data on all patients who had undergone replacement of the ascending aorta or hemiarch with an open distal anastomosis using deep hypothermic circulatory arrest and direct innominate artery cannulation with a 14 F pediatric venous cannula at our institution. After central cannulation and cooling to 25 °C to 28 °C, all patients had ACP initiated by way of a direct innominate cannula placed over a guidewire. RESULTS Fifty patients underwent direct innominate artery cannulation with our technique from 2010 to 2012. The operative mortality was 2% (n = 1), and the rates of neurologic morbidity were acceptable and similar to those with other methods of ACP delivery: stroke (2%, n = 1), seizure (0%, n = 0), and delirium (18%, n = 9). The mean operative time was 31 ± 9, 19 ± 5, 100 ± 39, 141 ± 39, and 259 ± 63 minutes for cooling, circulatory arrest, crossclamp, cardiopulmonary bypass, and total operative time, respectively. No local or arterial complications were observed. CONCLUSIONS Direct cannulation of the innominate artery using a 14 F pediatric venous cannula is a simple, reproducible, safe, and effective technique for establishing ACP in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. This technique avoids the additional time and potential local complications associated with other established methods for delivering ACP, such as axillary cannulation.
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Affiliation(s)
- Vinay Garg
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dimitrios N Tsirigotis
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Dickson
- Division of Anesthesiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Constantine Dalamagas
- Division of Cardiac Perfusion, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David A Latter
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Rylski B, Urbanski PP, Siepe M, Beyersdorf F, Bachet J, Gleason TG, Bavaria JE. Operative techniques in patients with type A dissection complicated by cerebral malperfusion. Eur J Cardiothorac Surg 2014; 46:156-66. [DOI: 10.1093/ejcts/ezu251] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Yan TD, Tian DH, LeMaire SA, Hughes GC, Chen EP, Misfeld M, Griepp RB, Kazui T, Bannon PG, Coselli JS, Elefteriades JA, Kouchoukos NT, Underwood MJ, Mathew JP, Mohr FW, Oo A, Sundt TM, Bavaria JE, Di Bartolomeo R, Di Eusanio M, Trimarchi S. Standardizing clinical end points in aortic arch surgery: a consensus statement from the International Aortic Arch Surgery Study Group. Circulation 2014; 129:1610-6. [PMID: 24733540 DOI: 10.1161/circulationaha.113.006421] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Tristan D Yan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.)
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Mesenterialischämie bei selektiver Hirnperfusion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sato K, Chiba K, Koizumi N, Ogino H. Successful repair of a syphilitic aortic arch aneurysm accompanied by serious cerebral infarction. Ann Thorac Cardiovasc Surg 2014; 20 Suppl:929-32. [PMID: 24492165 DOI: 10.5761/atcs.cr.13-00149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present a 52-year-old male with a syphilitic aortic arch aneurysm accompanied by relevant extensive cerebral infarction. He was admitted to a local hospital for sudden loss of consciousness, where he was diagnosed with serious cerebral infarction. During his treatment, a multilocular aortic arch aneurysm involving the arch vessels was found incidentally. He was transferred to our hospital for surgical treatment. A preoperative routine laboratory test for syphilis was highly positive, which suggested that the aneurysm was likely caused by syphilis and the cerebral infarction was also induced by the involvement of syphilitic aortitis or arteritis. After 2 weeks of antibiotic therapy for syphilis, total arch replacement was performed successfully using meticulous brain protection with antegrade selective cerebral perfusion and deep hypothermia. He recovered without any further cerebral deficits. The pathological examination of the surgical specimen showed some characteristic changes of syphilitic aortitis.
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Affiliation(s)
- Katsutoshi Sato
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
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47
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Pacini D, Pantaleo A, Di Marco L, Leone A, Barberio G, Murana G, Castrovinci S, Sottili S, Di Bartolomeo R. Visceral organ protection in aortic arch surgery: safety of moderate hypothermia. Eur J Cardiothorac Surg 2014; 46:438-43. [DOI: 10.1093/ejcts/ezt665] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Iba Y, Minatoya K, Matsuda H, Sasaki H, Tanaka H, Oda T, Kobayashi J. How should aortic arch aneurysms be treated in the endovascular aortic repair era? A risk-adjusted comparison between open and hybrid arch repair using propensity score-matching analysis. Eur J Cardiothorac Surg 2014; 46:32-9. [DOI: 10.1093/ejcts/ezt615] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Apostolakis E, Shuhaiber JH. Antegrade or retrograde cerebral perfusion as an adjunct during hypothermic circulatory arrest for aortic arch surgery. Expert Rev Cardiovasc Ther 2014; 5:1147-61. [DOI: 10.1586/14779072.5.6.1147] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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50
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Zhou W, Zhou W, Qiu J, Zeng Q. Hybrid procedure to treat aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm (Case Report). J Cardiothorac Surg 2014; 9:3. [PMID: 24387673 PMCID: PMC3898389 DOI: 10.1186/1749-8090-9-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/30/2013] [Indexed: 11/14/2022] Open
Abstract
Aortic arch aneurysm is a rare condition but carries a high risk of rupture. We report one case of aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm, which is extremely rare. Left internal carotid artery aneurysm resection and revascularization, carotid and carotid graft bypass combined with endovascular stent graft and embolization with coils were successfully performed. There were no any complaints and complications at 8 months follow-up. The follow-up CTA demonstrated thrombus formation in the aneurysm lumen, no endoleak and the aortic arch and bypass graft were all patent. We feel that hybrid procedure may be a valuable therapeutic alternative when treating this type of lesion. However, long-term clinical efficacy and safety have yet to be confirmed.
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Affiliation(s)
- Weimin Zhou
- Department of Vascular Surgery, the second affiliated hospital of Nanchang University, No 1#, Minde Road, Nanchang, China.
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