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Nakanishi K, Sato H, Iba Y, Arihara A, Miura S, Shibata T, Nakazawa J, Nakajima T, Hasegawa T, Kawaharada N. Effects of temperature on transient neurologic dysfunction after total arch replacement. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02068-0. [PMID: 39103712 DOI: 10.1007/s11748-024-02068-0] [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: 05/04/2024] [Accepted: 07/29/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVES The relationship between cooling status during aortic surgery with hypothermic circulatory arrest and postoperative neurologic dysfunction remains unknown. In the present study, we evaluated the effect of cooling status on transient neurologic dysfunction after total arch replacement. METHODS We studied patients who underwent elective total arch replacement with hypothermic circulatory arrest and antegrade selective cerebral perfusion from December 2011 to January 2021. Changes in tympanic temperature trends recorded during surgery were plotted. Several parameters, including the nadir temperature, cooling speed, and degree of cooling (cooling area, or the area under the curve of inverted temperature trends from cooling to rewarming as calculated by the integral method), were analyzed. The relationships between these variables and transient neurologic dysfunction were evaluated. RESULTS Transient neurologic dysfunction was observed in 33 (14.5%) of the 228 included patients. In the transient neurologic dysfunction group, the cooling area was larger (2417.3 vs. 1920.8 °C min; P < 0.001) and the cooling speed was higher (0.68 vs. 0.51 °C/min; P < 0.001) than in the non-transient neurologic dysfunction group. A multivariate logistic model revealed that both the cooling area (odds ratio = 1.13 per 100 °C min; P < 0.001) and cooling speed (odds ratio = 3.69 per °C/min; P = 0.041) were independent risk factors for transient neurologic dysfunction. CONCLUSIONS Both the cooling area, which indicates the degree of cooling, and cooling speed had significant relationships with transient neurologic dysfunction after total arch replacement. Together, these findings indicate that overcooling and rapid cooling may contribute to brain injury.
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Affiliation(s)
- Keitaro Nakanishi
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Hiroshi Sato
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Ayaka Arihara
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Shuhei Miura
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Jyunji Nakazawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Takeo Hasegawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Zhang K, Zhou C, Gao S, Ji Y, Qiu J, Cao F, Qiu J, Yu C. The optimal degree of core temperature for hypothermic circulatory arrest in complex aortic arch surgery: results from 1310 patients. Eur J Cardiothorac Surg 2024; 66:ezae311. [PMID: 39137134 DOI: 10.1093/ejcts/ezae311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/27/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVES The optimal core temperature for hypothermic circulatory arrest during aortic arch surgery remains contentious. This study aims to evaluate patient outcomes under various temperatures within a large single-centre cohort. METHODS Between 2010 and 2018, patients diagnosed with type A aortic dissection underwent total arch replacement at Fuwai Hospital were enrolled. They were categorized into 4 groups: deep hypothermia group, low-moderate hypothermia group, high-moderate hypothermia group and mild hypothermia group. Clinical data were analysed to ascertain differences between the groups. RESULTS A total of 1310 patients were included in this cohort. Operative mortality stood at 6.9% (90/1310), with a higher incidence observed in the deep hypothermia group [29 (12.9%); 35 (6.9%); 21 (4.8%); 5 (3.4%); all adjusted P < 0.05]. Overall 10-year survival was 80.3%. Long-term outcomes did not significantly differ among the groups. Multivariable logistic analysis revealed a protective effect of higher core temperature on operative mortality (odds ratio 0.848, 95% confidence interval 0.766-0.939; P = 0.001). High-moderate hypothermia emerged as an independent protective factor for operative mortality (odds ratio 0.303, 95% confidence interval 0.126-0.727; P = 0.007). Multivariable Cox analysis did not detect an effect of hypothermic circulatory arrest on long-term survival (all P > 0.05). CONCLUSIONS High-moderate hypothermia (24.1-28°C) offers the most effective protection against surgical mortality and is therefore recommended. Different hypothermic circulatory arrest temperatures do not influence long-term survival or quality of life.
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Affiliation(s)
- Kai Zhang
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenyu Zhou
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shiqi Gao
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yumeng Ji
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Surgical Intensive Care Unit, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Bindal P, Kumar V, Kapil L, Singh C, Singh A. Therapeutic management of ischemic stroke. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2651-2679. [PMID: 37966570 DOI: 10.1007/s00210-023-02804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.
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Affiliation(s)
- Priya Bindal
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Vishal Kumar
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Lakshay Kapil
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Charan Singh
- Department of Pharmaceutical Sciences, HNB Garhwal University (A Central University), Chauras Campus, Distt. Tehri Garhwal, Uttarakhand, 246174, India
| | - Arti Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India.
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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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Lin X, Xie L, He J, Xie Y, Zhang Z, Chen L, Chen M. A nomogram-based model to predict postoperative transient neurological dysfunctions in patients receiving acute type A aortic dissection surgery. J Clin Hypertens (Greenwich) 2023; 25:1193-1201. [PMID: 37964741 PMCID: PMC10710554 DOI: 10.1111/jch.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/16/2023]
Abstract
The purposes of this study were to develop and validate a nomogram for predicting postoperative transient neurological dysfunctions (TND) in patients with acute type A aortic dissection (AAAD) who underwent modified triple-branched stent graft implantation. This retrospective study developed a nomogram-based model in a consecutive cohort of 146 patients. Patient characteristics, preoperative clinical indices, and operative data were analyzed. Univariate and multivariable analyses were applied to identify the most useful predictive variables for constructing the nomogram. Discrimination and the calibration of the model was evaluated through the receiver operating characteristic curve (ROC), the Hosmer-Lemeshow goodness-of-fit test and the decision curve analysis (DCA). At the same time, to identify and compare long-term cumulative survival rate, Kaplan-Meier survival curve was plotted. The incidence rate of postoperative TND observed in our cohort were 40.9%. Supra-aortic dissection with or without thrombosis, creatinine >115 μmol and albumin <39.7 g/L, selective antegrade cerebral perfusion (SACP) time >7 min and total operation time >303 min, were confirmed as independent predictors that enhanced the likelihood of TND. Internal validation showed good discrimination of the model with under the ROC curve (AUC) of 0.818 and good calibration (Hosmer-Lemeshow test, p > .05). DCA revealed that the nomogram was clinically useful. In the long-term survival there was no significant difference between patients with or without TND history. The results showed the predict model based on readily available predictors has sufficient validity to identify TND risk in this population, that maybe useful for clinical decision-making.
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Affiliation(s)
- Xin‐fan Lin
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
| | - Lin‐feng Xie
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
| | - Jian He
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
| | - Yu‐ling Xie
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
| | - Zhao‐feng Zhang
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
| | - Liang‐wan Chen
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
| | - Mei‐fang Chen
- Department of Cardiovascular SurgeryFujian Medical University Union HospitalFuzhouFujianPR China
- Fujian Provincial Center for Cardiovascular MedicineFuzhouFujianPR China
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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7
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He W, Cong Z, Liu Y, Yao Z, Cheng F, Zhang Y, Niu Z. A novel technique for avoidance of sternotomy, diaphragmic incision and cardiopulmonary bypass during cavoatrial tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus: a case series at a single center. BMC Surg 2023; 23:252. [PMID: 37620830 PMCID: PMC10463378 DOI: 10.1186/s12893-023-02156-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy in patients with renal cell carcinoma (RCC) and level IV thrombus extending to the right atrium (RA) offers improved survival. However, this procedure is associated with significant perioperative morbidity and mortality. In this report, we describe a novel milking technique for patients with RA tumor thrombus using abdominal access, which does not require diaphragmic incision, sternotomy, right atriotomy, or cardiopulmonary bypass (CPB). METHODS Between January 2019 and January 2022, four patients underwent resection of renal cell carcinoma extending into RA by a milking technique developed to avoid diaphragmic incision, sternotomy, or CPB. Patient characteristics, perioperative data, pathological features, and survival were evaluated. RESULTS Complete resection was successful through pure transabdominal access without diaphragmic incision, sternotomy, or CPB in all patients. CONCLUSION We conclude that radical nephrectomy and thrombectomy in optimized cases with renal cell carcinoma extending into RA can be safely and effectively performed without diaphragmic incision, sternotomy, or CPB, avoiding serious perioperative complications while providing acceptable oncological outcomes.
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Affiliation(s)
- Wei He
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zixiang Cong
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China
| | - Yaqing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhongshun Yao
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Fajuan Cheng
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yiming Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zhihong Niu
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China.
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China.
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Robu M, Marian DR, Margarint I, Radulescu B, Știru O, Iosifescu A, Voica C, Cacoveanu M, Ciomag (Ianula) R, Gașpar BS, Dorobanțu L, Iliescu VA, Moldovan H. Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1365. [PMID: 37629655 PMCID: PMC10456610 DOI: 10.3390/medicina59081365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 08/27/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.
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Affiliation(s)
- Mircea Robu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Diana Romina Marian
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Irina Margarint
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Bogdan Radulescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Ovidiu Știru
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Andrei Iosifescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Cristian Voica
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
| | - Mihai Cacoveanu
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
| | - Raluca Ciomag (Ianula)
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Bogdan Severus Gașpar
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of General Surgery, Bucharest Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Lucian Dorobanțu
- Faculty of Medicine, Titu Maiorescu University, 040441 Bucharest, Romania
- Department of Cardiovascular Surgery, Monza Metropolitan Hospital, 040204 Bucharest, Romania
| | - Vlad Anton Iliescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Horațiu Moldovan
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
- Academy of Romanian Scientists, 54 Splaiul Independentei, 050711 Bucharest, Romania
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Montisci A, Maj G, Cavozza C, Audo A, Benussi S, Rosati F, Cattaneo S, Di Bacco L, Pappalardo F. Cerebral Perfusion and Neuromonitoring during Complex Aortic Arch Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12103470. [PMID: 37240576 DOI: 10.3390/jcm12103470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.
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Affiliation(s)
- Andrea Montisci
- Division of Cardiothoracic Intensive Care, Cardiothoracic Department, ASST Spedali Civili, 25123 Brescia, Italy
| | - Giulia Maj
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Corrado Cavozza
- Department of Cardiac Surgery, AO SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Andrea Audo
- Department of Cardiac Surgery, AO SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Stefano Benussi
- Division of Cardiac Surgery, Cardiothoracic Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy
| | - Fabrizio Rosati
- Division of Cardiac Surgery, Cardiothoracic Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy
| | - Sergio Cattaneo
- Division of Cardiothoracic Intensive Care, Cardiothoracic Department, ASST Spedali Civili, 25123 Brescia, Italy
| | - Lorenzo Di Bacco
- Division of Cardiac Surgery, Cardiothoracic Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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Cui Y, Liu X, Xiong J, Tan Z, Du L, Lin J. Cardiopulmonary bypass for total aortic arch replacement surgery: A review of three techniques. Front Cardiovasc Med 2023; 10:1109401. [PMID: 37063959 PMCID: PMC10098116 DOI: 10.3389/fcvm.2023.1109401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
One treatment for acute type A aortic dissection is to replace the ascending aorta and aortic arch with a graft during circulatory arrest of the lower body, but this is associated with high mortality and morbidity. Maintaining the balance between oxygen supply and demand during circulatory arrest is the key to reducing morbidity and is the primary challenge during body perfusion. The aim of this review is to summarize current knowledge of body perfusion techniques and to predict future development of this field. We present three perfusion techniques based on deep hypothermic circulatory arrest (DHCA): DHCA alone, DHCA with selective cerebral perfusion, and DHCA with total body perfusion. DHCA was first developed to provide a clear surgical field, but it may contribute to stroke in 4%–15% of patients. Antegrade or retrograde cerebral perfusion can provide blood flow for the brain during circulatory arrest, and it is associated with much lower stroke incidence of 3%–9%. Antegrade cerebral perfusion may be better than retrograde perfusion during longer arrest. In theory, blood flow can be provided to all vital organs through total body perfusion, which can be implemented via either arterial or venous systems, or by combining retrograde inferior vena caval perfusion with antegrade cerebral perfusion. However, whether total body perfusion is better than other techniques require further investigation in large, multicenter studies. Current techniques for perfusion during circulatory arrest remain imperfect, and a technique that effectively perfuses the upper and lower body effectively during circulatory arrest is missing. Total body perfusion should be systematically compared against selective cerebral perfusion for improving outcomes after circulatory arrest.
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Ishida K, Kohno H, Matsuura K, Watanabe M, Sugiura T, Jujo Sanada T, Naito A, Shigeta A, Suda R, Sekine A, Masuda M, Sakao S, Tanabe N, Tatsumi K, Matsumiya G. Modification of pulmonary endarterectomy to prevent neurologic adverse events. Surg Today 2023; 53:369-378. [PMID: 36018416 DOI: 10.1007/s00595-022-02573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/16/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. METHODS We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH-stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. RESULTS PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29%) of the 49 group S patients suffered NAEs, associated with total circulatory arrest time (cutoff, 57 min) and Jamieson type I disease. The Group M1 and M2 patients did not suffer NAEs, although the group M1 patients had prolonged cardiopulmonary bypass (CPB) and more frequent respiratory failure. CONCLUSIONS NAEs were common after PEA performed under periods of deep HCA. The modified surgical strategy could decrease the risk of NAEs but increase the risk of respiratory failure. Multiple short periods of moderate HCA may be useful for patients at risk of NAEs.
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Affiliation(s)
- Keiichi Ishida
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Takayuki Jujo Sanada
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Akira Naito
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Ayako Shigeta
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Rika Suda
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Ayumi Sekine
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Seiichiro Sakao
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
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Sugiyama K, Watanuki H, Tochii M, Futamura Y, Ishizuka K, Matsuyama K. Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta. Ann Vasc Dis 2022; 15:295-300. [PMID: 36644259 PMCID: PMC9816034 DOI: 10.3400/avd.oa.21-00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/04/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.
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Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan,Corresponding author: Kayo Sugiyama, MD, PhD. Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195, Japan Tel: +81-561-62-3311, Fax: +81-561-63-6193, E-mail:
| | - Hirotaka Watanuki
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Masato Tochii
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Yasuhiro Futamura
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Koki Ishizuka
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Katsuhiko Matsuyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
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Li J, Stadlbauer A, Heller A, Song Z, Petermichl W, Foltan M, Schmid C, Schopka S. Impact of fluid balance and blood transfusion during extracorporeal circulation on outcome for acute type A aortic dissection surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:734-741. [PMID: 35913035 DOI: 10.23736/s0021-9509.22.12339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND In thoracic aortic surgery, fluid replacement and blood transfusion during extracorporeal circulation (ECC) are associated with increased coagulopathy, elevated inflammatory response, and end-organ dysfunction. The optimal strategy has not been established in this regard. The aim of this study was to evaluate the effect of the fluid balance during ECC in thoracic aortic dissection surgery on outcome. METHODS Between 2009 and 2020, 358 patients suffering from acute type A aortic dissection (ATAAD) underwent aortic surgery at our heart center. In-hospital mortality, major complications (postoperative stroke, respiratory failure, heart failure, acute renal failure), and follow-up mortality were assessed. Logistic regression analysis was used to identify whether fluid balance and blood transfusion during ECC were risk factors for occurring adverse events. RESULTS The in-hospital mortality amounted to 20.4%. Major complications included temporary neurologic deficit in 13.4%, permanent neurologic deficit in 6.1%, acute renal failure in 32.7%, prolonged ventilation for respiratory failure in 17.9%, and acute heart failure in 10.9% of cases. At a mean of 42 months after discharge of 285 survivors, follow-up mortality was 13.3%. Multivariate analysis revealed major complications as well as the risk of in-hospital and follow-up mortality to increase with fluid balance and blood transfusion during ECC. CONCLUSIONS Fluid balance and blood transfusion during ECC present with predictive potential concerning the risk of postoperative adverse events.
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Affiliation(s)
- Jing Li
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany -
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
| | - Anton Heller
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
| | - Zhiyang Song
- Institute of Mathematics, Ludwig-Maximilian University Munich, Munich, Germany
| | - Walter Petermichl
- Department of Anesthesiology, University Medical Center of Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
| | - Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center of Regensburg, Regensburg, Germany
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Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection. JTCVS OPEN 2022; 11:37-48. [PMID: 36172412 PMCID: PMC9510789 DOI: 10.1016/j.xjon.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/01/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
Objectives To compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. Methods Using an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. Results Among 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. Conclusions Despite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.
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Vinzant NJ, Christensen JM, Smith MM, Leibovich BC, Mauermann WJ. Perioperative Outcomes for Radical Nephrectomy and Level III-IV Inferior Vena Cava Tumor Thrombectomy in Patients with Renal Cell Carcinoma. J Cardiothorac Vasc Anesth 2022; 36:3093-3100. [PMID: 35570081 DOI: 10.1053/j.jvca.2022.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/08/2022] [Accepted: 04/17/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study examined the characteristics, intraoperative, and postoperative course of patients undergoing inferior vena cava tumor thrombectomy for metastatic renal cell carcinoma. DESIGN A single-center case series that reported demographic data and intraoperative and postoperative outcomes for patients with renal cell carcinoma undergoing inferior vena cava thrombectomy. SETTING This investigation was performed at a large quaternary referral center. PARTICIPANTS Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2005, to March 10, 2017, undergoing inferior vena cava thrombectomy for level III and IV renal cell carcinoma. INTERVENTIONS No interventions were performed. MEASUREMENTS AND MAIN RESULTS Sixty-five patients who met the inclusion criteria were identified, with 31 patients diagnosed with level III and 34 with level IV renal cell carcinoma. Patients with level IV tumors were significantly more likely to have greater intraoperative blood loss, had longer surgical duration and hospital stays, and had more frequently required blood products, pressors, and cardiopulmonary bypass intraoperatively. Intraoperative transesophageal echo was more frequently used in level IV thrombectomy compared to level III (91.2% v 67.7%). Of patients with level IV thrombus, 41.2% developed postoperative atrial fibrillation compared to only 3.2% with level III thrombus. The 30-day mortality was 4.6% for both groups. CONCLUSIONS Patients undergoing inferior vena cava tumor thrombectomy for renal cell carcinoma had more complex intraoperative and postoperative courses with level IV compared to level III tumor thrombus.
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Affiliation(s)
- Nathan J Vinzant
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Bradley C Leibovich
- Department of Urology (Surgical), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Matalanis G, Sharma VJ. Branch-first continuous perfusion aortic arch replacement: insight into our results. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:281-287. [PMID: 35238522 DOI: 10.23736/s0021-9509.22.12272-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Aortic-arch surgery often necessitates interruption of perfusion conferring higher morbidity and mortality compared to other aortic segments. We describe our Branch-first continuous-perfusion aortic-arch replacement (BF-CPAR) technique which overcomes these shortcomings, describing technique, results and improved outcomes. METHODS This represents the senior author's 15-year experience with BF-CPAR. Description of demographics, procedures and outcomes have been stratified by dissection and aneurysm etiology, with prediction of mortality, cerebrovascular events, renal failure, and end-organ ischemia undertaken using multivariable logistic regression analysis. RESULTS From July 2005 to February 2021, 155 patients underwent BF-CPAR, 93 for aneurysms and 62 for dissections. Median age at intervention was 66.8 years, 96 (61.9%) male, 18 (11.6%) with history of previous dissection repair, and 49 (31.6%) on an emergent basis. We observed an overall mortality of 4.5% (N.=7) and stroke of 3.2% (N.=5). Comparing elective to urgent cases, the mortality and stroke rates were significantly lower at 0.0% and 1.9% versus 14.2% and 6.1% (risk differences: 14.3% and 2.3%, P<0.01) respectively. Predictors of mortality were age (1.11 per year, 95% CI: 1.00-1.23, P=0.05); of stroke were hypercholesterolemia (14.4, 1.84-111.9, P=0.01) and hypertension (0.07, 0.01-0.84, P<0.01); and of dialysis were dissection (6.60, 1.76-24.7, P<0.01). CONCLUSIONS BF-CPAR is safe and adds to the armamentarium of aortic arch repair. In elective and uncomplicated acute-dissection cases, it has no mortality and low stroke (1.9%), and vital organ dysfunction risk. Its results which are comparable to many of the best currently reported series, is driven by avoidance of cerebral circulatory arrest and reduction of cardiac and visceral ischemic time.
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Affiliation(s)
- George Matalanis
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia -
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia -
- Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia -
| | - Varun J Sharma
- Department of Thoracic Aortic Surgery, Austin Health, Melbourne, Australia
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
- Department of Surgery (Austin Health), Melbourne Medical School, The University of Melbourne, Australia
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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Tan SZ, Bashir M, Jubouri M, Williams I, Bailey D. Neuroprotection in aortic arch surgery: untold flaws and future directions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:254-264. [PMID: 35238526 DOI: 10.23736/s0021-9509.22.12291-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The current paradigm of brain protection in aortic surgery falls short of delivering good outcomes with minimal complications. A renewed understanding of neuroprotective methods and biomarkers to predict brain injury and aortic disease are crucial towards the development of more effective clinical management strategies. A review of current literature was carried out to identify current flaws in our approach to neuroprotection in aortic surgery. Emerging evidence surrounding neuroprotective strategies, biomarkers for brain injury, and biomarkers for predicting aortic disease are evaluated in terms of their impact for future therapeutic approaches. Current literature suggests that the prevailing methods of neuroprotection need renewal. Clinical outcomes associated with deep hypothermic circulatory arrest remain varied. Branch-first and endovascular approaches to aortic repair are particularly promising alternatives. The use of biomarkers to identify and manage brain injury, as well as to diagnose aortic disease in the nonacute and acute settings, would further help to improve our overall paradigm of neuroprotection in aortic surgery. Though much prospective research is still required, the outlook for neuroprotection in aortic surgery is promising. Adopting alternative surgical techniques and exploiting predictive novel biomarkers will help us to gradually eliminate the risk of brain damage in aortic surgery.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohamad Bashir
- Unit of Vascular and Endovascular Surgery, Health Education and Improvement Wales, Velindre University NHS Trust, Cardiff, UK
| | - Matti Jubouri
- Hull-York Medical School, University of York, York, UK
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, UK -
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Patel PM, Chen EPC. Optimal brain protection in aortic arch surgery. Indian J Thorac Cardiovasc Surg 2022; 38:36-43. [PMID: 35463699 PMCID: PMC8980966 DOI: 10.1007/s12055-021-01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022] Open
Abstract
There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.
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20
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Kacani A, Goga M, Kuci S, Aliu A, Ibrahimi A, Gjergo P, Janko A, Dogjani A. Invading of Renal Cell Carcinoma in Inferior Vena Cava and Right Atrium with a Huge Metastatic Thrombus. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Renal cell carcinoma (RCC) with cavoatrial involvement represents a major surgical challenge. Several surgical techniques for the treatment of these tumors have been proposed, but due to a small number of patients and limited follow-up, substantial controversy about the best operative management still exists.
CASE REPORT: A 54-year-old woman, with no previous comorbidities, comes to the emergency room with low back pain, weight loss, and edema of the lower legs that computed tomography revealed a massive infiltrative expansive formation in the abdomen that affected practically the entire right kidney, measuring 8.2 cm × 7.6 cm that invaded the collecting system and was in close contact with the right hepatic lobe and the head of the pancreas. During the intervention, infiltration of the renal vein on this side is found, and the inferior vena cava (IVC) that extends in its intrahepatic part, up to the junction of the suprahepatic veins, with almost complete closure of the lumen accompanied by the presence of retroperitoneal lymph nodes, with size up to 10 mm.
CONCLUSION: Advanced extension of RCC can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of RCC should be considered in a patient presenting with the right atrial mass detected by echocardiography. RCC with IVC and right atrium extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques, and close perioperative patient care.
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Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study. J Clin Med 2022; 11:jcm11030644. [PMID: 35160094 PMCID: PMC8836663 DOI: 10.3390/jcm11030644] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.
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Karrar S, Reniers T, Filius A, Bunge JJH, Bekkers JA, Hoeks SE, Horst MT. Rotational Thromboelastometry-Guided Transfusion Protocol to Reduce Allogeneic Blood Transfusion in Proximal Aortic Surgery With Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2021; 36:1029-1039. [PMID: 34518103 DOI: 10.1053/j.jvca.2021.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the impact of a rotational thromboelastometry (ROTEM)-guided transfusion protocol on the use of blood products, patient outcomes, coagulation factor concentrates, and costs. DESIGN A single-center retrospective cohort study. SETTING A tertiary university hospital. PATIENTS Adults undergoing proximal aortic surgery with deep hypothermic circulatory arrest. INTERVENTION ROTEM-guided transfusion protocol compared with clinically-guided transfusion. MEASUREMENTS AND MAIN RESULTS Two hundred seventeen patients were included; seventy-one elective and 24 emergency patients in the clinically-guided group, and 59 elective and 63 emergency patients in the ROTEM-guided transfusion protocol group. In the ROTEM-guided transfusion protocol group, a significant reduction in transfusion of red blood cells (5 [3-8] v 2 [0-4], p < 0.001), platelet concentrate (2 [2-3] v 1 [1-2], p < 0.001), and plasma (1,980 mL [1,320-3,300] v 800 mL [0-1,000], p < 0.001) was seen in elective surgery. Emergency patients received fewer red blood cells (7 [5-10] v 5 [2-10], p = 0.040), platelet concentrate (3 [2-4] v 2 [2-3], p = 0.023), and plasma (3,140 mL [1,980-3,960] v 1,000 mL [0-1,400], p < 0.001). Prothrombin complex concentrate and fibrinogen concentrate were increased significantly in elective and emergency patients. The surgical reexploration for bleeding rate was decreased in elective patients 33.8% v 5.1%. CONCLUSION The implementation of a ROTEM-guided transfusion protocol might have the potential to decrease blood product transfusion and may improve patient outcomes.
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Affiliation(s)
- Senned Karrar
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ted Reniers
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anika Filius
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J H Bunge
- Department of Cardiology and department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maarten Ter Horst
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Hussain A, Uzzaman M, Mohamed S, Khan F, Butt S, Khan H. Femoral versus axillary cannulation in acute type A aortic dissections: A meta-analysis. J Card Surg 2021; 36:3761-3769. [PMID: 34263486 DOI: 10.1111/jocs.15810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/11/2021] [Accepted: 06/02/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE There has been a growing interest in antegrade cannulation techniques in type A aortic dissection surgery. Axillary cannulation has previously been reported to provide better outcomes in terms of short-term mortality and neurological event. Consensus regarding the best cannulation strategy still remains controversial. METHOD The MEDLINE and EMBASE databases were conducted up until October 3, 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random-effects modelling and the I2 -test for heterogeneity. Fourteen retrospective observational studies were included, enrolling a total of 2621 patients. RESULTS There were a total of 2621 patients (1327 axillary cannulation and 874 femoral cannulation). Axillary cannulation was associated with reduced short term mortality (pooled odds ratio [OR] = +0.42, 95% confidence interval [CI] = +0.25 to +0.70; p = .0009) compared to femoral cannulation. Axillary cannulation was also associated with a lower incidence of neurological events (pooled OR = +0.63, 95% CI = +0.42 to +0.94; p = .02). CONCLUSION Our meta-analyses suggests that axillary cannulation has superior outcomes in terms of mortality and stroke following emergency surgery for type A aortic dissection. However, the lack of high quality randomized controlled trials does not make this recommendation generalisable to all units.
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Affiliation(s)
- Azhar Hussain
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Mohsin Uzzaman
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Sameh Mohamed
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Fakyha Khan
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Salman Butt
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
| | - Habib Khan
- Department of Cardiothoracic Surgery, King's College Hospital, London, UK
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Elhelali A, Hynes N, Devane D, Sultan S, Kavanagh EP, Morris L, Veerasingam D, Jordan F. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2021; 6:CD012923. [PMID: 34085713 PMCID: PMC8407084 DOI: 10.1002/14651858.cd012923.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery. OBJECTIVES To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.
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Affiliation(s)
- Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Edel P Kavanagh
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Liam Morris
- Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, Galway, Ireland
| | - Dave Veerasingam
- Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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25
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Jabagi H, Juanda N, Nantsios A, Boodhwani M. Aortic arch surgery at 32°C: mild hypothermia and unilateral antegrade cerebral perfusion. Interact Cardiovasc Thorac Surg 2021; 32:773-780. [PMID: 33432355 DOI: 10.1093/icvts/ivaa321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/31/2020] [Accepted: 11/18/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. METHODS Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. RESULTS Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. CONCLUSIONS In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.
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Affiliation(s)
- Habib Jabagi
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Nadzir Juanda
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alex Nantsios
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Qu JZ, Kao LW, Smith JE, Kuo A, Xue A, Iyer MH, Essandoh MK, Dalia AA. Brain Protection in Aortic Arch Surgery: An Evolving Field. J Cardiothorac Vasc Anesth 2020; 35:1176-1188. [PMID: 33309497 DOI: 10.1053/j.jvca.2020.11.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
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Affiliation(s)
- Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Smith
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Albert Xue
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Szpakowski E, Biederman A. Type A Aortic Dissection. General Considerations and Results of 173 Operations. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- E. Szpakowski
- First Department of Cardiac Surgery, National Institute of Cardiology, Warsaw
| | - A. Biederman
- First Department of Cardiac Surgery, National Institute of Cardiology, Warsaw
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Imasaka KI, Tomita Y, Morita S, Shiose A. Surgical outcome of elective total arch replacement with coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 2020; 36:572-579. [PMID: 33100618 DOI: 10.1007/s12055-020-01013-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose We aimed to compare the surgical outcome between total arch replacement with coronary bypass surgery and that without. Methods Between 2008 and 2016, 157 consecutive patients underwent total arch replacement with antegrade cerebral perfusion and moderate hypothermic circulatory arrest using the proximal first approach. They were divided into two groups: total arch replacement with coronary bypass surgery (group 1, n = 38) and that without (group 2, n = 119). Results Of the 38 patients in group 1, 37 (97%) were asymptomatic. The left internal thoracic artery and saphenous vein were used in one (2.6%) and 38 (100%) patients, respectively. The mean number of coronary anastomoses was 1.5 ± 1.0. In-hospital mortality rate was 3.8%. Cardiopulmonary bypass time and operation time in group 1 were significantly longer than those in group 2 (336 ± 52 min vs. 276 ± 38 min, P < 0.0001 and 702 ± 122 min vs. 619 ± 94 min, P < 0.0001, respectively). No differences in in-hospital mortality and perioperative myocardial infarction were found between the groups (5.3% vs. 3.4%, P = 0.633 and 0% vs. 1.7%, P = 1.000, respectively). In the multivariate analysis, age (odds ratio, 1.208; 95% confidence interval, 1.041-1.497; P = 0.008) and cardiopulmonary bypass time (odds ratio, 1.019; 95% confidence interval, 1.001-1.041; P = 0.041) were significant determinants of in-hospital mortality. Conclusions Although prolonged cardiopulmonary bypass time was a significant determinant of in-hospital mortality, total arch replacement with coronary bypass surgery could be safely performed with favorable outcomes.
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Affiliation(s)
- Ken-Ichi Imasaka
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.,Department of Cardiovascular Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho, Shimonoseki, 750-8520 Japan
| | - Yukihiro Tomita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Shigeki Morita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, Fukuoka, Japan
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Giambuzzi I, Mastroiacovo G, Roberto M, Pirola S, Alamanni F, Cavallotti L, Bonalumi G. Preoperative neurological dysfunctions: what is their meaning in patients presenting with acute type A aortic dissection? Minerva Cardioangiol 2020; 68:511-517. [PMID: 32524808 DOI: 10.23736/s0026-4725.20.05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Type A aortic dissection (AAD) is a life-threatening disease with very high mortality. The gold standard treatment is surgical, as medical treatment has been proven to be ineffective. It is still unclear the role of preoperative neurological dysfunction in the prognosis of the patient. Therefore, the choice of performing surgery in patients with neurological symptoms is still left to the surgeon at the time of the diagnosis. The aim of this study is to make a narrative review of the current literature about the management of patients with neurological symptoms in AAD patients. EVIDENCE ACQUISITION A bibliographical research was performed on PubMed, looking for papers containing the words: "((preoperative neurological symptoms in type a aortic dissection) OR brain injury type A aortic dissection) AND ("2010"[Date - Publication]: "3000"[Date - Publication])". A total of 35 papers were found. EVIDENCE SYNTHESIS A total of 6 papers were chosen to be reviewed. All of them concluded that even patients with severe neurological symptoms (up to comatose state) had a good chance to recover neurological functions after surgery if treated in the first hours from the onset of symptoms. Interestingly, a hemorrhagic stroke was rarely found. CONCLUSIONS Preoperative neurological dysfunction have been long considered a contraindication to surgery. Nevertheless, several authors show neurological and survival good results in patients with preoperative neurological dysfunction. They also stress the importance of surgical timing finding in 5 to 10 hours the surgical time limit to improve neurological dysfunction. A preoperative neurological dysfunction could be considered a strong advice towards surgical intervention. It is time to change and consider prompt surgery not only for survival but also for cerebral protection.
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Affiliation(s)
- Ilaria Giambuzzi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy -
| | | | - Maurizio Roberto
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Sergio Pirola
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | | | - Laura Cavallotti
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Giorgia Bonalumi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
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Axillary artery cannulation reduces early embolic stroke and mortality after open arch repair with circulatory arrest. J Thorac Cardiovasc Surg 2020; 159:772-778.e4. [DOI: 10.1016/j.jtcvs.2019.02.112] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 02/13/2019] [Accepted: 02/24/2019] [Indexed: 01/16/2023]
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Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-1209. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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Itagaki S, Chikwe J, Sun E, Chu D, Toyoda N, Egorova N. Impact of Cerebral Perfusion on Outcomes of Aortic Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. Ann Thorac Surg 2020; 109:428-435. [DOI: 10.1016/j.athoracsur.2019.08.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/17/2019] [Accepted: 08/12/2019] [Indexed: 01/16/2023]
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Wang X, Yang F, Zhu J, Liu Y, Sun L, Hou X. Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159:374-387.e4. [DOI: 10.1016/j.jtcvs.2019.01.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/16/2023]
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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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Eldeiry M, Aftab M, Bergeron E, Pal J, Cleveland JC, Fullerton D, Reece TB. The Buffalo Trunk Technique for Aortic Arch Reconstruction. Ann Thorac Surg 2019; 108:680-686. [DOI: 10.1016/j.athoracsur.2019.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/12/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
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Tokuda Y, Narita Y, Fujimoto K, Mutsuga M, Terazawa S, Ito H, Uchida W, Usui A. Neurologic Deficit After Aortic Arch Replacement: The Influence of the Aortic Atherosclerosis. Ann Thorac Surg 2019; 108:107-114. [PMID: 30710519 DOI: 10.1016/j.athoracsur.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative neurologic deficits are associated with severe morbidity in aortic arch replacement. METHODS A group of 198 consecutive patients undergoing isolated total aortic arch replacement with the use of antegrade cerebral perfusion were analyzed for the risk factors for predicting neurologic deficit. With the use of computed tomography, atherothrombotic lesions (defined as extensive intimal thickening exceeding 4 mm) were identified in the proximal aorta (the ascending aorta or aortic arch) in 26.2% of cases and in the distal aorta in 34.9% of cases. RESULTS Permanent neurologic deficits occurred in 11.1% (including non-disabling stroke confirmed by imaging) and transient neurologic deficits in 8.1% of patients. A univariate analysis identified proximal atherothrombotic aorta (p = 0.0057), distal atherothrombotic aorta (p = 0.032), and retrograde systemic perfusion from the femoral artery in the presence of distal atherothrombotic aorta (p = 0.0022) as risk factors for neurologic deficits. A multivariate logistic regression analysis identified atherothrombotic proximal aorta (odds ratio 2.4, p = 0.033) as the independent risk factor. The presence of carotid stenosis did not affect the rate of neurologic deficit. Intracranial hemorrhagic lesions were found in 23% of permanent neurologic deficit cases. CONCLUSIONS Atherothrombotic lesions found by objectively graded computed tomography were predictors of neurologic deficit. Retrograde perfusion in the presence of a distal atherothrombotic lesion should be avoided whenever possible. Strategies based on the full assessment of the whole aortic morphologic characteristics appear to be mandatory. Anticoagulation therapy should be performed carefully to avoid intracranial hemorrhagic changes.
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Affiliation(s)
- Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Yuji Narita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazuro Fujimoto
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Sachie Terazawa
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Wataru Uchida
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Imasaka KI, Tayama E, Morita S, Tomita Y. Neurological outcome and efficacy of intensive craniocervical screening for elective cardiac surgery. Interact Cardiovasc Thorac Surg 2019; 26:216-223. [PMID: 29049799 DOI: 10.1093/icvts/ivx307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/13/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy of intensive craniocervical screening before elective cardiovascular surgery. METHODS A retrospective analysis of 1134 consecutive patients who underwent routine screening before cardiovascular surgery between November 2004 and December 2014 was conducted. The study was divided into 2 distinct cohorts of patients undergoing surgery: before (n = 500) and after (n = 634) the introduction of intensive screening in January 2009. In 2009, preoperative screening underwent a transition from the evaluation of carotid atherosclerosis alone to that of craniocervical atherosclerosis. Additionally, patients with moderate or greater stenosis on intensive screening underwent single-photon emission computed tomography with acetazolamide. Craniocervical atherosclerosis was classified as no or mild [0-49%: n = 836 (before/after: 370/466)], moderate [50-69%: n = 118 (56/62)] or severe [70-100%: n = 141 (36/105)]. One of 166 (0.6%) patients with moderate or greater stenosis undergoing single-photon emission computed tomography with acetazolamide after the introduction of intensive screening was diagnosed as having impaired cerebral autoregulation. RESULTS The occurrences of perioperative stroke were 2.8% before the introduction of intensive screening and 0.9% after that (P = 0.033). Notably, intraoperative stroke significantly decreased from 1.4% to 0.2% (P = 0.034). Specifically, the occurrence of perioperative stroke in patients with no or mild stenosis decreased significantly after the introduction of intensive screening, from 2.7% to 0.4% (P = 0.007). CONCLUSIONS The incidence of perioperative stroke decreased following the introduction of intensive screening. Intensive screening may be able to detect patients with a greater risk of perioperative stroke.
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Affiliation(s)
- Ken-Ichi Imasaka
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Eiki Tayama
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Shigeki Morita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yukihiro Tomita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Ma H, Xiao Z, Shi J, Liu L, Qin C, Guo Y. Aortic arch cannulation with the guidance of transesophageal echocardiography for Stanford type A aortic dissection. J Cardiothorac Surg 2018; 13:106. [PMID: 30309362 PMCID: PMC6182824 DOI: 10.1186/s13019-018-0779-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Aortic arch cannulation for an antegrade central perfusion during the surgery for Stanford type A aortic dissection can be performed within median sternotomy. We summarize the safety and convenient profile of the central cannulation strategy using the guidance of transesophageal echocardiography (TEE) in comparison to traditional femoral cannulation strategy. METHODS Sixty-two patients with acute Stanford type A aortic dissection underwent aortic arch surgery in our hospital. All the patients were operated by the same surgeon. Cannulation was performed in 33 patients through the aortic arch under the guidance of TEE (Group A) and in 29 patients through the femoral artery (Group F). Under moderate hypothermic circulatory arrest, the brain is continuously perfused in an anterograde manner through the brachiocephalic and left common carotid arteries. Preoperative characeristics and surgical information were collected for each patient. Additionally, 30-day mortality rate and the incidence of the temporary neurological dysfunction were recorded as the outcomes. To compare the categorical variables, we used the chi-squared test. Continuous variables were compared using the t-test. RESULTS Preoperative characteristics were almost similar between the two groups. The mean operation time (7.33 ± 1.14 h vs. 8.93 ± 2.59 h, P = 0.002) and the mean cardiopulmonary bypass (CPB) time (260.97 ± 45.14 min vs. 298.28 ± 95.89 min, P = 0.024) were significantly shorter in Group A than those in Group F. The 30-day mortality rates were 9.09 and 27.59% in Groups A and F, respectively (P = 0.057). And the incidences of temporary neurological dysfunction were 39.39 and 65.52% in Group A and F, respectively (P = 0.040). CONCLUSIONS Aortic arch cannulation with the guidance of TEE during the aortic arch surgery is a simple, fast, safe, and less invasive technique for establishing cardiopulmonary bypass for Stanford type A aortic dissection.
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Affiliation(s)
- Hao Ma
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenghua Xiao
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Shi
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lulu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Bashir M, Harky A, Bilal H. Is there a prospect for hybrid aortic arch surgery? Gen Thorac Cardiovasc Surg 2018; 67:132-136. [PMID: 29767819 DOI: 10.1007/s11748-018-0940-z] [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: 03/12/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
The surge of endovascular repair of aortic aneurysm in current modern aortic surgery practice has been the key for surgical management of elective cases of thoracic aortic aneurysms. This has paved way for the combined hybrid approach to be amongst the armamentarium for the management of aortic arch disease. The pivotal understanding of the aortic arch natural history coupled with device technology advancement allowed surgeons insight into delivery of hybrid surgery with acceptable morbidity and mortality results. This review article provides current insights into hybrid technique of aortic arch aneurysm repair and the evidences behind its applicability to arch surgery. It is aimed to highlight the challenges encountered for this innovative approach and correlate its challenges to those that are met by the conventional open aortic arch repair.
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Affiliation(s)
- Mohamad Bashir
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
| | - Amer Harky
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,Department of Cardiothoracic Surgery, Northwest Deanery, North West, Liverpool, UK
| | - Haris Bilal
- Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Guan X, Gong M, Wang X, Zhu J, Liu Y, Sun L, Zhang H. Low preoperative fibrinogen level is risk factor for neurological complications in acute aortic dissection. Medicine (Baltimore) 2018; 97:e10830. [PMID: 29794773 PMCID: PMC6392557 DOI: 10.1097/md.0000000000010830] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aortic arch surgery in patients with acute aortic dissection is frequently complicated by neurological complications and coagulopathy. However, the relationship between the coagulation system and neurological complications in patients with acute aortic dissection has not been clarified. Thus, the aim of this study was to investigate the relationship between the coagulation system and neurological complications in patients with acute aortic dissection.From September 2014 to January 2016, a total of 126 patients with acute type A aortic dissection were enrolled. Perioperative characteristics and standard laboratory tests upon admission were analyzed using univariate and multivariate logistic regression analysis in this study. The primary outcome was the correlation between the coagulation system and neurological complications.Univariate logistic regression analysis showed that the neurological complications (+) group underwent more serious and complicated postoperative outcomes. Multivariable logistic regression analysis revealed serum creatinine level (OR, 1.049; 95% CI, 1.011-1.089; P = .01), white blood cell counts (OR, 1.581; 95% CI, 1.216-2.057; P = .001) and fibrinogen concentration upon admission (OR, 0.189; 95% CI, 0.060-0.596; P = .004) as predictors of neurological complications. However, we found that there was no association between the coagulation system and in-hospital mortality.Low preoperative fibrinogen level is the preferred marker for predicting clinical neurological complications in patients with acute type A aortic dissection treated with surgical repair.
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Hosoyama K, Kawamoto S, Kumagai K, Akiyama M, Adachi O, Kawatsu S, Saiki Y. Selective Cerebral Perfusion with the Open Proximal Technique during Descending Thoracic or Thoracoabdominal Aortic Repair: An Option of Choice to Reduce Neurologic Complications. Ann Thorac Cardiovasc Surg 2018; 24:89-96. [PMID: 29375096 DOI: 10.5761/atcs.oa.17-00138] [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] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Selective cerebral perfusion with the open proximal technique for thoracoabdominal aortic repair has not been conclusively validated because of its procedural complexity and unreliability. We report the clinical outcomes, particularly the cerebroneurological complications, of an open proximal procedure using selective cerebral perfusion. METHODS A retrospective chart review identified 30 patients between 2007 and 2015 who underwent aortic repair through left lateral thoracotomy with selective cerebral perfusion, established through endoluminal brachiocephalic and left carotid artery and retrograde left axillary artery. RESULTS The mean durations of the open proximal procedure and cerebral ischemia (the duration of the open proximal procedure minus the duration of selective cerebral perfusion) were 110.3 ± 40.1 min and 24.8 ± 13.0 min, respectively. There were two cases (7%) of permanent neurologic dysfunction (PND) but no in-hospital deaths. Multivariate analysis identified the duration of cerebral ischemia as an independent risk factor for neurologic complications including temporary neurologic dysfunction (TND; odds ratio (OR): 1.13; p = 0.007), but no correlation was found between selective cerebral perfusion duration and neurologic complications. CONCLUSION Despite the relatively long duration of the open proximal procedure, selective cerebral perfusion has a potential to protect against cerebral complications during thoracic aortic repair through a left lateral thoracotomy.
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Affiliation(s)
- Katsuhiro Hosoyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kiichiro Kumagai
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Masatoshi Akiyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Osamu Adachi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Satoshi Kawatsu
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Gupta P, Harky A, Jahangeer S, Adams B, Bashir M. Varying Evidence on Deep Hypothermic Circulatory Arrest in Thoracic Aortic Aneurysm Surgery. Tex Heart Inst J 2018; 45:70-75. [PMID: 29844738 DOI: 10.14503/thij-17-6364] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiovascular surgeons have long debated the safe duration of deep hypothermic circulatory arrest during thoracic aortic aneurysm surgery. The rationale for using adjunctive cerebral perfusion (or not) is to achieve the best technical aortic repair with the lowest risk of morbidity and death. In this literature review, we highlight the debates surrounding these issues, evaluate the disparate findings on deep hypothermic circulatory arrest durations and temperatures, and consider the usefulness of adjunctive perfusion.
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Elhelali A, Hynes N, Devane D, Sultan S, Kavanagh EP, Morris L, Veerasingam D, Jordan F. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2018. [DOI: 10.1002/14651858.cd012923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Ala Elhelali
- Galway-Mayo Institute of Technology; Mechanical and Industrial Engineering; Dublin Road Galway Ireland
| | - Niamh Hynes
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Declan Devane
- National University of Ireland Galway; School of Nursing and Midwifery; University Road Galway Ireland
| | - Sherif Sultan
- Galway University Hospital; Vascular Surgery; Newcastle Galway Ireland
| | - Edel P Kavanagh
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Liam Morris
- Galway-Mayo Institute of Technology; Mechanical and Industrial Engineering; Dublin Road Galway Ireland
| | - Dave Veerasingam
- Galway University Hospital; Cardiothoracic Surgery; Newcastle Road Galway Ireland
| | - Fionnuala Jordan
- National University of Ireland Galway; School of Nursing and Midwifery; University Road Galway Ireland
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Li JC, Guan XL, Gong M, Zhang HJ. Iatrogenic aortic dissection during percutaneous coronary intervention: A case report and review of the literature. J Int Med Res 2018; 46:526-532. [PMID: 28679305 PMCID: PMC6011289 DOI: 10.1177/0300060517716342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/30/2017] [Indexed: 01/16/2023] Open
Abstract
A 64-year-old female complaining of unrelieved chest pain for 2 days was admitted to the Emergency Room of the Beijing Anzhen Hospital, Beijing, China. After definitive diagnosis, a percutaneous coronary intervention was implemented, but immediately after embedding the stent in the distal area of the right coronary artery, an acute coronary and aortic dissection was found. Cardiologists immediately gave the patient conservative management. At the same time, another smaller stent was immediately embedded in the proximal area of the right coronary artery and plunged into the ascending aorta by 2 mm, with the intention of covering the tear of the dissection. Repeated coronary angiography showed that a 40% stricture of the distal right coronary artery remained and less contrast agent had been extravasated. The patient was then transferred to the Department of Cardiac Surgery and received emergency surgery consisting of right coronary artery bypass grafting and ascending aorta replacement. The patient remained in the intensive care unit for 18 days after the surgery. The patient recovery was acceptable and she was discharged with a small amount of bilateral hydrothorax, moderate malnutrition oedema and iron deficiency anaemia.
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Affiliation(s)
- Jia-Chen Li
- Department of Cardiac Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Beijing Laboratory for Cardiovascular Precision Medicine, Beijing, China
- Beijing Engineering Research Centre of Vascular Prostheses, Beijing, China
| | - Xin-Liang Guan
- Department of Cardiac Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Beijing Laboratory for Cardiovascular Precision Medicine, Beijing, China
- Beijing Engineering Research Centre of Vascular Prostheses, Beijing, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Beijing Laboratory for Cardiovascular Precision Medicine, Beijing, China
- Beijing Engineering Research Centre of Vascular Prostheses, Beijing, China
| | - Hong-Jia Zhang
- Department of Cardiac Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Beijing Laboratory for Cardiovascular Precision Medicine, Beijing, China
- Beijing Engineering Research Centre of Vascular Prostheses, Beijing, China
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Elective Aortic Arch Repair: Factors Influencing Neurologic Outcome in 791 Patients. Ann Thorac Surg 2017; 104:2016-2023. [DOI: 10.1016/j.athoracsur.2017.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 11/20/2022]
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46
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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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47
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Aalaei-Andabili SH, Scali S, Klodell C, Lee T, Hess P, Martin T, Beck A, Feezor R, Alhussaini M, Arnaoutakis G, Beaver T. Outcomes of Antegrade Stent Graft Deployment During Hybrid Aortic Arch Repair. Ann Thorac Surg 2017; 104:538-544. [DOI: 10.1016/j.athoracsur.2016.11.087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 10/19/2022]
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Geube M, Sale S, Svensson L. Con: Routine Use of Brain Perfusion Techniques Is Not Supported in Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2017; 31:1905-1909. [PMID: 28478907 DOI: 10.1053/j.jvca.2017.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Mariya Geube
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH.
| | - Shiva Sale
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Lars Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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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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Patient management in aortic arch surgery†. Eur J Cardiothorac Surg 2017; 51:i4-i14. [DOI: 10.1093/ejcts/ezw337] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 08/23/2016] [Accepted: 09/02/2016] [Indexed: 12/31/2022] Open
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