Is limited aortic resection more justified in elderly patients with type A acute aortic dissection?-insights from single center experience

Management for lower limb malperfusion in acute type a aortic dissection patients

OBJECTIVE

Acute type A aortic dissection (ATAAD) accompanied with lower limb malperfusion (LLM) is considered to be a catastrophic event, and remains a great challenge for cardiac surgeons. Here we introduce our experience in treating ATAAD patients accompanied with LLM.

METHODS

61 patients diagnosed with ATAAD accompanied by LLM enrolled in this study. All patients received aortic repair (Total-arch replacement or Hemi-arch replacement) as soon as possible on admission. Patients who still suffered LLM were performed extra-anatomic bypass using artificial vessels. All the discharged patients underwent the standard follow-up protocol.

RESULTS

38 patients (38/61, 62.3%) got satisfied reperfusion of the lower limbs after aortic repair while the others did not. Five patients had femorofemoral bypass, 16 received aortofemoral bypass, and two underwent aortofemoral bypass plus femorofemoral bypass. The ICU stay time was 5.4 ± 3.6 days. Fifty-five patients were discharged home successfully, while six patients died postoperatively with hospital mortality of 9.8%. Major postoperative complications included acute kidney injury requiring hemodialysis in seven patients, delayed wake-up (>3 days) in 5, prolonged ventilation (>4 days) in 8, and lower limb ischaemia in 1. Follow-up was successfully conducted in 50 patients with a mean follow-up time 4.9 ± 2.6 years. Five patients died during the follow-up. The estimated 5-year survival rate was 87.5 ± 6.1%. CTA images showed 100% patency of the extra-anatomic bypass.

CONCLUSION

Aortic repair plus concomitant extra-anatomic bypass grafting in one operative setting could be a simple, safe and effective treatment on ATAAD patients with LLM.

Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection

Objective

This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection.

Subjects

From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta.

Methods

Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed.

Results

The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134).

Conclusions

No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BACKGROUND

Aortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.

METHOD

Data were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.

RESULTS

63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).

CONCLUSION

Reduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.

Outcomes of hemi- vs. total arch replacement in acute type A aortic dissection: A systematic review and meta-analysis

Background

Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD.

Methods

The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022.

Results

We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70–0.97; P = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; P = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; P = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; P = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia.

Conclusion

In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis.

Systematic review registration:

[INPLASY.COM], identifier [INPLASY202250088].

Outcomes of surgical treatment on type A acute aortic dissection accompanied with coronary artery involvement

Background

Coronary artery (CA) involvement due to acute aortic dissection (AAD) is a catastrophic cardiovascular disease with high mortality. Two main surgery strategies, local coronary repair and coronary artery bypass grafting (CABG) can be applied to reestablish the blood flow in the aortic repair. This study was to evaluate the operative and long-term outcomes of type A AAD patients, who received aortic dissection repair plus CABG or local coronary repair.

Method

We reviewed our database and screened 148 type A AAD patients with CA involvement from January 2001 to December 2021. Local coronary repair or CABG was performed concomitantly on these enrolled patients.

Results

At the time of aortic repair, there were 58 patients with concomitant CABG (Group I) and 90 patients with local coronary repair (Group II). The basal characteristics of these two groups had no difference, except for acute myocardial ischemia (AMI) and CA involvement type. 45 patients with AMI in Group I, but none in Group II (P < 0.001). There was a higher frequency of type B and C lesions of CA involvement in Group I than that in Group II (P < 0.001). There was no difference in surgical procedures and complications, except for postoperative acute kidney injury (AKI) (34.5% vs. 8.9%, P < 0.001). Hospital mortality in Group I was higher than that in Group II, but without statistical difference (20.7% vs. 11.1%, P = 0.155). No significant difference was obtained in long-term survival rate between the two groups (82.5 ± 4.8% vs. 81.2 ± 6.9%, P = 0.19).

Conclusion

CABG and local coronary repair suits different types of CA involvement, and their effects on perioperative results and long-term survival for type A AAD patients with CA involvement are equal.

Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis

INTRODUCTION

The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET.

EVIDENCE ACQUISITION

In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET.

EVIDENCE SYNTHESIS

Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I²=76%) and 12% for renal failure (95% CI 0.09-0.15; I²=88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I²=0%) and 6% (95% CI 0.05-0.08; I²=73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I²=0%).

CONCLUSIONS

Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.

Early outcomes of Sun's procedure in elderly patients with acute aortic dissection: a single-center retrospective study

OBJECTIVE

The effect of patient age on the outcome of Sun's procedure for acute type A aortic dissection (ATAAD) remains controversial. We retrospectively investigated the early outcomes of Sun's procedure in elderly patients with ATAAD in our single center.

METHODS

This study involved 106 patients who underwent Sun's procedure. The patients were divided into the elderly group (≥70 years, n = 17) and younger group (<70 years). Baseline, intraoperative, and postoperative data were compared between the groups.

RESULTS

The mean age in the elderly and younger groups was 75.7 and 50.7 years, respectively. The type of aortic root operations were not significantly different between the groups. Concomitant surgeries were more frequently performed in the elderly group, but without statistical significance. All intraoperative cardiopulmonary bypass variables as well as the in-hospital and 30-day mortality rates were similar between the groups. The incidences of most postoperative complications were also similar except for a higher incidence of sepsis in the elderly group.

CONCLUSIONS

Emergency performance of Sun's procedure for patients with ATAAD characterized by dissection and/or entry tear in the aortic arch should not be denied on the basis of advanced age alone. Comparable early in-hospital outcomes can be achieved in elderly patients.

The association between lymphocyte-monocyte ratio and postoperative acute kidney injury in patients with acute type A aortic dissection

BACKGROUND

The aim of this study was to investigate the relationship between baseline lymphocyte-monocyte ratio (LMR) and postoperative acute kidney injury (AKI) in patients with acute type A aortic dissection (ATAAD).

METHODS

ATAAD patients undergoing surgery in Nanjing First Hospital were enrolled from January 2019 to April 2021. Lymphocyte and monocyte were measured on admission. Multivariable logistic regression analyses were performed to explore the relationship between LMR and postoperative AKI. We also used receiver operating characteristic (ROC), net reclassification index (NRI) and integrated discrimination improvement (IDI) analyses to assess the predictive ability of LMR.

RESULTS

Among the 159 recruited patients, 47 (29.6%) were diagnosed with AKI. Univariate logistic regression analysis indicated that ATAAD patients with higher levels of LMR were prone to have lower risk to develop AKI (odds ratio [OR], 0.493; 95% confidence interval [CI] 0.284-0.650, P = 0.001). After adjustment for the potential confounders, LMR remained an independent related factor with postoperative AKI (OR 0.527; 95% CI 0.327-0.815, P = 0.006). The cutoff value for LMR to predict AKI was determined to be 2.67 in the ROC curve analysis (area under curve: 0.719). NRI and IDI further confirmed the predictive capability of LMR in postoperative AKI.

CONCLUSION

Elevated baseline LMR levels were independently associated with lower risk of postoperative AKI in ATAAD patients.

Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis

OBJECTIVES

Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD).

METHODS

A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed.

RESULTS

A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm.

CONCLUSIONS

In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.