1
|
Kim LE, Park JH, Lee HC, Bae MJ, You JH. Midterm Clinical Outcomes of Endovascular Treatment for Acute Aortic Dissection with Malperfusion Syndrome. Vasc Specialist Int 2024; 40:17. [PMID: 38845442 PMCID: PMC11157333 DOI: 10.5758/vsi.240006] [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: 01/05/2024] [Revised: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 06/09/2024] Open
Abstract
Purpose There is limited data on the midterm results of endovascular treatment for acute type B aortic dissection (TBAD) with malperfusion syndrome (MS), particularly in Asia. This study aimed to investigate the clinical outcomes of endovascular treatment of acute TBAD with MS. Materials and Methods We retrospectively analyzed 27 patients who underwent endovascular treatment for acute TBAD with MS. Results Among the 27 patients with TBAD and MS, malperfusion was observed in the isolated renal (44.4%), visceral (7.4%) and iliofemoral (25.9%) arteries, as well as their combinations (22.2%). The patients underwent thoracic endovascular aortic repair (TEVAR) only (25.9%), selective stenting only in arteries affected by malperfusion (22.2%), or combined treatment with TEVAR and selective stenting (51.9%). Primary technical success was achieved in all the patients. No inhospital mortality or early death within 30 days after operation occurred. The rates of stroke, limb ischemia, acute kidney injury, and reintervention at 30 days were 7.4%, 3.7%, 25.9%, and 3.7%, respectively. The mean follow-up period was 4.3±3.1 years. During the follow-up, the rates of death, stroke, maintenance hemodialysis, aneurysmal change, and reintervention were 0%, 3.7%, 7.4%, 7.4%, and 7.4%, respectively. Two patients required reintervention due to limb ischemia and aneurysmal changes in the distal portion of the stent graft. Computed tomography scans revealed a significant increase in aortic diameters in patients who underwent selective stenting compared to those who underwent TEVAR over a 3-year period, with changes in aortic area measuring 878.9 mm2 vs. 188.4 mm2 at the middle of the lesion (P=0.037), 303.7 mm2 vs. 22.8 mm2 at the level of the celiac trunk (P=0.025), and 442.9 mm2 vs. 37.3 mm2 at the level of the renal artery (P=0.019). Conclusion The endovascular treatment of acute TBAD with MS demonstrated a high primary technical success rate and promising short- and midterm clinical outcomes.
Collapse
Affiliation(s)
- La Eun Kim
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Jong Ha Park
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Han Cheol Lee
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Mi Ju Bae
- Department of Cardiovascular Surgery, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Ji Hoon You
- Department of Cardiothoracic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| |
Collapse
|
2
|
Deng C, Tang H, Li J, Li Z, Shen K, Zhang Z, Jiang B, Tan L. Development and validation of a prediction model for postoperative ischemic stroke following total arch replacement and frozen elephant trunk under mild hypothermia. Heliyon 2024; 10:e25925. [PMID: 38390179 PMCID: PMC10881848 DOI: 10.1016/j.heliyon.2024.e25925] [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: 08/08/2023] [Revised: 12/28/2023] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
Background Early identification of postoperative ischemic stroke among patients with acute DeBakey type I aortic dissection (ADIAD) is of great significance to taking timely effective treatment. We aimed to develop and validate a prediction model for postoperative ischemic stroke in ADIAD patients who underwent total arch replacement (TAR) and frozen elephant trunk (FET) under mild hypothermia. Methods ADIAD patients who underwent TAR and FET between January 2017 and April 2023 were enrolled in our study. Preoperative and intraoperative variables were selected using pairwise comparisons, the Least Absolute Shrinkage and Selection Operator (LASSO), and logistic regression to construct a prediction model for postoperative ischemic stroke. The accuracy and calibration of the model were assessed using 1000 bootstrap resamples for internal validation, with the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test. The AUC was also used to evaluate the model's accuracy in the validation cohort. Results The development cohort included 246 patients. The mean [standard deviation (SD)] age of patients in the cohort was 50.7 (11.2) years, 196 (79.7%) were men, and 22 (8.9%) were diagnosed with postoperative ischemic stroke. The validation cohort included 73 patients with a mean (SD) age of 52.5 (11.9) years, 58 (79.5%) were men and 3 (4.1%) were diagnosed with postoperative ischemic stroke. Three variables out of the initial 40 potential predictors were included in the final prediction model: the platelet count [odd ratio (OR), 0.992; 95% confidence interval (CI), 0.983-1.000], the presence of innominate artery dissection (OR, 3.400; 95% CI, 1.027-11.260), and the flow of selective cerebral perfusion (OR, 0.147; 95% CI, 0.046-0.469). The mean AUC in the development cohort was 0.77 (95% CI, 0.68-0.87), and calibration was checked with the Hosmer-Lemeshow test (P = 0.78). In the validation cohort, the AUC was 0.98 (95% CI, 0.94-1.00). A prediction model and a clinical impact curve were developed for practical purposes. Conclusions In this study, we have developed a prediction model with competent discriminative ability and calibration. This model can be used for early assessment of the risk of postoperative ischemic stroke in patients with ADIAD following TAR and FET under mild hypothermia.
Collapse
Affiliation(s)
- Chao Deng
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Hao Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Jingyu Li
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Zhenxiong Li
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Kangjun Shen
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Zhiwei Zhang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Bo Jiang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Ling Tan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| |
Collapse
|
3
|
Liu H, Qian SC, Li HY, Shao YF, Zhang HJ. Chinese Additive Anti-inflammatory Action for Aortopathy & Arteriopathy (5A) Registry protocol: rationale, design and methodology. BMC Cardiovasc Disord 2024; 24:120. [PMID: 38383323 PMCID: PMC10882838 DOI: 10.1186/s12872-024-03760-y] [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: 01/25/2024] [Accepted: 02/02/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Acute aortic syndrome (AAS) is a life-threatening condition. Inflammation plays a key role in the pathogenesis, development and progression of AAS, and is associated with significant mortality and morbidity. Understanding the inflammatory responses and inflammation resolutions is essential for an appropriate management of AAS. METHOD Thirty Chinese cardiovascular centers have collaborated to create a multicenter observational registry (named Chinese Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [5A] registry), with consecutive enrollment of adult patients who underwent surgery for AAS that was started on Jan 1, 2016 and will be ended on December 31, 2040. Specially, the impact of inflammation and anti-inflammatory strategies on the early and late adverse events are investigated. Primary outcomes are severe systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), Sequential Organ Failure Assessment (SOFA) scores at 7 days following this current surgery. Secondary outcomes are SISR, 30-day mortality, operative mortality, hospital mortality, new-onset stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. DISCUSSION The analysis of this multicenter registry will allow our better knowledge of the prognostic importance of preoperative inflammation and different anti-inflammatory strategies in adverse events after surgery for AAS. This registry is expected to provide insights into novel different inflammatory resolutions in management of AAS beyond conventional surgical repair. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04398992 (Initial Release: 05/19/2020).
Collapse
Affiliation(s)
- Hong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China.
| | - Si-Chong Qian
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hai-Yang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yong-Feng Shao
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Hong-Jia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
| |
Collapse
|
4
|
Doukas P, Dalibor N, Keszei A, Frankort J, Krabbe J, Zayat R, Jacobs MJ, Gombert A, Akhyari P, Mehdiani A. Factors Associated with Early Mortality in Acute Type A Aortic Dissection-A Single-Centre Experience. J Clin Med 2024; 13:1023. [PMID: 38398336 PMCID: PMC10889250 DOI: 10.3390/jcm13041023] [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: 01/24/2024] [Revised: 01/31/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Acute aortic dissection type A (AADA) is a surgical emergency with relevant mortality and morbidity despite improvements in current management protocols. Identifying patients at risk of a fatal outcome and controlling the factors associated with mortality remain of paramount importance. METHODS In this retrospective observational study, we reviewed the medical records of 117 patients with AADA, who were referred to our centre and operated on between 2005 and 2021. Preoperative, intraoperative, and postoperative variables were analysed and tested for their correlation with in-hospital mortality. RESULTS The overall survival rate was 83%. Preoperatively, factors associated with mortality were age (p = 0.02), chronic hypertension (p = 0.02), any grade of aortic valve stenosis in the patient's medical history (p = 0.03), atrial fibrillation (p = 0.04), and oral anticoagulation (p = 0.04). Non-survivors had significantly longer operative times (p = 0.002). During the postoperative phase, mortality was strongly associated with acute kidney injury (AKI) (p < 0.001), acute heart failure (p < 0.001), stroke (p = 0.02), focal neurological deficits (p = 0.02), and sepsis (p = 0.001). In the multivariate regression analysis, the onset of postoperative focal neurological deficits was the best predictor of a fatal outcome after adjusting for ARDS (odds ratio: 5.8, 95%-CI: 1.2-41.7, p = 0.04). CONCLUSIONS In this retrospective analysis, atrial fibrillation, oral anticoagulation, hypertension, and age were significantly correlated with mortality. Postoperatively, acute kidney injury, acute heart failure, sepsis, and focal neurological deficits were correlated with in-hospital mortality, and focal neurological deficit has been identified as a significant predictor of fatal outcomes. Early detection and interdisciplinary management of at-risk patients remain crucial throughout the postoperative phase.
Collapse
Affiliation(s)
- Panagiotis Doukas
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Nicola Dalibor
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - András Keszei
- Center for Translational & Clinical Research Aachen (CTC-A), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Jelle Frankort
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Julia Krabbe
- Institute of Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rachad Zayat
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
| | - Michael J. Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Alexander Gombert
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Payam Akhyari
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
| | - Arash Mehdiani
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
| |
Collapse
|
5
|
Adiarto S, Kurnianingsih N, Prasetya I, Nugroho FW, Uberoi R. Successful Primary PCI in Stanford Type A Aortic Dissection Complicated by Inferior ST-Elevation Myocardial Infarction: A Case in a Facility with No Surgical Backup. Int J Angiol 2024; 33:62-65. [PMID: 38352639 PMCID: PMC10861288 DOI: 10.1055/s-0041-1735205] [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: 10/20/2022] Open
Abstract
Mortality of type A aortic dissection (TAAD) complicated with coronary malperfusion syndrome is very high even when emergency surgery is performed. Several reports suggested that primary percutaneous coronary intervention (PPCI) followed by immediate corrective surgery may reduce mortality. In many countries, immediate transfer to an aortic surgery center may not be possible. We report a case of TAAD complicated by coronary malperfusion successfully treated with PPCI followed by elective corrective surgery. A 48-year-old man was referred to emergency department with acute inferior ST-elevation myocardial infarction (STEMI) and underwent PPCI. During the procedure, we realized that the cause of STEMI was TAAD. We decided to continue because the patient experienced seizures and bradycardia. Subsequently, echocardiography and computed tomography confirmed the dissection. The patient was discharged and referred to the National Cardiovascular Center where he underwent successful elective surgery. In this patient, immediate revascularization was lifesaving and served as a bridging procedure before surgical correction.
Collapse
Affiliation(s)
- Suko Adiarto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia/Harapan Kita National Cardiovascular Center, West Jakarta, Jakarta, Indonesia
| | - Novi Kurnianingsih
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Indra Prasetya
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Faris W. Nugroho
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Brawijaya University/Dr. Saiful Anwar Hospital, Malang, East Java, Indonesia
| | - Raman Uberoi
- Department of Radiology, John Radcliffe Hospital, Headington, Oxford, United Kingdom
| |
Collapse
|
6
|
Robu M, Margarint IM, Robu C, Hanganu A, Radulescu B, Stiru O, Iosifescu A, Preda S, Cacoveanu M, Voica C, Iliescu VA, Moldovan H. Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:27. [PMID: 38256288 PMCID: PMC10820683 DOI: 10.3390/medicina60010027] [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: 11/26/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.
Collapse
Affiliation(s)
- Mircea Robu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Irina Maria Margarint
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Department of Cardiac Surgery, Emergency Clinical Hospital for Children “Maria Skłodowska Curie”, 077120 Bucharest, Romania
| | - Cornel Robu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Andreea Hanganu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Neurology Department, Fundeni Clinical Institute, 022322 Bucharest, Romania
| | - Bogdan Radulescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Ovidiu Stiru
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- 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; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Prof. Dr. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Silvia Preda
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
| | - Mihai Cacoveanu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
| | - Cristian Voica
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
| | - Vlad Anton Iliescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- 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; (C.R.); (A.H.); (B.R.); (O.S.); (A.I.); (S.P.); (M.C.); (C.V.); (V.A.I.); (H.M.)
- Department of Cardiovascular Surgery, Emergency Clinical Hospital Bucharest, 014461 Bucharest, Romania
- Academy of Romanian Scientists, 050045 Bucharest, Romania
| |
Collapse
|
7
|
Zhang J, Gao S. Clinical analysis of 908 patients with aortic dissection under different Stanford types: A cross-sectional study. Medicine (Baltimore) 2023; 102:e35219. [PMID: 37713852 PMCID: PMC10508451 DOI: 10.1097/md.0000000000035219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023] Open
Abstract
This study aims to investigate the difference of clinical characteristics and risk factors in aortic dissection (AD) of patients with 2 Stanford subtypes. A retrospective analysis was conducted on 908 patients admitted to Tongji Hospital from July 2019 to January 2021, and the aortic computed tomography angiography was used to clearly diagnose the artery dissection. Patient basic information as well as blood test indicators containing leukocytes, neutrophils, lymphocytes, hemoglobin, myoglobin, hypersensitive cardiac troponin, γ-glutamyl transferase, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, ultrasensitive C-reactive protein, glucose were recorded and analyzed. There was no significant difference in gender, heart rate, smoking history, hypertension history and diabetes history between the 2 groups (P > .05), however, compared with type A patients, type B patients were older, and had a significantly higher frequency of alcohol consumption (P < .05); On laboratory tests, type A patients had significantly higher mean leukocytes and neutrophils (P < .05), and significantly lower frequency of reduced hemoglobin than type B patients (P < .05), although there was no statistical difference in lymphocyte, γ-glutamyl transferase, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein and glucose counts between the 2 groups. Additionally, type A patients had a significantly higher number of abnormal myoglobin, hypersensitive cardiac troponin and ultrasensitive C-reactive protein test results than type B patients (P < .05). The receiver operating characteristic curve analysis showed that the area under the curve for each parameter was 0.605 (0.538-0.673) for hemoglobin, 0.610 (0.543-0.677) for leukocytes and 0.627 (0.561-0.693) for neutrophils. Understanding the relevant clinical indicators and risk factors of patients with different types of AD can provide a new perspective to assist the classification and diagnosis of AD and a basis for effective and rational treatment.
Collapse
Affiliation(s)
- Jinhua Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sikang Gao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
8
|
Eranki A, Wilson-Smith AR, Williams ML, Gupta A, Flynn C, Iliopoulos J, Manganas C. The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:247. [PMID: 37596605 PMCID: PMC10439544 DOI: 10.1186/s13019-023-02341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/21/2023] [Indexed: 08/20/2023] Open
Abstract
INTRODUCTION Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion. METHODS An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair. RESULTS The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02-0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02-0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%). CONCLUSION A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.
Collapse
Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia.
| | - Ashley R Wilson-Smith
- John Hunter Hospital, New Lambton Heights, Newcastle, Australia
- The Collaborative Research Group (CORE), Sydney, Australia
- The University of Sydney, Sydney, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, Australia
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Campbell Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Jim Iliopoulos
- Department of Vascular Surgery, St George Hospital, Kograh, Sydney, Australia
| | - Con Manganas
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| |
Collapse
|
9
|
Ma M, Cao H, Li K, Pan J, Zhou Q, Tang X, Qin X, Zhu F, Wang D. Evaluation of Two Online Risk Prediction Models for the Mortality Rate of Acute Type A Aortic Dissection Surgery: The German Registry of Acute Aortic Dissection Type A Score and the European System for Cardiac Operative Risk Evaluation II. J Clin Med 2023; 12:4728. [PMID: 37510842 PMCID: PMC10381328 DOI: 10.3390/jcm12144728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
EuroSCORE II is one of the most widely utilized cardiovascular surgery risk scoring systems. Recently, a new online score calculator, namely the German Registry of Acute Aortic Dissection Type A (GERAADA), was launched to predict 30-day surgical mortality for acute type A aortic dissection (ATAAD) patients. The aim of this study is to evaluate the predictive performance of these two scores. We calculated the two scores for 1346 ATAAD patients from January 2012 to December 2021. The overall performance was evaluated using Brier scores and Hosmer-Lemeshow statistics. Receiver Operating Characteristic (ROC) curves were employed to assess diagnostic ability, and the standardized mortality ratio (SMR) was utilized to evaluate calibration. The GERAADA score and EuroSCORE II predicted 30-day mortality rates of 14.7% and 3.1%, respectively, while the observed rate was 12.5%. The predictive ability of EuroSCORE II (AUC 0.708, 95% CI: 0.664-0.792) was superior to that of the GERAADA score (0.648, 95% CI: 0.605-0.692). The GERAADA score had higher sensitivity but lower specificity than EuroSCORE II. And the GERAADA score may overestimate mortality (0.76, 95% CI: 0.65-0.89), while EuroSCORE II may underestimate the mortality rate (3.17, 95% CI: 2.92-3.44). The EuroSCORE II was superior in predicting surgical mortality among ATAAD patients. But the observed 30-day mortality rate certified a good calibration for the GERAADA score.
Collapse
Affiliation(s)
- Ming Ma
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Kai Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xinlong Tang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xichun Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Feng Zhu
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| |
Collapse
|
10
|
Öz T, Rantner B, Stana J, Stavroulakis K, Peterß S, Pichlmaier M, Fernandez Prendes C, Tsilimparis N. [Malperfusion after Aortic Dissection - Management and Techniques]. Zentralbl Chir 2023. [PMID: 37327818 DOI: 10.1055/a-2058-9080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Malperfusion is a common complication of aortic dissection and further increases this deadly disease's mortality. An effective treatment strategy requires a timely diagnosis based on the clinical findings and the available instruments, understanding the disease's pathomechanism, recognising the therapy options recommended by the guidelines, and the diagnostic and therapeutic innovations of the area of research. The final treatment decision should be patient- and case-specific. In this work, we have considered malperfusion after aortic dissection, not only as a complication of aortic dissection but as a separate disease and summarise important information that can contribute to efficient therapy decisions in everyday clinical practice.
Collapse
Affiliation(s)
- Tugce Öz
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Jan Stana
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Konstantinos Stavroulakis
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Sven Peterß
- Abteilung für Herzchirurgie, University Hospital Munich, Munchen, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Standort Großhadern, Munchen, Deutschland
| | - Carlota Fernandez Prendes
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| |
Collapse
|
11
|
Petrov I, Stankov Z, Vasilev S, Tasheva I, Kozareva G. Endovascular Treatment of Complex Aortic Dissection. A Single Center 5 Years' Experience with 36 Patients. Rev Cardiovasc Med 2023; 24:133. [PMID: 39076745 PMCID: PMC11273010 DOI: 10.31083/j.rcm2405133] [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: 09/30/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 07/31/2024] Open
Abstract
Background We present an analysis that compares aortic morphological and clinical outcomes of 36 patients, all treated with endovascular uncovered stents implantation preceded or not by stent-graft implantation, or surgical treatment in the context of complex treatment of type A or type B aortic dissection. Methods Between 2014 and 05/2018 our team treated 36 patients with acute aortic dissection and end-organ ischemia due to true lumen compression. All clinical and periprocedural data were obtained prospectively, followed by a retrospective analysis. The case series aim is to show induction of aortic remodeling by depressurization of the false lumen and increasing the size of the true lumen by non-covered stents implantation in the aorta and its affected side branches. Secondary endpoints were survival, branch patency, true lumen and false lumen size evolution. Results Results from the diameter of both lumens measured by computed tomography angiography (CTA) before and at least 1 year after the treatment showed statistically significant differences, patent stents, as well as symptomatic improvement in all patients. Both aorta-related and general mortality in this complex group of patients was 0%. Conclusions The concept of redirection of flow in aortic dissection with non-covered stents was safe, led to positive aorta remodeling and resulted in excellent survival rate.
Collapse
Affiliation(s)
- Ivo Petrov
- Department of Cardiology, angiology and electrophysiology, “Acibadem City Clinic” University Hospital, 1700 Sofia, Bulgaria
| | - Zoran Stankov
- Department of Cardiology, angiology and electrophysiology, “Acibadem City Clinic” University Hospital, 1700 Sofia, Bulgaria
| | - Strahil Vasilev
- Department of Cardiology, angiology and electrophysiology, “Acibadem City Clinic” University Hospital, 1700 Sofia, Bulgaria
| | - Iveta Tasheva
- Department of Cardiology, angiology and electrophysiology, “Acibadem City Clinic” University Hospital, 1700 Sofia, Bulgaria
| | - Galina Kozareva
- Department of Diagnostic Imaging, “Acibadem City Clinic” University
Hospital, 1700 Sofia, Bulgaria
| |
Collapse
|
12
|
Gobinath S, Vinojan S, Mathivaanan S, Gobishangar S. Intermittent malperfusion of bilateral upper limbs - An uncommon presentation of Type A Acute Aortic Dissection (TAAD). Int J Surg Case Rep 2023; 106:108262. [PMID: 37119753 PMCID: PMC10173198 DOI: 10.1016/j.ijscr.2023.108262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023] Open
Abstract
INTRODUCTION Aortic dissection occurs following a tear in the tunica intima of the aortic wall resulting in blood entering between the intima and media. Type A aortic dissection can rarely manifest as upper limb malperfusion. CASE PRESENTATION This is regarding a patient who presented with intermittent malperfusion of the bilateral upper limbs and was initially managed as acute limb ischemia. An attempt of embolectomy didn't yield any clots. Urgent imaging with computed tomography angiogram of bilateral upper limbs revealed type A aortic dissection (TAAD). DISCUSSION TAAD is a surgical emergency which can rarely manifest as intermittent malperfusion of upper limbs. This could be explained by the dissection flap's dynamic obstruction of the right brachiocephalic trunk and left subclavian artery. CONCLUSION In patients with a discrepancy in pulse between both limbs or intermittent ischemia of limbs, aortic dissection should be considered a differential diagnosis.
Collapse
Affiliation(s)
| | | | - Sivalingam Mathivaanan
- Consultant General Surgeon With Special Interest in Vascular Surgery, Teaching Hospital Jaffna, Sri Lanka
| | | |
Collapse
|
13
|
Zhang Y, Yang Y, Guo J, Zhang X, Cheng Y, Sun T, Lin L. Risk factors for early death after surgery in patients with acute Stanford type A aortic dissection: A systematic review and meta-analysis. Int J Cardiol 2023; 377:33-41. [PMID: 36513283 DOI: 10.1016/j.ijcard.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are many risk factors related to early death after surgery among patients with acute Stanford type A aortic dissection (ATAAD) that have been analyzed in previous studies, but no evidence-based study has been conducted to confirm these risk factors. AIMS The aims of this study were to investigate risk factors for early death after surgery in patients with ATAAD via systematic review and meta-analysis and assess evidence-based strategies for preventing adverse events. METHODS The protocol for this study was prospectively registered with PROSPERO (CRD 42022332772). The authors systematically searched PubMed, Ovid, Scopus, Web of Science and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines from database construction to May 2021. Studies that met the selection criteria were determined by two independent researchers, and the odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for the risk factors and were pooled using Stata 15.0. RESULTS A total of 23 studies including 5510 patients met the inclusion criteria, and 10 risk factors were analyzed in this meta-analysis. The preoperative risk factors for early death after surgery in patients with ATAAD were age [(OR: 1.03, 95% CI (1.01, 1.06)], male sex [(OR: 1.43, 95% CI (1.06, 1.92)], shock [(OR: 1.91, 95% CI (1.06, 3.45)], malperfusion [(OR: 3.45, 95% CI (2.24, 5.31)] and cardiac tamponade [(OR: 3.89, 95% CI (1.17, 12.98)]. CONCLUSION Patients with ATAAD who have an older age, male sex, shock, malperfusion and cardiac tamponade have a higher risk for early death after surgery. However, more highly homogenous studies are needed to demonstrate these results. Clinical staff should pay more attention to these factors and take individual actions to reduce mortality after surgery in patients with ATAAD.
Collapse
Affiliation(s)
- Yi Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Yuanyuan Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Jinhua Guo
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Xiaotian Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Yunqing Cheng
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Tucheng Sun
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China
| | - Lixia Lin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, Guangdong Province, China.
| |
Collapse
|
14
|
Arnaoutakis GJ, Ogami T, Patel HJ, Pai CW, Woznicki EM, Brinster DR, Leshnower BG, Serna-Gallegos D, Bekeredjian R, Sundt TM, Shaffer AW, Peterson MD, Geuzebroek GSC, Eagle KA, Trimarchi S, Sultan I. Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection. Ann Thorac Surg 2023; 115:879-885. [PMID: 36370884 DOI: 10.1016/j.athoracsur.2022.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/27/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. METHODS Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. RESULTS A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). CONCLUSIONS AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.
Collapse
Affiliation(s)
- George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, Michigan
| | - Chih-Wen Pai
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Elise M Woznicki
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Derek R Brinster
- Department of Cardiac Surgery, Northwell Health, New York, New York
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raffi Bekeredjian
- Department of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew W Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Mark D Peterson
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital, Toronto, Canada
| | - Guillaume S C Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim A Eagle
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| |
Collapse
|
15
|
Nakai C, Izumi S, Haraguchi T, Henmi S, Nakayama S, Mikami T, Tsukube T. Impact of time from symptom onset to operation on outcome of repair of acute type A aortic dissection with malperfusion. J Thorac Cardiovasc Surg 2023; 165:984-991.e1. [PMID: 33941373 DOI: 10.1016/j.jtcvs.2021.03.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We analyzed patients with acute type A aortic dissection complicated by malperfusion syndrome to establish whether the timing of operative treatment and the location of malperfusion are factors in determining outcomes. METHODS A total of 331 patients with acute type A aortic dissection were treated surgically between August 2003 and May 2019. Eighty-four patients (25%) presented with preoperative malperfusion syndrome. Fifty-eight patients with malperfusion syndrome (69%) were transferred to the operating room within 5 hours of the onset of symptoms (immediate repair); 26 patients (31%) were transferred after 5 hours (later repair). We analyzed the effects of immediate aortic repair on surgical outcomes. RESULTS There was no significant difference in the early mortality rates between patients with immediate and later aortic repair, which were 20.0% (n = 11/58) and 26.9% (n = 7/19), respectively (P = .12). Preoperative coronary malperfusion was the only predictor of early mortality. The cumulative 5-year survivals of patients with malperfusion syndrome in the immediate and later repair groups were 76.7% and 45.4%, respectively. A significant difference was noted in the long-term outcomes between the 2 groups (P = .02). On multivariable Cox survival analysis, coronary malperfusion and shock on arrival were associated with increased long-term mortality (P < .01 and P = .04). Conducting surgery within 5 hours of the onset of symptoms was a significant predictor of favorable long-term outcome (P = .03). CONCLUSIONS Although preoperative coronary malperfusion and shock on arrival worsened the long-term outcomes in patients undergoing aortic repair for acute type A aortic dissection with preoperative malperfusion syndrome, conducting an operation within 5 hours of the onset of symptoms significantly improved their long-term outcomes.
Collapse
Affiliation(s)
- Chikashi Nakai
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - So Izumi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Tomonori Haraguchi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Soichiro Henmi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | | | - Takuro Tsukube
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
| |
Collapse
|
16
|
Li J, Zhou Y, Qin W, Su C, Huang F, Chen X. Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience. Asian Cardiovasc Thorac Ann 2023; 31:8-14. [PMID: 35014890 DOI: 10.1177/02184923211070115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. METHODS Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. RESULTS A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 - 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 - 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 - 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 - 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. CONCLUSIONS Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.
Collapse
Affiliation(s)
- Jian Li
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Yueyun Zhou
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Wei Qin
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, 385685Nanjing First Hospital, 385685Nanjing Medical University, P.R. China
| |
Collapse
|
17
|
Dalal AR, Dossabhoy S, Heng E, Yasin A, Leipzig MM, Bonham SA, Fischbein MP, Lee JT, Woo YJ, Watkins AC. Midterm Outcomes in Type A Aortic Dissection Repair With and Without Malperfusion in a Hybrid Operating Room. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00280-5. [PMID: 36567047 DOI: 10.1053/j.semtcvs.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair vs upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least 1 endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7% (122/125) as compared to the traditional cohort at 87.2% (109/125) (P = 0.002). There were no significant differences in perioperative paralysis (1.6% vs 1.6%, P > 0.9), new hemodialysis (12% vs 9.6%, P = 0.5), fasciotomy (2.4% vs 5.6%, P = 0.20, and exploratory laparotomy (1.6% vs 4.8%, P = 0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.
Collapse
Affiliation(s)
- Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Shernaz Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Elbert Heng
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Aleena Yasin
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Matthew M Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Spencer A Bonham
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
| |
Collapse
|
18
|
Bayamin K, Power A, Chu MWA, Dubois L, Valdis M. Malperfusion syndrome in acute type A aortic dissection: Thinking beyond the proximal repair. J Card Surg 2022; 37:3827-3834. [PMID: 35989530 DOI: 10.1111/jocs.16872] [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: 05/03/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Malperfusion syndrome (MPS) is associated with the highest mortality and major morbidity risk in patients with acute Type A aortic dissection (TAAD). The timing of the open proximal aortic repair in the presence of MPS remains debatable given variability in clinical presentation and different local treatment algorithms. This paper provides an up to date and comprehensive overview of published outcomes and available techniques for addressing malperfusion in the setting of acute TAAD. METHODS We have reviewed published data from the major aortic dissection registries including the International Registry of Acute Aortic Dissection, the German Registry for Acute Aortic Dissection In Type A, and the Nordic Consortium for Acute Type A Aortic Dissection, as well as the most up to date literature involving malperfusion in the setting of acute TAAD. This data highlights unique strategies that have been adopted at aortic centers internationally to address malperfusion in this setting pre-, intra-, and postoperatively, which are summarized here and may be of great clinical benefit to other centers treating this disease with more traditional methods. RESULTS The review of the available data has definitively shown an increased mortality up to 43% and morbidity in patients presenting with MPS in the setting of acute TAAD. More specifically, preoperative MPS has been shown to be an independent predictor of mortality with mesenteric malperfusion associated with the worst mortality outcomes from 70% to 100%. Addressing MPS pre or intraoperatively is associated with significantly reduced mortality outcomes down to 4%-13%. CONCLUSION Adapting a dynamic and easily accessible diagnostic method for the comprehensive assessment of different forms of malperfusion (dynamic/static) and incorporating it within the surgical plan is the first step toward early diagnosis and prevention of malperfusion related complications.
Collapse
Affiliation(s)
- Karama Bayamin
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Adam Power
- Division of Vascular Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| |
Collapse
|
19
|
Montagner M, Kofler M, Seeber F, Pitts L, Starck C, Sündermann SH, Kurz S, Grubitzsch H, Falk V, Kempfert J. The Arch Remodeling Stent for DeBakey I Acute Aortic Dissection: Experience with 100 Implantations. Eur J Cardiothorac Surg 2022; 62:6637516. [PMID: 35809065 DOI: 10.1093/ejcts/ezac384] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES A novel hybrid non-covered stent was developed to treat malperfusion and prevent aneurysm formation following hemiarch procedure for DeBakey I acute aortic dissection (AAD). The present analysis investigates the performance of the device in 100 consecutive implantations. METHODS Between 2018 and 2021, 100 patients underwent surgical repair of DeBakey I AAD with implantation of a non-covered stent in the arch and descending aorta. The primary entry tear was located in the root or in the ascending aorta. Clinical and imaging data were collected and analyzed retrospectively. Endpoints of the study were 30-day mortality, neurologic outcome and need of additional procedures due to postoperative malperfusion. Technical success was assessed in the first post-operative computed tomography in regard to the induction of false lumen thrombosis in the descending aorta. RESULTS Median age was 61 [54-73] years. Preoperative malperfusion was present in 46 (46%) patients. Primary arterial cannulation strategy was the right axillary artery and an open distal anastomosis was performed in a median caudal circulatory arrest of 40 [34-52] minutes. In 48% of cases, a 55-40 tapered stent was implanted. The 30-day mortality was 18%, an operation-related new postoperative neurologic deficit was present in 8%. Technical success was achieved in 76% of patients. CONCLUSIONS The novel non-covered stent can be safely applied to complement aortic repair with the hemiarch procedure for DeBakey I AAD. The expansion of the true lumen through the device may prevent postoperative malperfusion and induces positive vascular remodeling with thrombosis of false lumen.
Collapse
Affiliation(s)
- Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Fabian Seeber
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany.,Charité - Universitaetsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Stephan Kurz
- Charité - Universitaetsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Herko Grubitzsch
- Charité - Universitaetsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany.,Charité - Universitaetsmedizin Berlin, Department of Cardiovascular Surgery, Berlin, Germany.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| |
Collapse
|
20
|
Buech J, Radner C, Fabry TG, Horke KM, Ali A, Saha S, Hagl C, Pichlmaier MA, Peterss S. Visceral and renal malperfusion syndromes in acute aortic dissection type A: the fate of the branch vessel. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:117-123. [PMID: 35238524 DOI: 10.23736/s0021-9509.22.12276-7] [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 Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections. METHODS Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion. RESULTS Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion. CONCLUSIONS Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.
Collapse
Affiliation(s)
- Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Caroline Radner
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Thomas G Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Konstanze M Horke
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Ahmad Ali
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Shekhar Saha
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site of Munich Heart Alliance, Munich, Germany
| | | | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany -
| |
Collapse
|
21
|
Malperfusion in acute type A aortic dissection: how we handle the challenge? Indian J Thorac Cardiovasc Surg 2022; 38:122-131. [PMID: 35463696 PMCID: PMC8980967 DOI: 10.1007/s12055-021-01292-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
Malperfusion syndrome (MPS) complicating acute type A aortic dissection (ATAAD) poses a continuing challenge and management dilemma for cardiovascular surgeons. MPS may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral, and/or limb ischemia with varying frequency and severity. Despite the continuous improvement in diagnosis and management strategies for MPS with ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable. The present review aimed to assess current evidence on ATAAD patients with MPS and how best to handle the challenge.
Collapse
|
22
|
Abstract
Acute aortic syndromes, classified into aortic dissection, intramural hematoma, and penetrating aortic ulcer, are associated with high early mortality for which early diagnosis and management are crucial to optimize outcomes. Patients often present with nonspecific clinical symptoms and signs; therefore, it is important for providers to maintain a high index of suspicion for acute aortic syndromes. Electrocardiogram-gated computed tomographic angiography of the chest, abdomen, and pelvis is currently the most practical imaging modality for diagnosis and identification of complications. Evolution in surgical techniques and the development of aortic endografts have improved patient outcomes, but randomized trials are still needed.
Collapse
Affiliation(s)
- R Kevin Rogers
- Division of Cardiology, University of Colorado, School of Medicine, Section of Vascular Medicine, Mail Stop B132, Leprino Building, 12401 East 17th Avenue, Room 560, Aurora, CO 80045, USA.
| | - T Brett Reece
- Division of Cardiovascular Surgery, University of Colorado, School of Medicine, 12631 East 17th Avenue, Room 6111, Aurora, CO 80045, USA
| | - Marc P Bonaca
- Division of Cardiology, University of Colorado, School of Medicine, Section of Vascular Medicine, Mail Stop B132, Leprino Building, 12401 East 17th Avenue, Room 560, Aurora, CO 80045, USA; CPC Clinical Research, 2115 North Scranton Street Suite 2040, Aurora, CO 80045, USA
| | - Connie N Hess
- Division of Cardiology, University of Colorado, School of Medicine, Section of Vascular Medicine, Mail Stop B132, Leprino Building, 12401 East 17th Avenue, Room 560, Aurora, CO 80045, USA; CPC Clinical Research, 2115 North Scranton Street Suite 2040, Aurora, CO 80045, USA
| |
Collapse
|
23
|
White A, Bozso SJ, Ouzounian M, Chu MW, Moon MC. Acute type A aortic dissection and the consequences of a patent false lumen. JTCVS Tech 2021; 9:1-8. [PMID: 34647041 PMCID: PMC8500985 DOI: 10.1016/j.xjtc.2021.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Abigail White
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sabin J. Bozso
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael W.A. Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Michael C. Moon
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
- Address for reprints: Michael C. Moon, MD, Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, Department of Surgery, University of Alberta, 8602 112 St NW, Edmonton, Alberta T6G 2E1, Canada.
| | | |
Collapse
|
24
|
Beck CJ, Germano E, Artis AS, Kirksey L, Smolock CJ, Lyden SP, Bakaeen FG, Menon V, Roselli EE, Farivar BS. Outcomes and role of peripheral revascularization in type A aortic dissection (TAAD) presenting with acute lower extremity ischemia. J Vasc Surg 2021; 75:495-503.e5. [PMID: 34500026 DOI: 10.1016/j.jvs.2021.08.050] [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: 02/02/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI. METHODS Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis. RESULTS From 2010 to 2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 patients (17%) presented with ALI; 48% (39/81) with isolated ALI, and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular (46%; 11/24), open (33%; 8/24), and hybrid (21%; 5/24) interventions. The major amputation rate was 4% (3/81), and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared with those who did not (log-rank P = .023). Overall survival did not significantly differ between the two groups (log-rank P = .095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared with those with isolated ALI (log-rank P = .0017). Distal extent of dissection flap into zone 11 (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.58-20.2; P = .008) and partial/complete thrombosis of any iliac artery (OR, 3.94; 95% CI, 1.23-12.6; P = .021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR, 8.84; 95% CI, 1.74-44.9; P = .0086) was associated with increased risk of in-hospital mortality. CONCLUSIONS ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.
Collapse
Affiliation(s)
- Cassandra J Beck
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emidio Germano
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Behzad S Farivar
- Division of Vascular & Endovascular Surgery, University of Virginia, Charlottesville, Va; Aortic Center, University of Virginia Medical Center, Charlottesville, Va.
| |
Collapse
|
25
|
Saha S, Fabry TG, Buech J, Ali A, Joskowiak D, Tsilimparis N, Hagl C, Pichlmaier M, Peterss S. Time is of the essence: where can we improve care in acute aortic dissection? Interact Cardiovasc Thorac Surg 2021; 33:941-948. [PMID: 34255060 DOI: 10.1093/icvts/ivab190] [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: 03/07/2021] [Revised: 04/10/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In acute aortic dissection type A various components of the diagnostic and logistic pathways may affect the time to definitive treatment. This study aimed to characterize these components and to identify factors delaying the optimal management within our institutional referral network. METHODS Between January 2017 and January 2020, 96 consecutive patients with classical aortic dissection type A were admitted (28%) or referred (72%) to our tertiary care centre and analysed retrospectively. Data are presented as medians (25th-75th quartile). RESULTS Median age was 66 years (56-74), 63% were male. Most of the patients were primarily admitted to a cardiology department (40%), whereas about a fourth were admitted to departments for internal medicine (26%) and general surgery (27%). The median interval from the onset of symptoms to hospital admission was 2.1 (1-4.4) h. From admission to confirmed diagnosis it took 2.1 (0.6-9.5) h and the median interval from confirmed diagnosis to admission at our specialized tertiary care aortic centre was 1.5 (0.9-2.4) h. Following admission to our centre, 1.1 (0.5-1.9) h passed until the induction of anaesthesia and 0.8 (0.0-1.1) h until the start of surgery. The total interval from the onset of symptoms to the start of surgery was 7.6 h (5.1-12.3). CONCLUSIONS The marked variability of the time from symptoms to diagnosis at any medical facility demonstrates the importance of awareness in the optimization of the treatment of acute aortic dissection type A.
Collapse
Affiliation(s)
- Shekhar Saha
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Thomas G Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Ahmad Ali
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | | | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | | | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| |
Collapse
|
26
|
Visceral malperfusion after Frozen Elephant Trunk in chronic aortic dissection: post-operative predictors and outcomes. Int J Cardiol 2021; 335:26-31. [PMID: 33838151 DOI: 10.1016/j.ijcard.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aims of this study were to analyse the incidence of visceral malperfusion syndrome (MPS) following Frozen Elephant trunk operations in patients affected by chronic aortic dissection and the associated risk factors. METHODS Between January 2007 and February 2019, 165 patients underwent surgery with FET for chronic aortic dissection. Post-operative computer tomography angiogram parameters (diameters, early post-operative false lumen enhancement and involving of aortic branches by the dissection) were collected and analysed to evaluate their impact on the occurrence of visceral malperfusion. RESULTS Visceral (renal and mesenteric) MPS (with both clinical and radiological signs of MPS) was detected in 10 cases (6.1%). Post-operative visceral malperfusion was strongly related with in hospital mortality. The involvement of the visceral branches in the dissection was not a risk factor for visceral malperfusion occurrence, while a larger post-operative total aortic diameter at level of the coeliac trunk increased the risk of visceral MPS (OR 1.05; CI 1.002-1.102, p-value = 0.04). Furthermore, visceral MPS was associated to a complete thrombosis of the false lumen at level of the distal descending thoracic aorta. CONCLUSIONS The development of post-operative MPS in frozen elephant trunk is strongly related to in-hospital mortality. The involvement of aortic branches by the dissection does not represent a real predictive risk factor for MPS, while early larger aortic diameters and false lumen thrombosis represent independent risk factors for MPS and in-hospital mortality.
Collapse
|
27
|
Ko JP, Goldstein JM, Latson LA, Azour L, Gozansky EK, Moore W, Patel S, Hutchinson B. Chest CT Angiography for Acute Aortic Pathologic Conditions: Pearls and Pitfalls. Radiographics 2021; 41:399-424. [PMID: 33646903 DOI: 10.1148/rg.2021200055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chest CT angiography (CTA) is essential in the diagnosis of acute aortic syndromes. Chest CTA quality can be optimized with attention to technical parameters pertaining to noncontrast imaging, timing of contrast-enhanced imaging, contrast material volume, kilovolt potential, tube-current modulation, and decisions regarding electrocardiographic-gating and ultra-fast imaging, which may affect the accurate diagnosis of acute aortic syndromes. An understanding of methods to apply to address suboptimal image quality is useful, as the accurate identification of acute aortic syndromes is essential for appropriate patient management. Acute aortic syndromes have high morbidity and mortality, particularly when involving the ascending aorta, and include classic aortic dissection, penetrating atherosclerotic ulcer, and acute intramural hematoma. An understanding of the pathogenesis and distinguishing imaging features of acute aortic syndromes and aortic rupture and some less common manifestations is helpful when interpreting imaging examinations. Related entities, such as ulcerated plaque, ulcerlike projections, and intramural blood pools, and mimics, such as vasculitis and aortic thrombus, are important to recognize; knowledge of these is important to avoid interpretive pitfalls. In addition, an awareness of postsurgical aortic changes can be useful when interpreting CTA examinations when patient history is incomplete. The authors review technical considerations when performing CTA, discuss acute aortic syndromes, and highlight diagnostic challenges encountered when interpreting aortic CTA examinations. ©RSNA, 2021.
Collapse
Affiliation(s)
- Jane P Ko
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Jonathan M Goldstein
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Larry A Latson
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Lea Azour
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Elliott K Gozansky
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - William Moore
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Smita Patel
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Barry Hutchinson
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| |
Collapse
|
28
|
Möller CM, Ellmauer PP, Zeman F, Bitzinger D, Flörchinger B, Graf BM, Zausig YA. Postoperative acute respiratory dysfunction and the influence of antibiotics after acute type A aortic dissection surgery: A retrospective analysis. PLoS One 2021; 16:e0246724. [PMID: 33571258 PMCID: PMC7877985 DOI: 10.1371/journal.pone.0246724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/25/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Surgery for acute type A aortic dissection is associated with several perioperative complications, such as acute respiratory dysfunction (ARD). The aim of this study was to investigate perioperative risk factors involved in the development of ARD and whether antibiotic treatment has an impact. METHODS 243 patients underwent surgery for acute type A aortic dissection between 2008 and 2017. The patients were retrospectively divided into the ARD and NON-ARD group. ARD was defined as PaO2/FiO2 ≤ 200 mmHg (PF ratio) within 48 hours after surgery. All patients received either narrow- or broad-spectrum antibiotics. RESULTS After the exclusion of 42 patients, 201 patients were analyzed. The PF ratio of the ARD group was significantly lower than of the NON-ARD group within the first 7 days. ARD patients (n = 111) were significantly older (p = .031) and had a higher body mass index (BMI) (p = .017). ARD patients required longer postoperative ventilation (2493 vs. 4695 [min], p = .006) and spent more days in the intensive care unit (7.0 vs. 8.9 [days], p = .043) compared to NON-ARD. The mortality was significantly lower for ARD than for NON-ARD patients (p = .030). The incidence of pneumonia was independent of the antibiotic treatment regime (p = .391). Renal and neurological complication rate was higher in patients treated with broad-spectrum antibiotic. CONCLUSION ARD is the main complication (55%) that occurs approximately 24 hours after surgery for acute type A aortic dissection. The preoperative risk factors for ARD were higher age and increased BMI. Patients on broad-spectrum antibiotics did not show an improved postoperative outcome compared to patients with narrow-spectrum antibiotics.
Collapse
Affiliation(s)
- Christina M. Möller
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Peter-Paul Ellmauer
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Florian Zeman
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Diane Bitzinger
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Bernhard Flörchinger
- Department of Cardiac Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Bernhard M. Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - York A. Zausig
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
- * E-mail: ,
| |
Collapse
|
29
|
Usefulness of Transesophageal Echocardiography in the Evaluation of Celiac Trunk and Superior Mesenteric Artery Involvement in Acute Aortic Dissection. J Am Soc Echocardiogr 2020; 34:327-335. [PMID: 33385502 DOI: 10.1016/j.echo.2020.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/08/2020] [Accepted: 12/27/2020] [Indexed: 12/27/2022]
Abstract
Mesenteric ischemia is a serious complication of acute aortic dissection (AAD), and its early diagnosis is vital for prognosis and appropriate treatment indication. Arteries affected by this complication are the celiac trunk and superior mesenteric artery, and their evaluation is usually based on computed tomographic angiography. Transesophageal echocardiography is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when computed tomographic angiography is not available. However, the usefulness of transesophageal echocardiography for evaluating celiac trunk and superior mesenteric artery involvement and mesenteric ischemia mechanisms in AAD is not well established. Real-time information on mesenteric malperfusion is needed at the bedside, in primary care facilities, and in the operating room to achieve prompt diagnosis and better therapeutic management. The aims of this review are to assess the role of TEE to diagnose celiac trunk and superior mesenteric artery involvement in AAD, determine the mechanisms that can cause flow obstruction in patients with mesenteric ischemia, and analyze possible implications in the treatment of this complication.
Collapse
|
30
|
Capoccia M, Mireskandari M, Cheshire NJ, Rosendahl UP. Delayed repair of aortic dissection in sickle cell anaemia as a combined cardiac and vascular surgical approach. J Saudi Heart Assoc 2020; 32:208-212. [PMID: 33154918 PMCID: PMC7640567 DOI: 10.37616/2212-5043.1043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/12/2020] [Accepted: 01/12/2020] [Indexed: 11/28/2022] Open
Abstract
We discuss a patient who presented with a type B aortic dissection with a retrograde progression in the context of sickle cell anaemia. Given the involvement of the superior mesenteric artery and concern for bowel ischaemia, a delayed approach was considered. Subsequently, a frozen elephant trunk was performed in the hybrid theatre with the back-up of the vascular surgeon for mesenteric protection. A technically demanding procedure followed by a prolonged and challenging postoperative course finally led to a successful outcome. We argue that the case presented is an example of how a close cooperation between professionals can offer additional options to treatment based on a mixture of skills and background to achieve the desired outcome.
Collapse
Affiliation(s)
- Massimo Capoccia
- Aortic and Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
| | | | | | - Ulrich P Rosendahl
- Aortic and Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
| |
Collapse
|
31
|
Iannacone E, Robinson B, Rahouma M, Girardi L. Management of malperfusion: New York approach and outcomes. J Card Surg 2020; 36:1757-1765. [PMID: 32949048 DOI: 10.1111/jocs.15025] [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: 07/31/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIM Aortic branch malperfusion complicates up to one-third of acute type A aortic dissection (ATAAD), and it is a strong predictor of poor outcomes. We analyzed our results for the surgical management of this high-risk cohort. METHODS We queried our aortic database for consecutive patients undergoing ATAAD repair. Those presenting with malperfusion were compared with those without. Outcomes were compared using univariate and multivariate analysis. RESULTS From 1997 to 2019, a total of 336 patients underwent ATAAD repair. A total of 97 ATAAD patients presented with malperfusion. Malperfusion patients were more likely to be male (54.8% vs. 75.3%; p = .001), have had a prior myocardial infarction (11.9% vs. 26.8%; p = .001), to present with preoperative renal dysfunction (22.2% vs. 54.6%; p < .001), and to present with shock (12.6% vs. 28.9%; p = .001). The malperfusion group more often underwent coronary artery bypass grafting (5.4% vs. 24.7%; p < .001), and required additional noncardiac procedures 10.3% of the time. Operative mortality (0.8% vs. 15.5%; p < .001) and major adverse events (MAEs) (7.6% vs. 20.6%; p = .001) were both greater for the malperfusion patients. Ejection fraction, diabetes, and malperfusion were predictors of MAEs. Cerebral, coronary, mesenteric, and multiple vascular bed malperfusion were predictors of MAEs, while extremity, renal, and spinal were not. CONCLUSION Improving outcomes for this high-risk cohort requires rapid diagnosis and reversal of ischemia while minimizing the risk of aortic rupture, irrespective of the strategic approach.
Collapse
Affiliation(s)
- Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
32
|
Leone A, Beckmann E, Aandreas M, Di Marco L, Pantaleo A, Reggiani LB, Haverich A, Di Bartolomeo R, Pacini D, Sherestha M. Total aortic arch replacement with frozen elephant trunk technique: Results from two European institutes. J Thorac Cardiovasc Surg 2020; 159:1201-1211. [DOI: 10.1016/j.jtcvs.2019.03.121] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
|
33
|
Bozso SJ, Nagendran J, Chu MW, Kiaii B, El-Hamamsy I, Ouzounian M, Kempfert J, Starck C, Shahriari A, Moon MC. Single-Stage Management of Dynamic Malperfusion Using a Novel Arch Remodeling Hybrid Graft. Ann Thorac Surg 2019; 108:1768-1775. [DOI: 10.1016/j.athoracsur.2019.04.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/06/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
|
34
|
Yang B, Rosati CM, Norton EL, Kim KM, Khaja MS, Dasika N, Wu X, Hornsby WE, Patel HJ, Deeb GM, Williams DM. Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome. Circulation 2019; 138:2091-2103. [PMID: 30474418 DOI: 10.1161/circulationaha.118.036328] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. METHODS From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). RESULTS Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03). CONCLUSIONS Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.
Collapse
Affiliation(s)
- Bo Yang
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - Carlo Maria Rosati
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | | - Karen M Kim
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - Minhaj S Khaja
- Radiology (M.S.K., N.D., D.M.W.), Michigan Medicine, Ann Arbor
| | | | - Xiaoting Wu
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | | - Himanshu J Patel
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - G Michael Deeb
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | |
Collapse
|
35
|
Bin Mahmood SU, Mori M, Luo J, Zhang Y, Safdar B, Ulrich A, Geirsson A, Elefteriades JA, Mangi AA. Rapid Diagnosis and Treatment of Patients with Acute Type A Aortic Dissection and Malperfusion Syndrome May Normalize Survival to that of Patients with Uncomplicated Type A Aortic Dissection. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2019; 7:42-48. [PMID: 31529427 PMCID: PMC6748843 DOI: 10.1055/s-0039-1691790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives
Malperfusion syndrome in the setting of acute Type A dissection (ATAD) is typically associated with poor prognosis. We evaluated the contemporary outcomes of patients with ATAD presenting with and without malperfusion syndrome who underwent aortic surgery.
Methods
We performed a single-center, retrospective review of 103 consecutive patients that underwent surgery for ATAD. The cohort was dichotomized by patients with and without malperfusion syndromes. Multivariate and bivariate analyses were performed to evaluate association between the presence of malperfusion syndrome and operative outcomes.
Results
A total of 29 (28.1%) patients presented with malperfusion syndrome. The 30-day mortality for patients presenting with and without malperfusion was 13.7 and 9.4%, respectively (
p
= 0.49). Patients with malperfusion syndrome had a shorter mean admission-to-incision interval of 4.3 ± 2.5 hours compared with 6.3 ± 4.6 hours for those without malperfusion (
p
= 0.02). Difference in 30-day mortality for patients with and without malperfusion syndrome was found to be nonsignificant on multivariate regression analysis (odds ratio: 1.53; 95% confidence interval: 0.40–5.82,
p
= 0.49).
Conclusions
This series demonstrated that there was nonsignificant difference in early- or midterm outcomes for patients with and without malperfusion syndrome. Patients with malperfusion were taken to the operating room more rapidly than those without, which offers a potential explanation for the comparable outcome of the malperfusion cohort.
Collapse
Affiliation(s)
- Syed Usman Bin Mahmood
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Jiajun Luo
- Section of Surgical Outcomes and Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - John A Elefteriades
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Abeel A Mangi
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
36
|
Zhang HW, Huang Y, Yang P, Li KD, Hu J. Urgent retrograde two-stage hybrid repair of a complicated blunt traumatic aortic injury. J Vasc Surg 2019; 70:1669-1672. [PMID: 31521399 DOI: 10.1016/j.jvs.2018.12.046] [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: 09/25/2018] [Accepted: 12/26/2018] [Indexed: 02/05/2023]
Abstract
Blunt traumatic aortic injury (BTAI) is a rare but life-threatening emergency that is usually caused by sudden acceleration/deceleration injuries in vehicular accidents. We describe our initial experience of a retrograde two-stage hybrid treatment approach for the emergent management of a 63-year-old motorcyclist who presented with a complicated BTAI with malperfusion syndrome. To our best knowledge, this uncommon BTAI case with fatal distal malperfusion saved by an urgent retrograde two-stage hybrid procedure has been reported rarely. This early reperfusion strategy with two-stage retrograde endovascular technique could be an effective and life-saving treatment option for polytrauma patients with suitable aortic anatomy.
Collapse
Affiliation(s)
- Hong-Wei Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yao Huang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Kai-di Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
| |
Collapse
|
37
|
Tadros RO, Tang GH, Barnes HJ, Mousavi I, Kovacic JC, Faries P, Olin JW, Marin ML, Adams DH. Optimal Treatment of Uncomplicated Type B Aortic Dissection. J Am Coll Cardiol 2019; 74:1494-1504. [DOI: 10.1016/j.jacc.2019.07.063] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/26/2019] [Indexed: 01/16/2023]
|
38
|
Heran MK, Balaji N, Cook RC. Novel Percutaneous Treatment of Cerebral Malperfusion Before Surgery for Acute Type A Dissection. Ann Thorac Surg 2019; 108:e15-e17. [DOI: 10.1016/j.athoracsur.2018.10.055] [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: 07/26/2018] [Revised: 10/05/2018] [Accepted: 10/16/2018] [Indexed: 10/27/2022]
|
39
|
Malperfusion in type A aortic dissection: results of emergency central aortic repair. Gen Thorac Cardiovasc Surg 2019; 67:594-601. [DOI: 10.1007/s11748-019-01072-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/19/2019] [Indexed: 12/25/2022]
|
40
|
Siti D, Abudesimu A, Ma X, Yang L, Ma X, Ma YT. Incidence and risk factors of recurrent pain in acute aortic dissection and in-hospital mortality. VASA 2018; 47:301-310. [PMID: 29808775 DOI: 10.1024/0301-1526/a000704] [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: 01/16/2023]
Abstract
BACKGROUND We investigated the prevalence of recurrent pain and its relationship with in-hospital mortality in acute aortic dissection (AAD). PATIENTS AND METHODS Between 2011 and 2016, 234 AAD patients were selected. Recurrent pain was defined as a mean of VAS > 3, within 48 hours following hospital admission or before emergency operation. Patients with and without recurrent pain were divided into group I and group II, respectively into type A AAD and type B AAD patients. Our primary outcome was in-hospital mortality. RESULTS The incidence of recurrent pain was 24.4 % in AAD patients. Incidence of recurrent pain was higher in type A AAD patients than type B AAD patients (48.9 vs. 9.6 %). Overall in-hospital mortality was 25.6 %. Type A AAD had a higher in-hospital mortality than type B AAD patients (47.7 vs. 12.3 %). Group I had significantly higher in-hospital mortality than group II (type A: 79.1 vs. 17.8 %; type B: 57.1 vs. 7.6 %, all P < 0.001), as was the case with medical managed patients (type A: 72.1 vs. 13.3 %; type B: 35.7 vs. 2.3 %, all P < 0.001). Logistic regression analysis showed that use of one drug alone and waist pain were predictive factors for recurrent pain in type A AAD and type A AAD patients, respectively (OR 3.686, 95 % CI: 1.103~12.316, P = 0.034 and OR 14.010, 95 % CI: 2.481~79.103, P = 0.003). Recurrent pains were the risk factors (type A: OR 11.096, 95 % CI: 3.057~40.280, P < 0.001; type B: OR 14.412, 95 % CI: 3.662~56.723, P < 0.001), while invasive interventions were protective (type A: OR 0.133, 95 % CI: 0.035~0.507, P < 0.001; type B: OR 0.334, 95 % CI: 0.120~0.929, P = 0.036) for in-hospital mortality in AAD patients. CONCLUSIONS Approximately one-fourth of AAD patients presented with recurrent pains, which might increase in-hospital mortality. Thus, interventional strategies at early stages are important.
Collapse
Affiliation(s)
- Dilixiati Siti
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Asiya Abudesimu
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaojie Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lei Yang
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiang Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yi-Tong Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| |
Collapse
|
41
|
Khayat M, Cooper KJ, Khaja MS, Gandhi R, Bryce YC, Williams DM. Endovascular management of acute aortic dissection. Cardiovasc Diagn Ther 2018; 8:S97-S107. [PMID: 29850422 DOI: 10.21037/cdt.2017.10.07] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.
Collapse
Affiliation(s)
- Mamdouh Khayat
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Kyle J Cooper
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Minhaj S Khaja
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Ripal Gandhi
- Department of Radiology, Division of Vascular and Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
| | - Yolanda C Bryce
- Department of Radiology, Division of Vascular and Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David M Williams
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| |
Collapse
|
42
|
Clendenen N, Weitzel N. Predictors of Prolonged Mechanical Ventilation in Adults After Acute Type-A Aortic Dissection Repair-Implications for the Future. J Cardiothorac Vasc Anesth 2017; 31:1562-1563. [PMID: 28864159 DOI: 10.1053/j.jvca.2017.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Nathan Clendenen
- Department of Anesthesiology University of Colorado Denver School of Medicine Aurora, CO
| | - Nathaen Weitzel
- Department of Anesthesiology University of Colorado Denver School of Medicine Aurora, CO
| |
Collapse
|
43
|
Tribble C. To Know Acute Aortic Dissection Is to Know All of Cardiovascular Surgery. Semin Thorac Cardiovasc Surg 2017; 29:186-187. [PMID: 28823326 DOI: 10.1053/j.semtcvs.2017.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 11/11/2022]
Abstract
This thought-provoking review demonstrates that, although it may be true that knowing a lot about the treatment of type A aortic dissection is essential for all cardiovascular surgeons, there remains a lot to be learned about the best possible strategies for dealing with the malperfusion syndromes that often accompany them.
Collapse
Affiliation(s)
- Curt Tribble
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia.
| |
Collapse
|