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Dumani S, Likaj E, Dibra L, Ibrahimi A, Baboci A. Giant Aneurysm of Ascending Aorta and Aortic Arch: A Report of a Rare Case. Cureus 2024; 16:e59393. [PMID: 38689670 PMCID: PMC11060756 DOI: 10.7759/cureus.59393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/02/2024] Open
Abstract
A thoracic aortic aneurysm is considered giant when its diameter exceeds 10 cm. We report a rare case of a giant aneurysm involving the ascending aorta and aortic arch in a 40-year-old man, initially diagnosed as an acute aortic dissection. The patient underwent emergency surgery, during which the ascending aorta and aortic arch were replaced under deep hypothermia and circulatory arrest with selective antegrade cerebral perfusion. Strong teamwork resulted in a favorable postoperative course for the patient.
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Affiliation(s)
- Selman Dumani
- Division of Cardiac Surgery, University Hospital Centre "Mother Theresa", Tirana, ALB
| | - Ermal Likaj
- Division of Cardiac Surgery, University Hospital Center "Mother Theresa", Tirana, ALB
| | - Laureta Dibra
- Division of Cardiac Surgery, University Hospital Center "Mother Theresa", Tirana, ALB
| | - Alfred Ibrahimi
- Division of Cardiac Surgery, University Hospital Center "Mother Theresa", Tirana, ALB
| | - Arben Baboci
- Division of Cardiac Surgery, University Hospital Center "Mother Theresa", Tirana, ALB
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Nakajima T, Iba Y, Shibata T, Arihara A, Kawaharada N. Huge, Infected Pancreatic Necrosis After Total Arch Replacement in a Patient With Immunoglobulin G4-Related Syndrome. Cureus 2024; 16:e56805. [PMID: 38654774 PMCID: PMC11036144 DOI: 10.7759/cureus.56805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/26/2024] Open
Abstract
A 77-year-old male patient with immunoglobulin (Ig)G4-related disease was diagnosed with a 60-mm aortic arch aneurysm and atherosclerosis of the aorta advanced throughout the body. Aortic arch replacement surgery was performed with circulatory arrest at 28°C. One week later, the patient developed acute pancreatitis, followed by encapsulated necrosis in the chronic phase. After debridement surgery, the patient's condition improved.
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Affiliation(s)
| | - Yutaka Iba
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Tsuyoshi Shibata
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Ayaka Arihara
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
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Brown JA, Aranda-Michel E, Navid F, Serna-Gallegos D, Thoma F, Sultan I. Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome. J Thorac Cardiovasc Surg 2024; 167:882-892.e2. [PMID: 35989124 DOI: 10.1016/j.jtcvs.2022.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/13/2022] [Accepted: 04/10/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection. METHODS This was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan-Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival. RESULTS A total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05). CONCLUSIONS Malperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Park SJ, Kim HR, Shinn SH, Kim HJ, Jung SH, Choo SJ. Aortic arch isolation to reduce cerebral embolic risk during replacement of the atherosclerotic aortic arch. J Thorac Cardiovasc Surg 2024; 167:927-934.e1. [PMID: 35606177 DOI: 10.1016/j.jtcvs.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 03/15/2022] [Accepted: 04/10/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the efficacy of isolating the upper body circulation from the lower body (isolation technique) in reducing the risk of embolic stroke during cardiopulmonary bypass in patients with severe atherosclerosis undergoing aortic arch surgery. METHODS Between 2006 and 2019, 156 patients with severe atherosclerosis undergoing total arch replacement were enrolled. Since 2017, the right axillary or innominate artery and ascending aorta were both cannulated before cardiopulmonary bypass in the isolation group (n = 30). The left common carotid artery was clamped and inserted with a 13-Fr balloon perfusion catheter. The innominate artery was clamped in succession and cardiopulmonary bypass was instituted, establishing a parallel noncommunicating circulation for the upper and lower body. Patients without atherosclerosis that were not considered at high risk of embolic complications were excluded. The no-isolation group was drawn from historically matched control patients undergoing total arch replacement. RESULTS The permanent stroke rate in the isolation and no-isolation groups were 3.3% (n = 1) and 15.9% (n = 15.9), respectively. After inverse-probability-of-treatment-weighting adjustment, the early mortality (P = .043), stroke (P = .044), and composite of early mortality or stroke (P = .005) rates were significantly lower in the isolation group. The logistic regression analysis after inverse-probability-of-treatment-weighting risk adjustment showed a significantly reduced composite risk of early death and stroke in the isolation group (odds ratio, 0.09; 95% confidence interval, 0.01-0.70; P = .023). CONCLUSIONS The isolation technique was associated with a significant reduction in early postoperative embolic stroke and mortality risks in patients with severe aortic atherosclerosis undergoing total arch replacement.
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Affiliation(s)
- Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Ho Shinn
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Xia L, Yang Z, Liu Y, Ge Y, Wang L, Jiang H. Total arch replacement via single upper hemisternotomy approach for aortic aneurysm in syphilis: Case report. Medicine (Baltimore) 2024; 103:e37222. [PMID: 38335375 PMCID: PMC10860978 DOI: 10.1097/md.0000000000037222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
RATIONALE Syphilitic aortic aneurysm is a relatively rare type of cardiovascular syphilis. A small number of patients with syphilitic aortic aneurysms will be accompanied by aortic regurgitation and coronary stenosis. Apart from aortic rupture or dissection, syphilitic aortic aneurysm often causes associated vascular disorders, including left common carotid artery, innominate artery, and celiac artery stenosis or obstruction. PATIENT CONCERNS In this case, we observed left common carotid artery occlusion based on both ultrasound and intraoperative exploration. For patients with syphilitic aortic aneurysm, the first choice is still sufficient antibiotic therapy. The surgical indications include symptom relief and prevention of aortic rupture or sudden death. DIAGNOSES Aortic valve insufficiency, aortic aneurysm, and syphilis. INTERVENTIONS Aortic valve replacement, aneurysmectomy and total arch replacement combined with frozen elephant trunk implantation via single upper hemisternotomy approach. OUTCOMES The patient did not suffer reventilation and reoperation. No transient or permanent neurological dysfunction was observed in this patient. And no acute renal failure occurred. The patient was discharged on 43 days after the operation. LESSONS SUBSECTIONS The upper hemisternotomy has the advantages of faster postoperative recovery, shorter ventilation time, shorter intensive care unit stay, less blood transfusion, and less incisional pain compared with the full sternotomy, which is one of the reasons why we chose this procedure for this patient.
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Affiliation(s)
- Lin Xia
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Zhonglu Yang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Yu Liu
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Yuguang Ge
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Lu Wang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Hui Jiang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
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Gao J, Yan J, Duan Y, Yu J, Li W, Luo Z, Yu W, Xie D, Liu Z, Xiong J. Aortic arch branch-prioritized reconstruction for type A aortic dissection surgery. Front Cardiovasc Med 2024; 10:1321700. [PMID: 38348137 PMCID: PMC10859855 DOI: 10.3389/fcvm.2023.1321700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/26/2023] [Indexed: 02/15/2024] Open
Abstract
Background Acute Stanford type A aortic dissection (STAAD) is a fatal condition requiring urgent surgical intervention. Owing to the complexity of the surgical process, various complications, such as neurological disorders, are common. In this study, we prioritized the reconstruction of aortic arch branches during surgery and investigated the association between prioritizing the branches and the postoperative outcomes of patients with STAAD. Methods Ninety-seven patients were included in the observational study and underwent total arch replacement and frozen elephant trunk technique between January 2018 and June 2021. Of these, 35 patients underwent the branch-priority technique, and 62 patients underwent the classic technique. By analyzing the perioperative outcomes, we compared the differences between the two techniques. Results The branch priority group had significantly shorter cardiopulmonary bypass and ventilator times and earlier postoperative wake-up times than the classic group. Additionally, the ICU stay time was shorter, with a significant decrease in neurological complications and 24 h drainage in the branch priority group compared to the classic group. Conclusion The branch priority technique can effectively provide better brain protection, resulting in earlier awakening of patients after surgery, reduced neurological complications, shorter ventilation time and decreased ICU hospitalization time. Therefore, it is recommended for use in aortic dissection surgeries.
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Affiliation(s)
- Jianfeng Gao
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Jie Yan
- Department of Thoracic Surgery, The First People’s Hospital of Nankang District, Ganzhou, China
| | - Yanyu Duan
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Engineering Research Center of Intelligent Acoustic Signals of Jiangxi Province, Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
- Ganzhou Cardiovascular Rare Disease Diagnosis and Treatment Technology Innovation Center, Gannan Medical University, Ganzhou, China
| | - Junjian Yu
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Wentong Li
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zhifang Luo
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Wenbo Yu
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Dilin Xie
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Ziyou Liu
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jianxian Xiong
- Heart Medical Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
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Kiziltepe U, Ince I, Senkal M, Surer S, Duvan I, Ersoy O, Delibalta O, Mavi O, Sahin E. Total aortic arch replacement without deep hypothermic circulatory arrest in type A aortic dissection: Left axillar artery for arterial cannulation. JTCVS Tech 2023; 22:120-131. [PMID: 38152213 PMCID: PMC10750496 DOI: 10.1016/j.xjtc.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Total aortic arch replacement (TAR) necessitates hypothermic circulatory arrest (CA). The frozen elephant trunk technique (FET) additionally requires commercial hybrid grafts. Herein we describe a novel modified FET technique without CA using standard grafts thanks to left axillary artery (LAxA) cannulation in patients with acute type A aortic dissection. Methods LAxA anastomosis is made first using a homemade debranching graft, and cardiopulmonary bypass is initiated, followed by anastomoses of left common carotid and innominate arteries. The rest of the operation is performed with complete cerebral perfusion. Following replacement of ascending aorta/root, cardiac reperfusion is started using a root cannula which continues throughout the procedure. Distal arch anastomosis is performed clamp-on, allowing lower body perfusion via left subclavian artery. Lower body perfusion is interrupted for 5 to 8 minutes to deploy an endograft to complete a modified FET. Following cannulation of distal arch graft, perfusion of distal aorta is restarted, and all three grafts are incorporated to construct a neo-ascending aorta and arch. Results Between December 2018 and May 2022, 38 patients underwent TAR without operative mortality. Hospital mortality was %15.7, and spinal cord ischemia and stroke were not encountered in surviving patients. The mean lower body CA time was 7.2 ± 2.8 minutes. Conclusions TAR using standard endografts without CA is possible with LAxA cannulation. To perform a FET, only a short interruption of lower body circulation is sufficient to deploy an endograft, also improving hemostasis of distal anastomosis. Further studies are required with a higher number of patients to evaluate the efficiency of this novel technique.
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Affiliation(s)
- Ugursay Kiziltepe
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ilker Ince
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Melike Senkal
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Suleyman Surer
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ibrahim Duvan
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ozgur Ersoy
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Delibalta
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Osman Mavi
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Elif Sahin
- Department of Cardiovascular Surgery, Health Sciences University Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Wang Z, Xue Y, Qian S, Liu Y, Zhu J, Sun L, Zhang H, Li H. Differences between sexes in patients who underwent total arch replacement and frozen elephant trunk procedures for acute dissection. Perfusion 2023; 38:1478-1491. [PMID: 35941723 DOI: 10.1177/02676591221118322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To analyze the effect of sex on the short-time prognosis in two different age subgroups (≤55 years old and >55 years old). METHODS From January 2009 to 2019, 1522 patients with DeBakey I acute aortic dissection (AAD) underwent frozen elephant trunk and total arch replacement at a Tertiary Center in China were divided into female group (n = 324) and male group (n = 1198). The demographic characteristics, clinical presentation, management, short-term outcomes were described in the different sex groups. The risk factors of 30-days mortality for females and males were identified by univariate and multivariable logistic regression analysis. Then, random Forest regression was used to analyze the association between age and 30-days mortality in the different sexes groups. The cut-off age for 30-days mortality in females was then identified as 55 years. The patients were divided into two subgroups: young patients (≤55 years old) and elderly patients (>55 years old). Clinical prognosis between different sex groups was further compared in the age subgroups. RESULTS Approximately four-fifths of the patients were males. Males with DeBakey I AAD were younger than females (47 vs 52 years; p < 0.01). The proportion of males gradually declined with age. The cut-off age for 30-days mortality in females and males was identified as 55 years old and 63 years old, respectively. In young patients (≤55 years old), the 30-days mortality rate for females was lower than males (hazard ratio [HR, 2.02, p < 0.05). Following adjustment using the multivariable Cox regression analysis, females were identified as an independent protective factor for 30-days mortality (HR, 2.24, p = 0.03). CONCLUSIONS Our study showed that females present with DeBakey I AAD less frequently than males and they tend to present with DeBakey AAD later in life. In young patients, females had better early outcomes despite similar time for symptom onset to diagnosis and surgical technique than males.
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Affiliation(s)
- Zeling Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Xue
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Henmi S, Nakai C, Izumi S, Nakashima Y, Tsukube T. Giant Patent Ductus Arteriosus Aneurysm Compressing the Esophagus. Ann Vasc Dis 2023; 16:265-267. [PMID: 38188975 PMCID: PMC10766742 DOI: 10.3400/avd.cr.23-00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/24/2023] [Indexed: 01/09/2024] Open
Abstract
It is extremely rare to observe aneurysmal changes in patients with patent ductus arteriosus (PDA), especially in adults. If left untreated, a PDA aneurysm can increase the risk of life-threatening complications, including rupture, dissection, esophageal fistula, and infection. Following is a description of successful surgical repair in a 55-year-old man with PDA aneurysm compressing the esophagus. Histologically, the aneurysmal wall showed mild thickening of the intima and media with hyperplastic smooth muscle cells, but no destructive changes were observed.
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Affiliation(s)
- Soichiro Henmi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, Kobe, Hyogo, Japan
| | - Chikashi Nakai
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, Kobe, Hyogo, Japan
| | - So Izumi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, Kobe, Hyogo, Japan
| | - Yutaka Nakashima
- Division of Pathology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Fukuoka, Japan
| | - Takuro Tsukube
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, Kobe, Hyogo, Japan
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Dong Z, Liu H, Kim JB, Gu J, Li M, Li G, Du J, Gu W, Shao Y, Ni B. False lumen-dependent segmental arteries are associated with spinal cord injury in frozen elephant trunk procedure for acute type I aortic dissection. JTCVS Open 2023; 15:16-24. [PMID: 37808063 PMCID: PMC10556951 DOI: 10.1016/j.xjon.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/18/2023] [Accepted: 05/02/2023] [Indexed: 10/10/2023]
Abstract
Objective To investigate the association between false lumen (FL) dependency of segmental arteries (SAs) at T9-L3 levels and the risk of spinal cord injury (SCI) following total arch replacement and frozen elephant trunk (FET) implantation in the setting of acute DeBakey type I aortic dissection (AAD). Methods The study involved consecutive patients with AAD who underwent total arch replacement and FET implantation between 2020 and 2022. Primary outcome was postoperative SCI. The inverse probability of treatment weighting (IPTW) method was employed to minimize the impact of no-randomization bias. Antegrade placement of FET was followed by end-to-end anastomosis of a 4-branch arch graft at the proximal landing site of FET. Results A total of 146 patients were included (age, 50.5 ± 11.7 years, 115 male), of whom 35 (24%) had SAs at T9-L3 levels completely dependent on FL (FL-dependency group). There was no significant difference in early (30-day or in-hospital) mortality rates between FL-dependency (14.3%) and FL-independency (18.0%) groups (P = .80), however, the rate of SCI was significantly higher in the FL-Dependency group (34.3% vs 2.7%, P < .001). After adjustments, FL dependency was associated with a significantly increased risk of SCI (odds ratio, 13.1; 95% confidence interval, 4.2-41.0; P < .001), whereas it was not significantly associated with risks of early mortality or other major complications (P = .16-.98). Conclusions FL dependency of SAs at the T9-L3 levels was significantly associated with the development of SCI following FET implantation in AAD, warning against its uses on patients presenting with FL dependency of SAs at critical segments.
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Affiliation(s)
- Zhiqiang Dong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiaxi Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minghui Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junjie Du
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weidong Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Buqing Ni
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Al-Tawil M, Jubouri M, Tan SZ, Bailey DM, Williams IM, Mariscalco G, Piffaretti G, Chen EP, Velayudhan B, Mohammed I, Bashir M. Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection? Asian Cardiovasc Thorac Ann 2023; 31:596-603. [PMID: 36560846 DOI: 10.1177/02184923221147442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement. AIMS This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase. RESULTS TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair. CONCLUSION Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.
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Affiliation(s)
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gabrielle Piffaretti
- Vascular Surgery - Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, DUMC 3442, Durham, NC, USA
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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12
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Takei Y, Wu IH, Chan CY, Chi NH. Case report: Total arch replacement with a frozen elephant trunk utilizing open hybrid in-situ fenestration technique for thoracic aortic arch aneurysm. Front Surg 2023; 10:1224013. [PMID: 37538391 PMCID: PMC10394511 DOI: 10.3389/fsurg.2023.1224013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction The frozen elephant trunk technique is a surgical procedure developed for concomitant repair of downstream descending thoracic aorta as a first stage operation for arch resections. Proximalization of the sutured anastomosis reduces technical difficulty of total arch replacement. In this procedure, an anastomosis is performed more proximally using a stent graft. Connect the head and neck vessels are created using in-situ fenestration method. Case presentation This study presents the case of a 78-year-old woman with a large thoracic aortic arch aneurysm that was successfully treated with a modified frozen elephant trunk technique (open in situ fenestration). For this method, a hole was created in the neck branches (the left subclavian artery and left common carotid artery), and peripheral stent grafts were placed to simplify neck branch reconstruction. This minimized the risk of recurrent laryngeal nerve injury and bleeding and shortened the procedure time. Conclusion The outcomes of this study showed a safe alternative total arch replacement procedure.
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Affiliation(s)
- Yusuke Takei
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University School of Medicine Graduate School of Medicine, Tochigi, Japan
| | - I-Hui Wu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chih-Yang Chan
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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13
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Lyu Y, Liu Y, Xiao X, Yang Z, Ge Y, Jiang H. High level of intraoperative lactate might predict acute kidney injury in aortic arch surgery via minimally invasive approach in patients with type A dissection. Front Cardiovasc Med 2023; 10:1188393. [PMID: 37469483 PMCID: PMC10352579 DOI: 10.3389/fcvm.2023.1188393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Background A high incidence of acute kidney injury (AKI) has been recorded in total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation in patients with acute type A dissection (ATAAD) via median sternotomy approach with some risk factors. However, the independent risk factors for AKI via a minimally invasive approach have not yet been identified. Methods A total of 207 patients with ATAAD were enrolled from January 2018 and November 2019 and were divided into AKI and non-AKI groups. The current surgical strategy was TAR combined with FET via a single upper hemisternotomy approach, a minimally invasive method. An increase in the serum creatinine (Cr) level to ≥2 times the baseline level 48 h post-surgery was defined as AKI. The morbidity of AKI was investigated with a step-by-step backward multivariate analysis of its independent risk factors and a receiver-operating characteristic curve analysis. Results Postoperative AKI was observed in 39 (18.8%) patients, and the total hospital mortality was 8.7%. Univariate analysis found that preoperative Cr, weight, circulatory arrest time ≥60 min, intraoperative highest lactate (Lac), and intraoperative transfusion had significant differences between the two groups. However, multivariate step-by-step backward logistic regression analysis identified intraoperative highest Lac and transfusion as independent risk factors for postoperative AKI and intraoperative highest Lac was identified as the most critical independent risk factor estimated by the partial chi-square statistic minus the predicted degrees of freedom with 4.3 mmol/L as the optimal cut-off point for prediction for AKI. Conclusions Intraoperative highest Lac and transfusion were independent risk factors for postoperative AKI, which led to high hospital mortality. Moreover, intraoperative highest Lac was the most critical independent risk factor and high level of intraoperative highest Lac (4.3 mmol/L) might predict for postoperative AKI.
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Affiliation(s)
- Ying Lyu
- Graduate School, China Medical University, Shenyang, China
| | - Yu Liu
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiong Xiao
- Graduate School, China Medical University, Shenyang, China
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhonglu Yang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yuguang Ge
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Hui Jiang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
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14
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Wilson King R, Carroll AM, Higa KC, Cleveland JC, Rove JY, Aftab M, Brett Reece T. Frozen Elephant Trunk for Acute Type A Dissection: Is Risk from Procedure or Patient Characteristics? Aorta (Stamford) 2023; 11:112-115. [PMID: 37619568 PMCID: PMC10449567 DOI: 10.1055/s-0043-1768970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/07/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND The initial goal of acute Type A aortic dissection (ATAAD) repair remains to get the patient off the table safely. More extensive repair is being pushed at the index operation with the frozen elephant trunk (FET) operation, but outcomes are suggested to be worse. However, we hypothesize that the risk associated with the FET in ATAAD is from the patient presenting factors rather than the operation itself. METHODS A retrospective review of a single institution prospective database from 2015 to 2021 was performed. Two cohorts were created based on the indication for FET: evidence of radiographic malperfusion (n = 44) or clinical malperfusion (n = 31). Data were analyzed for preoperative characteristics, intraoperative characteristics, and postoperative outcomes. Statistical univariate analysis was performed with chi-square analysis and t-tests with significance determined at an alpha level of 0.05. RESULTS Preoperative characteristics were similar in each group, independent of malperfusion markers. The intraoperative characteristics were similar, except the clinical malperfusion group had more packed red blood cells and cryoprecipitate given. The clinical malperfusion group had longer intensive care unit length of stay (p < 0.001), more postoperative strokes (p < 0.001), more reoperations (p <0.0001), and higher mortality rate (p = 0.0003). CONCLUSION These data suggest that clinical malperfusion increases the risk of major complications and death. However, full arch replacement with FET in the absence of clinical malperfusion does not appear to add risk to the operation for ATAAD. Patients with increased risk of distal degeneration should be considered for more aggressive replacement to avoid subsequent arch replacement.
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Affiliation(s)
- R. Wilson King
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Adam M. Carroll
- Department of Surgery, University of Colorado, Denver, Colorado
| | - Kelly C. Higa
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Joseph C. Cleveland
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Jessica Y. Rove
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Muhammad Aftab
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
| | - Thomas Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado, Denver, Colorado
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15
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Takeyoshi D, Konuma T, Kojima A, Takeuchi T. Total arch replacement for re-coarctation of the aorta after a Norwood procedure. Asian Cardiovasc Thorac Ann 2023; 31:266-268. [PMID: 36683326 DOI: 10.1177/02184923231151568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This is the first report of total arch replacement to repair re-coarctation. A 14-year-old boy with hypoplastic left heart syndrome developed re-coarctation, severe stenosis of neck vessels, and right ventricle dysfunction after a Norwood procedure. We performed total arch replacement; the postoperative course was unremarkable. He was followed up until 18 years of age and did not need re-intervention. Using artificial blood vessels in total arch replacement is rarely indicated but can be safely achieved when required. Mismatch between patient and graft size may be an issue in the future.
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Affiliation(s)
- Daisuke Takeyoshi
- Department of Cardiovascular Surgery, 36699Nagano Children's Hospital, Azumino, Nagano, Japan
| | - Takeshi Konuma
- Department of Cardiovascular Surgery, 36699Nagano Children's Hospital, Azumino, Nagano, Japan
| | - Ai Kojima
- Department of Cardiovascular Surgery, 36699Nagano Children's Hospital, Azumino, Nagano, Japan
| | - Takamasa Takeuchi
- Department of Cardiovascular Surgery, 36699Nagano Children's Hospital, Azumino, Nagano, Japan
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16
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Ho JYK, Kim CH, Chow SCY, Kwok MWT, Lee H, Kim TH, Fujikawa T, Wong RHL, Song SW. Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies. J Thorac Dis 2023; 15:484-493. [PMID: 36910067 PMCID: PMC9992573 DOI: 10.21037/jtd-22-1055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/24/2022] [Indexed: 02/24/2023]
Abstract
Background Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. Methods We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Results Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. Conclusions We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.
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Affiliation(s)
- Jacky Y. K. Ho
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Chong Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Simon C. Y. Chow
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Micky W. T. Kwok
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Ha Lee
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Takuya Fujikawa
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Randolph H. L. Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, South Korea
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17
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Sultan I, Bianco V, Aranda-Michel E, Kilic A, Serna-Gallegos D, Navid F, Wang Y, Gleason TG. The use of blood and blood products in aortic surgery is associated with adverse outcomes. J Thorac Cardiovasc Surg 2023; 165:544-551.e3. [PMID: 33838909 DOI: 10.1016/j.jtcvs.2021.02.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products. METHODS All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival. RESULTS A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001). CONCLUSIONS In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.
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Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Xie LF, He J, Wu QS, Qiu ZH, Jiang DB, Gao HQ, Chen LW. Do obese patients with type A aortic dissection benefit from total arch repair through a partial upper sternotomy? Front Cardiovasc Med 2023; 10:1086738. [PMID: 36776260 PMCID: PMC9915564 DOI: 10.3389/fcvm.2023.1086738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/11/2023] [Indexed: 02/14/2023] Open
Abstract
Background Minimal research has been performed regarding total arch replacement through partial upper sternotomy in patients with acute type A aortic dissection who are obese, and the safety and feasibility of this procedure need to be further investigated. The present study investigated the potential clinical advantages of using a partial upper sternotomy versus a conventional full sternotomy for total arch replacement in patients who were obese. Methods This was a retrospective study. From January 2017 to January 2020, a total of 65 acute type A aortic dissection patients who were obese underwent total arch replacement with triple-branched stent graft. Among them, 35 patients underwent traditional full sternotomy, and 30 patients underwent partial upper sternotomy. The perioperative clinical data and postoperative follow-up results of the two groups were collected, and the feasibility and clinical effect of partial upper sternotomy in total arch replacement were summarized. Results The in-hospital mortality rates of the two groups were similar. The total operative time, cardiopulmonary bypass, aortic cross-clamp, cerebral perfusion, and deep hypothermic circulatory arrest times were also similar in both groups. The thoracic drainage and postoperative red blood cell transfusion volumes in the partial upper sternotomy group were significantly lower than those in the full sternotomy group. Mechanical ventilation time was shorter in the partial upper sternotomy group than that in the full sternotomy group. Additionally, the incidences of pulmonary infection, hypoxemia, and sternal diaphoresis were lower in the partial upper sternotomy group than those in the full sternotomy group. Conclusion This study showed that total arch replacement surgery through a partial upper sternotomy in patients with acute type A aortic dissection who are obese is safe, effective, and superior to full sternotomy in terms of blood loss, postoperative blood transfusion, and respiratory complications.
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Affiliation(s)
- Lin-Feng Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian He
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qing-Song Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhi-Huang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - De-Bin Jiang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hang-Qi Gao
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liang-wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China,*Correspondence: Liang-wan Chen,
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Kim CH, Song SW. How we repair acute type A dissection in Gangnam severance hospital. Asian Cardiovasc Thorac Ann 2023; 31:48-50. [PMID: 35678833 DOI: 10.1177/02184923221106776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Total arch replacement for aortic dissection is traditionally associated with high mortality and morbidity rates. Here, we share our strategies for improving surgical outcomes such as Y incision, unilateral antegrade cerebral perfusion, Teflon felt neo-media formation, and reinforcement of the anastomosis site.
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Affiliation(s)
- Chong Hoon Kim
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, 65655Gangnam Severance Hospital, Seoul, Republic of South Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, 65655Gangnam Severance Hospital, Seoul, Republic of South Korea
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20
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Okada K. Total arch replacement: When and how? Asian Cardiovasc Thorac Ann 2023; 31:42-47. [PMID: 35509182 DOI: 10.1177/02184923211073374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high hospital mortality rate. Open aortic surgery for ATAAD is always required to save the patient, particularly elderly patients. Tear-oriented surgery is recommended as the frontline treatment for ATAAD, and hemiarch replacement (HAR) is sufficient because the primary entry is often observed in the ascending aorta (60%-70%). However, HAR has some drawbacks, such as new creation of an anastomotic entry and unfavorable distal aortic remodeling during long-term follow-up. Although total arch replacement (TAR) is a demanding procedure, it is another useful option for ATAAD. Proper patient selection for TAR is controversial. Standardized procedure for TAR, including the optimal brain protection methods and the use of excellent sealed vascular prosthetic grafts, has been established over the past decades. Therefore, TAR is increasingly being selected for HAR in patients who are young or have enlarged aortic arch, severely dissected supra-aortic arch vessels, or hereditary thoracic aortic disorders. The emerging technology of commercially available frozen elephant trunk accelerated the application of TAR, facilitates distal anastomosis, and improves distal aortic remodeling. Although further evidence is required, TAR could be the best choice for HAR for selected patients. Currently, appropriate selection of the surgical technique is important to maximize the benefits of open surgery for ATAAD.
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Affiliation(s)
- Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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21
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Sugiyama K, Watanuki H, Tochii M, Futamura Y, Ishizuka K, Matsuyama K. Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta. Ann Vasc Dis 2022; 15:295-300. [PMID: 36644259 PMCID: PMC9816034 DOI: 10.3400/avd.oa.21-00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/04/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.
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Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan,Corresponding author: Kayo Sugiyama, MD, PhD. Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195, Japan Tel: +81-561-62-3311, Fax: +81-561-63-6193, E-mail:
| | - Hirotaka Watanuki
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Masato Tochii
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Yasuhiro Futamura
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Koki Ishizuka
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Katsuhiko Matsuyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
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22
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Chang Y, Guo H, Yu C, Sun X, Yang K, Qian X. Visceral protection in total arch replacement for aortic dissection: Effect of lower body hypothermia. J Card Surg 2022; 37:4841-4849. [PMID: 36352779 DOI: 10.1111/jocs.17104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Optimal hypothermia strategy for total arch replacement in acute type A aortic dissection (ATAAD) is unclear. A higher temperature during circulatory arrest might reduce tolerance to ischemia for visceral organs. We sought to investigate the effect of hypothermia on visceral protection. METHODS From January 2010 to December 2019, 1138 consecutive patients underwent total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data were retrospectively collected and analyzed. Visceral organ injury and visceral-related adverse outcomes were defined as acute renal failure or spinal cord injury or both. Multivariate logistic regression analysis and multivariate linear regression model were used. RESULTS The mean age of patient was 46.9 ± 10.0 years, with a male preponderance (79.6%). Operative mortality was 6.1% (69 patients). Spinal cord injury occurred in 55 (4.8%) patients and 133 (11.7%) patients had acute renal failure. In the multivariate logistic regression model, neither bladder temperature (odds ratio [OR] 0.971, 95% confidence interval [CI] 0.922-1.024, p = .278) nor circulatory arrest duration (OR 1.017, 95% CI 0.987-1.047, p = .267) significantly associated with visceral-related adverse outcomes. Female, lower limb malperfusion, age, cardiopulmonary bypass (CPB) duration and preoperative serum creatinine level were independent risk factors of visceral-related outcomes. There was a significant negative correlation between bladder temperature and CPB duration in multiple linear regression model (β = -3.67, p < .0001). CONCLUSIONS Bladder temperature had no effect on outcomes related to visceral protection under the premise of short circulatory arrest duration, but female gender, lower limb malperfusion, age, CPB duration, and preoperative serum creatinine level were independent risk factors. Bladder temperature negatively correlated to CPB duration.
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Affiliation(s)
- Yi Chang
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Hongwei Guo
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Cuntao Yu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Xiaogang Sun
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Kan Yang
- Department of Cardiovascular Surgery, Nanyang central hospital, Nanyang, P. R. China
| | - Xiangyang Qian
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
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23
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Brown JA, Serna-Gallegos D, Zhu J, Warraich N, Yousef S, Aranda-Michel E, Bianco V, Sultan I. The impact of prior cardiac surgery on patients undergoing surgical repair for acute type A aortic dissection. J Card Surg 2022; 37:4748-4754. [PMID: 36352813 DOI: 10.1111/jocs.17121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the impact of reoperative versus first-time sternotomy for emergent open repair of acute Type A aortic dissection (ATAAD). METHODS This was an observational study of consecutive aortic surgeries from 2007 to 2021. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of reoperative versus first-time sternotomy upon survival after ATAAD repair. RESULTS A total of 601 patients with ATAAD were identified, of which 72 (12%) underwent reoperative sternotomy. The reoperative group had a higher prevalence of baseline comorbidities, including hypertension, diabetes, peripheral vascular disease, atrial fibrillation, and coronary artery disease. Central cannulation of the aorta was achieved at a similar rate across each group (81.9% vs. 81.5%, p = .923), and cardiopulmonary bypass (CPB) time was similar across each group (204 ± 84.8 vs. 203 ± 72.4 min, p = .923). Postoperative outcomes were similar across both groups, including in-hospital mortality, stroke, pulmonary complications, renal failure, and reexploration for excessive bleeding. Five-year survival was 74.5% (70.5, 78.3) for the first-time group and was 71.6% (60.0, 81.9) for the reoperative group. After multivariable Cox regression, reoperative sternotomy was not significantly associated with an increased hazard of death compared to first-time sternotomy (hazards ratio: 0.90, 95% confidence interval: 0.56, 1.43, p = .642). CONCLUSIONS These findings suggest that re-sternotomy can be safely performed with similar outcomes as first-time sternotomy. Central initiation of CPB after sternal reentry limits CPB time and may therefore represent a protective strategy that enhances outcomes for patients presenting with ATAAD and prior cardiac surgery.
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Affiliation(s)
- James A Brown
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nav Warraich
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Valentino Bianco
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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24
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Yang Z, Jiang H, Liu Y, Ge Y, Wang H. Both J- and L-shaped upper hemisternotomy approaches are suitable for total arch replacement with frozen elephant trunk in patients with Type A dissection. Front Cardiovasc Med 2022; 9:998139. [PMID: 36440043 PMCID: PMC9687356 DOI: 10.3389/fcvm.2022.998139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/26/2022] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Minimally invasive total arch replacement (TAR) with frozen elephant trunk (FET) implantation can be carried out through J-, L-, and inverted T-shaped upper ministernotomy. L- and inverted T-shaped upper ministernotomy are selected mostly for their better surgical view compared to J-shaped. However, few studies have paid attention to the difference in clinical effects between J- and L-shaped upper hemisternotomy in acute Type A aortic dissection (ATAAD). MATERIALS AND METHODS We retrospectively analyzed 74 consecutive patients with ATAAD who underwent TAR with FET implantation between December 2019 and October 2020. Patients were divided into the L group (n = 31, L-shaped upper hemisternotomy) and the J group (n = 43, J-shaped upper hemisternotomy). Perioperative characteristics were recorded. RESULTS No significant difference was found in any of the pre-operative, post-operative, or follow-up variables between the two groups. However, the CPB establishment time in the J group was significantly shorter than that in the L group (65.0 ± 17.9 min vs. 77.9 ± 17.2 min, P < 0.05). Other intraoperative variables showed no significant difference. CONCLUSION Total arch replacement with frozen elephant trunk implantation is feasible and can be carried out safely through J-shaped or L-shaped incision. A J-shaped incision might be beneficial for single incision, while an L-shaped incision might be beneficial if an extra incision is required to achieve better artery perfusion.
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Affiliation(s)
| | | | - Yu Liu
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
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25
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Hashizume K, Matsuoka T, Mori M, Takaki H, Koizumi K, Kaneyama H, Funaishi K, Kuroo K, Shimizu H. Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome. JTCVS Tech 2023; 17:1-9. [PMID: 36820356 DOI: 10.1016/j.xjtc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/25/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
Objective Emergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called "branched stented anastomosis frozen elephant trunk repair." Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A. Methods We compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration. Results Of 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75 ± 24, 118 ± 47), total operation (313 ± 83, 470 ± 151), and cardiopulmonary bypass (195 ± 46, 277 ± 96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P < .001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery-related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P < .05). Conclusions Extended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.
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Key Words
- AADA, acute aortic dissection type A
- B-SAFER, branched stented anastomosis frozen elephant trunk repair
- CT, computed tomography
- CTAR, conventional total arch replacement
- EAVR, estimated arch vessel reconstruction
- EB-SAFER
- EB-SAFER, extended branched stented anastomosis frozen elephant trunk repair
- FET, frozen elephant trunk
- FFP, fresh-frozen plasma
- HCA, hypothermic circulatory arrest
- LSCA, left subclavian artery
- RBC, red blood cells
- SACP, selective antegrade cerebral perfusion
- SAVSTEB, supra-aortic vessel anastomosis stent bridging
- TAR, total arch replacement
- acute aortic dissection type A
- frozen elephant trunk
- total arch replacement
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26
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Tong G, Zhao S, Wu J, Sun Z, Zhuang D, Chen Z, Liu Y, Yang Y, Fan R, Sun T. Right axillary artery cannulation in acute type A aortic dissection with involvement of the right axillary artery. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01064-9. [PMID: 36464509 DOI: 10.1016/j.jtcvs.2022.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/06/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The right axillary artery is currently recommended for arterial cannulation in surgery for acute type A aortic dissection. However, the feasibility of cannulation on a dissected right axillary artery remains undetermined. The objective was to examine the feasibility of cannulation on a dissected right axillary artery. METHODS From 2016 to 2020, 835 patients who underwent acute type A aortic dissection repair were included in this study. Cannulation strategy and perioperative outcomes of patients who did and did not have right axillary artery dissection were compared. Propensity score matching and logistic regression were applied. RESULTS A total of 124 patients had right axillary artery dissection, and 711 patients did not. Direct right axillary artery cannulation was used for cardiopulmonary bypass in the majority of patients, but with a lower rate in patients with right axillary artery dissection (n = 88 [71.0%] vs n = 579 [81.4%], P = .007). Right axillary artery cannulation failure (n = 3 [2.4%] vs n = 5 [0.7%], P = .102) and related complications (n = 1 [0.8%] vs n = 6 [0.8%], P = 1.000) were rare in both groups. In-hospital mortality (n = 18 [14.5%] vs n = 59 [8.3%], P = .027) and stroke (n = 14 [11.3%] vs n = 42 [5.9%], P = .027) were significantly higher in the right axillary artery dissection group, but after propensity score matching, in-hospital outcomes were comparable. Right axillary artery dissection was not a risk factor for mortality, stroke, right axillary artery cannulation not performed, or right axillary artery cannulation failure. CONCLUSIONS Direct right axillary artery cannulation is feasible for most patients with acute type A aortic dissection with right axillary artery dissection.
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Affiliation(s)
- Guang Tong
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Shuang Zhao
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; School of Medicine, Jishou University, Jishou, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Zhongchan Sun
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Donglin Zhuang
- Department of Cardiovascular Surgery, Department of Structural Heart Disease, National Center for Cardiovascular Disease, China and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zerui Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yaorong Liu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yongchao Yang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.
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27
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Hayashi J, Nakajima H, Asakura T, Sho R, Tokunaga C, Takazawa A, Yoshitake A. Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial? JTCVS Open 2022; 11:14-22. [PMID: 36172444 PMCID: PMC9510885 DOI: 10.1016/j.xjon.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 05/26/2022] [Accepted: 06/17/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1. METHODS We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the TAR group, the HAR group was older (68.1 vs 60.9 years; P < .01) and had more thrombosed false lumen (28.8% vs 4.1%, P < .01). RESULTS In-hospital death occurred for 7 patients in the HAR group and 1 patient in the TAR group (P = .17). More patients in the TAR group had a postoperative thrombosed false lumen, compared with the HAR group (68% vs 54%, P = .03). In patients with preoperative nonthrombosed false lumen in the HAR group, the rate of postoperative thrombosis was significantly lower than with versus without an open stent (31% vs 65%, P = .01). The rate of freedom from an aortic arch event in the TAR group at 5 years was significantly greater than that in the HAR group (100% vs 83.7%, P = .01). CONCLUSIONS Stented elephant trunk with TAR provided a high rate of false lumen thrombosis and a low incidence of arch events, whereas an open stent during HAR was not beneficial in terms of false lumen thrombosis and arch event prevention.
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Affiliation(s)
- Jun Hayashi
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Ri Sho
- Department of Public Health & Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Chiho Tokunaga
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Akitoshi Takazawa
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, International Medical Center, Saitama Medical University, Saitama, Japan
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Abstract
Early surgical intervention is critical for treatment of aortic arch aneurysms and dissections, but limited comprehensive data exist to define the optimal approach for surgical management with respect to postoperative outcomes. We conducted a systematic review of the 2 most common surgical approaches-total arch replacement and hybrid arch repair. We referenced the electronic PubMed database reporting on outcomes for these surgical approaches from inception to June 2022. Our initial search query returned a total of 2,517 records. All records were independently screened for adherence to our inclusion criteria and a total of 12 retrospective cohort studies were identified as appropriate for inclusion. Across the included studies, a total of 618 patients underwent hybrid repair, as compared to 2,104 patients who underwent total arch replacement. We found that most of the literature supported the findings of similar rates of permanent neurologic dysfunction, acute kidney injury, and short-term mortality between approaches and higher postoperative reintervention rates following hybrid repair. Reported outcomes of studies included in this review often conflicted regarding midterm and long-term survival, as well as hospital and intensive care unit length of stay following open and hybrid repair. Future studies should address midterm and long-term survival with a prospective study design.
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Affiliation(s)
- Omar M Sharaf
- College of Medicine, 12233University of Florida, Gainesville, FL, USA
| | - Patrick D Kohtz
- Department of Surgery, Division of Cardiovascular Surgery, 440202University of Florida Health, Gainesville, FL, USA
| | - George J Arnaoutakis
- Department of Surgery, Division of Cardiovascular Surgery, 440202University of Florida Health, Gainesville, FL, USA
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Brown JA, Serna-Gallegos D, Navid F, Thoma FW, Zhu J, Kumar R, Aranda-Michel E, Bianco V, Yousef S, Sultan I. The long-term impact of acute renal failure after aortic arch replacement for acute type A aortic dissection. J Card Surg 2022; 37:2378-2385. [PMID: 35582756 DOI: 10.1111/jocs.16614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the long-term impact of developing acute renal failure (ARF) on survival after open aortic arch reconstruction for acute type A aortic dissection (ATAAD). METHODS This was an observational study of consecutive aortic surgeries from 2007 to 2021. Patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by the presence or absence of postoperative ARF (by RIFLE criteria). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. RESULTS A total of 601 patients undergoing open surgery for ATAAD were identified, of which 516 (85.9%) did not develop postoperative ARF, while 85 (14.1%) developed ARF, with a median follow-up time of 4.6 years (1.6, 7.9). Baseline characteristics were similar across each group, except for higher rates of branch vessel malperfusion and lower preoperative ejection fraction in the ARF group. Patients with ARF underwent more total arch replacement and elephant trunk procedures, with longer cardiopulmonary bypass and circulatory arrest times than patients without ARF. ARF was associated with worse short-term outcomes, including increased in-hospital mortality, prolonged mechanical ventilation, higher rates of sepsis, more blood transfusions, and longer length of hospital stay. Unadjusted Kaplan-Meier survival estimates were significantly lower in the ARF group, compared to the group without ARF (p < .001, log-rank test). After multivariable adjustment, the development of postoperative ARF was significantly associated with an increased hazard of death over the study's follow-up time-period (hazard ratio: 2.74, 95% confidence interval: 1.95, 3.86, p < .001). CONCLUSIONS ARF is a highly morbid postoperative event that may adversely impact long-term survival after aortic surgery.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd W Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rishabh Kumar
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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30
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Chang Y, Lin H, Qian X, Guo H, Yu C, Sun X, Wei B, Ma Q, Wei Y, Shi Y. Comparison of Single Axillary vs. Dual Arterial Cannulation for Acute Type a Aortic Dissection: A Propensity Score Matching Analysis. Front Cardiovasc Med 2022; 9:809493. [PMID: 35282342 PMCID: PMC8904879 DOI: 10.3389/fcvm.2022.809493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
Background The optimal arterial cannulation site for acute aortic dissection repair is unclear, especially for complex arch surgery. Axillary artery cannulation is widely accepted but adding femoral artery cannulation to it was considered to potentially improve perfusion and early outcomes. To clarify this point, a comparison of perioperative outcomes for these two different cannulation strategies was conducted regarding the pathological features of dissection. Methods From January 2010 to December 2019, 927 consecutive patients underwent a total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data, including detailed pathological features, were retrospectively collected and analyzed. Propensity score matching and multivariate logistic regression analysis were used for adjusting confounders that are potentially related to the outcome. Results A total of 523 patients (56.3%) accepted a dual arterial cannulation (DAC group), and 406 patients (43.7%) received a single axillary artery cannulation (SAC group). In total, 388 pairs of patients were well-matched. Whether before or after adjusting the preoperative characteristics by matching, there were no significant differences in operative mortality (6.7 vs. 5.4%, P = 0.420 before matching; 5.4 vs. 5.4%, P = 1 after matching), stroke (6.7 vs. 5.4%, P = 0.420 before matching; 6.4 vs. 5.2%, P = 0.435 after matching), spinal cord injury (5 vs. 5.7%, P = 0.640 before matching; 5.4 vs. 5.7%, P = 1. After matching), and acute renal failure requiring dialysis (13.8 vs. 9.6%, P =0.050 before matching; 12.6 vs. 9.5%, P = 0.174) between the two groups. Dual arterial cannulation was not an independent protective factor of operative mortality (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.55–1.86), stroke (OR 1.17, 95% CI 0.65–2.11), spinal cord injury (OR 1.17, 95% CI 0.65–2.11), and acute renal failure requiring continuous renal replacement therapy (CRRT) (OR 1.24, 95% CI 0.78–1.97) after adjusting for confounding factors by multivariable logistic regression analysis. In the subgroup analysis, no advantage of dual arterial cannulation was found for a particular population. Conclusions Single axillary artery cannulation was competent in the complex arch repair for acute aortic dissection, presenting with a satisfactory result as dual arterial cannulation. Adding femoral artery cannulation was necessary when a sufficient flow volume could not be achieved by axillary artery cannulation or when a lower limb malperfusion existed.
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Affiliation(s)
- Yi Chang
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongyuan Lin
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Bo Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Qiong Ma
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yizhen Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yi Shi
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Cardiovascular Institute, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
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Wang SP, Xue Y, Li HY, Jiang WJ, Zhang HJ. High-TSH Subclinical Hypothyroidism Is Associated With Postoperative Mortality in Acute Type A Aortic Dissection. Front Endocrinol (Lausanne) 2022; 13:844787. [PMID: 35574037 PMCID: PMC9102593 DOI: 10.3389/fendo.2022.844787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/31/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism can negatively affect the cardiovascular system and increase the risk of mortality, especially for individuals with thyroid-stimulating hormone (TSH) levels above 10 mU/L. We investigated the relationship between high-TSH subclinical hypothyroidism and postoperative mortality in acute type A aortic dissection (ATAAD) patients. METHOD We enrolled 146 patients with ATAAD who underwent aortic surgery in Beijing Anzhen Hospital from July 2016 to November 2018. Thyroid hormone levels were obtained before surgery, and participants were divided into a ≥10mU/L TSH level group and a <10mU/L level group. Cox proportional hazard regression and subgroup analysis were conducted to examine the association of preoperative high-TSH subclinical hypothyroidism with postoperative mortality. RESULT Participants with preoperative high-TSH (≥10mU/L) subclinical hypothyroidism tended to have longer hospitalization stays after surgery [16.0 (IQR 11.0-21.0) days vs 12.5 (IQR 8.0-16.0) days, P=0.001]. During the first 30 days after operation, 15 of 146 patients died (10.3%); during a median of 3.16 (IQR 1.76-4.56) years of follow-up, 24 patients died (16.4%). Cox proportional hazard regression showed that preoperative high-TSH subclinical hypothyroidism was independently associated with 30-day mortality (HR=6.2, 95% CI, 1.7-22.0, P=0.005) and postoperative mortality after adjusting for age, sex, BMI, hypertension, ejection fraction, diabetes and history of PCI (HR=3.4, 95% CI, 1.4-8.0, P=0.005). CONCLUSION This study showed that preoperative high-TSH subclinical hypothyroidism was an independent predictor of postoperative mortality in ATAAD patients who underwent aortic surgery.
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Affiliation(s)
- Shi-Pan Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital,Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
- Key Laboratory of Medical Engineering for Cardiovascular Disease, Beijing, China
| | - Yuan Xue
- Department of Cardiac Surgery, Beijing Anzhen Hospital,Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
- Key Laboratory of Medical Engineering for Cardiovascular Disease, Beijing, China
| | - Hai-Yang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital,Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
- Key Laboratory of Medical Engineering for Cardiovascular Disease, Beijing, China
- *Correspondence: Hai-Yang Li, ; Wen-Jian Jiang, ; Hong-Jia Zhang,
| | - Wen-Jian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital,Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
- Key Laboratory of Medical Engineering for Cardiovascular Disease, Beijing, China
- *Correspondence: Hai-Yang Li, ; Wen-Jian Jiang, ; Hong-Jia Zhang,
| | - Hong-Jia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital,Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
- Key Laboratory of Medical Engineering for Cardiovascular Disease, Beijing, China
- *Correspondence: Hai-Yang Li, ; Wen-Jian Jiang, ; Hong-Jia Zhang,
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Omiya H, Takatori M, Yunoki K, Morimatsu H. Factors for Acute Kidney Injury Following Total Arch Replacement and Association with Temperature Management During Cardiopulmonary Bypass: A Single-center Retrospective Observational Study. Acta Med Okayama 2021; 75:585-593. [PMID: 34703041 DOI: 10.18926/amo/62771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Many patients develop acute kidney injury (AKI) after vascular surgery. In this retrospective observational study, we investigated the risk factors for AKI defined using the Kidney Disease Improving Global Outcomes criteria after total arch replacement (TAR). Additionally, we investigated the influence of temperature manage-ment during cardiopulmonary bypass (CPB) on postoperative renal function by propensity score-matched anal-ysis. We retrospectively analyzed 161 consecutive patients who underwent TAR between 2016 and 2019. Postoperative AKI occurred in 48.7% of the patients. In the multivariate analysis, male sex (odds ratio [OR] 3.95, 95% confidence interval [95%CI] 1.56-8.27, p = 0.002), ACE inhibitors/ARB medication (OR 3.19, 95%CI 1.49-6.82, p = 0.003), preoperative chronic kidney disease (OR 2.47, 95%CI 1.17-5.23, p = 0.02), pro-longed CPB time (OR 2.36, 95%CI 1.05-5.34, p = 0.04), and lower body ischemic time during CPB (OR 2.20, 95%CI 1.05-4.46, p = 0.04) were identified as independent risk factors for AKI. Propensity score-matched anal-ysis showed no significant difference in the risk of AKI following TAR between mild hypothermia or normo-thermia and moderate hypothermia (37.2% vs. 41.9%, p = 0.83). In conclusion, modifiable risk factors for AKI included prolonged CPB time and lower body ischemic time. Temperature management during CPB had no clear effect on outcomes.
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Affiliation(s)
- Hiroki Omiya
- Department of Anesthesiology and Critical Care Medicine, Hiroshima Citizens Hospital.,Department of Anesthesiology and Resuscitation, Okayama University Hospital
| | - Makoto Takatori
- Department of Anesthesiology and Critical Care Medicine, Hiroshima Citizens Hospital
| | - Keiji Yunoki
- Department of Cardiovascular Surgery, Hiroshima Citizens Hospital
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitation, Okayama University Hospital
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Gocoł R, Bis J, Hudziak D, Piekarska M, Morkisz Ł, Deja MA. Open aortic arch surgery: 10 years' single-center experience. Kardiochir Torakochirurgia Pol 2021; 18:159-64. [PMID: 34703473 DOI: 10.5114/kitp.2021.109395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022]
Abstract
Introduction Open aortic arch surgery is a complex cardiac surgical procedure. Aim We reviewed the 10-year outcomes of elective aortic arch aneurysm surgery in a single cardiac surgical center. Material and methods The analysis includes all patients who underwent elective aortic arch surgery at our institution between January 2010 and December 2020. The study population was divided into group A consisting of patients operated on during the first 5 years, and group B, including patients operated on during the subsequent 5 years. The groups were compared with regard to baseline characteristics, scope of the surgery, operative and postoperative data as well as morbidity and mortality. Results Eighty-six elective aortic arch procedures were performed during the analyzed period, including 25 (29%) patients in group A and 61 (71%) patients in group B. The hemiarch procedure was more frequently performed in group A (17 patients, 68%) in comparison to group B (21 patients, 34%) (p = 0.008). Stroke was recorded in 6 (20%) patients from group A and 5 (8.2%) patients from group B (p = 0.002). Five-year survival was 60 ±9.8% for group A, and 81 ±6.2% for group B (log-rank test, p = 0.003). Conclusions After completion of the learning curve, open aortic arch surgery is associated with acceptable early mortality, low incidence of stroke, and a high 5-year survival rate.
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Liu P, Wen B, Liu C, Xu H, Zhao G, Sun F, Zhang H, Yao X. En Bloc Arch Reconstruction With the Frozen Elephant Trunk Technique for Acute Type a Aortic Dissection. Front Cardiovasc Med 2021; 8:727125. [PMID: 34651025 PMCID: PMC8505743 DOI: 10.3389/fcvm.2021.727125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: The study objective was to evaluate the effect of en bloc arch reconstruction with frozen elephant trunk (FET) technique for acute type A aortic dissection. Methods: 41 patients with acute Stanford type A dissection underwent en bloc arch reconstruction combined with FET implantation between April 2018 and August 2020. The mean age of the patients was 46 ± 13 years, and 9 patients were female. One patient had Marfan syndrome. Six patients had pericardial tamponade, 9 had pleural effusion, 5 had transient cerebral ischemic attack, and 3 had chronic kidney disease. Results: The hospital mortality rate was 9.8% (4 patients). 2 (4.9%) patients had stroke, 23 (56.1%) had acute kidney injury, and 5 (12.2%) had renal failure requiring hemodialysis. During follow-up, the rate of complete false lumen thrombosis was 91.6% (33/36) around the FET, 69.4% (25/36) at the diaphragmatic level, and 27.8% (10/36) at the superior mesenteric artery level. The true lumen diameter at the same three levels of the descending aorta increased significantly while the false lumen diameter reduced at the two levels: pulmonary bifurcation and the diaphragm. The 1-, 2-and 3-year actuarial survival rates were 90.2% [95% confidence interval (CI), 81.2–99.2], 84.2% (95% CI, 70.1–98.3) and 70.2% (95% CI, 42.2–98), respectively. Conclusions: In patients with acute type A dissection, en bloc arch reconstruction with FET technique appeared to be feasible and effective with early clinical follow-up results. Future studies including a large sample size and long-term follow-up are required to evaluate the efficacy.
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Affiliation(s)
- Penghong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bing Wen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huashan Xu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guochang Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hang Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xingxing Yao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Luo C, Qi R, Zhong Y, Chen S, Liu H, Guo R, Ge Y, Sun L, Zhu J. Early and Long-Term Follow-Up for Chronic Type B and Type Non-A Non-B Aortic Dissection Using the Frozen Elephant Trunk Technique. Front Cardiovasc Med 2021; 8:714638. [PMID: 34595221 PMCID: PMC8476759 DOI: 10.3389/fcvm.2021.714638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background: This study aimed to evaluate the early and long-term outcomes of a single center using a frozen elephant trunk (FET) procedure for chronic type B or non-A non-B aortic dissection. Methods: From February 2009 to December 2019, 79 patients diagnosed with chronic type B or non-A non-B aortic dissection who underwent the FET procedure were included in the present study. We analyzed operation mortality and early and long-term outcomes, including complications, survival and interventions. Results: The operation mortality rate was 5.1% (4/79). Spinal cord injury occurred in 3.8% (3/79), stroke in 2.5% (2/79), and acute renal failure in 5.1% (4/79). The median follow-up time was 53 months. The overall survival rates were 96.2, 92.3, 88.0, 79.8, and 76.2% at 1/2, 1, 3, 5 and 7 years, respectively. Moreover, 79.3% of patients did not require distal aortic reintervention at 7 years. The overall survival in the subacute group was superior to that in the chronic group (P = 0.047). Conclusion: The FET technique is a safe and feasible approach for treating chronic type B and non-A non-B aortic dissection in patients who have contraindications for primary endovascular aortic repair. The technique combines the advantages of both open surgical repair and endovascular intervention, providing comparable early and long-term follow-up outcomes and freedom from reintervention.
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Affiliation(s)
- Congcong Luo
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruidong Qi
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongliang Zhong
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Suwei Chen
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hao Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rutao Guo
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg 2021; 36:4292-4300. [PMID: 34405439 DOI: 10.1111/jocs.15920] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Serna-Gallegos
- UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,UPMC Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Brown JA, Navid F, Serna-Gallegos D, Aranda-Michel E, Wang Y, Bianco V, Sultan I. Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01137-5. [PMID: 34420792 DOI: 10.1016/j.jtcvs.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/11/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. METHODS This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. RESULTS A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). CONCLUSIONS Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Jakob H, Ho JYK, Wong RHL, Idhrees M, Velayudhan B, Matalanis G, Dohle DS, Görlinger K, Bashir M. Paving the way for E-vita open NEO hybrid prosthesis implantation for complex aortic arch disease in Asia-Pacific. J Card Surg 2021; 36:3963-3967. [PMID: 34338352 DOI: 10.1111/jocs.15882] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022]
Abstract
We report first in man implantations of the newly designed Evita-open-NEO hybrid prosthesis for complex aortic arch disease from three different countries in Asia-Pacific including instructions on how to proceed with perioperative coagulation management.
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Affiliation(s)
- Heinz Jakob
- Diagnosticum Mülheim, Mülheim, Germany.,Department of Cardiothoracic and Vascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Jacky Y K Ho
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Hong Kong
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Hong Kong
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disease, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disease, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - George Matalanis
- Austin Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Melbourne University, Melbourne, Victoria, Australia
| | - Daniel-Sebastian Dohle
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz, Mainz, Germany
| | | | - Mohamad Bashir
- SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
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Wan Z, Li Y, Ye H, Zi Y, Zhang G, Wang X. Plasma S100β and neuron-specific enolase, but not neuroglobin, are associated with early cognitive dysfunction after total arch replacement surgery: A pilot study. Medicine (Baltimore) 2021; 100:e25446. [PMID: 33847649 PMCID: PMC8051968 DOI: 10.1097/md.0000000000025446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 03/08/2021] [Indexed: 01/04/2023] Open
Abstract
To investigate whether plasma concentrations of S100β protein, neuron-specific enolase (NSE), and neuroglobin (NGB) correlate with early postoperative cognitive dysfunction (POCD) in patients undergoing total arch replacement.This prospective study analyzed 40 patients who underwent total arch replacement combined with stented elephant trunk implantation at our hospital between March 2017 and January 2019. Cognitive function was assessed using the Mini-mental State Examination (MMSE) preoperatively, on the day after extubation and on day 7 after surgery. Plasma levels of S100β, NSE, and NGB POCD were assayed preoperatively and at 1, 6, and 24 hours after cardiopulmonary bypass. POCD was defined as a decrease of at least 1 unit in the MMSE score from before surgery until day 7, and patients were stratified into those who experienced POCD or not. The 2 groups were compared in clinicodemographic characteristics and plasma levels of the 3 proteins.Plasma levels of all 3 biomarkers increased significantly during and after cardiopulmonary bypass. Levels of S100β and NSE, but not NGB, were significantly higher in the 15 patients who showed POCD than in the remainder who did not. For prediction of early POCD, S100β showed an area under the receiver operating characteristic curve (AUC) of 0.71 (95% confidence interval [CI] 0.55-0.87), sensitivity of 48%, and specificity of 87%. The corresponding values for NSE were 0.77 (95%CI 0.60-0.94), 92%, and 67%. Together, S100β and NSE showed an AUC of 0.81 (95%CI 0.66-0.96), sensitivity of 73%, and specificity of 80%. NGB did not significantly predict early POCD (AUC 0.62, 95%CI 0.43-0.80).Plasma S100β protein and NSE, but not NGB, may help predict early POCD after total arch replacement.
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Affiliation(s)
- Zilin Wan
- Department of Cardiovascular Anesthesiology
| | - Yaxiong Li
- Department of Cardiovascular Surgery, Yan’An Hospital, Kunming Medical University, Kunming, 650051, Yunnan, China
| | - Huishun Ye
- Department of Cardiovascular Anesthesiology
| | - Yunfeng Zi
- Department of Cardiovascular Surgery, Yan’An Hospital, Kunming Medical University, Kunming, 650051, Yunnan, China
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Xie E, Wu J, Qiu J, Dai L, Qiu J, Luo Q, Jiang W, Cao F, Zhao R, Fan S, Gao W, Guo H, Sun X, Yu C. Early Outcomes of Three Total Arch Replacement Strategies for DeBakey Type I Aortic Dissection. Front Cardiovasc Med 2021; 8:638420. [PMID: 33937356 PMCID: PMC8081908 DOI: 10.3389/fcvm.2021.638420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study employed three surgical techniques: total arch replacement (TAR) with frozen elephant trunk (FET), aortic balloon occlusion technique (ABO) and hybrid aortic arch repair (HAR) on patients with type I aortic dissection in Fuwai Hospital, aiming to compare the early outcomes of these surgical armamentariums. Methods: From January 2016 to December 2018, an overall 633 patients (431 of TAR+FET, 122 of HAR, and 80 of ABO) with type I aortic dissection were included in the study. Thirty-day mortality, stroke, paraplegia, re-exploration for bleeding, and renal replacement therapy were compared using the matching weight method (MWM). Results: After MWM process, the baseline characteristics were comparable among three TAR groups. It showed that ABO group had the longest cardiopulmonary bypass (p < 0.001) and aortic cross-clamp time (p < 0.001), while the operation time was longest in the HAR group (p = 0.039). There was no significant difference in 30-day mortality among groups (p = 0.783). Furthermore, the incidence of stroke (p = 0.679), paraplegia (p = 0.104), re-exploration for bleeding (p = 0.313), and CRRT (p = 0.834) demonstrated no significant difference. Of note, no significant differences were found regarding these outcomes even before using MWM. Conclusions: Based on the early outcomes, the three TAR approaches were equally applicable to type I aortic dissection. We may choose the specific procedure relatively flexibly according to patient status and surgeon's expertise. Importantly, long-term investigations are warranted to determine whether above approaches remain to be of equivalent efficacy and safety.
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Affiliation(s)
- Enzehua Xie
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Juntao Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Dai
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenxiang Jiang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuya Fan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Gao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ogino H, Okita Y, Uchida N, Kato M, Miyamoto S, Matsuda H, Nakai M. Comparative study of Japanese frozen elephant trunk device for open aortic arch repairs. J Thorac Cardiovasc Surg 2021; 164:1681-1692.e2. [PMID: 33965229 DOI: 10.1016/j.jtcvs.2021.03.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We performed a multicenter prospective comparative study to determine the impact of a Japanese frozen elephant trunk device on total arch replacement compared with conventional repair without it. METHODS Between 2016 and 2019, a total of 684 patients (frozen elephant trunk procedure; n = 369; conventional repair, n = 315) from 41 institutions were enrolled. The 2 procedures were selected according to each center's strategy. RESULTS The frozen elephant trunk procedure was applied more for aortic dissection, whereas the conventional repairs were predominantly performed for aneurysms. In the former, only hypothermic circulatory arrest time was reduced among the intraoperative parameters. Although there were no differences in the 30-day and in-hospital mortality rates (0.8% and 1.6%, respectively, for the frozen elephant trunk procedure vs 0.3% and 0.6%, respectively, for conventional repair), the neurologic complication rates were significantly higher in stroke (5.7% vs 2.2%; P = .022) and paraplegia (1.6% vs 0%; P = .023). In the propensity score matching analyses using 11 variables, statistical significance disappeared in the differences for mortality and neurologic morbidity (stroke and paraplegia/paraparesis) rates of 194 patients of each group, although they were still higher for the frozen elephant trunk procedure. CONCLUSIONS The early outcomes of total arch replacement with the frozen elephant trunk procedure were acceptable despite its higher prevalence of emergency or redo surgery, which was comparable to that of the conventional repair. This procedure had higher rates of spinal cord injury than the conventional repair, which is a disadvantage of this approach.
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Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan.
| | - Yutaka Okita
- Cardioaortic Center, Takatsuki General (former: Kobe University), Osaka, Japan
| | - Naomichi Uchida
- Department of Cardiovascular Surgery, Yao Tokushukai Hospital, Osaka, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University, Oita, Japan
| | - Hitoshi Matsuda
- Department of Vascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michikazu Nakai
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
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Liu H, Wang X, Liu S, Cong S, Lu Y, Yang Y, Wang W, Lai H, Li X, Wei L, Wang C. Postoperative hypothermia after total aortic arch replacement in acute type A aortic dissection-multivariate analysis and risk identification for postoperative hypothermia occurrence. J Thorac Dis 2020; 12:7089-7096. [PMID: 33447397 PMCID: PMC7797820 DOI: 10.21037/jtd-20-1709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background Postoperative hypothermia (PH) is a common physiological abnormality associated with increased morbidity and mortality after non-cardiac surgery. The incidence, risk factors of PH and its impact on early outcomes after total aortic arch replacement are not clear. Methods We conducted a retrospective cohort study in patients with acute type A aortic dissection who underwent total arch replacement from January 2013 to December 2016 at our institution. Basic variables, procedural and postoperative early outcomes were collected. Univariate and multivariate statistical analysis were performed for statistical interpretation. The early outcomes were compared between patients with or without PH. Results A total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent total arch replacement. Forty-four patients (14.7%) developed PH. The independent risk factors of PH are age and the intraoperative lowest bladder temperature. There is no significant difference in major postoperative morbidity and mortality between patients with or without PH. Conclusions The incidence of PH after total arch replacement in acute type A aortic dissection is relatively low. The independent risk factors of PH in this population include age and the intraoperative lowest bladder temperature. With comprehensive rewarming strategy upon arrival at the ICU, the PH is easy to be corrected, and the adverse effect of transient PH on early outcomes after arch surgery is minimal.
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Affiliation(s)
- Huan Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Xiuwen Wang
- Department of Intensive Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shun Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Shuo Cong
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Yuntao Lu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Wenshuo Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Lai Wei
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
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Iino K, Takago S, Saito N, Ueda H, Yamamoto Y, Kato H, Kimura K, Takemura H. Total arch replacement and frozen elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg 2020:S0022-5223(20)33094-4. [PMID: 33341270 DOI: 10.1016/j.jtcvs.2020.10.135] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The present study aimed to evaluate the outcomes of total aortic arch replacement with proximalization of distal anastomosis using the frozen elephant trunk technique with the J Graft FROZENIX (Japan Lifeline, Tokyo, Japan) and Gelweave Lupiae (Vascutek Terumo Inc, Scotland, United Kingdom) graft (distal anastomosis performed in zones 1 and 2) in patients with acute Stanford type A acute aortic dissection. METHODS A total of 50 patients underwent total aortic arch replacement using the frozen elephant trunk technique, deploying the J Graft FROZENIX into zone 1 or 2 (zone 1: n = 17, zone 2: n = 33) in combination with the Gelweave Lupiae graft for acute Stanford type A acute aortic dissection. Patient characteristics, intraoperative data, and early and midterm outcomes were analyzed. RESULTS The overall in-hospital mortality rate was 4% (2 patients). The in-hospital mortality rate in patients with visceral malperfusion was 11% (1/9). There were no patients with paraplegia and stent graft-induced new entry. Resection or closure of the most proximal entry tear was achieved in 100% of 42 patients who had postoperative computed tomography. The overall survival was 87.9%, 84.1%, and 84.1% at 1, 2, and 3 years, respectively. However, 1 patient required endovascular extension for the dilatation of the descending thoracic aorta 4 months after the initial surgery. CONCLUSIONS Total aortic arch replacement with the frozen elephant trunk technique (zone 1-2) and Gelweave Lupiae graft was safe and effective in simplifying surgery for acute Stanford type A acute aortic dissection.
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Okita Y, Kumamaru H, Motomura N, Miyata H, Takamoto S. Current status of open surgery for acute type A aortic dissection in Japan. J Thorac Cardiovasc Surg 2020:S0022-5223(20)33045-2. [PMID: 33334600 DOI: 10.1016/j.jtcvs.2020.09.147] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study objective was to report the clinical outcomes of open surgery for acute aortic dissection by using the Japan Cardiovascular Database. METHODS Between 2013 and 2018, a total of 29,486 patients with acute aortic dissection who underwent open surgery were registered in the Japan Cardiovascular Database. Some 50% of patients were male. Age of patients at surgery was 59.8 ± 14.2 years; 61% of patients were aged less than 65 years, and 21% of patients were aged more than 75 years. Connective tissue disease was found in 1.2% of patients. Some 13% of patients had disturbed consciousness, and 12% of patients had cardiogenic shock. Some 11% of patients had moderate or severe aortic valve regurgitation, and 2.3% of patients had acute myocardial infarction. Some 94% of patients underwent surgery within 24 hours after diagnosis. Antegrade cerebral perfusion was used in 74% of patients, hypothermic circulatory arrest with retrograde cerebral perfusion was used in 17.1% of patients, and deep hypothermic circulatory arrest was used in 9.4% of patients. Cardiopulmonary bypass time was 216 ± 90 minutes, and cardiac ischemic time was 132 ± 60 minutes. Lowest body temperature was 24.6°C ± 3.2°C. Replacement of the ascending aorta (zone I) was performed in 69% of patients, and total arch replacement (zone 0 to zone II, III-) was performed in 29% of patients. The aortic valve was replaced in 7.9% of patients and repaired in 4.4% of patients. RESULTS The 30-day mortality was 9.2%, and in-hospital mortality was 11%. The number of operations has increased through the study periods. The in-hospital mortality has been stable or in a decreasing trend. Major complications consisted of stroke in 12% of patients, new hemodialysis in 7.3% of patients, spinal cord ischemia in 3.9% of patients, and prolonged ventilation in 15% of patients. CONCLUSIONS Approximately 30,000 patients with acute aortic dissection in the recent 6 years (2013 - 2018) underwent open surgery according to the nationwide Japanese database. The number of operations has increased, and in-hospital mortality has been stable or in a decreasing trend. Although the early outcomes are acceptable, there is still room for improvement in patients with preoperative comorbidities.
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Nagata T, Yamada T, Johno H. Modified total arch replacement with the frozen elephant trunk technique for a right-sided aortic arch and aortic diverticulum in a teenager. J Card Surg 2020; 36:323-325. [PMID: 33032384 DOI: 10.1111/jocs.15114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND A right sided aortic arch (RAA) and an aortic diverticulum (AD) are a rare congenital anomaly associated with an aortic rupture and dissection. Recently, various methods for the surgical management have been described to treat RAAs and ADs. CASE REPORT We describe a case of an RAA with a mirror image branching (RAMI) and AD in a teenager who complained of chest pain. We planned a total arch replacement with the frozen elephant trunk technique. Further, we needed to devise a way to reconnect the cerebral vessels because of his small arch anatomy and limited space in the mediastinum. We performed a right subclavian artery debranching, creating an anastomosis using one graft and diamond anastomosis, and performed the left innominate and right carotid anastomosis in an island fashion. This surgical approach could be a treatment option for young or small patients with RAMIs and ADs, whose arch anatomy is very small.
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Affiliation(s)
- Tomoki Nagata
- Department of Cardiovascular Surgery, Takaishi Fujii Cardiovascular Hospital, Takaishi-shi, Japan
| | - Takashi Yamada
- Department of Cardiology, Takaishi Fujii Cardiovascular Hospital, Takaishi-shi, Japan
| | - Hiroyuki Johno
- Department of Cardiovascular Surgery, Takaishi Fujii Cardiovascular Hospital, Takaishi-shi, Japan
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Chiba Y, Yamasaki K, Ikegami H, Yatera K. Pseudoaneurysm after total arch replacement mimicking malignant lymphadenopathy. Respirol Case Rep 2020; 8:e00645. [PMID: 32832089 PMCID: PMC7438812 DOI: 10.1002/rcr2.645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/05/2022] Open
Abstract
Pseudoaneurysm should be considered in the differential diagnosis when the computed tomography (CT) findings show a mediastinal mass in patients with a history of cardiovascular surgery even if such surgery occurred over two decades previously.
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Affiliation(s)
- Yosuke Chiba
- Department of Respiratory MedicineUniversity of Occupational and Environmental Health, JapanKitakyushuJapan
| | - Kei Yamasaki
- Department of Respiratory MedicineUniversity of Occupational and Environmental Health, JapanKitakyushuJapan
| | - Hiroaki Ikegami
- Department of Respiratory MedicineUniversity of Occupational and Environmental Health, JapanKitakyushuJapan
| | - Kazuhiro Yatera
- Department of Respiratory MedicineUniversity of Occupational and Environmental Health, JapanKitakyushuJapan
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Arnaoutakis G, Bianco V, Estrera AL, Brinster DR, Ehrlich MP, Peterson MD, Bossone E, Myrmel T, Pacini D, Montgomery DG, Eagle KA, Bekeredijan R, Shalhub S, De Vincentiis C, Chad Hughes G, Chen EP, Eckstein HH, Nienaber CA, Sultan I. Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD. J Card Surg 2020; 35:3467-3473. [PMID: 32939836 DOI: 10.1111/jocs.15017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. METHODS Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. RESULTS Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. CONCLUSIONS A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.
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Affiliation(s)
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony L Estrera
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Derek R Brinster
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Marek P Ehrlich
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Mark D Peterson
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Eduardo Bossone
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Truls Myrmel
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Davide Pacini
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Daniel G Montgomery
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Kim A Eagle
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Raffi Bekeredijan
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Sherene Shalhub
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Carlo De Vincentiis
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - G Chad Hughes
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Edward P Chen
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | | | - Christoph A Nienaber
- International Registry of Acute Aortic Dissections (IRAD), Ann Arbor, Michigan, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Liu H, Liu S, Zaki A, Wang X, Cong S, Yang Y, Li J, Lai H, Sun Y, Wei L, Wang C. Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection. J Thorac Dis 2020; 12:4070-4081. [PMID: 32944318 PMCID: PMC7475536 DOI: 10.21037/jtd-20-912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Acute type A aortic dissection with arch involvement is a life-threatening condition, which requires immediate surgical attention. Emergent total arch replacement and root reconstruction is a technically demanding operation with varying outcomes based on surgeon experience. The human factors in total arch replacement in the emergent setting have never been systematically investigated. The ability of surgeons with low volumes to achieve acceptable results in their start-up period is not known. Methods From January 2013 to December 2016, patients with acute type A aortic dissection who underwent emergent total arch replacement with three surgeons were enrolled. Basic characteristics, procedural and postoperative outcomes were collected. The time of critical surgical steps and operative mortality were calculated using descriptive statistics and cumulative SUM (CUSUM) analysis. Results A total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent emergent total arch replacement. A total of 219 patients (73.0%) had root reinforcement, 295 patients (98.3%) underwent frozen elephant trunk repair. Mean circulatory arrest and cross-clamp times were 29.8±9.8 and 112.3±32.1 min, respectively. The operative mortality was 6.7%, the stroke rate was 4.0%. The mean length of postoperative ICU and hospital stays were 8.4±10.6 and 18.0±12.2 days, respectively. By CUSUM depictions, surgeons appeared to have different learning curves with regards to operative time. By CUSUM failure analysis on operative mortality, two newly appointed surgeons in their start-up period stayed in an acceptable range, while one senior surgeon with higher volumes experienced superior outcomes and better performance. Conclusions Although emergent total arch replacement for acute type A dissection is a complex scenario, surgeons well-trained in adult cardiac surgery are able to achieve acceptable results in their start-up period.
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Affiliation(s)
- Huan Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Shun Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Xiuwen Wang
- Department of Intensive Care Medicine of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Shuo Cong
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Jun Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Yongxin Sun
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Lai Wei
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
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Zhang B, Liu Y, Guo H, Li Y, Shi Y, Liang S, Liu H, Sun X. Renal protective effect of the aortic balloon occlusion technique in total arch replacement with frozen elephant trunk. Ann Cardiothorac Surg 2020; 9:209-219. [PMID: 32551253 DOI: 10.21037/acs-2019-0177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Organ dysfunction caused by hypothermic circulatory arrest continues to concern surgeons. The aortic balloon occlusion (ABO) technique can significantly shorten the circulatory arrest time in total arch replacement with frozen elephant trunk (TAR with FET). This study aims to analyze the renal protective effect of the ABO technique and to analyze the predictors of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) after TAR with FET. Methods Between August 2017 and September 2018, 247 patients who underwent TAR with FET were divided into ABO and moderate hypothermic circulatory arrest (MHCA) groups. The primary endpoint was postoperative AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic analysis was used to identify the predictors of AKI and CRRT after TAR with FET. Results With the application of the ABO technique, the circulatory arrest time was significantly shortened (ABO 4, IQR: 3-6 vs. MHCA 18, IQR: 16-20, P<0.001). Meanwhile, surgeons safely set the lowest nasopharyngeal temperature at a higher grade (ABO 28.1, IQR: 27.4-28.5 vs. MHCA 24.7, IQR: 24.1-25.1, P<0.001). The peak serum creatinine (SCr) values within 48 hours after the surgery was lower in the ABO group than in the MHCA group (ABO 124, IQR: 97-173 vs. MHCA 146, IQR: 108-221, P=0.008). The distribution of AKI grade according to the KDIGO criteria differed between the two groups (P=0.04): more patients in the ABO group were free from AKI (Grade 0) than patients in the MHCA group (33% vs. 23.1%), and the proportion of patients with high-grade AKI (Grades 2 and 3) in the ABO group was lower than that in the MHCA group (21% vs. 32%). The ABO technique was associated with reduced potential for AKI, but was not protective for CRRT. Conclusions The ABO technique significantly shortened the circulatory arrest time and safely elevated temperature, and provided better renal protection in patients undergoing TAR with FET. The ABO technique did not reverse the need for CRRT, nor did it reduce mortality or major adverse events.
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Affiliation(s)
- Bowen Zhang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yunfeng Li
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Shi
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shenghua Liang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Hong Liu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Kawajiri H, Khasawneh MA, Bower TC, Bagameri G. Two-Stage Redo Aortic Arch Repair in a Patient With an Isolated Left Vertebral Artery. Innovations (Phila) 2020; 15:376-378. [PMID: 32412398 DOI: 10.1177/1556984520922985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 47-year-old male presented with an enlarging distal aortic arch false lumen 6 months status post ascending and hemiarch replacement with antegrade endograft insertion for acute type A aortic dissection complicated by lower body malperfusion. Preoperative computed tomographic angiography showed an isolated but dominant left vertebral artery. A 2-stage open surgical repair was performed. First, the left subclavian artery was transposed on the common carotid and vertebral onto the subclavian. At the second stage, a redo total arch reconstruction was done with bypass grafts taken to the innominate and left common carotid arteries. The patient did well postoperatively.
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Affiliation(s)
- Hidetake Kawajiri
- 6915 Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohammad A Khasawneh
- 4352 Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Thomas C Bower
- 4352 Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gabor Bagameri
- 6915 Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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