Hybrid repair versus conventional open repair for aortic arch dissection

BACKGROUND

A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection.

OBJECTIVES

To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE.

MAIN RESULTS

We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection.

AUTHORS' CONCLUSIONS

This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.

The 301 Classification: A Proposed Modification to the Stanford Type B Aortic Dissection Classification for Thoracic Endovascular Aortic Repair Prognostication

OBJECTIVE

To assess the usefulness of a modified Stanford classification for risk stratification of complications after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

PATIENTS AND METHODS

This retrospective analysis included 201 patients from an observational multicenter cohort study who underwent TEVAR for TBAD from January 1, 2011, to December 31, 2016. The patients were divided by using a modified Stanford classification, termed 301, into 3 groups: types B1 (n=62) and B3 (n=24), with a true and false lumen, respectively, descending closely along the thoracic vertebral bodies, and type B2 (n=115), a semi-spiral or spiral configuration. The value of the 301 classification in assessing the risk for post-TEVAR thoracic aortic expansion, as main outcome, and other complications was assessed by using the Kaplan-Meier method and multivariable Cox proportional hazards models.

RESULTS

Median follow-up duration was 26.37 months, and the 24-month cumulative rate of freedom from thoracic aortic enlargement was 0.58 (95% CI, 0.25 to 0.81) for type B3, 0.75 (95% CI, 0.64 to 0.83) for type B2, and 0.97 (95% CI, 0.88 to 0.99) for type B1. In the multivariable Cox regression models, types B2 and B3 with type B1 as reference were independently associated with the risk for thoracic aortic expansion (type B2: hazard ratio, 7.81; 95% CI, 1.84 to 33.13; type B3: hazard ratio, 13.91; 95% CI, 2.86 to 67.69).

CONCLUSION

The 301 classification, a modified Stanford classification system in the era of endovascular repair, appears to improve the risk stratification of patients with TBAD undergoing TEVAR.

TRIAL REGISTRATION

Chinese Clinical Trial Registry number: ChiCTR-POC-17011726.

Predicting in-hospital death in patients with type B acute aortic dissection

The outcome of patients with acute type B aortic dissection (BAAD) is largely dictated by whether or not the case is "complicated." The purpose of this study was to investigate the risk factors leading to in-hospital death among patients with BAAD and then to develop a predictive model to estimate individual risk of in-hospital death.A total of 188 patients with BAAD were enrolled. Risk factors for in-hospital death were investigated with univariate and multivariable logistic regression analysis. Significant risk factors were used to develop a predictive model.The in-hospital mortality rate was 9% (17 of 188 patients). Univariate analysis revealed 7 risk factors to be statistically significant predictors of in-hospital death (P < .1). In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: hypotension (odds ratio [OR], 4.85; 95% confidence interval [CI], 1.12-18.90; P = .04), ischemic complications (OR, 8.24; 95% CI, 1.25-33.85; P < .001), renal dysfunction (OR, 12.32; 95% CI, 10.63-76.66; P < .001), and neutrophil percentage ≥80% (OR, 5.76; 95% CI, 2.58-12.56; P = .03). Based on these multivariable results, a reliable and simple prediction model was developed, a total score of 4 offered the best point value.Independent risk factors associated with in-hospital death can be predicted in BAAD patients. The prediction model could be used to identify the prognosis for BAAD patients and assist physicians in their choice of management.

Type B Aortic Dissection - A Single Center Series

BACKGROUND

Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution.

METHODS

This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification.

RESULTS

Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation.

CONCLUSIONS

The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.

Clinical application of high-resolution MRI in combination with digital subtraction angiography in the diagnosis of vertebrobasilar artery dissecting aneurysm: An observational study (STROBE compliant)

Vertebrobasilar artery dissecting aneurysm (VBA-DA) is associated with serious complications and poor prognosis in patients. High-resolution magnetic resonance imaging (HR-MRI) is a noninvasive method for the diagnosis of VBA-DA.VBA-DAs were classified according to the feature of HR-MRI in combination with digital subtraction angiography (DSA), and the clinical outcomes of different types of VBA-DAs were analyzed. Thirty-nine patients with 42 VBA-DAs were included and underwent HR-MRI, including three-dimensional T1 weighted image, three-dimensional T2 weighted image (3D-T2WI), three-dimensional time of flight MRA (3D-TOF-MRA), and three-dimensional fast imaging employing steady state acquisition (3D-FIESTA), and hematoma and flaps were compared. The follow-up was 3 to 25 months. The VBA-DAs were classified based on the images of HR-MRI and DSA, and the prognosis was analyzed.VBA-DAs more frequently occurred on the vertebral artery, especially on the dominant vertebral artery. 3D-TOF-MRA showed high signal from hematoma, and 3D-FIESTA showed high signal from flaps. Based on HR-MRI images in combination with DSA, VBA-DAs were classified into 4 types: classical, stenosis, spiral, and hemorrhagic. The patients with the classical VBA-DAs had a higher improvement rate and a lower exacerbation rate. The patients with spiral and hemorrhagic VBA-DAs had poor clinical outcomes. The patients with stenosis VBA-DAs had poorer clinical outcomes than classical types and better clinical outcomes than spiral and hemorrhagic types.The detection of intramural hematoma and dissection flap using HR-MRI provides basic information for the diagnosis of VBA-DA. Individualized therapeutic strategies can be designed for the treatment of VBA-DAs with different features of DSA and HR-MRI.

A case report of hemorrhagic cardiac tamponade with rapid blood clot formation: A serious complication of acute type a aortic dissection

RATIONALE

Acute type A aortic dissection (AAAD) remains a life-threatening disease. We previously reported a case with ultrasound findings of a homogeneous hemopericardium and evidence highly indicative of hemorrhagic cardiac tamponade complicated by AAAD. Here, we report a similar case who presented with a more serious situation and for whom critical care ultrasound revealed fast blood clot formation within the hemopericardium.

PRESENTING CONCERNS

A 63-year-old man was admitted to our emergency department with a complaint of a tearing chest pain for 10 minutes. Asymmetric blood pressure was detected in the upper limbs and AAAD was highly suspected. An electrocardiogram (ECG) monitor was placed in a timely manner. However, during this procedure, he went into cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated.

DIAGNOSES

Critical care ultrasound revealed hemorrhagic cardiac tamponade with blood clot formation surrounding the epicardium, strongly indicating the rupture of an ascending aortic root dissection.

INTERVENTIONS

Standard CPR continued for 30 minutes.

OUTCOMES

Spontaneous cardiac rhythm was not restored and the patient died.

LESSONS

Critical care ultrasound is a useful tool for assessing emergency cardiac arrest. Ultrasound findings of fast clot formation within the hemopericardium may indicate faster bleeding due to the rupture of an AAAD and may predict poor clinical outcomes.

Classification of spontaneous isolated superior mesenteric artery dissection: correlation with multi-detector CT features and clinical presentation

PURPOSE

The purpose of the study is to propose a computed tomography (CT) classification of spontaneous isolated superior mesenteric artery dissection (SISMAD) correlated with clinical presentation METHODS: We retrospectively reviewed CT images of 40 patients with SISMAD at our institution from 2006 to 2015 and proposed a new classification: type I, patent false lumen with both entry and re-entry; type II, patent false lumen without re-entry; type III, completely or partially thrombosed false lumen; and type IV, thrombosed false lumen with ulcer-like projection. Additionally, we included a subtype (S) at each type when there was either a long segment of dissection and/or significant true lumen stenosis. CT features were statistically analyzed using Fisher's exact and Mann-Whitney test.

RESULTS

The CT findings classified patients as type I (15%), type II (12.5%), type III (35%), and type IV (37.5%). Of the 40 patients, 25 (62.5%) were symptomatic. There was a significantly different proportion of each type between symptomatic and asymptomatic patients (p = 0.005). There were 25 patients with subtype (S); no type I or II, 12 type III, and 13 type IV. The symptomatic patients showed longer dissection tendency and more severe true lumen stenosis (78% vs. 53%, p = 0.000) compared with asymptomatic patients.

CONCLUSION

The proposed multi-detector CT classification of SISMAD correlates with clinical presentation. This new classification could be helpful for treatment planning.

[Aortic dissection]

Aortic dissection is a life-threatening condition due to a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation of the different layers of the aortic wall. Among the risk factors, age, hypertension, dyslipidemia and genetic disorders of the connective tissue have been identified. A prompt diagnosis and an adequate treatment are important in the management of affected patients. The type of treatment depends on the location and extension of the dissection. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas endovascular intervention is indicated for descending aorta dissections that are complicated. In this paper, we will review the epidemiology, and physiopathology of aortic dissection and describe the appropriate management for each type of dissection (open surgery, endovascular or medical treatment).

Dissections in Peripheral Vascular Interventions: A Proposed Classification Using Intravascular Ultrasound

Dissections following interventions in the infrainguinal arteries occur very frequently and are mostly under-appreciated on angiographic imaging. Media and external elastic lamina injury can contribute to loss of patency, and intravascular ultrasound (IVUS) can identify this type of injury. The circumference of injury also has been proposed to be a predictor of outcome. We therefore propose a classification combining depth of injury from intima to adventitia with circumference of dissection. This classification exhibits six dissection grades (A1, A2, B1, B2, C1, and C2) as seen on IVUS (the "iDissection" classification).

Natural course and outcomes of spontaneous isolated celiac artery dissection according to morphological findings on computed tomography angiography: STROBE compliant article

We aimed to identify natural course and optimal management of spontaneous isolated celiac artery dissection (SICAD) according to morphologic classification determined on computed tomography angiography (CTA), and to investigate the association between symptoms and morphological classification of SICAD.This retrospective observational study included 21 consecutive patients with SICAD from January 2012 to April 2017. Demographic data, clinical features, treatment modalities, follow-up results, and CTA findings including morphologic classification, dissection length, and relative diameter of the true lumen (TLRD) were reviewed. Changes in follow-up CTA were recorded and compared to prior studies to reveal natural course of the disease.The serial changes of SICAD on follow-up CTA according to morphologic classifications were as follows; type I (5/5, no interval change), type IIa (1/1, no interval change), type IIb (1/1, partial remodeling), type IIIa (1/4, complete remodeling; 1/4, partial remodeling; 1/4, no interval change; 1/4, deterioration), type IIIb (4/6, no interval change; 2/6, partial remodeling), and type IV (2/2, no interval change). Thirteen (61.9%) symptomatic and 8 (38.1%) asymptomatic patients were all treated with conservative management with or without antiplatelet and/or anticoagulation therapies. Symptomatic group (SG) more commonly had type IIb, IIIa, IIIb, and IV than asymptomatic group (AG) (SG; 11 patients, AG; 1 patient, P = .002). TLRD in AG was larger than that in SG (SG: 40.5 ± 24.1%, AG: 61.7 ± 7.0%, P = .045).SICAD might be treated by conservative management in stable patients irrespective of the morphologic classification except for with type IV (dissecting aneurysm) and extension of celiac branch who may need an early intervention. Types IIb, IIIa, IIIb, and IV are TLRD are associated with patients' symptoms. Further studies on extended natural course of SICAD with a larger number of subjects are needed to draw a strong conclusion.

Prognostic significance of early aortic remodeling in acute uncomplicated type B aortic dissection and intramural hematoma

BACKGROUND

Patients with Stanford type B aortic dissections (ADs) are at risk of long-term disease progression and late complications. The aim of this study was to evaluate the natural course and evolution of acute type B AD and intramural hematomas (IMHs) in patients who presented without complications during their initial hospital admission and who were treated with optimal medical management (MM).

METHODS

Databases from 2 aortic centers in Europe and the United States were used to identify 136 patients with acute type B AD (n = 92) and acute type B IMH (n = 44) who presented without complications during their index admission and were treated with MM. Computed tomography angiography scans were available at onset (≤14 days) and during follow-up for those patients. Relevant data, including evidence of adverse events during follow-up (AE; defined according to current guidelines), were retrieved from medical records and by reviewing computed tomography scan images. Aortic diameters were measured with dedicated 3-dimensional software.

RESULTS

The 1-, 2-, and 5-year event-free survival rates of patients with type B AD were 84.3% (95% confidence interval [CI], 74.4-90.6), 75.4% (95% CI, 64.0-83.7), and 62.6% (95% CI, 68.9-73.6), respectively. Corresponding estimates for IMH were 76.5% (95% CI, 57.8-87.8), 76.5% (95% CI, 57.8-87.8), and 68.9% (95% CI, 45.2-83.9), respectively. In patients with type B AD, risk of an AE increased with aortic growth within the first 6 months after onset. A diameter increase of 5 mm in the first half year was associated with a relative risk for AE of 2.29 (95% CI, 1.70-3.09) compared with the median 6 months' growth of 2.4 mm. In approximately 60% of patients with IMH, the abnormality resolved within 12 months and in the patients with nonresolving IMH, risk of an adverse event was greatest in the first year after onset and remained stable thereafter.

CONCLUSIONS

More than one third of patients with initially uncomplicated type B AD suffer an AE under MM within 5 years of initial diagnosis. In patients with nonresolving IMH, most adverse events are observed in the first year after onset. In patients with type B AD an early aortic growth is associated with a greater risk of AE.

Acute Type A Aortic Dissection: Beyond the Diameter

Aortic dissection is a life-threatening condition in which early diagnosis, treatment and close follow up are critical for survival. Between 60% and 70% of patients with acute aortic dissection are affected at the ascending aorta, classified as Stanford type A (TAD). Preventive surgery of the aorta in asymptomatic patients on the basis of aortic size alone remains controversial among patient populations without known risk factors for aortic dissection. In fact, many dissection patients do not appear to have markedly dilated aortas at the time of presentation. In contrast, previous studies have indicated that the incidence of aortic dissection did not decrease, regardless of elective aortic replacement therapy. An increased aortic size as a follow up parameter is not sufficient to predict aortic dissection and rupture. Here, published evidence is reported regarding the limited role of aortic size in the genesis of TAD. Currently, a need exists to develop new markers to prevent aortic complications, especially in patients with sporadic ascending aneurysms (S-TAAs). It is important to emphasize this interesting aspect to the scientific cardiothoracic surgery forum in an attempt to improve guidelines for this disease.

Penn classification in acute aortic dissection patients

OBJECTIVE

The objective of this study was to evaluate the effectiveness of the Penn classification in predicting in-hospital mortality after surgery in acute type A aortic dissection patients.

METHODS

We evaluated 58 patients (42 men and 16 women; mean age 62.17 ± 10.6 years) who underwent emergency surgery for acute type A aortic dissection between September 2003 and June 2010 in our department. We investigated the correlation between the pre-operative malperfusion and in-hospital outcome after surgery.

RESULTS

Twenty-eight patients (48%) were Penn class Aa (absence of branch vessel malperfusion or circulatory collapse), 11 (19%) were Penn class Ab (branch vessel malperfusion with ischaemia), 5 (9%) were Penn class Ac (circulatory collapse with or without cardiac involvement) and 14 (24%) were Penn class Abc (both branch vessel malperfusion and circulatory collapse). The number of patients with localized or generalized ischaemia or both, Penn class non-Aa, was 30 (52%). In-hospital mortality was 24%. In-hospital mortality was significantly higher in Penn class Abc and Penn class non-Aa. Intensive unit care stay, hospital ward stay and overall hospital stay was longer in Penn class non-Aa vs Penn class Aa. De Bakey type I dissection and type II diabetes mellitus were associated with in-hospital mortality.

CONCLUSION

Preoperative malperfusion is important for the evaluation of patients with acute aortic type A dissection. The Penn classification is a simple and quick method to apply and predict in-hospital mortality and outcomes.

Acute renal failure and hepatocellular damage as presenting symptoms of type II aortic dissection

INTRODUCTION

Pericardial effusion can be a consequence of a number of pathological conditions, and as such it can cause impaired left ventricular filling followed by decreased cardiac output and blood pressure. This kind of hemodynamic compromise and its consequences are extremely uncommon unless pericardial effusion causes tamponade.

CASE OUTLINE

We describe a very rare case of a 30-year old male patient, with an acute aortic dissection type II causing pericardial effusion without clinical nor echocardiographic signs of tamponade, while presenting with an acute renal and hepatic failure. After initial diagnostic uncertainties, and following final diagnosis of an acute aortic dissection, this patient underwent surgical aortic valve replacement with a satisfactory outcome.

CONCLUSION

It is important to underscore the significance of clinical situation of simultaneously existing acute renal and hepatic failures in the setting of a “non-tamponade” pericardial effusion, following a type II aortic dissection. Although most commonly aortic dissection presents itself with typical clinical symptoms or patient history data, it is not that unusual for it to be hidden in an entirely atypical clinical milieu as the one described in this case.

Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection

Type A aortic dissection (AD) is a deadly disease. Rapid identification of patients requiring immediate advanced aortic imaging or transfer to specialized centers is needed to improve outcomes. We evaluated the diagnostic performance of transthoracic focus cardiac ultrasound (FOCUS) performed by emergency physicians, alone and in combination with the aortic dissection detection (ADD) risk score in suspected type A AD. This was a prospective study performed on patients with suspected type A AD. FOCUS evaluated the presence of intimal flap/intramural hematoma (direct signs of AD), ascending aorta dilatation, aortic valve insufficiency or pericardial effusion/tamponade (indirect signs of AD). The ADD risk score of each patient was calculated according to guidelines. The final diagnosis was established after review of complete clinical data. 50 (18%) patients of 281 had a final diagnosis of type A AD. Detection of any FOCUS sign (direct or indirect) of AD had a sensitivity of 88% (95% CI 76-95%) for the diagnosis of type A AD. Presence of ADD risk score > 0 or detection of any FOCUS sign increased diagnostic sensitivity to 96% (95% CI 86-99%). Detection of direct FOCUS signs had a specificity of 94% (95% CI 90-97%), while combination of ADD risk score > 1 with detection of direct FOCUS signs had a specificity of 98% (95% CI 96-99%). FOCUS demonstrated acceptable accuracy as a triage tool to rapidly identify patients with suspected type A AD needing advanced aortic imaging or transfer, but it cannot be used as a stand-alone test even if combined with ADD risk score classification.

Stented elephant trunk technique for retrograde type A aortic dissection after endovascular stent graft repair

BACKGROUND

Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique.

METHODS

Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1±8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results.

RESULTS

Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2±13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival.

CONCLUSIONS

The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.

[Lower body ischemia due to bending of the stent after hybrid treatment for chronic stanford type B aortic dissection]

Lower body ischemia due to bending of a stented graft at the thoracic aorta was rare, particularly when it occurred in several days after surgery. We experienced this complication and performed the 3rd-time thoracic endovascular repair( TEVAR).A 49-year-old man with a chronic aortic dissection of Stanford type B underwent TEVER;however we failed to close the entry because of the tortuously bended distal arch of the aorta. Then it was decided the patient undergo a hybrid treatment with arch replacement and frozen elephant trunk. Seventeen days after the surgery, the blood pressure of the patient's lower limb was reduced rapidly and his renal function deteriorated. Bending of the stent was revealed by computed tomography( CT). The patient underwent the 3rd-time emergency TEVAR, and his symptoms improved.

[Endovascular aortic repair plus chimney technique in the treatment of Stanford type B aortic dissection involving aortic arch]

OBJECTIVE

To evaluate the efficacy of endovascular aortic repair plus chimney technique in the treatment of Stanford type B aortic dissection involving aortic arch.

METHODS

From June 2009 to March 2012, 32 patients of aortic arch dissection with primary entry tear next to the orifices of supra-aortic arteries were treated with chimney technique. Chimney technique was used to reconstruct left subclavian artery (n = 2) and left common carotid artery (n = 28). Double chimney technique was use to reconstruct innominate artery and left common carotid artery simultaneously in 2 patients.

RESULTS

Four patients received emergency operation. All patients survived and were followed up for 14.3 ± 7.4 months. No type I endoleak occurred. Among 4 patients with Type II endoleak, 3 received PDA occluding implantation in left subclavian artery and 1 patient in puerperium with Marfan syndrome and pregnancy-induced hypertension syndrome recovered by conservative treatment. No severe neurological complications and left subclavian artery ischemia occurred. The locations of aortic and chimney stent-grafts were stable without any migration. All stent-grafts remained patent.

CONCLUSION

Endovascular aortic repair plus chimney technique is a safe and effective treatment for Stanford type B aortic dissection involving aortic arch.

[Thoracic aortic replacement with concomitant endoluminal stent grafting for DeBakey type I aortic dissection]

OBJECTIVE

To evaluate the therapeutic effect and safety of thoracic aortic replacement with concomitant endoluminal stent grafting in the treatment of DeBakey type I aortic dissection.

METHODS

From September 2007 to January 2010, 6 patients with DeBakey type I aortic dissection (including one with aortic dissection relapse) received ascending aortic (or Bentall) and total aortic arch replacement and simultaneous stent graft implantation into the descending aorta. Multi-slice spiral CT scans (MSCT) were performed in each patient regularly after the surgery. Cardio-pulmonary bypass including deep hypothermic circulatory arrest with selective antegrade cerebral perfusion were used during the surgery.

RESULTS

All the patients recovered smoothly after the surgical procedure without serious complications. The time of cardiopulmonary bypass ranged from 208 to 291 min (mean 242 min), arrest time of the ascending aortic was 112-194 min (mean 145 min), and selective cerebral perfusion time was 63-102 min (mean 76 min). The patients were followed up for 4-32 months (mean 15.5 months), and MSCT revealed smooth blood flow in the prosthesis, complete thrombus formation in the false lumen in the perigraft space and shrinkage of the distal false lumen without internal fistula or stent dislocation.

CONCLUSION

Thoracic aortic replacement with concomitant endoluminal stent grafting is a safe and effective treatment of DeBakey type I dissection.

Acute aortic dissection: natural history and classification

Acute aortic dissection is an uncommon but potentially catastrophic pathology with high mortality and morbidity. Significant advances in the understanding, diagnosis and management of aortic dissection have been made since the first case was reported 3 centuries ago. This article aims to review our current understanding of the natural history and classification of acute aortic dissection.

Thoracic aortic dissection in a 38-year-old man

A few days before Christmas, a flight team was activated for an interfacility transfer of a 38-year-old man with a history of hypertension and spinal stenosis diagnosed with a thoracic aortic dissection. The patient was presented to a local community hospital complaining of nearly 5 days of left-sided rib pain. This afternoon when he stood up from a chair, he experienced a near-syncopal episode. Concurrently, he had an abrupt onset of a tearing sensation in his chest that radiated to thoracic spine in the region between his shoulder blades. Ground emergency medical services (EMS) was called, and the patient was transported to the community hospital. During the initial transport and evaluation by the emergency department (ED) staff, the patient was noted to be hypertensive, with a systolic blood pressure greater than 180 mmHg. In the ED, the patient received aspirin, morphine, and Lopressor. He underwent a chest x-ray (Figure 1) and computed tomography (CT) scan and was diagnosed with a type B thoracic aorta dissection, which was noted to start on the descending thoracic aorta distal to the left subclavian artery and extend to the level of the celiac trunk (Figure 2). Despite the initial beta blockade, the patient was noted to be profoundly hypertensive, with initial blood pressure greater than 190 mmHg systolic. The flight team was activated for hemodynamic management and rapid transport to a facility capable of vascular and cardiothoracic surgery.

Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up

BACKGROUND

Although rare, iatrogenic left main coronary artery (LM) dissection is a feared complication of coronary catheterization. Its incidence, optimal therapeutic management, and prognosis remain largely unknown. The aim of the present study was to estimate the incidence, characterize the population at risk, depict the initial management, and evaluate the long-term prognosis of iatrogenic LM dissection.

METHODS

Thirty-eight patients who fulfilled the National Heart, Lung, and Blood Institute diagnostic criteria for iatrogenic LM dissection were retrieved from our database and followed up by telephone or physician visit. The primary end point was freedom from major adverse cardiac events (MACE) at 5 years.

RESULTS

The overall incidence of iatrogenic LM dissection during the study period was 0.07% (38/51,452 patients) and almost twice as common with percutaneous coronary intervention than coronary angiography. From 38 patients, 1 (3%) patient died before any therapeutic attempt was performed, 6 (16%) patients were treated conservatively, and 31 (82%) patients underwent stent implantation and/or coronary artery bypass grafting (CABG). In-hospital outcome was favorable irrespective of the therapeutic strategy. During the 5-year follow-up, among 31 patients who underwent revascularization treatment by stenting or CABG, one patient died in each group from a cardiac cause, and MACE were observed in 12 patients (39%). Kaplan-Meier cumulative survival estimates showed no significant difference between different revascularization treatment strategies.

CONCLUSIONS

Iatrogenic LM dissection is a rare complication of cardiac catheterization procedures with favorable early and long-term outcome when recognized timely and managed properly.

[On the classification of dissecting aortic aneurysms]

Aortic dissections are most commonly categorized into types A and B depending on the involvement of ascending or descending aorta based on the Stanford system and into types I, II and III using DeBakey classification. The latest classification was proposed by the European Society of Cardiology in 2001. The authors present their own classification of distal aortic dissecting aneurysms that takes into account antegrade and retrograde dissection of the aorta, besides localization of proximal fenestration. Surgical strategies for the treatment of different variants of aortic dissecting aneurysms are considered.

[Surgical treatment of acute type A aortic dissection]

The objective of this study was to evaluate the short-term results of surgical treatment in patients with acute aortic dissection.

PATIENTS AND METHODS

A retrospective analysis of 38 patients with acute type A aortic dissection who were surgically treated at the Clinic of Cardiac, Thoracic, and Vascular Surgery, Hospital of Kaunas University of Medicine, from January 2004 to December 2007 was conducted. The diagnosis of aortic dissection was confirmed by employing special techniques. Two-dimensional transthoracic echocardiography was performed in 34 (89.5%) patients; transesophageal echocardiography, in 24 (63.1%); computed tomography, in 29 (76.3%); coronagraphy and angiography, in 20 (52.6%). Preoperative shock was reported in 3 (7.9%) and cardiac tamponade in 18 (47.4%) cases. More than half (57.9%) of patients were operated on within the first 24 hours after admission. In the majority of cases (73.7%), the diameter of the aorta exceeded 4 cm. In the presence of type A aortic dissection, all patients underwent surgery on cardiopulmonary bypass; its duration varied from 20 to 485 min, with a mean of 214.6+/-102.9 min. The mean aortic cross-clamp time was 114.5+/-62.7 min. Complete circulatory arrest was needed in the majority of cases (86.8%), and it lasted 2 to 97 min (mean, 27.4+/-18.6 min). During cardiopulmonary bypass, body temperature was decreased to 17-28 degrees C (mean, 18.9+/-1.95 degrees C). The duration of surgery ranged from 1 to 14 hours, with a mean of 6.1+/-2.49 hours. During the early postoperative period, 12 (31.6%) patients died. Postoperative bleeding was seen in 16 (42.1%) patients, and 6 of them died later. Due to prolonged bleeding, 4 (10.5%) patients were left with an open sternum after surgery. Resternotomy was performed in 9 patients; 3 of them died due to multiorgan injury. During postoperative period, cardiogenic shock of various degrees was seen in 7 (18.4%) patients. Central nervous system injury occurred in 9 (23.7%) patients.

CONCLUSION

The main risk factor for acute aortic dissection is the diameter of the aorta exceeding 4 cm (diagnosed in 73.7% of cases). The main postoperative complications are bleeding (42.1%), injuries of central nervous system (23.7%), and cardiogenic shock (18.4%).

[Changing trend of clinical characteristics on aortic dissection over the last 10 years in Urumqi]

OBJECTIVE

To discuss both clinical and epidemiological features as well as the changing trend of aortic dissection (AD).

METHODS

Retrospective analysis on 238 patients with AD over a 10 year period in the First Affiliated Hospital of Xinjiang Medical University. Hospital records and data on prognosis were compared between the two five-year periods.

RESULTS

238 cases with AD were hospitalized during the past 10 years with mean age as 51.9 +/- 12.1. The male/female ratio was 3.67 to 1. Hypertension was present in 73.5% of all the patients. Heavy smoking history was elicited in 44.1% of all the patients. Type I dissection were identified in 35.3% of all the cases, 7.6% in type II and 57.1% in type III. The mean age of the type A was much younger than in type B. In-hospital mortality of acute type A dissection was 36.5% and acute type B dissection was 9.5%. In the two five-year periods, the total number of cases increased by 240%, among which type I the fastest which increased by 360%. Changes regarding mean age and male/female ratio were not obvious. For acute AD, one-year survival rate improved but did not reach statistical significance.

CONCLUSION

Our data provided insight into current regional profiles of AD. The number of hospitalized patients with AD was increasing dramatically. Also the mean age of the first-attack was much younger and proportion of males and in-hospital mortality of acute type A dissection were together with both much higher than reports provided by researchers from other regions. These data suggested that there was an urgent need for further improvement in prevention and treatment of AD.

[Combined surgery of acute type A aortic dissections by ascending aorta replacement and bare stent]

Aim. After surgical treatment of type A aortic dissections a long segment of these aortas often remain dissected. Our goal was to analyse feasibility and first clinical and pathophysiological results of a combined treatment by ascending aorta replacement and stenting of the arch or descending aorta with Djumbodis(R) bare stents.

PATIENTS AND METHODS

Twenty two cases from two centres were analyzed (Universitary Hospital of Parma and Rangueil Universitary Hospital of Toulouse).

RESULTS

All the stents have been implanted with short times of circulatory arrest. Average follow-up was 278 days (0-2005). There were two peroperative deaths (9.1%). One year cumulate survival rate was 72.7%. Postoperative complications were mainly respiratory and renal. We have shown a reduction in number of perfused false lumen for aortic arches, more often stented, than for descending aortas (p=0.0104), and for dissected and stented segments versus dissected unstented segments (p=0.0083).

CONCLUSION

Our study demonstrates feasibility of this combined procedure and its positive effect on pathophysiologic evolution. Long term results have to be evaluated, but we think promising to extend this treatment to the whole dissected aorta.

[Progress in the acute aortic syndrome]

Acute aortic syndrome is an acute lesion of the aortic wall involving the aortic media. The term covers aortic dissection, intramural hematoma, and penetrating ulcer. In the last few years, imaging techniques have increased our understanding of the natural history of these disease entities and of the dynamics of the disease processes. Despite significant advances in diagnosis and surgical treatment, the mortality rate in the acute phase remains high. Early clinical suspicion and greater surgical expertise appear to be the only factors that are able reduce mortality. Once the acute phase is past, the descending aorta continues to be involved in most patients, 30% of whom develop complications within 3-5 years. During this later phase, it is essential to optimize medical treatment and to use imaging techniques to follow-up the patient closely. The availability of endovascular treatment has provided new approaches to the management of the condition and could improve long-term prognosis. The aim of this article was to review recent progress in the diagnosis and therapeutic management of this syndrome.

[Evaluation of aortic aneurysm and dissection by abdominal echography]

Aortic dissection and aneurysm are related to increased vulnerability of the aortic wall due to arteriosclerosis. Echographic findings of aortic sclerosis include irregularity and strong punctate echoes in the intima and meandering of the aorta. Unruptured abdominal aneurysms are often found incidentally by routine echography. The "maximum diameter" and "increase in the size" of aortic aneurysm on echography are important information closely related to the risk of its rupture. In the evaluation of acute aortic dissection, the flap length indicates the range of dissection. The presence or absence of blood flow in the false lumen must be examined simultaneously using color Doppler echography. Some aortic dissections and aneurysms require emergency treatment on detection, and the evaluation of their images on echography, which is often performed for screening of patients with back or abdominal pain, are important for the determination of the therapeutic approach. In patients who are treated conservatively or observed, echography is very useful for the follow-up. Such patients must also be diagnosed or followed up by combining echography with other imaging techniques depending on the condition and necessary information in each patient.

Neurological Symptoms in Type A Aortic Dissections

BACKGROUND AND PURPOSE

Aortic dissection typically presents with severe chest or back pain. Neurological symptoms may occur because of occlusion of supplying vessels or general hypotension. Especially in pain-free dissections diagnosis can be difficult and delayed. The purpose of this study is to analyze the association between type A aortic dissection and neurological symptoms.

METHODS

Clinical records of 102 consecutive patients with aortic dissection (63% male, median age 58 years) over 7.5 years were analyzed for medical history, preoperative clinical characteristics, treatment and outcome with main emphasis on neurological symptoms.

RESULTS

Thirty patients showed initial neurological symptoms (29%). Only two-thirds of them reported chest pain, and most patients without initial neurological symptoms experienced pain (94%). Neurological symptoms were attributable to ischemic stroke (16%), spinal cord ischemia (1%), ischemic neuropathy (11%), and hypoxic encephalopathy (2%). Other frequent symptoms were syncopes (6%) and seizures (3%). In half of the patients, neurological symptoms were transient. Postoperatively, neurological symptoms were found in 48% of all patients encompassing ischemic stroke (14%), spinal cord ischemia (4%), ischemic neuropathy (3%), hypoxic encephalopathy (8%), nerve compression (7%), and postoperative delirium (15%). Overall mortality was 23% and did not significantly differ between patients with and without initial neurological symptoms or complications.

CONCLUSIONS

Aortic dissections might be missed in patients with neurological symptoms but without pain. Neurological findings in elderly hypertensive patients with asymmetrical pulses or cardiac murmur suggest dissection. Especially in patients considered for thrombolytic therapy in acute stroke further diagnostics is essential. Neurological symptoms are not necessarily associated with increased mortality.

Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept

PURPOSE

To report the use of a technique (PETTICOAT: provisional extension to induce complete attachment) to obliterate sustained abdominal false lumen flow and pressurization despite successful stent-graft sealing of the thoracic entry tear in patients with complicated type B aortic dissection.

METHODS

Of 100 initial patients subjected to stent-graft repair for complex type B aortic dissection with thoracoabdominal extension, 12 patients (10 men; mean age 58.7 years, range 44-76) demonstrated distal true lumen collapse and a perfused abdominal false lumen despite successful sealing of the proximal tears. As an adjunctive or staged procedure, a scaffolding stent was placed for distal extension of the previously implanted stent-graft. In each case, a Sinus aortic stent, Fortress stent, or a Z-stent system was customized with maximum 2-mm oversizing versus the original stent-graft diameter. Magnetic resonance or computed tomographic angiography was performed at discharge, at 3 months, and then annually to determine false channel thrombosis, true and false lumen dimensions, and re-entry flow.

RESULTS

Delivery was successful in all cases (100%). The compressed distal true lumen (mean 4+/-3 mm) was reconstructed to a mean width of 21+/-3 mm, and malperfusion was abolished without any obstruction of the abdominal side branches. At up to 1-year follow-up, there were no signs of expansion or distal progression of the scaffolded dissected aorta. All patients with complete thoracic thrombosis showed evidence of improved aortic remodeling; 1 patient with no false lumen thrombosis died at 11 months from thoracoabdominal aortic rupture.

CONCLUSION

The PETTICOAT technique may offer a safe and promising adjunctive endovascular maneuver for patients with distal malapposition of the dissecting membrane and false lumen flow. The technique can both abolish distal true lumen collapse and enhance the remodeling process of the entire dissected aorta.

Radiological diagnosis and classification of antegrade and retrograde Stanford type A intimal intussusception

Intimal intussusception is an uncommon variation of aortic dissection, resulting from circumferential detachment and stripping of the intima in the setting of a Stanford type A dissection. The resultant tube of detached intima may prolapse either antegrade into the aortic lumen or retrograde into the left ventricular cavity. We classify these forms of dissection as antegrade and retrograde Stanford type A intimal intussusception. We present two cases with intimal intussusception and a review of the current literature. The majority of previous cases have been reported in the cardiology and cardiothoracic surgical literature, with few previous radiological reports.

Acute type A aortic dissection complicated by stroke: Can immediate repair be performed safely?

OBJECTIVE

Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke.

METHODS

Between September 1999 and March 2005, 151 consecutive patients presented with acute type A aortic dissection. Of this group, 16 (10.6%) patients had sustained a preoperative stroke. Mean age was 56 years (range 43-73 years), with 6 (38%) women. Right hemispheric, left hemispheric, and bilateral strokes occurred in 81%, 13%, and 6%, respectively. Computed tomographic scan or transesophageal echocardiography diagnosed aortic dissection; clinical examination, computed tomographic scan, or transcranial Doppler ultrasound diagnosed stroke. Aortic repair was performed with cardiopulmonary bypass, profound hypothermic circulatory arrest, and retrograde cerebral perfusion. One patient with complete neurologic devastation (coma) was not operated on.

RESULTS

Overall hospital mortality was 18.8% (3/16). Mortality in 2 patients who did not undergo surgery (1 patient who was neurologically devastated, and 1 patient whose aorta ruptured while awaiting surgery) was 100% (2/2). Operative mortality was 7% (1/14). Among patients undergoing surgery, neurologic status completely recovered in 2 (14%) patients, improved in 6 (43%) patients, remained the same in 6 (43%) patients, and worsened in none. Median time from onset of stroke to surgery was 9 hours (range 1-240 hours). Eighty percent of patients who underwent surgical repair within 10 hours had improvement in neurologic status, where as none operated on beyond 10 hours improved (P < .02).

CONCLUSIONS

In our experience, surgical repair of acute type A aortic dissection can be performed in the setting of preoperative stroke with acceptable mortality. Moreover, no worsening of neurologic condition was observed after surgical repair. Immediate surgical repair is warranted even if acute type A aortic dissection is complicated by stroke.

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.