Operation on acute type A aortic dissection using transapical aortic cannulation

We experienced a case of operation for acute type A aortic dissection using transapical aortic cannulation (TAC). A 62-year-old male with chest and back pain admitted to our hospital. The chest computed tomography (CT) showed the dissection of total aorta. Hemiarch repair (circulatory arrest time: 64 min, pump time: 152 min) was performed by cardiopulmonary bypass (CPB) established with bicaval cannulation and TAC in this case. The reason why we use TAC is that retrograde perfusion by femoral artery has a high-risk of malperfusion and cerebral embolism because of atheromatous change in aorta, and the use of the axillary artery can be troublesome because of the vessel's small diameter. We considered that in cases of acute aortic dissection, TAC is much safer and simpler than femoral or axillary cannulation.     

Aortic root rupture during an operation in a patient with acute aortic dissection

A 73-year-old woman with acute aortic dissection (DeBakey type II) and cardiac tamponade was transferred to our emergency unit. She had a temporary blackout during transfer. An emergency operation was performed. We started core cooling with the superior vena cava, inferior vena cava, and transapical aortic cannulation. When the bladder temperature was 30.5 degrees C, esophageal temperature was 28.7 degrees C, and rectal temperature was 30.5 degrees C, the aortic root suddenly ruptured. We changed the arterial cannulation sites from the apex to the dissecting ascending aorta, and the ascending aorta was cross-clamped. However, the patient's pupils became dilated. Therefore, we started selective cerebral perfusion to avoid prolonged cerebral malperfusion. This procedure took approximately 30 minutes, from the aortic root rupture to selective perfusion. We performed both aortic root and ascending aortic replacement. After the operation, the patient had no neurological or other organ complications and she was discharged 11 days after surgery.     

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30°C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.     

Transapical endovascular aortic repair to treat complex aortic pathologies

Clinical condition, hostile anatomy, and previous heart/aortic surgery may preclude standard open surgery and standard endovascular interventions in patients with complex aortic pathologies. We report our initial experience using the transapical endovascular approach to treat a type IA endoleak after transfemoral endovascular graft repair for a contained rupture of a penetrating descending aortic ulcer; an ascending aortic anastomotic pseudoaneurysm after open surgical repair of an ascending aortic dissection; and a type A aortic dissection after minimally invasive mitral valve repair. There were no neurologic or cardiovascular complications, and the 30-day mortality was 0%.     

Transapical aortic cannulation using a deep hypothermic procedure through a left thoracotomy for acute traumatic aortic rupture

We describe a transapical aortic cannulation procedure through a left thoracotomy for a case of acute traumatic aortic rupture. A 26-year-old man was involved in a motor vehicle accident and admitted in a state of hypovolemic shock. Chest computed tomography findings revealed a rupture of the proximal portion of the descending aorta and a massive hematoma around the aorta extending into the thoracic cavity. Under hypothermic circulatory arrest, he underwent an emergency graft replacement through a left thoracotomy. We used transapical aortic cannulation together with femoral cannulation, in order to avoid malperfusion of the brain and upper body that can occur as a result of retrograde perfusion. The postoperative outcome was favorable. Transapical cannulation is a useful alternative for hypothermic aortic operations through a left thoracotomy.     

Ascending aorta cannulation in stanford type a acute aortic dissection

Establishment of cardiopulmonary bypass for Stanford type A acute aortic dissection( type A AAD) should be quick and safe. The femoral artery, axillary artery, ascending aorta, and left ventricular apex are potential access points for cannulation. The most important reason for establishing cardiopulmonary bypass for type A AAD is to allow antegrade blood flow through the true lumen. Starting in 2007, Jakob et al, and Inoue et al. applied the technique of ascending aortic cannulation for type A AAD. From 2008, we applied this method of ascending aorta cannulation in 8 patients and compared preoperative, operative, and postoperative data with a control group, or the femoral artery cannulation group. Ascending aorta cannulation was done safely and easily with the use of the Seldinger technique under epiaortic color Doppler echography and transesophageal echography. No cerebral events or hypoperfusion-based complications occurred in the group of ascending aorta cannulation. Given that no cases of complication occurred using this method, it could be considered as an effective choice of cannulation for cardiopulmonary bypass.     

The advantages of axillary artery cannulation in surgical treatment of type A acute aortic dissection

There are more alternative cannulation techniques during surgery of type A aortic dissection. The most frequently used femoro-atrial cannulation method provides limited possibility for brain protection during surgery. This theory is confirmed by relatively high frequency of major brain complications in patients operated on while using this cannulation technique. During the last years cannulationis used more often, as it may provide more protection for the brain than other methods. In 2003 seven patients underwent aortic reconstruction because of type A acute aortic dissection using axillary cannulation. All patients except one were discharged after uneventful recovery. There were no postoperative neurological complications following surgery. We lost one patient due to distal progression of the dissection. He was the only patient with clinical evidence of transient postoperative brain damage. We are strongly convinced that the spectacular improvement in our results for the surgery of type A acute aortic dissection is due to the axillary cannulation, the anterograde flow and the isolated cerebral perfusion. We recommend the axillary cannulation technique as the first choice in type A acute aortic dissection.     

Creating an appropriate access for endovascular repair by replacing a dissected femoral artery in aortic dissection

Transfemoral endovascular repair has been widely accepted as an effective treatment for type B aortic dissection. However, if the dissection extends to the femoral artery, the transfemoral approach increases the risk of access complications. We describe a case of acute complicated type B aortic dissection involving the dissected bilateral femoral arteries. Successful endovascular repair without access complications was performed through an appropriate access route created by a femoral arterial conduit. We believe that this approach results in reliable cannulation of the true lumen and the reduction of the risk for intimal injury in aortic dissection with the dissected femoral artery.     

Surgical treatment for acute type A aortic dissection

The purpose of this study was to assess the factors for clinical outcome of the surgical treatment of acute type A aortic dissection. From April 1996 to March 2006, 44 patients underwent emergency operation for acute type A dissection within 2 weeks from the onset. Resection of the intimal tear was performad with open distal anastomosis. The mean age was 63.4 (range 29-83) years, and 28 were female. As for their preoperative condition, 5 patients were in severe hemodynamic instability including cardiac arrest in 2, apnea in 1, and rupture in 4. Distal resection extended to ascending aorta in 24 patients (54.5%), hemiarch in 7 (15.9%), and total arch in 13 (29.5%). 30-day mortality was 4.5% and the incidence of stroke was 13.6%. Several methods were used including axillary artery cannulation and central repair with adventitial inversion technique. Patients with malperfusions caused by acute type A dissection should undergo immediate aortic reconstruction by adequate circulatory assisting methods.     

Acute type A aortic dissection and coarctation of aortic isthmus

Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

Postoperative compartment syndrome in a patient with acute aortic dissection (DeBakey type I)

We report a case of compartment syndrome caused by femoral arterial cannulation during cardiopulmonary bypass. A 62-year-old man who had been diagnosed as acute aortic dissection (type I) received a operation of partial arch replacement with reconstruction of brachiocephalic and left carotid arteries. Compartment syndrome was noticed just after the operation, which was caused by long-term ischemia during femoral arterial cannulation combined with poor collateral circulation by the dissection of iliac arteries. The emergency fascitomy was performed, therefore, he could be discharged without any complications. It is concluded that in case of acute aorte aortic dissection, the back-flow of blood should be checked at the time of femoral arterial cannulation, and whenever the back-flow is poor, some procedures should be added to increase distal blood flow.     

Advantages of subclavian artery perfusion for repair of acute type A dissection.

OBJECTIVE: Arterial perfusion through the right subclavian artery is proposed to avoid intraoperative malperfusion during repair of acute type A dissection. This study evaluated the clinical and neurological outcome of patients undergoing surgery of acute aortic type A dissection following subclavian arterial cannulation compared to femoral artery approach. METHODS: From 1/97 to 1/03, 122 consecutive patients underwent surgery for acute type A aortic dissection. Subclavian cannulation was performed in 62 versus femoral cannulation in 60 patients. Clinical characteristics in both groups were similar. Mean age was 61 years (SD+/-14 years, 72% male) and mean follow-up was 3 years (+/-2 years). Patient outcome was assessed as the prevalence of clinical complications, especially neurological deficits, mortality at 30 days, perioperative morbidity and time of body temperature cooling and analyzed by nominal logistic regression analysis for odds ratio calculation. RESULTS: Arterial subclavian cannulation was successfully performed without any occurrence of malperfusion in all cases. Patients undergoing subclavian cannulation showed an odds ratio of 1.98 (95% CI 1.15-3.51; P=0.0057) for an improved neurological outcome compared to patients undergoing femoral cannulation. Re-exploration rate for postoperative bleeding was significantly reduced in the subclavian group (P<0.0001), as well as occurrence of myocardial infarction (P<0.0001) and duration for body temperature cooling (P=0.004). The 30-day mortality of patients with femoral cannulation was significantly higher compared to patients with subclavian artery cannulation (24 versus 8%; P=0.0179). CONCLUSIONS: Arterial perfusion through the right subclavian artery provides an excellent approach for repair of acute type A dissection with optimized arterial perfusion body perfusion and allows for antegrade cerebral perfusion during circulatory arrest. The technique is safe and results in a significantly improved clinical and especially neurological outcome.     

升主动脉和头臂干双动脉插管在急性A型主动脉夹层手术中应用的倾向性评分匹配分析

目的 探讨升主动脉、头臂干双动脉插管在急性A型主动脉夹层手术中的应用.方法 筛选2017年1月至2020年1月我院急性A型主动脉夹层患者183例,其中42例采用升主动脉、头臂干双动脉插管建立体外循环,为DAC组(男33例、女9例,中位年龄50岁);141例采用单独腋动脉插管建立体外循环,为AAC组(男116例、女25例...     

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection

OBJECTIVE: Neurologic complications after repair of acute type A aortic dissection remain significant. The use of power M-mode transcranial Doppler monitoring to verify cerebral blood flow during these repairs might decrease cerebral ischemia by correcting malperfusion. The purpose of this study was to analyze the use of power M-mode transcranial Doppler monitoring during repairs of acute type A dissection with regard to neurologic outcome. METHODS: We performed a prospective study of patients undergoing repairs of acute type A aortic dissection. Repairs included profound hypothermic circulatory arrest and retrograde cerebral perfusion. Patients in whom transcranial Doppler monitoring was used to monitor cerebral blood flow and modify operative technique during repair (study group) were compared with those without monitoring and modification (control group). RESULTS: Between September 2001 and October 2003, we repaired 56 cases of acute type A dissection. Power M-mode transcranial Doppler monitoring was used in 50% (28/56) of cases. Power M-mode transcranial Doppler monitoring altered operative cannulation and guided retrograde cerebral perfusion flow in 28.5% (8/28) and 78.6% (22/28) of cases, respectively. Two patients presented with preoperative stroke, one in each group. One operative death occurred in each group. In-hospital mortality and the occurrence of new stroke were not significantly different between the 2 groups. Temporary neurologic dysfunction occurred less often in the study group (14.8% [4/27] vs 51.8% [14/27], P = .008). CONCLUSIONS: Identification of cerebral malperfusion requires cerebral monitoring. By ensuring cerebral blood flow by using power M-mode transcranial Doppler monitoring and correcting cerebral malperfusion by modifying operative technique, neurologic outcome was improved during repairs of acute type A aortic dissection.     

Axillary artery cannulation in type a aortic dissection operations.

BACKGROUND: Femoral arteries are the preferred site of peripheral cannulation for arterial inflow in type A aortic dissection operations. The presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may preclude their utilization. Axillary artery cannulation may represent a valid alternative in these circumstances. METHODS: Between January 15, 1989, and August 20, 1998, in our institution, 22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients (13. 6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral perfusion was used in 9 patients (40.9%). RESULTS: Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery cannulation followed an attempt of femoral artery cannulation in 15 patients (68. 2%). All patients survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients (9.1%) died in the hospital of complications not related to axillary artery cannulation. CONCLUSIONS: In patients with type A aortic dissection in whom femoral arteries are acutely or chronically diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow during cardiopulmonary bypass.     

Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: Twenty-year experience

ObjectiveThe study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection.MethodsFrom 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.ResultsPatients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.ConclusionsAortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.     

Successful treatment for intraoperatively evolving acute aortic dissection in a neonate

Acute aortic dissection is a life-threatening condition. We report the case of a neonatal one-stage correction of coarctation and hypoplastic aortic arch repair plus ventricular septal defect closure. While dissecting the head vessels after cannulation of the ascending aorta and commencing cardiopulmonary bypass, type A aortic dissection evolved. This required immediate ascending aorta and aortic arch reconstruction with coarctation of the aorta resection under hypothermic circulatory arrest. The surgical management of this rather unique situation is discussed here.     

Ascending aorta cannulation in acute type A aortic dissection

Objective: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. Methods: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n = 6). Antegrade systemic perfusion via ascending aorta was performed. Results: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32 = 3.1%), two cases of cerebral infarction (2/32 = 6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32 = 90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. Conclusions: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.     

Axillary Artery Perfusion in Acute Type A Aortic Dissection Repair

Abstract Background: We evaluated our experience with axillary artery perfusion technique in acute type A aortic dissection repair. Methods: Between September 2000 and July 2006, 41 consecutive patients with acute type A aortic dissection underwent surgical repair. In 35 of 41 patients (85.4%), arterial perfusion was performed through right axillary artery and in the remaining six patients (14.6%), arterial perfusion site was femoral artery. Indication for femoral artery perfusion was cardiac arrest and ongoing cardiopulmonary resuscitation in one and pulslessness of right upper limb in five patients. Mean age was 54.9 ± 15.3 (16 to 90 years) and 28 were male. Unilateral antegrade cerebral perfusion (perfusate temperature 22 to 25 °C) through axillary artery was performed in all axillary artery perfused patients and in three patients who had femoral artery perfusion. Results: Five patients died postoperatively (hospital mortality 12.2%). All of them had evidence of single or multiple organ malperfusion preoperatively. We did not experience any new transient or permanent neurologic deficit after the procedure in the unilateral antegrade cerebral perfusion patients. Complications related to axillary artery cannulation were observed in two patients (5.3%). One patient with femoral artery cannulation experienced femoral arterial thrombosis, postoperatively. Conclusions: Right axillary artery cannulation for repair of acute type A aortic dissection is a simple and safe procedure. In the case of pulslessness of right upper limb, femoral artery is still the choice of cannulation site.