Differential outcomes of open and clamp-on distal anastomosis techniques in acute type A aortic dissection

Objectives

Open-distal anastomosis is the preferred technique over clamp-on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD were affected by the use of either technique.

改良全主动脉弓置换治疗老年Stanford A型主动脉夹层

目的总结改良全主动脉弓置换治疗老年Stanford A型主动脉夹层的临床经验,并探讨其疗效。方法 39例老年Stanford A型主动脉夹层患者在深低温停循环、双侧顺行脑灌注下行外科手术。根部处理根据不同病变情况,选择不同术式,包括单纯升主动脉置换、Bentall、Wheat手术。主动脉弓部采用四分支血管行全主动脉弓置换,降主动脉内置入硬象鼻支架,并行支架开窗,完成左锁骨下动脉重建。结果全组平均体外循环时间为(180.49±30.46)min,平均停循环时间(27.22±10.58)min,平均脑灌注时间(32.42±12.36)min,平均心肌阻断时间(94.84±24.83)min。升主动脉置换17例,Wheat手术10例,Bentall手术12例。全组无术中死亡,术后住院死亡2例,脑梗塞1例,短暂性神经功能障碍3例,行肾脏透析治疗3例。全组无出血再次开胸、声音嘶哑、左上肢感觉运动功能障碍等情况。术后复查主动脉CTA弓部分支血管血流通畅,象鼻支架无内漏。无术后死亡及二次手术者。结论选择合适的手术时机及手术方式,老年Stanford A型主动脉夹层患者仍能获得满意的外科手术效果。     

Surgery for acute type a aortic dissection using retrograde cerebral perfusion

OBJECTIVE: We reviewed the surgical management of acute type A aortic dissection between 1989 and 1998. METHODS: Subjects were 28 consecutive patients (mean age: 61.8 +/- 10.7 years) with acute type A aortic dissection were studied. The mean duration between aortic dissection onset and surgery was 17.5 +/- 17.0 hours. In surgery, aortic pathology and flow patterns in dissected aortic channels were evaluated using transesophageal and epiaortic echo. Simple, safe combination of profound hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis was used for brain protection. Hypothermic circulatory arrest was 46.9 +/- 24.8 minutes. Aortic repair consisted in ascending aortic replacement in 5 patients, with hemiarch repair in 17, and total arch repair in 6. Intimal tears were resected in all but 2 patients. Concomitantly resuspension of the aortic valve was done in 9 and aortic root replacement in 2. RESULTS: No operative (30-day) deaths occurred, although 2 died from unrelated hepatic failure during hospitalization or late-stage pancreatic cancer in the late stage. In cerebral sequellae, 1 patient suffered a stroke and 2 patients developed temporary neurologic dysfunction. CONCLUSION: Our experience demonstrated that the simplified conjunction of hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis, associated with real-time assessment by transesophageal and epiaortic echo, is safe and useful during emergency aortic repair for acute type A aortic dissection.     

Inducing false lumen thrombosis for retrograde type A aortic dissection

Background

How to choose the proximal landing zone in endovascular interventions for a patient with a patent retrograde false lumen in dissection of the ascending aorta and aortic arch remains unclear. This study sought to report the safety and efficiency of inducing thrombosis of the retrograde false lumen to enhance a proximal landing zone to treat retrograde type A aortic dissection.

Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Objective

To evaluate short-term outcomes following direct aortic root and arch repair in patients with acute type A aortic dissection (ATAAD) without technical adjuncts.

A new paradigm in the management of acute type A aortic dissection: Total aortic repair

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and “hemi-arch” with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of “branch first” total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.     

Total arch replacement using a 4-branched graft with antegrade cerebral perfusion

Objective

Total arch replacement (TAR) is an established standard surgical procedure. We report >1000 cases of TAR using a 4-branched graft with antegrade cerebral perfusion (ACP) during a 15-year period.

Improved survival of surgery for acute type a aortic dissection

Objectives: In the past decade, progress in cardiovascular technology has been incorporated into the surgical treatment of acute type A dissection resulting in remarkable improvement. Factors in this progress encompass rapid noninvasive diagnosis, intraoperative introduction of aprotinine, surgical glue, sealed grafts, and refined surgical technique. The objective of this study is to identify which factors contributed to the improvement of the surgical outcome of acute type A dissections. Methods: Between January 1989 and February 2001, 78 consecutive patients had emergency surgeries for acute type A dissection. The initial 31 patients (group I) received preoperative angiography, when possible. Since 1996, the next 47 patients (group II) have received noninvasive rapid diagnosis with hemostatic surgical management. This included aggressive proximal resection and judicious use of gelatin resorcine formol glue and felt strips. Between the two groups, in-hospital mortality and morbidity, incidence of neurological complications, late survival and cardiovascular events were compared. Risk factors for in-hospital death were investigated with univariate and multivariate analysis. Results: The in-hospital mortality was significantly improved in group II (4.3%) compared with group I (29.0%). Overall mortality was 14.1%. Multivariate analysis revealed preoperative limb ischemia and delayed timing of operation (>3 hours after arrival) as independent risk factors for in-hospital death. Late survival at 5 years was 61.5±7.5%. Between the two groups there was no significant difference in late survival or cardiovascular events. Conclusions: Immediate surgical intervention, using rapid noninvasive diagnosis with hemostatic management, substantially improves the surgical outcome of acute aortic dissection.     

Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection

Objectives

To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry.

Changing predictors of postoperative mortality in acute type A aortic dissection

OBJECTIVES: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION: Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.     

杂交技术治疗DeBakeyⅠ型夹层的早中期结果

目的:比较杂交和冷冻象鼻(FET)技术治疗DeBakeyⅠ型主动脉夹层的早中期结果。方法:回顾性分析2010年1月~2016年12月阜外医院血管外科中心诊治的937例DeBakeyⅠ型主动脉夹层患者的临床资料。815例(86.9%)患者行常规全弓替换+FET植入术(FET组);122例(13.1%)患者行头臂血管去分支+同期全弓腔内介入支架修复术(杂交组)。通过匹配分析方法确定了109对患者进行均衡比较。结果:(1)全组患者分析结果:全组平均年龄48.6岁,杂交组高于FET组(61.3岁比46.7岁,P<0.001)。全组早期死亡98例(10.5%,98/937),杂交组11例(9%,11/122),FET组87例(10.7%,87/815)(P=0.577);全组复合并发症率19.6%(184/937),杂交组[15.6%(19/122)]和FET组[20.2%(165/815)]比较差异无统计学意义(P=0.226);杂交组术后无持续性神经功能障碍发生,FET组有72例(8.8%)(P=0.010)。(2)匹配组分析结果:杂交组死亡率及复合并发症率均低于FET组,但两组比较差异无统计学意义[9.2%(10/109)比17.4%(19/109),P=0.073;15.6%(17/109)比25.7%(28/109),P=0.066]。术后新发肾功能不全、肝功能不全以及截瘫发生率,杂交组均低于FET组(P=0.013,P=0.022及P=0.014)。胸段假腔完全血栓化率杂交组均高于FET组[支架段:87.8%(79/90)比75.3%(58/77),P=0.044;下胸段:43.3%(39/90)比27.3%(21/77),P=0.038]。杂交组3、5及7年生存率分别为95.7%、91.7%及91.7%,FET组分别为95.6%、93.7%及82%(P=0.320)。结论:杂交全弓技术治疗DeBakeyⅠ型主动脉夹层有改善术后早期死亡和复合并发症的趋势;相比FET技术,杂交技术显著降低术后脊髓损伤和肝肾功能不全发生率,更能促进中远期胸段夹层假腔的完全血栓化。