Traumatic aortic rupture--an emergency indication?]

On the basis of a retrospective analysis that included 22 patients with traumatic rupture of the thoracic aorta, the appropriate time for surgical intervention will be evaluated. The patients were divided into two groups according to their clinical status at the time of surgery. Seven patients with unstable vital systems underwent immediate surgery; 5 out of 7 died intraoperatively. Because of either the surgeons decision or delayed diagnosis, 15 patients underwent surgical repair of the aorta after various time intervals; 3 of these expired late after the operation. These results indicate that the timing of surgical intervention in the stable covered aortic rupture with serious associated injuries should preferably be deferred until after the patients condition has stabilized.     

How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary?

OBJECTIVE: We analyzed two consecutive series of 69 and 34 patients, respectively, with kidney ruptures covering two time periods with different treatment strategies to assess whether outcome is better after initial surgical or initial conservative treatment. METHODS: One hundred and three patients with blunt kidney ruptures grade 2-4 (American Association for the Surgery of Trauma) excluding patients with pedicle injuries of the main renal vessels were evaluated. In the first time period, 1973-1988 (group A) the primary routine treatment of blunt kidney rupture at our institution was surgical. In the second time period 1989- 1995 (group B) the treatment was primarily conservative. Surgery was deferred and performed only if necessary. Rates of surgery, time of surgery, surgical procedures (open or minimal invasive) and loss of renal parenchyma by surgery or trauma were analyzed for the two time periods. Blood loss was estimated for all patients. Postoperative hypertension was evaluated for all patients excluding those who were treated by nephrectomy. RESULTS: In group A 42 of the 69 patients had 42 surgical interventions (61%) and in group B 11 of the 34 patients had 12 interventions (35%). Thirty-nine of the 69 group A patients (57%) had immediate surgery and 3 (4%) had deferred surgery. In group B 1 of the 34 patients (3%) had immediate surgery and 11 (32%) had deferred surgery. All interventions in group A were open. In group B 5 of the 12 interventions were minimally invasive (percutaneous or internal drainage with a JJ-stent). Partial or total nephrectomies were performed in 33 of the 42 surgically treated group A patients (79%) and in 5 of the 12 group B patients (42%). Blood loss in patients with isolated grade 4 kidney rupture seems to be less when treated conservatively or with deferred surgery than with immediate open surgery. The hypertension rate in patients after blunt kidney rupture is 10%; in a similar control population without renal trauma it is 12%. CONCLUSION: Patients with primary conservative treatment of blunt kidney rupture seem to need less surgery, especially less open surgery and loose less blood and renal parenchyma than patients treated by initial surgery. Posttraumatic hypertension is not higher than in a similar control population, independent of the treatment.     

Thoracic aortic emergencies: impact of endovascular surgery

BACKGROUND: Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure. METHODS: From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery. RESULTS: In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 +/- 0.8 and 5.9 +/- 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure. CONCLUSIONS: Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.     

Early and late outcome of operated and non-operated acute dissection of the descending aorta

Objective: At present debate continues concerning the optimal mode of treatment for type B dissections. Controversies are mainly due to discordant results regarding survival following medical or surgical treatment. We assessed early and long-term outcome of acute dissection of the descending aorta treated by emergency aortic replacement, medical treatment or delayed surgery. Methods: Between 1980 and 1995, 225 patients were hospitalized in the medical or surgical departement of our institution with the diagnosis of acute type B aortic dissection. A total of 38 patients (16.8%) underwent replacement of the descending aorta within the first week after hospital admission. Primary indications for immediate surgery were: rupturing aneurysm (n=15), diameter of the descending aorta (n=13), malperfusion of the thoracoabdominal aorta (n=8) and pseudocoarctation syndrome with uncontrollable hypertension (n=2). All other patients (n=187) underwent primary conservative treatment on the intensive care unit, including appropriate anti-hypertensive medication. In 12 of them, surgery was denied because of age or significant concomitant diseases. Results: Hospital mortality after urgent or emergency surgery was 21% (8/38 patients) for the overall time period. There has been a significant decrease in hospital mortality during the last 5 year-period (12% versus 30% between 1980 and 1994). Causes of death were: cardiac failure in 3, bleeding complications in 2, postoperative mesenteric ischemia in 2 and septicemia in one patient. From the 30 operative survivors, 9 (30%) patients required further surgery on the native aorta after a mean follow-up of 48±13 months. Hospital mortality during conservative treatment was 17.6% (33/187 patients). Main causes of death were rupture in 14, thoraco-abdominal malperfusion in 13 and cardiac failure in 3 patients, whereas in 3 patients, the cause of death could not be evaluated. In this group, 9 patients had to be shifted to early surgery during the initial hospitalization because of impending rupture (n=4), rapidly increasing diameter (n=2) and suspicion of intestinal ischemia (n=3). After hospital discharge, surgery for chronic dissection was performed in 47 patients, mainly because of expanding descending aortic aneurysm. Hospital mortality was 8% (4/47 patients). Actuarial survival rates after surgery during the first admission were 85±6% at 5 years and 61±8% at 10 years, versus 76±5 and 50±7% respectively, following conservative treatment (P<0.001). Conclusion: Nowadays, acute type B dissection can be treated surgically with a reasonable perioperative risk. Despite aggressive anti-hypertensive treatment, hospital mortality of primary conservative treatment is still high and a substantial percentage of patients requires surgery during initial hospitalization. Main causes of death in both groups are rupture and abdominal malperfusion: therefore, closed clinical and radiologic assessment of the whole thoraco-abdominal aorta is of utmost importance. Long-term results are satisfying; unlimited radiographic follow-up allows for detection of potential severe complications and for proper planning of elective reoperations when indicated.     

Preoperative Wilms tumor rupture in children

Purpose

According to the guidelines of International Society of Pediatric Oncology (SIOP) and National Wilms Tumor Study (NWTS), Wilms tumor with preoperative rupture should be classified as at least stage III. Few clinical reports can be found about preoperative Wilms tumor rupture. The purpose of this study was to investigate our experience on the diagnosis, treatment and prognosis of preoperative Wilms tumor rupture.

Methods

Patients with Wilms tumor who underwent treatment according to the NWTS or SIOP protocol from January 2008 to September 2017 in Beijing Children’s Hospital were reviewed retrospectively. The clinical signs of preoperative tumor rupture were acute abdominal pain, and/or fall of hemoglobin. The radiologic signs of preoperative tumor rupture are as follows: (1) retroperitoneal and/or intraperitoneal effusion; (2) acute hemorrhage located in the sub-capsular and/or perirenal space; (3) tumor fracture communicating with peritoneal effusion; (4) bloody ascites. Patients with clinical and radiologic signs of preoperative tumor rupture were selected. Patients having radiologic signs without clinical symptoms were also selected. The clinical data, treatments and outcomes were analyzed. Meanwhile, patients without preoperative Wilms tumor rupture during the same period were collected and analyzed.

Results

565 Patients with Wilms tumor were registered in our hospital. Of these patients, 45 patients were diagnosed with preoperative ruptured Wilms tumor. All preoperative rupture were confirmed at surgery. Spontaneous tumor rupture occurred in 41 patients, the other 4 patients had traumatic history. Of the 45 patients, 41 were classified as stage III, 3 patients with pulmonary metastases were classified as stage IV, and one patient with bilateral tumors were classified as stage V. Of these patients with preoperative tumor rupture at stage III, 30 patients had clinical and radiologic signs of tumor rupture, the other 11 patients had radiologic signs without clinical symptoms. Among the 41 patients at stage III, 13 patients had immediate surgery without preoperative chemotherapy (immediate group), and 28 patients had delayed surgery after preoperative chemotherapy (delayed group). In immediate group, 12 patients had localized rupture, 1 patient underwent emergency surgery because of continuous bleeding. In delayed group, 4 had inferior vena cava tumor embolus (1 thrombus extended to inferior vena cava behind the liver, three thrombi got to the right atrium), 4 crossed the midline with large tumors, 20 had extensive rupture without localization. In immediate group, tumor recurrence and metastasis developed in 2 patients, and no death occurred. In the delayed group, tumor recurrence and metastasis developed in 8 patients, and 7 patients died. During the same period, 41 patients were classified as stage III without preoperative rupture. In the non-ruptured group, tumor recurrence and metastasis developed in 3 patients, and 4 patients died. The median survival time in the ruptured group (both immediate group and delayed group) and non-ruptured group were (85.1 ± 7.5) and (110.3 ± 5.6) months, and the 3-year cumulative survival rates were 75.1% and 89.6%, respectively. The overall survival rate between the ruptured and non-ruptured groups showed no statistic difference (P = 0.256). However, there was significant difference in recurrence or metastasis rate between the ruptured and non-ruptured groups (24.4% vs 7.3%; P = 0.031).

Conclusion

Contrast-enhanced computed tomography (CT) and ultrasonography (US) are of major value in the diagnosis of preoperative tumor rupture, and immediate surgery or delayed surgery are available therapeutic methods. The treatment plan was based on patients’ general conditions, tumor size, position and impairment degree of tumor rupture, extent of invasion and experience of a multidisciplinary team (including surgeon and anesthesiologists). In our experience, for ruptured preoperative tumor diagnosed with stage III, the criteria for immediate surgery are as follows: tumor not acrossing the midline, tumor without inferior vena cava thrombus, localized rupture, being capable of complete resection. Selection criteria for delayed surgery after preoperative chemotherapy are as follows: large tumors, long inferior vena cava tumor thrombus, tumors infiltrating to surrounding organs, unlocalized rupture, tumors can not being resected completely. Additionally, patients with preoperative Wilms tumor rupture had an increased risk of postoperative recurrence or metastasis.

     

主动脉腔内修复术救治胸主动脉破裂的临床观察

目的:探讨主动脉腔内修复术(TEVAR)救治胸主动脉破裂的临床适应证及疗效,并总结相关临床经验。方法:回顾性分析2006年1月—2015年9月因胸主动脉破裂急症在广州军区武汉总医院心胸外科就诊的患者临床资料。结果:检索出应用TEVAR救治程序收治的胸主动脉破裂患者51例(胸主动脉夹层动脉瘤破裂15例,胸主动脉创伤32例,主动脉食管瘘4例)。51例患者中,术前死亡4例,47例获TEVAR救治;术后死亡6例(其中主动脉食管瘘3例),其余41例患者均无明显严重并发症,且术后1个月内无死亡。术后3、6、12个月,之后每年复查CT,随访截至2016年5月,36例患者获得了完整的随访,随访6~123个月,平均56.6个月。其中1例随访至术后6个月,4例随访至术后12个月,1例随访至术后24个月。随访患者均健康存活、人工血管旁路通畅,血管支架无内漏。结论:TEVAR是快速、有效的救治胸主动脉破裂的一种措施。     

Endovascular repair for acute traumatic rupture of the thoracic aorta

BACKGROUND: We report endovascular treatment of acute traumatic rupture of the thoracic aorta as a potential alternative to open surgery for high-risk patients. METHODS: Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the thoracic aorta were treated with a stent-graft. In all cases the endovascular management was selected because of age, associated polytrauma, or comorbidities. Preoperative workup included chest computed tomography scan, transoesophageal echography, and angiography. The devices used were the Excluder and the Talent stent-grafts. RESULTS: Eight patients underwent immediate repair and 1 patient was treated within 5 days of the accident because of delayed diagnosis of aortic rupture after surgical management of spleen rupture. The stent-graft was successfully expanded in all patients through the common femoral artery (n = 7) or the common iliac artery (n = 2). There was no perioperative death, renal failure, or neurologic complication (paraplegia or stroke). In 1 patient the computed tomography scan at 7 days postoperatively showed proximal endoleak requiring placement of a second stent-graft. Follow-up ranged from 4 to 20 months. All spiral computed tomography scans performed during follow-up revealed no evidence of endoleak, migration, or alteration of the stent-graft. CONCLUSIONS: Endovascular repair in the acute phase of traumatic rupture of the thoracic aorta is technically feasible and safe, and may represent an alternative to open surgery for high-risk patients.     

Aortoesophageal fistula: value of in situ aortic allograft replacement

PURPOSE: The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement. PATIENTS: Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32-77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage. RESULTS: Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived. CONCLUSION: Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.     

Traumatic rupture of the thoracic aorta: Should one always operate immediately?

Although the traditional therapy for blunt traumatic rupture of the thoracic aorta (TRA) is immediate operative repair, there may be a selective role for delayed repair, particularly in patients with head trauma, respiratory failure, or cardiac dysfunction. The present study examines the hypothesis that TRA can be managed by selective delayed operative repair. Clinical data were collected from 59 consecutive patients with TRA at a regional trauma unit. All TRAs were at the aortic isthmus. Patients were retrospectively classified into three groups: group I (n=12) included patients who either arrived in extremis or rapidly became unstable during triage; group II (n=3) included patients who had no contraindications to early repair and underwent repair at the time of diagnosis; and group III (n=44) consisted of patients who because of concomitant injuries or sepsis required initial admission and management in the intensive care unit until their clinical status had improved sufficiently to allow for deliberate delayed operative repair of the TRA. The delay ranged from 1 day to 7 months. Eight patients have yet to undergo repair and remain well at follow-up from 1 to 4 years. Overall survival rates in groups I, II, and III were 17%, 100%, and 82%, respectively. The surgery-related mortality rate in group III was 10% (three patients). Only two (4.5%) patients in group III died as a result of a ruptured aorta within 72 hours of admission. In conclusion, contrary to surgical doctrine, TRA may not require immediate operative repair in all cases, but may instead be managed selectively depending on the patient's clinical status.     

Treatment of ventricular septal defect after myocardial infarction

Between 1978 and 1984 6 cases of ventricular septal defect after myocardial infarction were referred to this hospital. All 6 patients underwent cardiac catheterisation, had severe pulmonary hypertension and large left-to-right shunts (mean 64%). They were treated with high doses of diuretics and vasodilators, and underwent delayed surgery 6 weeks after rupture. Follow-up is from 1 to 7 years. There has been 1 late, non-cardiac death. The remainder are well. In our experience patients with congestive cardiac failure complicating ventricular septal defect after infarction can be stabilized initially on diuretic and vasodilator therapy, and surgery can safely be deferred until septal fibrosis allows adequate closure.     

大动脉炎性脑缺血的临床对策

目的 探讨大动脉炎颈部动脉阻塞所致重症脑缺血的临床对策。方法 1984至2003年间共收治103例,女性占92例。行升主动脉-双颈内动脉（ICA）架桥7例,升主动脉-腋动脉、单侧ICA架桥38例,升主动脉-双腋动脉架桥6例（2例施二期手术,人工血管-左ICA架桥）,升主动脉至右ICA架桥3例（2例于二期完成人工血管至左ICA架桥术）,经皮腔内血管成形术（PTA）5例,支架3例。结果 27例行保守治疗,其中9例好转,15例略有改善或基本无变化,发生偏瘫及死于中风和心肌梗死各1例。76例实施手术或介入治疗。其中手术治疗者68例,55例（80．9％）获得平均48个月的随访,随访结果：满意20例（36．4％）、较好21例（38．2％）、改善11例（20．0％）、无变化2例（3．6％）、死亡1例（1．8％）。8例接受介入治疗（PTA或支架治疗）者即时疗效佳,但在3～5个月内均复发。结论 提倡进行升主动脉-腋动脉-单侧ICA重建,或对锁骨下动脉窃血者施行升主动脉与双腋动脉重建术,如果需要,二者均可行人工血管二期手术,重建对侧ICA。     

Traumatic rupture of the thoracic aorta: ten years of delayed management

OBJECTIVE: Traumatic rupture of the thoracic aorta is a highly fatal condition in which patient outcome is strongly conditioned by other associated injuries. Delayed aortic treatment has been proposed to improve results. METHODS: The charts of 69 patients with traumatic rupture of the thoracic aorta observed between 1980 and 2003 were reviewed. Patients were grouped according the timing of repair: group I, immediate repair (21 patients); and group II, delayed repair (48 patients). In group II, 45 patients were treated surgically or by endovascular procedure. RESULTS: In-hospital mortalities were 4 of 21 patients (19%) in group I and 2 of 48 patients (4.2%) in group II. There were 3 cases of paraplegia in group I and none in group II. CONCLUSION: Improvement of patient outcome with traumatic rupture of the thoracic aorta can be achieved by delaying surgical repair until after management of major associated injuries if there are no signs of impending rupture. Endovascular treatment is feasible and safe and may represent a valid alternative to open surgery in selected cases.     

Surgical versus endovascular treatment of traumatic thoracic aortic rupture

OBJECTIVES: Blunt traumatic thoracic aortic rupture is a life-threatening surgical emergency associated with high mortality and morbidity. The recent development of endovascular stent-graft prostheses offers a potentially less invasive alternative to open chest surgery, especially in patients with associated injuries. We sought to compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture in a single center. METHODS: From July 1998 to January 2004, 20 patients with acute blunt traumatic aortic rupture underwent treatment at our institution. All patients had a lesion limited to the isthmus, and associated injuries. Initial management included fluid resuscitation, treatment of other severe associated lesions, and strict monitoring of blood pressure. Eleven patients (9 men, 2 women; mean age, 32 years) underwent surgical repair, including direct suturing in 6 patients and graft interposition in 5 patients. Ten patients were operated on with cardiopulmonary support (left bypass with centrifugal pump, n = 2; extracorporeal circulation, n = 8). The delay between trauma and surgery was 2.6 days (range, 0-21 days). Nine patients (8 men, 1 woman; mean age, 32 years) underwent endovascular treatment with commercially available devices (Excluder, n = 2; Talent, n = 7). In all patients 1 stent graft was deployed. In 2 patients the left subclavian artery was intentionally covered with the device. The delay between trauma and endovascular treatment was 17.8 days (range, 1-68 days). RESULTS: One patient in the surgical group (9.1%) died during the intervention. Three surgical complications occurred in 3 patients (27%), including left phrenic nerve palsy (n = 1), left-sided recurrent nerve palsy (n = 1), and hemopericardium 16 days after surgery that required a repeat intervention (n = 1). No patient in this group had paraplegia. In the endovascular group successful stent-graft deployment was achieved in all patients, with no conversion to open repair. No patient died, and no procedure-related complications, including paraplegia, occurred in this group. Control computed tomography scans obtained within 7 days after endovascular treatment showed exclusion of pseudoaneurysm in all cases. Length of follow-up for endovascular treatment ranged from 3 to 41 months (mean, 15.1 months). Computed tomography scans obtained 3 months after endovascular treatment showed complete disappearance of pseudoaneurysm in all patients. CONCLUSION: In the treatment of blunt traumatic thoracic aortic rupture, the immediate outcome in patients who receive endovascular stent grafts appears to be at least as good as observed after conventional surgical repair. Long-term follow-up is necessary to assess long-term effectiveness of such management.     

胸部主动脉瘤的外科治疗

作者自１９９０年４月至１９９４年１２月共收治了各类胸主动脉瘤８０例，其中进行手术治疗共６１例，分别为Ｂｅｎｔａｌ手术３５例，Ｗｈｅａｔ手术３例，主动脉峡部瘤切除术３例，降主动脉瘤人造血管置换术１４例，其他６例。总手术死亡率为６％。１９例非手术治疗组中，有８例于术前动脉瘤破裂，５例死亡，３例出院后其中２例半年后死亡。在有夹层形成的４９例中，Ａ型夹层动脉瘤２８例，Ｂ型夹层动脉瘤２１例（Ｓｔａｎｆｏｒｄ分类法）。手术成功的重要因素是预防术后大出血，心律失常和感染。     

Results of Aortic Surgery in Patients with Marfan Syndrome

Purpose We reviewed the outcome of aortic operations in patients with Marfan syndrome to evaluate the immediate and long-term results of surgical treatment.Methods Between January 1985 and June 2002, 22 patients with Marfan syndrome underwent surgical treatment for aortic diseases at our hospital. Eight patients had Stanford type A aortic dissection and ten patients had aortic root aneurysm with aortic regurgitation. We performed aortic root replacement in 21 patients. Subsequent aortic operations were done in 11 patients, 6 of whom required a third operation. Five patients underwent repeat surgery of the previously operated aortic segment. A collective a total of 42 aortic operations were performed in the 22 patients. Seven patients underwent total aortic replacement.Results The in-hospital mortality rate was 4.5%, and there were three late deaths: two caused by rupture of the dissected aorta, 17 months and 24 months after the last surgical intervention, respectively, and one caused by heart failure 27 months after a total aortic replacement. The overall actuarial survival was 90.2% at 5 years and 74.4% at 10 years.Conclusions Surgical treatment of patients with Marfan syndrome can be accomplished with low mortality; however, new aortic lesions should be promptly explored, and appropriately timed surgical treatment can substantially improve the prognosis of patients with Marfan syndrome.     

Long-term experience with descending aortic dissection: the complication-specific approach.

We analyzed long-term results in 71 patients (45 men and 26 women) treated over 17 years for documented descending aortic dissection. Forty-nine patients were treated medically and 22, surgically. Actuarial survival was 65% at 1 year, 57% at 3 years, 50% at 5 years, and 28% at 10 years for the whole group. For the group treated medically, survival was 73%, 63%, 58%, and 25% at 1 year, 3 years, 5 years, and 10 years, respectively, and for the group treated surgically, 47%, 40%, and 28% at 1 year, 3 years, and 5 years, respectively. Ten (20.4%) of the 49 medically treated patients died early (5 of rupture), and 14 (28.6%) died late (8 of dissection). Five medically treated patients crossed over to surgical management for complications of dissection. Among the surgically treated patients, 6 underwent standard graft replacement of the proximal descending aorta, 8 underwent the fenestration procedure (with a standardized retroperitoneal abdominal approach), and 4 underwent the thromboexclusion operation. Specific analysis of fenestration in 14 patients (including some with persistent descending aortic dissection after replacement of the ascending aorta for dissection) found it to be safe and effective. Actuarial survival after fenestration was 77%, 77%, and 53% at 1 year, 3 years, and 5 years, respectively. Thromboexclusion was found effective, and postoperative studies confirmed thrombosis of the descending aorta with preservation of the lowest intercostal arteries. Fifteen of the 21 surviving medically treated patients agreed to return for follow-up imaging. Nine had thrombosis of the false lumen. An interesting radiographic finding was that 4 of the 15 restudied patients had a saccular aneurysm in the aorta at the level of the left subclavian artery. We recommend a complication-specific approach to the management of descending aortic dissection. Uncomplicated dissection is treated medically, whereas complicated dissection is treated surgically, with realized rupture treated by standard graft replacement, limb ischemia treated by fenestration, and enlargement or impending rupture treated by thromboexclusion.     

保留后瓣及瓣下结构的二尖瓣置换术临床分析

目的总结保留二尖瓣后瓣及瓣下结构二尖瓣置换术(MVR)的经验,评价其临床效果。方法回顾性分析首都医科大学北京安贞医院2006年1月至2011年3月行MVR患者1 035例的临床资料,其中男562例,女473例;年龄37～78(53.84±13.13)岁。风湿性心脏瓣膜病712例,退行性瓣膜病323例;二尖瓣狭窄为主389例,二尖瓣关闭不全为主646例;均排除冠状动脉疾病。不保留后瓣及瓣下结构的MVR(不保留组)457例,保留后瓣及瓣下结构的MVR(保留组)578例,两组患者术前情况差异无统计学意义。分析比较两组患者手术后并发症、死亡率,以及左心室大小与功能。结果不保留组与保留组患者的死亡率(2.63%vs.1.21%,P=0.091)及并发症发生率(8.53%vs.7.44%,P=0.519)差异无统计学意义,但不保留组左心室破裂发生率高于保留组(1.09%vs.0.00%,P=0.012);术后6个月心脏超声心动图提示左心室舒张期末内径(LVEDD)较术前缩小,但两组差异无统计学意义;两组患者左心室射血分数(LVEF)均较术前提高,保留组中二尖瓣关闭不全为主患者的LVEF优于不保留组(56.00%±3.47%vs.53.00%±3.13%,P=0.000),两组二尖瓣狭窄为主的患者中LVEF差异无统计学意义(57.00%±5.58%vs.56.00%±4.79%,P=0.066)。结论保留二尖瓣后瓣及瓣下结构的MVR安全有效,可以减少术后左心室破裂的发生并改善术后心功能。     

Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair

OBJECTIVE: The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS: A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS: In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS: In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.     

Prospective Randomized Study on Asymptomatic Severe Carotid Stenosis and Perioperative Stroke Risk in Patients Undergoing Major Vascular Surgery: Prophylactic or Deferred Carotid Endarterectomy?

We compared the perioperative (30-day) stroke risk in asymptomatic patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) before or after major vascular surgery. Seventy-nine patients with asymptomatic severe carotid lesion were randomly assigned to group I (n = 40) or group II (n = 39) to receive prophylactic CEA (within 1 week before major surgery) or deferred CEA (between 30 days and 6 months after major surgery), respectively. All procedures were eversion CEAs performed under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. There were no perioperative deaths or strokes relating to the major surgical procedure in either group. All group II patients underwent deferred CEA as planned (median 47 days, range 38-94) with no subsequent perioperative deaths or strokes. Two of these patients (5.1%) suffered a minor stroke, however, 65 and 78 days after their major surgical procedure, while awaiting carotid revascularization. Although data emerging from this analysis indicate that severe asymptomatic carotid disease may be safely postponed in patients undergoing major noncarotid vascular surgery, only a multicenter prospective study could determine the most appropriate management of this subset of patients.     

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.