Aortic arch aneurysm complicated with coronary artery disease: still a surgical challenge?

Recent surgical strategies and outcomes for the simultaneous operation of aortic arch repair (AAR) and coronary artery bypass grafting (CABG) were reviewed. The surgical treatment of aortic arch aneurysm complicated with coronary artery arteriosclerosis has been a challenge. In spite of recent improvements in cerebral protection during AAR such as deep hypothermia and circulatory arrest with/without retrograde cerebral perfusion, or antegrade selective cerebral perfusion (SCP), additional CABG poses a considerable surgical risk resulting in extremely higher mortality rates when compared with solo AAR. To minimize the cardiac ischemic time, several techniques such as distal coronary artery anastomosis on the perfused fibrillating heart, and coronary artery perfusion through a cardioplegic line during AAR have been employed. Recently, open stent grafting instead of aortic distal anastomosis has been attempted to minimize the cardiopulmonary time and operative complexity. Our recent experience suggested off-pump coronary artery bypass and AAR with the aid of SCP decreased cardiac ischemic time and cardiopulmonary time followed by improved operative morbidity and mortality. Further less-invasive surgical modalities that enhance the adequate myocardial protection and minimize the adverse effect of cardiopulmonary bypass can improve the outcome of this demanding operation for these elderly patients with aortic arch aneurysm and coronary artery occlusive disease.     

Aortic arch replacement for degenerative aneurysms: advances during the last decade

During the last decade, treatment paradigm for degenerative aortic arch aneurysms has been changed by a better understanding of the pathophysiology of brain complication and introduction of endovascular technologies. To avoid neurocognitive dysfunction, safe duration of deep hypothermic circulatory arrest is now considered <25 min, and retrograde cerebral perfusion became less frequently used. Selective cerebral perfusion (SCP) is not associated with neurocognitive decline unless profound hypothermia (<20 °C) is used, which may suggest profound hypothermic SCP is not advantageous but may be detrimental. Attempts have been made to use mild to moderate hypothermia during SCP, and safe duration of distal circulatory arrest seems <60 min at 28 °C to avoid ischemic spinal cord injury. Three-vessel perfusion seems advantageous to provide adequate brain and spinal cord protection. To avoid aortogenic brain atheroembolism in the high risk patients, we previously proposed the “isolation” technique, where SCP is established before systemic perfusion. This technique has subsequently been modified to use both axillary and left carotid arteries for systemic arterial return, so that aortogenic emboli may not enter the brain circulation. In the TEVAR (thoracic endovascular aortic repair) era, hybrid operations such as the frozen elephant trunk or TEVAR completion after the elephant trunk are increasingly performed for extensive or distal arch aneurysms. It should be noted, however, that the frozen elephant trunk operation for extensive aneurysms carries an increased risk of paraplegia, and for distal arch aneurysms its outcome is not better than that after the standard open repair in Japan.     

支架"象鼻"术治疗DeBakey Ⅰ型主动脉夹层动脉瘤

目的 探讨支架"象鼻"手术治疗DeBakey Ⅰ型主动脉夹层动脉瘤(AD)的方法和效果.方法 12例DeBakey Ⅰ型AD患者,平均年龄48.1岁.采用深低温停循环(DHCA),右腋动脉顺行灌注(SCP)脑保护,实施支架"象鼻"手术(即升主动脉和全弓置换及降主动脉腔内支架植入).结果 术后死亡1例,手术死亡率8.3%.术中体外循环时间(163.2±17.7)min,停循环时间(41.6±12.3)min.随访3～6个月,无死亡病例.结论 支架"象鼻"手术简单,停循环时间短,治疗DeBakey I型夹层主动脉瘤安全、有效.     

主动脉弓部手术75例

目的 总结主动脉弓部手术的方法和临床经验。方法75例弓部手术中74例采用深低温停循环（DHcA）技术，其中54例脑保护采用上腔静脉逆灌（RCP），20例采用右腋动脉顺灌（SCP）；仅1例在中度低温体外循环下行局部切除吻合。升主动脉和半弓置换53例，其中同期行降主动脉腔内支架植入术11例，弓部内膜破口修补6例，降主动脉近端内膜破口修补3例；升主动脉和全弓置换20例，其中同期行传统象鼻手术12例，降主动脉腔内支架植入4例；单纯弓部瘤切除缝合及弓部置换各1例。同期手术包括17例Bentall手术，12例AVR，3例Cabrol手术，5例二尖瓣成形术，9例主动脉瓣悬吊成形术等。DHCA9～120min，平均42．3min。结果手术死亡5例，死亡率6．7％。主要并发症为呼吸功能不全11例，肾功能不全7例，一过性精神异常9例。结论DHCA＋RCP及DHCA＋SCP技术均是主动脉弓部手术的有效方法，但后者更适用于复杂的弓部手术；手术范围和方式取决于病变性质和范围，术前状况和手术技术是影响手术效果的决定因素。     

Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion

BACKGROUND: Aortic arch aneurysm repair remains associated with considerable mortality and risk of cerebral complications. We present results of a technique utilizing a three-branched graft for arch replacement, deep hypothermic circulatory arrest (HCA), and selective antegrade cerebral perfusion (SCP). METHODS: Between March 2000 and November 2001, 22 patients (11 female) aged 40 to 77 years (mean 64 +/- 11.2) underwent arch replacement utilizing the trifurcated-graft technique. Serial anastomosis of the branched graft to individual cerebral vessels was carried out during HCA, followed by arch reconstruction during SCP through the graft. All 22 patients had surgery electively. Eight patients (36%) had undergone previous aortic surgery. In 19 patients, arch replacement was part of an elephant trunk procedure; 2 patients had Bentall operations and 1 had isolated arch replacement. Concomitant coronary artery bypass grafting was performed in 6 patients (27%). Mean HCA duration was 30 +/- 6 minutes at a mean temperature of 11.4 +/- 0.8 degrees C. Mean duration of SCP was 52 +/- 18 minutes. RESULTS: Adverse outcome--death before hospital discharge or permanent stroke or both--occurred in 2 patients (9%). Two patients experienced transient neurologic dysfunction (9%). Two patients (9%) developed renal failure requiring short-term hemodialysis and pulmonary complications occurred in 2 patients. CONCLUSIONS: Cerebral protection and prevention of atheroembolism remain challenges in aortic arch reconstruction. To reduce neurologic complications we developed an aortic arch reconstruction technique in which a trifurcated graft is anastomosed to the brachiocephalic vessels during HCA, reducing the risk of embolization while minimizing cerebral ischemia by permitting antegrade cerebral perfusion as arch repair is completed.     

急性Stanford A型主动脉夹层弓部病变处理决策

目的 总结急性Stanford A型主动脉夹层弓部处理的临床经验,探讨选择手术时机、确定治疗方案和手术方式的重要性.方法 2005年8月至2010年8月对210例急性Stanford A型主动脉夹层行弓部替换手术治疗.手术方式采用深低温停循环及顺行性脑灌注,半弓替换+支架象鼻手术92例;次全弓替换+支架象鼻手术50例;全弓替换+支架象鼻手术68例.术后随访,胸腹主动脉CT观察降主动脉假腔闭合情况.结果 全组体外循环(146±52)min,主动脉阻断(93±25)min,深低温停循环(35±14)min.主动脉弓部手术围手术期死亡10例(4.8%).术后18例(8.6%)发生并发症,主要包括急性肾功能不全、神经系统并发症、纵隔感染及急性呼吸功能衰竭.术后随访2～60个月,平均(27±18)个月.随访过程中无死亡,再次入院行降主动脉替换术1例.增强CT检查结果显示支架远端胸降主动脉假腔闭合率为74%.结论 主动脉弓部处理是急性Stanford A型主动脉夹层治疗的重要手段.正确的决策对于提高手术的疗效有重要意义.

Abstract：

Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.     

Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage "elephant trunk" repair

Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage "elephant trunk" repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1-64 months). Twelve patients (five women and seven men) with a mean age of 69 +/- 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.     

A re-operative case of bentall operation and aortic arch replacement using a stent graft for a Marfan syndrome, post sternum turnover and post mitral valve replacement

A 36-year-old male with Marfan syndrome succesfully underwent Bentall operation and aortic arch replacement using a stent graft as an elephant trunk. He had received MVR with sternum turn over 14 years previously. Median sternotomy was performed. Under circulatory arrest with rertograde cerebral perfusion we performed Bentall operation and aortic arch replacement using a stent graft. The sternum was cured well. Retractive breathing was not detected. This surgical procedure was effective for cardiovascular disease with Marfan syndrome.     

改良全弓置换加支架象鼻术在DeBakeyⅠ型主动脉夹层术中的应用

目的 总结改良主动脉全弓置换加支架象鼻术治疗DeBakey Ⅰ型主动脉夹层的临床经验.方法 2006年1月至2010年10月,101例DeBakey Ⅰ型主动脉夹层患者接受改良全弓置换加支架象鼻术,其中急诊手术73例.全组男性76例,女性25例;年龄21～77岁,平均(49±8)岁.手术包括升主动脉置换术31例、Bentall术29例、Wheat术7例、David术34例.支架象鼻术的同时行左锁骨下动脉开窗以重建血运.在深低温停循环时改行双侧顺行脑灌注下完成脑保护.结果 手术改良后平均心肺转流时间(212±40)min,平均心肌阻断时间(95±16)min,平均停循环时间(42±8)min.手术死亡1例,住院死亡5例,分别死于感染败血症、急性肾功能衰竭、偏瘫并发多器官功能衰竭.双侧脑灌注后脑血管意外和短暂脑神经功能障碍的发生率低于选择性脑灌注.76例患者出院前复查主动脉CT血管造影,人工血管无扭曲,血流通畅,胸降主动脉夹层假腔闭合率为78.9%.71例随访5～49个月,其中50例复查CT血管造影,胸降主动脉夹层假腔闭合率为88.0%,无晚期死亡及再次手术者.结论 改良的全弓置换加支架象鼻术治疗DeBakey Ⅰ型主动脉夹层安全、有效,可减少术后并发症.

Abstract：

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010, 101 cases of DeBakey Ⅰ aortic dissection were treated by modified total arch replacement and stent elephant trunk technique, in which emergency surgery for 73 cases. There were 76 male and 25 female patients, aged from 21 to 77 years with a mean of(49 ±8)years. Intraoperative ascending aortic replacement in 31 cases, Bentall procedure in 29 cases, Wheat procedure in 7 cases, David procedure in 34 cases. At the same time stent elephant trunk in the left subclavian artery corresponding position was windowed to rebuild the blood supply. Deep hypothermic circulatory arrest cerebral protection was completed by bilateral antegrade cerebral perfusion. Results The mean cardiopulmonary bypass time was(212 ±40)min, mean myocardial occlusion time was(95 ± 16)min, mean circulatory arrest time was (42 ±8)min. Operative mortality was 1 case and hospital mortality was 5 case, which died of septicemia,acute renal failure and hemiplegia complicated with multiple organ failure. Compared with selective cerebral perfusion, the incidence of postoperative cerebral vascular accident and transient neurological dysfunction decreased. Seventy-six cases received aorta CTA before discharged, the closure rate of descending thoracic aortic dissection false lumen was 78. 9%. Seventy-one patients were followed up for 5 to 49 months, 50cases was reviewed by CTA, of which closure rate of descending thoracic aortic dissection false lumen was 88.0%, no late death and re-surgery. Conclusions The modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection was safe and effective, with less postoperative complications.     

Arch repair with unilateral antegrade cerebral perfusion.

OBJECTIVE: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. METHODS: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58+/-12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. RESULTS: Mean antegrade cerebral perfusion time was 36+/-27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. CONCLUSIONS: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times.     

Secondary elephant trunk fixation with endovascular stent grafting for extensive/multiple thoracic aortic aneurysm.

Four patients who underwent secondary elephant trunk fixation by endovascular stent grafting are presented and the advantage of this method to treat multiple/extensive thoracic aortic aneurysm is discussed. In two of them, the elephant trunk installation has been performed at another hospital for extensive aortic aneurysm. In two other patients, the aortic arch replacement and the elephant trunk installation were performed through median sternotomy, initially for multiple aortic lesions, including both arch and descending aorta. No neurological deficit, stroke nor spinal cord injury was encountered during the follow-up period (24-40 months). The diameter of the aneurysms decreased markedly in three patients. In one patient, the aneurysm expanded gradually and type II endoleak was treated by coil embolization. In one patient, who showed marked shrinkage of the aneurysm, the stent graft kinked mildly. Based on the low mortality rate of well-established aortic arch surgery, concomitant elephant trunk installation which was followed by the secondary fixation with endovascular stent grafting might be useful to treat multiple/extensive thoracic aneurysm from distal arch to descending aorta.     

主动脉全弓置换加硬"象鼻"术治疗DeBakey Ⅰ型主动脉夹层

目的 总结主动脉全弓置换加硬"象鼻"术治疗DeBakey I型主动脉夹层的临床经验.方法 2005年6月至2008年3月,手术治疗41例DeBakey I型主动脉夹层病人,其中男32例、女9例;年龄27～76岁,平均57岁;急性主动脉夹层31例,慢性夹层10例.均在深低温停循环、低流量脑灌注下行主动脉全弓置换加硬"象鼻"手术.其中Bentall+全弓+硬象鼻术(术中支架系统直视下置入)24例,Wheat+全弓+象鼻术6例,升主动脉及全弓置换+硬象鼻术11例.结果 平均体外循环(168±32)min,平均主动脉阻断(109±24)min,选择性脑灌注(31±11)min.术后并发症14例(34.1%),12例治愈(85.8%),2例死亡.出院前均复查CT示升主动脉、主动脉弓部人工血管,术中支架系统血流通畅,位置良好,降主动脉真腔较术前明显扩大,未闭的降主动脉假腔血栓形成,无不良事件发生.随访1～12个月,死亡1例,无再次手术者.结论 主动脉全弓置换加硬"象鼻"术是治疗DeBakey I型主动脉夹层安全、有效的方法.     

Aortic arch and proximal supraaortic arterial repair under continuous antegrade cerebral perfusion and moderate hypothermia.

PURPOSE: In this prospective study the clinical and neurological outcome of continuous antegrade cerebral perfusion (ACP) and moderate hypothermia was evaluated in patients undergoing ascending and aortic arch repair including reconstruction of the proximal supraaortic arteries. METHODS: In 50 consecutive patients (mean age 47 yr, range 22-70) aortic arch and supraaortic arterial repair was performed: ascending aorta and aortic arch (n=34) and aortic arch and Bentall procedure (n = 16). In 12 patients the distal anastomosis was performed using the elephant trunk technique. Test-clamping of the innominate artery for 3 min was performed under EEG-monitoring followed by the same procedure for the left carotid artery. Cardiopulmonary bypass was instituted and the innominate artery replaced by a polyester graft before antegrade perfusion was carried out through the graft. While cooling to 28-30 degrees C, the left carotid artery was similarly treated with subsequent antegrade cerebral perfusion. The distal anastomosis was made at or beyond the left subclavian artery under circulatory arrest. During rewarming the innominate and carotid polyester grafts as well as the subclavian artery were anastomosed to the main graft, while antegrade cerebral perfusion was continued. RESULTS: In 46 patients antegrade cerebral perfusion was achieved with a mean volume flow of 12 ml/kg/min and a mean arterial pressure of 54 mmHg. EEG-monitoring delineated stable and symmetrical recordings. In four patients antegrade flow (mean 15 ml/kg/min) and pressure (mean 65 mmHg) had to be increased to establish baseline EEG-recordings. The mean time of circulatory arrest was 18 min.The overall hospital mortality was 6%: two patients died from cerebral infarction and one patient suffered from a ruptured abdominal aortic aneurysm. Three patients (6%) developed a temporary neurological deficit which resolved spontaneously. Two patients (4%) developed renal failure requiring temporary hemodialysis. Pulmonary complications occurred in 12 patients (25%). CONCLUSION: Continuous antegrade cerebral perfusion via selective grafts to the innominate and carotid arteries offers adequate protection in patients undergoing replacement of the ascending aorta or aortic arch and great vessels. This technique allows radical repair and optimal vascular reconstruction without time restrains and avoids the necessity for profound hypothermia     

Hybridverfahren zur Therapie aortaler Bogenpathologien

Patients with pathologies involving the aortic arch are considered to be a challenge for vascular and cardiovascular surgeons. Conventional open aortic arch replacement using extra-corporal circulation, selective antegrade cerebral perfusion and deep hypothermia is associated with a high morbidity and mortality in high risk patients. Aortic arch hybrid procedures combine supraaortic debranching procedures to create a sufficient proximal landing zone with an endovascular stent graft placement to exclude the aortic arch pathology. Midterm results with a 30-day mortality rate of less than 10%, a stroke rate of 3% and 1-year survival rate of 85% prove hybrid arch procedures to be an attractive alternative treatment modality for aortic arch pathologies, especially in high risk patients. Long term results are still missing. Until further developments in branched endograft technology arise, hybrid procedures offer an additional surgical approach for high risk patients, especially in emergencies. In summary, thoracic endografts can safely be used to treat a wide variety of thoracic aortic diseases including the arch, but long term data are needed to validate their use (evidence level III/B).     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

De BakeyⅠ型主动脉夹层的外科治疗

目的总结68例De BakeyⅠ型主动脉夹层的外科治疗经验,探讨手术方式和脑保护方案,以提高手术疗效。方法回顾性分析2004年5月至2010年4月沈阳军区总医院收治的68例De BakeyⅠ型主动脉夹层患者的临床资料,男45例,女23例;年龄29~72岁（44.5±17.2岁）。急性主动脉夹层（发病〈2周）57例,慢性主动脉夹层11例;主动脉夹层破口位于升主动脉45例,主动脉弓12例,主动脉弓降部11例。急诊手术35例,择期或限期手术33例。手术采用深低温停循环＋选择性顺行性脑灌注或右上腔静脉逆行灌注脑保护。行主动脉全弓置换＋支架象鼻手术25例,Bentall手术＋主动脉全弓置换＋支架象鼻手术16例,单纯右侧主动脉半弓置换术15例,主动脉全弓置换术7例,右侧主动脉半弓置换＋支架象鼻手术3例,升主动脉带瓣管道＋Cabrol手术＋主动脉全弓置换＋支架象鼻手术2例。结果手术死亡5例（急性夹层4例、慢性夹层1例）,手术死亡率7.4%（5/68）;死于术中吻合口顽固性渗血1例,术后低心排血量综合征和恶性心律失常2例,并发急性肾功能衰竭1例,脑部并发症1例。围术期出现精神异常5例,心包积液2例,声音嘶哑6例,切口愈合不良1例,均经相应的治疗治愈。随访60例（95.2%,60/63）,随访时间2个月~6年,失访3例。随访期间猝死1例,1例出现心包积液,经治疗好转;其余患者生活质量良好,心功能均明显改善,心功能分级（NYHA）I级54例,Ⅱ级5例。结论对De BakeyⅠ型主动脉夹层患者应积极手术治疗,术中根据不同病情选择最佳的手术方式和合适的脑保护方法,术后及时处理并发症,可取得良好的手术效果。     

Simultaneous individually controlled upper and lower body perfusion for valve-sparing root and total aortic arch replacement: a case study

Optimal perfusion strategies for extensive aortic resection in patients with mega-aortic syndromes include: tailored myocardial preservation, antegrade cerebral perfusion, controlled hypothermia and selective organ perfusion. Typically, the aortic arch resection and elephant trunk procedure are performed under hypothermic circulatory arrest with myocardial and cerebral protection. However, mesenteric and systemic ischemia occur during circulatory arrest and commonly rely upon deep hypothermia alone for metabolic protection. We hypothesized that simultaneously controlled mesenteric and systemic perfusion can attenuate some of the metabolic debt accrued during circulatory arrest, which may help improve perioperative outcomes. The perfusion strategy consisted of delivering a 1 to 3 liter per minute flow at 25 degrees C to the head/upper body via right axillary graft and simultaneous perfusion to the lower body/ mesenteric organs of 1 to 3 liters per minute at 30 degrees C via a right femoral arterial graft. We describe our technique of simultaneous mesenteric, systemic, cerebral and myocardial perfusion, and protection utilized for a young male patient with Marfan's syndrome, while undergoing a valve sparing root replacement, total arch replacement and elephant trunk reconstruction. This perfusion technique allowed us to deliver differential flow rates and temperatures to the upper and lower body (cold head/warm lower body perfusion) to minimize ischemic debt and quickly reverse metabolic derangements.     

Simple and uniform technique for combined repair of aortic arch and root replacement

We present herein a simple and uniform repair technique for combined aortic arch and root aneurysms. Our method is performed under an open distal procedure and includes selective antegrade cerebral perfusion, adequate myocardial preservation, a four-branched composite valve graft, and a long elephant trunk anastomosis proximal to the innominate artery. The technique was designed to reduce morbidity and mortality associated with aortic arch and root replacements, as well as allow for easier performance of subsequent downstream operations.     

Usefulness of antegrade selective cerebral perfusion during aortic arch operations

BACKGROUND: To evaluate the safety and usefulness of antegrade selective cerebral perfusion (SCP) during arch aneurysm or aortic dissection operations. METHODS: Between January 1986 and December 2001, 330 patients underwent aortic arch repair using SCP. Operations were performed with the aid of hypothermic extracorporeal circulation, SCP, and systemic circulatory arrest in most cases. In all, 89 patients (27%) were operated on for acute aortic dissection, 77 (23%) for chronic aortic dissection, and 164 (50%) for degenerative aneurysm. Total arch replacement using a branched graft was performed in 288 patients (94%). Mean SCP time was 86.2 +/- 28.5 minutes. RESULTS: The overall in-hospital mortality rate was 11.2% (falling to 3.2% in the 124 patients operated on between 1997 and 2001). Independent determinants of hospital mortality were pump time, renal/mesenteric ischemia, chronic renal failure, increasing age, period of operation, and nonuse of four-branched arch graft. The overall postoperative incidences of temporary and permanent neurologic dysfunction were 4.2% and 2.4%, respectively. There was no significant correlation between SCP time and in-hospital mortality or neurologic outcome. CONCLUSIONS: Selective cerebral perfusion is a reliable technique for cerebral protection and it facilitates complex and time-consuming total arch replacement.     

An alternative approach to diffuse thoracic aortomegaly: on-pump hybrid total arch repair without circulatory arrest

Diffuse thoracic aortomegaly has conventionally been managed with a two-stage elephant trunk procedure, requiring prolonged circulatory arrest, with an inherent risk of major morbidity and mortality. Recently, to improve outcomes, several hybrid arch procedures have been proposed using off-pump techniques. We have adopted an alternative, single-stage hybrid strategy using cardiopulmonary bypass without circulatory arrest to replace the ascending aorta and perform arch debranching and antegrade endovascular stent graft deployment. Unlike off-pump procedures, pathology of the aortic valve, root, and ascending aorta is addressed while avoiding the complications of stent graft placement in the native ascending aorta.