Our Distal Aortic Perfusion System in Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repairs

Abstract: We have used heparin-bonded partial cardio-pulmonary bypass to support distal aortic circulation during aortic cross-clamping. However, there were no cardiotomy reservoirs with fully reliable thromboresistance. To resolve this problem, a short-acting anticoagulant (nafamostat mesilate) was added into a cardiotomy reservoir. The present study was designed to evaluate the efficacy of our distal perfusion system. From May 1995 through the end of May 1996, 27 patients underwent descending thoracic and thoracoabdominal aortic aneurysm repairs with this adjunct, 4 being excluded from the experiment. Twenty patients who had undergone conventional partial cardiopulmonary bypass were defined as the control group. There were no significant differences between the 2 groups in the morbidity, mortality, gas transfer, or transfusion requirements despite the fact that more complicated surgical procedures (shown by a two-fold increase in the prevalence of reoperation) were required in the group that had received the current distal perfusion adjunct. the heparin-bonded group. In conclusion, our perfusion system is very effective for descending thoracic and thoracoabdominal aortic aneurysm repairs.     

Heparin-bonded circuits versus nonheparin-bonded circuits: an evaluation of their effect on clinical outcomes

Heparinization of the blood contact surface in cardiopulmonary bypass circuits has been promoted as an important step in the development of open heart surgery. As it decreases the inflammatory response resulting from the extracorporeal circulation, it may have a positive effect on clinical outcomes. This meta-analysis was carried out to examine if heparin-bonded circuits (HBCs) reduce the need for blood products and improve overall clinical outcome. A systematic literature search was performed to identify randomized controlled trials reporting outcomes of HBCs compared with non-HBCs. Primary outcomes assessed were postoperative blood/blood-product transfusion and blood loss. Secondary outcomes included all-cause mortality, acute postoperative myocardial infarction, stroke, re-sternotomy for postoperative bleeding, wound infection, atrial fibrillation, duration of ventilation, intensive care unit (ICU) and hospital-length of stay (LOS). Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Quality of the included studies and heterogeneity were assessed. From an initial review of 762-published studies, 41-randomized trials fulfilled the inclusion criteria, leaving 3434-patients’ data for analysis. HBCs significantly decreased the incidence of blood transfusion required (OR = 0.8; 95% CI = 0.6:0.9, P = 0.004). It also significantly decreased re-sternotomy (OR = 0.6; 95% CI = 0.4:0.8, P = 0.002), duration of ventilation (WMD = −1.3 h; 95% CI = −1.9:−0.6, P < 0.001), ICU-LOS (WMD = −9.3 h; 95% CI = −14.7:−3.9, P < 0.001) and hospital-LOS (WMD = −0.5 day; 95% CI = −0.9:−0.1, P = 0.02). HBCs had no effect on other adverse events evaluated. Although HBCs showed a positive effect on some of the clinical outcomes, we identified only marginal differences for other outcomes. Further evaluation of the cost-effectiveness of this technology is required.     

A New Heparin-Bonded Dense Membrane Lung Combined with Minimal Systemic Heparinization Prolonged Extracorporeal Lung Assist in Goats

Heparin was covalently bonded to a new hollow-fiber dense membrane artificial lung and extracorporeal circuit using a silane coupling agent and polyethyleneimine. This study investigated whether prolonged, venoarterial bypass extracorporeal lung assist (V-A bypass ECLA) could be sustained in a goat by the combination of the new membrane lung and minimal systemic heparinization. We maintained ECLA with the hollow-fiber lungs (surface area, 0.8 m²) and circuits by titrating the activated clotting time (ACT) to below 150 s with minimal systemic heparinization in 5 goats. The outcome was assessed from the function of the artificial lung via macro and microscopic examinations after the experiments and the incidence of systemic complications. The 5 goats were maintained on ECLA for 6 to 27 days. The bypass flow rate, blood gases at the return and drainage sites, platelet counts, and platelet aggregation activity were well maintained. Although the hemoglobin concentration, hematocrit, and plasma protein at the start of the ECLA were significantly lower than the pre-ECLA values due to hemodilution, the values remained stable during ECLA. A cerebral infarction occurred in 1 goat. However, in the other 4 goats, no complications such as bleeding, thrombosis, or plasma leakage from the artificial lung were observed. Although several thrombi were observed in the stagnant area of the artificial lung, these local thrombi did not cause the function of the artificial lung to deteriorate. We found that this new type of highly biocompatible, dense membrane artificial lung, when combined with minimal systemic heparinization, prolonged ECLA without the deterioration of the artificial lung function and was suitable for prolonged ECLA.     

肝素涂层人工血管在腔内治疗失败的严重下肢缺血血运重建中的应用

目的:评价肝素涂层人工血管在腔内治疗失败的严重下肢缺血(CLI)患者行下肢动脉旁路移植术中的疗效。方法:回顾性分析2017年10月至2019年4月北京医院血管外科收治的腔内治疗失败的CLI患者行下肢动脉旁路移植术治疗的临床资料,根据患者临床症状、病变特点,选择个性化治疗方案,包括支架取出术、动脉内膜剥脱和成形术、人工血管或人工血管复合自体静脉旁路移植术等多种手术方式完成下肢动脉血运重建。分析围术期并发症、症状缓解和溃疡伤口愈合情况、桥血管通畅率及保肢率。结果:入组患者共27例,其中16例静息痛患者术后疼痛均有效缓解,11例有足部溃疡和组织坏死者中,9例完全愈合,2例术后半年溃疡面缩小。术后并发症6例,术后30 d无死亡病例。所有患者获得随访,随访时间为(13.0±8.9)个月(范围:2~35个月)。通过Kaplan-Meier曲线计算,术后6、12及24个月一期通畅率分别为83.3%、73.7%及49.1%;二期通畅率分别为91.8%、82.1%及70.8%;保肢率分别为91.8%、86.9%及76.6%。其中15例股-腘动脉旁路移植术术后1、2年一期通畅率分别为86.7%、49.5%;二期通畅率分别为93.3%、81.7%;保肢率分别为93.3%、81.7%。8例股-小腿动脉旁路移植术术后1、2年一期通畅率分别为45.0%、45.0%;二期通畅率分别为58.3%、58.3%;保肢率分别为58.3%、58.3%。结论:肝素涂层人工血管动脉旁路移植术为腔内治疗失败的下肢动脉复杂病变提供了一种安全有效的治疗方式,能够有效缓解症状及提高保肢率。     

Heparin-bonded stent graft placement for treatment of massive epistaxis from ruptured radiation-induced internal carotid artery pseudoaneurysm: A case report

Rupture of an internal carotid artery (ICA) pseudoaneurysm is a rare but life-threatening complication of irradiation therapy for a nasopharyngeal carcinoma (NPC). A 36-year-old man had a history of NPC treated with radiotherapy 8 years previously. He was admitted to the hospital because of severe repetitive epistaxis with hemodynamically instablility. An emergent angiography showed the left ICA pseudoaneurysm at the petrous portion (C2 segment). The patient was successfully treated by a new-generation heparin-bonded stent graft without any complication. Emergent stent graft placement is effective in stopping hemorrhage and is therefore a life-saving intervention. Long-term follow-up is necessary to look out for delayed post-treatment complications.