Surgical repair of acute Stanford type A aortic dissection with lower extremity ischemia / 中华胸心血管外科杂志

Objective:To explore the application of cannulating the ischemic femoral and right axillary artery in Sun’s procedure for acute type A aortic dissection with lower extremity ischemia.Methods:Twelve patients of acute Stanford type A aortic dissection complicated by lower extremity ischemia were analyzed retrospectively between July 2017 and May 2019, and the right axillary and ischemic femoral artery were used for cardiopulmonary bypass. All the 12 patients were male and categorized as the complicated Stanford type A aortic dissection. The mean age was(48.4±8.4)years, and the median time from symptom onset to emergency operation was 24.00(18.50, 43.25)hours. Eleven patients presented with unilateral extremity ischemia, while bilateral extremity ischemia occurred in one. The prosthetic vessel, with a diameter of 8 mm, was anastomosed to the ischemic femoral artery via an end-to-side way. Both the right axillary artery and the prosthetic vessel were cannulated for CPB. For the proximal dissection in this cohort of patients, we performed Bentall procedure in 5 cases, ascending aortic replacement in 3, and the aortic valve commissure reconstruction with ascending aortic replacement in 4. Total arch replacement with stented elephant trunk implantation were carried out for arch and descending aortic lesion in 12 cases.Results:Early mortality was 8.3%(1/12). The time of CPB, aortic clamp, circulatory arrest, and selective cerebral perfusion averaged(204.6±26.3) min, (114.6±16.6) min, (23.4±8.5) min, and(33.5±11.0) min, respectively. Five patients underwent concomitant bypass procedures, including: ascending aorta-bilateral femoral artery bypass in 1, ascending aorta-right femoral artery bypass in 3, ascending aorta-left femoral artery bypass in 1. Acute renal failure with continuous renal replacement therapy occurred in 4 cases, re-thoratomy for hemaostsis in 1, and re-intubation in 1. One patient developed osteofascial compartment syndrome after aortic repair, and consequent left lower extremity compartment fasciotomy was performed. The mean follow-up time was(17.2±7.6)months, and no aortic-related adverse event was detected during follow up.Conclusion:To acute Stanford type A aortic dissection with lower extremity ischemia, cannulating the ischemic femoral and right axillary artery in Sun’s procedure were associated with lower perioperative mortality and better prognosis.

Surgical treatment for type Stanford A aortic dissection with Kommerell′s diverticulum / 中华外科杂志

Objective@#To examine the outcomes of surgical treatment in patients of type Stanford A aortic dissection with Kommerell′s diverticulum.@*Methods@#From January 2009 to August 2017, patients of type Stanford A aortic dissection with Kommerell′s diverticulum who underwent the Sun procedure were enrolled. Patient demographic, preoperative, intraoperative, early morbidity and mortality data were collected from medical and electronic patient records. Clinical follow-up data, including late morbidity and mortality, were obtained by telephone interview with the patient.@*Results@#A total of 13 patients (11 males and 2 females; mean age 47 years) were included. The mean maximum diameter of Kommerell′s diverticulum was (21.8±7.7) mm. The Kommerell′s diverticulum was repaired by direct suture of the orifice in 3 patients, ligation of the aberrant right subclavian artery in 9 patients, and suture and ligation in 1 patient, respectively. No perioperative death occurred. One patient underwent a reexploration for bleeding. There were 2 late deaths: unknown reason in 1 patient and septic shock secondary to renal abscess in 1 patient. Reintervention was performed in one patient for a persistent type Ⅱ endoleak.@*Conclusions@#The Sun procedure with femoral artery cannulation for cardiopulmonary bypass, unilateral carotid artery cannulation for selective cerebral perfusion and ligation of aberrant right subclavian artery on the right side of the trachea is an appropriate therapeutic strategy for patients of type Stanford A aortic dissection with Kommerell′s diverticulum.

Surgical treatment for type Stanford A aortic dissection with Kommerell′s diverticulum / 中华外科杂志

Objective@#To examine the outcomes of surgical treatment in patients of type Stanford A aortic dissection with Kommerell′s diverticulum.@*Methods@#From January 2009 to August 2017, patients of type Stanford A aortic dissection with Kommerell′s diverticulum who underwent the Sun procedure were enrolled. Patient demographic, preoperative, intraoperative, early morbidity and mortality data were collected from medical and electronic patient records. Clinical follow-up data, including late morbidity and mortality, were obtained by telephone interview with the patient.@*Results@#A total of 13 patients (11 males and 2 females; mean age 47 years) were included. The mean maximum diameter of Kommerell′s diverticulum was (21.8±7.7) mm. The Kommerell′s diverticulum was repaired by direct suture of the orifice in 3 patients, ligation of the aberrant right subclavian artery in 9 patients, and suture and ligation in 1 patient, respectively. No perioperative death occurred. One patient underwent a reexploration for bleeding. There were 2 late deaths: unknown reason in 1 patient and septic shock secondary to renal abscess in 1 patient. Reintervention was performed in one patient for a persistent type Ⅱ endoleak.@*Conclusions@#The Sun procedure with femoral artery cannulation for cardiopulmonary bypass, unilateral carotid artery cannulation for selective cerebral perfusion and ligation of aberrant right subclavian artery on the right side of the trachea is an appropriate therapeutic strategy for patients of type Stanford A aortic dissection with Kommerell′s diverticulum.

The application of moderate hypothermia circulatory arrest and bilateral selective antegrade cerebral perfusion in total arch replacement for acute Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the application of moderate hypothermia circulatory arrest(MHCA)with a higher temperature(29℃) and bilateral selective antegrade cerebral perfusion(bSACP) in acute Stanford type A aortic dissection(TAAD] treated by total arch replacement with stented elephant trunk implantation.Methods:From July 2019 to January 2020, fifteen patients of acute TAAD undergoing emergent operations via MHCA with a core temperature of 29℃ and bSACP were analyzed retrospectively(modified group), and 26 patients treated by MHCA(25℃) and unilateral selective antegrade cerebral perfusion(uSACP) during the same period were defined as the traditional group. All cases were complicated type A dissection. The mean age in this cohort was 49 years, and 32 patients(78%) were male. Thirty six patients(87.8%) suffered from arterial hypertension. The proximal manipulations included: aortic sinus repair in 13 cases(31.7%), ascending aortic replacement in 29(70.7%), Bentall in 12(29.3%). Total arch replacement with stented elephant trunk implantation was performed in all cases.Results:The in-hospital death occurred in 2(4.9%), and cerebral infarction in 3(7.3%), transient neurologic deficit in 5(12.2%), paraplegia in 2(4.9%). The ratios of above-mentioned adverse events in the traditional and modified group were[2(7.7%) vs. 0, P=0.524], [3(11.5%)vs. 0, P=0.287], [4(15.4%) vs. 1(6.7%), P=0.636], [1(3.8%) vs. 1(6.7%), P=1.000] respectively. The major adverse events in the modified group were transient neurologic deficit and paraplegia in 1 each. Compared with the traditional group, the time of operation, CPB, cardiac arrest, circulatory arrest of the lower part, anterograde low flow cerebral perfusion, mechanical ventilation and ICU stay was shorter. The drainage of 48 hours after surgery was less also. The differences in new acute renal failure requiring CRRT and re-sternotomy for bleeding between groups were not statistical significance. Conclusion:The early results of MHCA(29℃) and bSACP applied in total arch replacement with stented elephant trunk implantation for acute TAAD were satisfactory. The time of mechanical ventilation and ICU stay was shorter in the modified group, and the drainage of 48 hours after surgery was less also.

Frozen elephant trunk implantation for pseudoaneurysms of the distal aortic arch and descending aorta / 中华胸心血管外科杂志

Objective To review the outcomes of the frozen elephant trunk implantation in patients with pseudoaneurysms of the distal aortic arch and descending aorta.Methods From March 2009 to December 2017,patients with pseudoaneurysms of the distal aortic arch and descending aorta who underwent the frozen elephant trunk implantation were enrolled.Patient demographic,preoperative,intraoperative,early morbidity and mortality data were collected from medical and electronic patient records.Clinical follow-up data,including late morbidity and mortality,were obtained by telephone interview with the patient.Results A total of 14 patients were included,13 males and 1 females,aged(41.0 ± 14.7) years.Early mortality rate was 7.14％ (1/14).The cause of death was rupture of the distal descending thoracic aorta.The early complications included reexploration for bleeding in 1 patient and pericardial window for delayed pericardial effusion in 1 patient.The mean follow-up was(32.3 ± 22.3) months.There was 1 late death from severe pulmonary infection.Conclusion The frozen elephant trunk implantation is an appropriate therapeutic strategy for patients with pseudoaneurysms of the distal aortic arch and descending aorta.

Impact of renal malperfusion on the perioperative and long-term outcome in patients with type A aortic dissection / 中华胸心血管外科杂志

Objective To confirm the impact of renal malperfusion on early and late outcomes of patients undergoing sur-gery for type A aortic dissection(TAAD). Methods From June 2011 to July 2012,a total of 165 TAAD patients undergoing surgery in hospital were enrolled and divided into 2 groups based on the results:research group(complicated with renal malper-fusion),control group(without renal malperfusion). A cohort follow-up project was conducted among these patients. The pri-mary outcome was all-cause death. Baseline and operative characteristics,early and late outcomes were analyzed to assess difference between 2 groups. Cumlative survival rates within 72 months among the 2 groups was described with Kaplan-Meier curves. Cox proportional hazards model was used to estimate the hazard ratios(HR)and 95％ confidence intervals(95％ CI)of late mortality among the 2 groups. Results Renal malperfusion was detected in 38(23. 0％)of 165 TAAD patients. 30-day mortality was 15. 8％ and 3. 9％ in patients with and without renal malperfusion(P < 0. 05),respectively. The mean follow-up period was(67 ± 3)months,late survival was 68. 4％ in patients with renal malperfusion and 88. 2％ in patients without(P <0. 05). By Cox proportional hazards model,after adjusting forage,sex,group(acute or chronic),presence of cardiac tampon-ade,brachiocephalic vessels involvement,coronary arteries involvement,root replacement,total arch replacement,concomitant coronary artery bypass grafting(CABG)and other organ-malperfusion,when compared to the control group,the HR(95％ CI) of late mortality was 5. 18( 1. 07 - 5. 18)in the research group. Besides renal malperfusion,concomitant coronary artery bypass grafting was presented as an independent risk factor of long-term survival(HR = 10. 08,95％ CI:2. 28 - 44. 62,P = 0. 002). Conclusion Coexistence of renal malperfusion is associated with a substantially increased risk of death in patients undergoing surgery for TAAD. A more exact stratification that weight every malperfusion-affected organ but not base on the number of malp-erfusion-affected organ simply may be more helpful to TAAD patients with malperfusion syndrome.

One-stage hybrid procedure for treating thoracic aortic pathologies that involve distal aortic arch / 中华胸心血管外科杂志

Objective This study aims to evaluate the initial results of a hybrid procedure for treating descending thoracic aortic disease that involves distal aortic arch.It also intends to report our initial experience in performing this procedure.Methods A total of 45 patients(35 males and 10 females) with descending thoracic aortic disease underwent a hybrid procedure,namely,thoracic endovascular aortic repair(TEVAR) combined with supra-arch branch vessel bypass,in our center from April 2009 to August 2014.Right axillary artery to left axillary artery bypass(n =20) or right axillary artery to left common carotid artery and left axillary artery bypass(n =25) were performed.The conditions of all patients were followed up from the 14th month to the 77th month postoperative[mean(38.0 ± 17.1) months].Mortality within 30 days,complications such as endoleak after the hybrid procedure,and stenosis or blockage of the bypass graft during the follow-up period were assessed.Results One case of death and one case of cerebral infarction were reported within 30 days.Two patients underwent open surgery beacuse of endoleak.And a newly formed intimal tear was observed in one patient and the patient underwent a second TEVAR during the follow-up period.Condusion Initial results suggest that the one-stage hybrid procedure is a suitable therapeutic option for thoracic aortic pathologies that involve distal aortic arch.However,this procedure is not recommended for type-B aortic dissection,in which a tear is located in the greater curvature or near the left subclavian artery,because of the high possibility of endoleak occurrence.

Comparison of the long-term graft patency of on-pump versus off-pump coronary artery bypass grafting / 中华胸心血管外科杂志

Objective Off-pump coronary artery bypass grafting (OPCAB) is used more widely in recent years in China. However, there is an argument on benefits and risks of off-pump surgery. Many studies shown that OPCAB had more benefits in short-term outcomes than conventional coronary artery bypass grafting(CCABG). But evidences from other studies suggested that OPCAB resulted in less long-term graft patency as compared with on-pump surgery. This study examined the longterm graft patency of OPCAB and CCABG performed by one surgeon. Methods 50 patients who had received surgical revascularization by a surgeon for more than 5 years were reviewed, 25 patients received conventional coronary artery bypass grafting ( group 1 ) and 25 patients received OPCAB ( group 2). All patients had angiograms for compareing the graft patency between the two groups. Results Among 25 patients in group 1,21 were male and 4 were female. The mean age of patients at surgery was (55.4 ±8.9) years. 15 cases had unstable angina, 16 patients had old myocardial infarction and 6 cases had diabetes.The ejection fraction (EF) was 0.58 ±0.14. The mean number of bypasses per patient was 3.32 ±0.63. Mean duration of operation was (3.58 ± 0. 82) hours. Mean follow-up duration was ( 86.52 ± 12.48) months. 83 grafts were evaluated for patency ( open vs. closed) and were graded by Fitzgibbon as grade A ( excellent graft), B ( impaired graft, with a stenosis of ≥50%, or a diameter less than 50% of the grafted artery), or O ( completely occluded). The graft patency was 73.49%, 61grafts were graded as Fitzgibbon A, 6 grafts as Fitzgibbon B and 16 grafts as Fitzgibbon 0. 25 patients were in group 2, 21males and 4 females. The mean age of patients at procedure was (58.2 ± 9.09) years, 11 patients had unstable angina, 13 patients had old myocardial infarction and 6 cases had diabetes. The ejection fraction (EF) was 0.59 ± 0. 14. Conclusion No 2011.03.013 difference in long-term graft patency was identified between on-pump and off-pump coronary artery bypass grafting. Off-pump oronary artery bypass grafting preformed by an experienced surgeon may gain similar long-term graft patency to that of conventional bypass.

Thoracic endovascular aortic repair of chronic type B aortic dissection in 84 patients / 中华胸心血管外科杂志

Objective The optimal treatment for chronic type B dissection remains controversial. The purpose of this study was to report early and mid-term results of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection. Methods Methods From June 2001 to September 2007, 84 patients with chronic type B aortic dissection received TEVAR. The time between onset of dissection and TEVAR was (13.9 ± 22.0) months (ranged 1 - 120 months). All patients were followed for 6 - 86 months [mean (33.2 ± 19.2) months]. Results The entry tear was completely sealed in 77 cases ( 91.7% ) during TEVAR. The incidence of incomplete seal was 8.3%. One-month mortality was 1. 2%. One patient had retrograde type A dissection 1 month after operation. Four patients received a second TEVAR during follow-up :3 for endoleaking and 1 for newly formed intima tear. Seven patients (8.3%) died during follow-up: 3 thoracic aorta rupture due to endoleaking, 1 abdominal aorta rupture caused by continuous dilation of the abdominal aorta, unrelated to aortic dissection deaths in 2 and 1 died of unknown cause. The Kaplan Meier actuarial survival curve showed a 7-year survival rate of 84.4%. Conclusion Early and mid-term results showed that TEVAR was effective in treating chronic type B aortic dissection. Endoleak was the main cause of death during follow-up. With increasing of physician's experience and refinement of the stent-graft, results are likely to improve in the future.