Predictors of Lethality, Remodeling, and Aorta-Related Events in Different Types of Proximal Aortic Dissection Surgery.

The aim of the study is to analyze predictors of lethality, false lumen thrombosis, enlargement of aortic diameter, and frequency of aorta-related events in the early and remote postoperative periods for various types of proximal aortic dissection surgery using the logistic regression method. Materials and Methods: A retrospective observational comparison of the results of surgical treatment of 213 patients with the diagnosis of "DeBakey type I aortic dissection" has been carried out. The participants were divided into three groups: group 1 underwent classic aortic arch reconstruction using hemiarch technique or total reconstruction of the aortic arch with a multiple-branch prosthesis (n=121); group 2 was subjected to the hemiarch technique and implantation of bare-metal (uncoated) stents (n=55); in group 3, the "frozen elephant trunk" correction technique was used (n=37). The diagnosis of all patients included into the study was preoperatively confirmed by ultrasound and tomographic examination. Predictors of negative events have been identified by building the models of logistic regressions. Results: The multivariate model of logistic regression has revealed multiplicative significant predictors of lethality: postoperative neurological complications increased the probability of lethality by 3.39 (1.24-9.18) times and presence of a patent false lumen by 4.17 (1.49-13.68) times.Among the predictors of aorta-related events, the most important were connective tissue diseases (the probability increased by 6.68 (2.98-15.62) times), presence of partial thrombosis of the false lumen (the probability of event development increased by 2.39 (1.07-5.44) times), and aortic valve repair (the probability aorta-event occurrence increased by 2.84 (1.13-7.17) times).Hybrid prosthesis implantation appeared to be the most significant predictor of false lumen thrombosis increasing its probability by 4.19 (1.90-9.44) times among aortic repair methods, while a bare-metal stent implantation in contrast reduced the likelihood of false lumen thrombosis by 0.17 (0.03-0.62) times. Eventually, the type of repair had not any significant impact on the aorta-related events and lethality in the long-term period.

[Changes in Pulmonary Hemodynamics Resulted From Long-Term Mechanical Heart Support].

Aim      To study the dynamics of right ventricular function and pulmonary hemodynamics in patients with pulmonary hypertension during mechanical circulatory support of the heart.Material and methods  A retrospective analysis was performed for 25 implantations of left ventricular assist device performed in the Meshalkin National Medical Research Center from 2006 through 2021. Mechanical assist devices were implanted in 21 men and 4 women (median age, 37.5 [29; 48] years). All patients had severe, NYHA functional class III-IV chronic heart failure refractory to the optimal drug therapy. Invasive measurements showed that mean pulmonary arterial pressure (MPAP) was 50 [44.5; 60] mm Hg, transpulmonary pressure gradient (TPG) was 16 [14; 19] mm Hg, and calculated pulmonary vascular resistance was 5.4 [4.9; 9] Wood units, which is an absolute contraindication (TPG >15 mm Hg or pulmonary vascular resistance >5 Wood units) for heart transplantation (HT).Results Duration of left ventricular support was from 17 to 948 days. For 12 (48 %) patients, the HT was performed at 180-948 days following the implantation of left ventricular assist device; 3 patients are presently waiting for HT; 10 patients died from various complications, 6 of them died during the hospital stage. Already during the early stage after the implantation of the mechanical assist device, pulmonary hemodynamics significantly improved. Thus, in one week, MPAP decreased from 50 [44.5; 60] mm Hg to 36 [33; 38] mm Hg (р=0.012) whereas pulmonary vascular resistance decreased from 5.4 [4.9; 9] to 2.9 [2.4; 3.6] Wood units (р=0.008). Follow-up showed further improvement of pulmonary hemodynamics; at 1 month, MPAP was 29 [27; 30] mm Hg and by the time of HT, MPAP was 2.0 [24.8; 26.3] mm Hg (р=0.01), i.e., reached a normal level, which made it possible to perform HT. Similar dynamics was observed for other variables that reflected pulmonary hemodynamics.Conclusion      Mechanical support of the heart is able to alleviate manifestations of pulmonary hypertension in most patients with end-stage heart failure. It is necessary to develop an algorithm for identifying the category of patients with a high risk of progression of right ventricular failure.

[Hybrid treatment of Kommerell diverticulum and giant aneurysm of intra-thoracic segment of aberrant left subclavian artery]. / Klinicheskii sluchai gibridnogo lecheniya divertikula Kommerelya i gigantskoi anevrizmy vnutrigrudnogo segmenta aberrantnoi levoi podklyuchichnoi arterii.

Kommerell's diverticulum causes compression of the esophagus, trachea and laryngeal nerve between the aberrant mouth of the left subclavian artery and ascending aorta. This leads to dysphagia or shortness of breath. We describe hybrid treatment of the right aortic arch with Kommerell's diverticulum and giant aneurysm of the aberrant left subclavian artery.

Hybrid Technologies for Reconstruction of Proximal Aortic Dissection.

The aim of the study is to evaluate the efficacy of various types of hybrid technology in compare to the classical repair of the aortic arch of type I aortic dissection treatment in the in-hospital period. Materials and Methods: A retrospective observational study has been conducted, the results of surgical treatment of 213 patients with DeBakey type I aortic dissection operated on within the period from 2001 to 2017 were compared. Patients were divided into three groups: in group 1, patients undergone a hemiarch type of aortic repair or the total arch replacement (n=121); in group 2, a hemiarch aortic reconstruction and implantation of bare metal stent was performed (n=55); in group 3, a frozen elephant trunk technique was used (n=37). Taking into consideration the retrospective character of the investigation and nonequivalence of the groups by separate characteristics, they were equalized to improve the reliability of the results using the PSM (propensity score matching) pseudorandomization method. As a result, three groups of comparison were formed which were equalized by the PSM method and called PSM 1, 2, and 3. The mortality and complication rate in the in-hospital period, as well as the frequency of false lumen thrombosis development depending on the treatment method, have been analyzed. Results: The mortality rate in the PSM 1 group was 15 patients: group 1 (standard technique) - 10 patients (9%), group 2 (uncoated stents) - 5 patients (11%). A significant difference was found in the number of major bleedings (group 1 - 8%, group 2 - 21%, p=0.031) and cases of bowel ischemia (group 1 - 1%, group 2 - 9%, p=0.028). Complete false lumen thrombosis of the thoracic aorta was observed significantly more often in group 1 than in group 2 (22% vs 5%, p=0.015).In the examined group PSM 2, hospital mortality rate was 4 patients: group 1 - 3 patients (12%), group 3 - 1 patient (3%). No differences between the groups were found in the number of complications. In group 3, complete false lumen thrombosis of the thoracic aorta was observed in 59% of cases, whereas in group 1 it was found only in 4% of patients (p<0.001).In comparison group PSM 3, the mortality was 8 patients: group 2 - 5 patients (11%), group 3 - 3 patients (9%). The number of neurological complications differed significantly: in group 2 - 27%, in group 3 - 6% (p=0.019). Besides, 3% of cases of complete false lumen thrombosis were found in group 2, while there appeared 55% (p<0.001) of such patients in group 3. Conclusion: The comparative analysis showed that the use of bare metal stents and hybrid prostheses demonstrated a comparable low level of in-hospital mortality compared to the standard surgical technique of aortic arch reconstruction. At the same time, the use of the bare metal stents is associated with a higher rate of perioperative complications (bleeding, postoperative bowel ischemia, neurological complications) compared to the standard treatment and repair of the aortic dissection using hybrid prostheses. Complete thrombosis of the false lumen occurred significantly less commonly in case of using bare metal stents than with standard treatment and hybrid prostheses.

[Hybrid grafts for aortic arch reconstruction: evolution and state of the art]. / Gibridnye protezy dlia rekonstruktsii dugi aorty: évoliutsiia i sovremennoe sostoianie.

The analysis of the gained experience in treatment of patients with pathology of the arch and descending portion of the aorta is suggestive that the 'frozen elephant trunk' technique is an effective and safe method. In this connection, there is an increasing need for universal hybrid devices characterized by ease of use and durability in various aortic pathologies. Discussed in the article is the state of the art of the technology of treatment of patient with aortic arch pathology by means of hybrid grafts, followed by comparative analysis of currently used vascular hybrid prostheses, and although none of the hybrid grafts available worldwide is either universal or ideal, the grafts for the 'frozen elephant trunk' procedure continue to be improved, which will inevitably lead to wide implementation of this technique.

Surface characterization and biological assessment of corrosion-resistant a-C:H:SiOx PACVD coating for Ti-6Al-4V alloy.

The paper focuses on the SiOx-doped amorphous hydrocarbon (a-C:H:SiOx) coating on the titanium (Ti-6Al-4V) alloy substrate obtained by plasma-assisted chemical vapor deposition (PACVD) in a mixture of argon gas and polyphenylmethylsiloxane vapor using a bipolar substrate bias. It is shown that the a-C:H:SiOx coating deposition results in the formation of a negative surface potential important for application of this coating for medical implants. The a-C:H:SiOx coatings improve the corrosion resistance of Ti alloy to 0.5 M NaCl solution and phosphate-buffered saline. In particular, the corrosion current density of the a-C:H:SiOx-coated sample in a 0.5 M NaCl solution at 22 °C decreases from 1∙10-8 to 1.7∙10-10 A/cm2, that reduces the corrosion rate from 9∙10-5 to 15∙10-7 mm/year. The a-C:H:SiOx coating facilitates the surface endothelization of an implant located in the thoracic aorta of a mini pig, and reduces the risk of thrombosis and implant failure. This effect can be explained by the ability of the a-C:H:SiOx coating ability to reduce in vitro a 24-hour secretion of pro-inflammatory interleukins (IL-6, IL-12(p70), IL-15, and IL-17) and cytokines (IFN-g and TNF-a) by blood mononuclear cells (MNCs) and elevates the concentration of anti-inflammatory interleukin IL-1Ra. In vitro analysis shows no cytotoxicity of the a-C:H:SiOx coating for the human blood MNCs, suggesting a promising PACVD on Ti alloys for cardiovascular implants, including pumps for mechanical heart support systems.

[Quo vadimus? Fundamental problems of developing hybrid prostheses of thoracic aorta]. / Quo vadimus? Fundamental'nye problemy razrabotki gibridnykh protezov grudnoi aorty.

This article is a review briefly characterizing the state of the art of hybrid surgery of the thoracic aorta using the frozen elephant trunk technique worldwide and in Russia, also discussing unsolved problems of fundamental science, being key issues in creation of new models of hybrid prostheses of the thoracic aorta. The main attention is paid to the problem of radial stiffness of the stent-graft portion of the prosthesis. Performed is a detailed analysis of the factors influencing this characteristic of the sent graft: shape, size and number of cells of the stent element, thickness of the nitinol wire it is made of, method of edge connection, nitinol properties depending on the alloy grade and methods of thermoforming. It is shown that excessive stiffness leads to the development of d-SINE syndrome. This is followed by discussing the problem of optimal stiffness of stent grafts, based on the design of stent graft elements and elastic properties of the wall of the true channel of a dissecting aortic aneurysm. Also proposed is an approach to solving the problem of d-SINE, consisting in creation of conical stent grafts and/or a gradual decrease of radial stiffness of stent elements in the direction of the distal portion. Comprehensively addressed are disadvantages of the graft portion of the prosthesis, in 95% of items made of polyethylene terephthalate fiber: susceptibility to degradation associated with manufacturing defects and intraoperative microdamages, abrasive effect in the zone of contact with stent elements, partial postoperative hydrolysis and an inflammatory reaction to a foreign body, often being clinically pronounced. Also touched upon are certain aspects of creating hermetic coatings of the graft portion, with the use of vancomycin possessing low cytotoxicity as part of an antibacterial component being promising. As a whole, it is demonstrated that advances in creating a novel generation of hybrid prostheses should be associated with new approaches and materials, to be obtained at the junction of medicine and fundamental sciences.

Remote results of Florida Sleeve technique in patients with ascending aortic aneurysms and aortic insufficiency. / Otdalennye rezul'taty metodiki Florida Sleeve u patsientov s anevrizmoi voskhodiashchego otdela i aortal'noi nedostatochnost'iu.

AIM: The aim of our investigation was to assess the remote results of valve-sparing aortic root reimplantation into the graft (Florida Sleeve technique) compared with reimplantation of the aortic valve into the graft (David technique) during surgical correction of ascending aortic aneurysms accompanied by concomitant aortic insufficiency. PATIENTS AND METHODS: Our single-centre, blind, prospective, randomized study carried out from 2011 to 2015 included a total of 64 patients with ascending aortic aneurysms and aortic insufficiency. The patients were randomized into 2 groups: group I - aortic root reimplantation according to the Florida Sleeve technique (FS group) and group II - reimplantation of the aortic valve according to the T. David technique in David I modification (D group). The groups did not statistically differ by the baseline clinical profile. RESULTS: The overall 7-year survival for the FS group and D group amounted to 83% and 85.6%, respectively (p=0.98). Assessing the competing risks of mortality related to cardiovascular or other causes revealed no differences. Freedom from prosthetic repair of the aortic valve in the remote follow-up period amounted to 92.8% and 85.8% for the FS group and D group, respectively (p=0.4). According to the obtained findings, the technique of a valve-sparing operation is not a predictor of either lethality (RR 0.98 (95% CI 0.23-4.15), p=0.98) or prosthetic repair of the aortic valve (RR 2.03 (95% CI 0.40-14.63), p=0.40) in the remote period of follow up. RCONCLUSION: Aortic root reimplantation inside the prosthesis according to the Florida Sleeve technique makes it possible to simplify and accelerate the procedure of aortic root reconstruction in patients with aortic root aneurysms and concomitant aortic insufficiency, demonstrating long-term results comparable with those of the David technique.

[Djumbodis stent migration in a patient with aortic dissection]. / Migratsiia stenta Djumbodis u bol'nogo s rassloeniem aorty.

Treatment of patients presenting with type I aortic dissection is known to be a surgical challenge. The Djumbodis bare metal stent was developed to ease the burden of a reconstructive intervention on the aortic arch, to decrease the duration of the operation, and to minimize complications associated with artificial circulation. Currently, insufficiently explored remains the problem of complications occurring due to the technological fatigue of the metal and possible stent migration. Described herein is a clinical case report regarding migration of a Djumbodis stent, diagnosed 6 months after implantation for DeBakey type I acute aortic dissection. We revealed dislocation of the stent's distal portion with fenestration of the membrane of the true channel and perfusion of the false channel, as well as fractured fragments of the stent. The patient underwent repeat 'open' intervention.

[Florida sleeve operation in a patient with pronounced aortic root calcification]. / Operatsiia po metodike Florida Sleeve u patsienta s vyrazhennym kal'tsinozom kornia aorty.

Aneurysmatic dilatation of the aortic root and ascending portion of the aorta is one of the most complicated pathologies of the cardiovascular system. The 5-year survival rate does not exceed 13%. Especially difficult from the point of view of surgical reconstruction are variants of massive calcification of the aortic root. This article describes a case report concerning the Florida sleeve technique in a patient with diffuse calcification of the aortic root, involving the ostia of the coronary arteries. An important advantage of this type of intervention is technical simplicity consisting in no need for reimplantation of coronary artery ostia, thus decreasing the number of surgical manipulations and sutures on the aortic root, as well as reducing the risk of haemorrhage.

[Hybrid procedures for aortic arch disease]. / Obzor gibridnykh vmeshatel'stv pri zabolevaniiakh dugi aorty.

Different surgical approaches for aortic arch disease were reviewed in the article. We have also compared various vascular prostheses for aortic replacement.

[Microsurgery of coronary arteries using an operating microscope]. / Mikrokhirurgiia koronarnykh arterii s ispol'zovaniem operatsionnogo mikroskopa.

The world experience of coronary artery bypass surgery using an operating microscope is reviewed in the article. Important role of operating microscope and microsurgical techniques for coronary anastomoses formation is shown. High optical magnification provided by operating microscope directly affects the quality of surgical technique and accuracy of coronary anastomoses suturing that affects postoperative graft patency. Thus, the use of operating microscope can affect the results of coronary artery bypass surgery, as shown in several reports.

[Use of uncoated metal stents in surgery of aortic dissection]. / Primenenie nepokrytykh metallicheskikh stentov v khirurgii rassloeniia aorty.

Presented herein is a review of the literature concerning the use of uncoated metal stents in surgery of aortic dissection. A conclusion was drawn that the results of using the Djumbodis stent should not be directly extrapolated to the outcomes obtained in case of the E-XL stent which had mainly been used for hermetic sealing and for creation of optimal conditions for TEVAR. It is pointed out that the use of uncoated metal stents in aortic surgery is acceptable, however, it is required to solve a series of problems associated with elimination of certain shortcomings of the available devices. Also, it is necessary to work out clear-cut indications for using these stents.

[Predictors of neurological complications during surgical treatment of the ascending aorta and aortic arch chronic dissection]. / Prediktory nevrologicheskikh oslozhnenii pri khirurgicheskoi korrektsii khronicheskogo rassloeniia voskhodiashchego otdela i dugi aorty.

AIM: To evaluate the prognostic significance of oxygen supply to the brain in the risk of neurological complications in the early post operative period of surgical treatment of the ascending aorta and aortic arch. MATERIAL AND METHODS: The level of oxygenation (rSO2) in the right and left hemispheres was measured in 68 patients with ascending aorta and aortic arch chronic dissection. Before and in the nearest period after surgery, the patients underwent a clinical/instrumental neurological study. RESULTS: The incidence of ischemic stroke in the early post operative period was 5.9%, cognitive impairment was recorded in 22% of patients. Among the parameters of oxygen supply to the brain, the dynamics of rSO2 during circulatory arrest had a significant impact on the post operative neurological status. The risk of cognitive impairment, besides the association with the oxygen status of the brain, increased with the age of patients and comorbid pathology. CONCLUSION: The decrease in rSO2 by ≥30% during surgical treatment of ascending aorta and aortic arch dissection increases the risk of ischemic stroke and cognitive impairment in the early post operative period.

[Exoprosthetic repair of the ascending portion of the aorta: midterm results]. / Ékzoprotezirovanie voskhodiashchego otdela aorty: srednesrochnye rezul'taty.

The authors analyse herein their experience gained in performing the operation of exoprosthetic repair of the ascending portion of the aorta in patients presenting with an ascending aortic aneurysm. This is followed by assessing the results in the remote period. Over the period of follow up from 2012 to 2016 a total of 23 interventions were performed. The average duration of postoperative follow up amounted to 27±9.4 (2-40) months. In the remote period we managed to obtain the data for 20 (90.1%) patients. The patients were interviewed by means of either remote or face-to-face consultations during which we performed assessment of the dimensions of the thoracic portion of the aorta by the findings of MSCT angiography of the aorta. Health-related quality of life was evaluated by means of the Short Form Health Survey Questionnaire SF-36. No statistically significant changes of the aortic sizes were revealed in the remote period as compared with the findings at discharge from hospital. Neither were there repeat interventions related to the operation performed. According to the findings of the SF-36 questionnaire, patients mainly reported improved well-being as compared with that at discharge, including patients having endured coronary artery bypass grafting or prosthetic repair of the aortic valve. Experience shows that using the technique of exoprosthetic repair of the ascending portion of the aorta makes it possible to eliminate dilatation with satisfactory remote results. However, fuller and more reliable assessment of the results requires further studies.

Hybrid surgery in chronic thoracoabdominal aortic dissection. / Gibridnaia khirurgiia pri khronicheskom rassloenii torakoabdominal'nogo otdela aorty.

The authors describe and analyse their experience gained in performing prosthetic repair of the thoracoabdominal portion of the aorta, combined with open aortic stenting using the Djumbodis uncovered metal stent. Over the period from 2013 to 2015 we performed a total of 16 hybrid interventions. All patients were found to have type B aortic dissection, with their false and true lumens patent. All patients underwent reconstruction of the thoracoabdominal aorta combined with open implantation of the Djumbodis uncovered metal stent into the area of lower thoracic and visceral arteries. The patients underwent either isolated prosthetic repair of the thoracic aortic portion - type A correction, or prosthetic repair of the thoracic and infrarenal portions - type B correction. In the postoperative period we performed MSCT angiography of the thoracic and abdominal aortic portions in order to control patency of the true and false lumens, patency of visceral arteries, to assess the diameter of the aorta, presence or absence of thrombosis. All five patients subjected to type B correction (100% of the total number of this type operation) were found to develop thrombosis of the false lumen, and eight patients undergoing type A correction (72.7% of the total number of operations of this type) were diagnosed with false channel thrombosis. There was 1 (6.3%) lethal case registered at the hospital stage in the group of patients with type A correction. There were no cases of neurological deficit, malperfusion of visceral organs or lower-limb ischaemia. Our experience shows that using hybrid technologies in surgery of the thoracoabdominal portion of the aorta is (appears to be) optimal from the point of view of decreasing intraoperative trauma, reducing the complications rate and without detriment to the radicality.

[Four-year follow up of the results of the first in Russia use of a hybrid prosthesis for surgical management of type I aortic dissection]. / Chetyrekhletnee nabliudenie rezul'tatov pervogo v Rossii primeneniia gibridnogo proteza pri khirurgicheskom lechenii rassloeniia aorty I tipa.

Presented in the articles is a case report of successfully using hybrid prosthesis "E-vita Open plus" (Jotec) in surgical treatment of a female patient presenting with type I chronic aortic dissection according to the DeBakey classification. Careful consideration is given to an uncomplicated course of the early and remote postoperative periods in the first-in-Russia patient to undergo surgery with the use of a new-type prosthesis. The control examinations carried out 6, 12, 28 and 39 months after the operation were unequivocally indicative of complete thrombosis of the false canal of the aorta at the level of the prosthesis and lack of signs of aortic diameter growth below the zone of the surgical intervention. An example of successful treatment of DeBakey type I aortic dissection may be regarded as an important stage in the development of more effective methods of surgery for the severe pathology concerned.

[A case of treating a patient with a false aneurysm of the xenoconduit of the ascending aorta and pronounced cardiac insufficiency].

Described in the article is a clinical case of treating a previously operated patient presenting with a pseudoaneurysm of the xenoconduit of the ascending aortic portion, functioning Cabrol fistula and pronounced cardiac insufficiency, who was admitted to our institution in the state of decompensation. The obtained outcomes of treating this patient demonstrated a possibility of successfully using vascular grafts for establishing an anastomosis between the left coronary artery and ascending portion of the aorta in complicated conditions of a repeat intervention.

[Open stenting of thoracic aorta in combination with the borst operation].

Described herein in is a clinical case report concerning combined method of surgical treatment for chronic DeBakey type I aortic dissection: prosthetic repair of the ascending aorta and aortic arch according to Borst's technique in combination with open stenting of the descending aorta with the "Djumbodis" uncoated metal stent. This technique makes it possible to achieve expanding of the vascular prosthesis in the descending portion, thus increasing the probability of thrombosis of the false channel at this level and, consequently, to decrease the probability of further dilatation of the thoracic aorta, which is one of the main purposes in aortic reconstruction. Besides, the use of this technique does not exclude a second stage of surgical treatment, both within the framework of the classical surgical technology and with the use of endovascular methods.