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OBJECTIVES: The objective of this study was to enhance the efficiency of aortic arch replacement through the development of a novel frozen elephant trunk (FET) prosthesis with an endovascular side branch for left subclavian artery (LSA) connection. After successful pre-clinical testing, the feasibility and safety of implementing this innovative prosthesis in human subjects were investigated. METHODS: Between September 2020 and September 2021, 4 patients (mean age 67) with conditions such as penetrating ulcer, non A-non B aortic dissection and chronic arch aneurysm underwent surgery utilizing the customized device. Surgeries were performed under high moderate hypothermia (27°C), employing bilateral selective antegrade cerebral perfusion (SACP) and distal aortic perfusion. Anastomosis of the FET prosthesis with the aortic arch occurred in zone 1, followed by separate reimplantation of the left common carotid artery and the brachiocephalic artery. RESULTS: All patients were discharged in good clinical condition. The mean aortic cross-clamp, antegrade selective cerebral perfusion and distal aortic perfusion times were 111, 71 and 31 min, respectively. Endovascular extension of the side branch for the LSA was required in all cases to prevent endoleak formation. One patient received a stent graft extension at the end of the operation, while 2 others underwent the procedure during their hospital stay. One patient was diagnosed with an endoleak at the first follow-up after 3 months, and endoleak sealing was achieved via the brachial artery with an extension stent graft. CONCLUSIONS: Preliminary clinical outcomes suggest that the newly designed FET prosthesis shows promise in simplifying total arch replacement. These initial findings provide a foundation for planned clinical studies to further assess the effectiveness of this modified surgical hybrid graft, with particular attention to the length and diameter of the LSA sidearm.
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Implante de Prótese Vascular , Prótese Vascular , Procedimentos Endovasculares , Artéria Subclávia , Humanos , Artéria Subclávia/cirurgia , Idoso , Masculino , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/efeitos adversos , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/instrumentação , Dissecção Aórtica/cirurgia , Desenho de Prótese , Aneurisma da Aorta Torácica/cirurgia , Feminino , Aorta Torácica/cirurgiaRESUMO
The frozen elephant trunk (FET) technique is an established therapeutic option in the treatment of complex aortic diseases. We report our long-term clinical outcomes after FET repair. A total of 187 consecutive patients underwent FET repair at our department between 8/2005 and 3/2023. Indications included acute and chronic aortic dissections and thoracic aneurysms. Endpoints included operative morbidity and mortality, long-term survival, and the need for reinterventions. Operative mortality, spinal cord injury and permanent stroke rates were: 9.6%, 2.7% and 10.2%, respectively. At five years, overall survival was 69.9 ± 3.9% and freedom from aortic-related death was 82.5 ± 3.0%, whereas at ten years, overall survival was 53.0 ± 5.5% and freedom from aortic-related death was 75.8 ± 4.8%. Sixty-one reinterventions on the thoracic aorta were necessary. Freedom from secondary interventions at ten years was 44.7 ± 6.4% overall (63.1 ± 10.0% for acute dissections, 40.8 ± 10.3% for chronic dissections and 28.9 ± 13.1% for aneurysms, respectively). The high reintervention rate for chronic dissections and for aneurysms is related to the pre-existing aortic pathology. Late aortic growth of untreated segments with potentially fatal outcome occurs even after ten years, so careful annual follow-up is mandatory in this patient cohort.
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Background: Saline is still the most widely used storage and rinsing solution for vessel grafts during cardiac surgery despite knowing evidence of its negative influence on the human endothelial cell function. Aim of this study was to assess the effect of DuraGraft©, an intraoperative graft treatment solution, on human saphenous vein segments and further elaborate the vasoprotective effect on rat aortic segments in comparison to saline. Methods: Human Saphenous vein (HSV) graft segments from patients undergoing aortocoronary bypass surgery (n = 15), were randomized to DuraGraft© (n = 15) or saline (n = 15) solution before intraoperative storage. Each segment was divided into two subsegmental parts for evaluation. These segments as well as rat aortic segments stored in DuraGraft© underwent assessment of vascular function in a multichamber isometric myograph system in comparison to Krebs-Henseleit solution (KHS), a physiologic organ buffer solution. Results: Potassium-Chloride (KCL)-induced contraction depicted a tendency towards increase when treated with DuraGraft© compared to saline preservation of HSV segments (23.02 ± 14.77 vs 14.44 ± 9.13 mN, p = 0.0571). Vein segments preserved with DuraGraft© showed a significant improvement of endothelium-dependent vasorelaxation in response to cumulative concentrations of bradykinin compared to saline treated segments (p < 0.05). Rat aortic segments stored in saline showed significantly impaired vasoconstriction (3.59 ± 4.20, p < 0.0001) and vasorelaxation when compared to KHS and DuraGraft© (p < 0.0001). Conclusions: DuraGraft© demonstrated a favorable effect on graft relaxation and contraction indicating preservation of vascular endothelial function. Clinical Trial Registration Number: NCT04614077.
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OBJECTIVES: Our goal was to develop a modified frozen elephant trunk (FET) prosthesis with a stented left subclavian artery (LSA) side branch for LSA connection and to perform preclinical testing in a human cadaver model. METHODS: We measured aortic diameters, distance between and diameters of supra-aortic vessels and the distance from the LSA offspring to the level of the left vertebral artery offspring in 70 patients. Based on these measurements, a novel FET prosthesis was developed (Cryolife/Jotec, Hechingen, Germany) featuring a stented side branch for an intrathoracic LSA connection. The feasibility and ease of implantation were tested in 2 human cadaver models at the Anatomical Institute of the Medical University Graz. A covered stent graft (Advanta V12™ by Atrium Medical Corp., Hudson, NH, USA) was used for an LSA extension. RESULTS: Accurate deployment of the novel FET prosthesis with anatomical orientation of the stented side branch towards the LSA ostium followed by consecutive stent graft deployment was feasible in both cases. Proximalizing the distal anastomosis level from zone 3 to zone 1 not only diminished the complexity of the procedure but substantially facilitated the completion of the distal anastomosis. A 2.5-cm long extension stent graft was sufficient to seal to the LSA and to maintain left vertebral artery patency in both cases. CONCLUSIONS: This initial study in human anatomical bodies could demonstrate the feasibility of implanting a newly designed FET prosthesis. This evolution of the FET technique has the potential to substantially ease total aortic arch replacement by proximalization of the distal anastomosis into zone 1 and by shortening spinal and lower body hypothermic circulatory arrest times via a stented side branch to the LSA. This direct connection enables early restoration of systemic perfusion.
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Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Dissecção Aórtica/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Estudos de Viabilidade , Alemanha , Humanos , Stents , Artéria Subclávia/cirurgia , Resultado do TratamentoRESUMO
Performing transcatheter aortic valve implantation in the presence of aneurysmatic aortopathy is widely contraindicated but needs to be taken into account as a bailout strategy in selected patients. Deliberate preoperative assessment of measurements becomes the crucial key element in this context. After meticulous valve selection, retrograde access is obtained through the right subclavian artery additionally serving as a backup arterial cannulation site in case of conversion. Transcatheter aortic valve implantation is then performed through the transapical route. Transcatheter aortic valve implantation in complex aneurysmatic aortic morphology is feasible in highly selected patients after comprehensive preoperative evaluation. The present article describes our initial experience, safeguards, and technical details.
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Aneurisma Aórtico/complicações , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/métodos , HumanosRESUMO
BACKGROUND: The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE. METHODS: A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively. RESULTS: The patients' mean age was 60.9 ± 15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%. CONCLUSIONS: The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.
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Endocardite/cirurgia , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Valva Mitral/cirurgia , Toracotomia , Idoso , Bases de Dados Factuais , Endocardite/diagnóstico por imagem , Endocardite/mortalidade , Endocardite/fisiopatologia , Estudos de Viabilidade , Feminino , Alemanha , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Intervalo Livre de Progressão , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Risco , Toracotomia/efeitos adversos , Toracotomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: To analyse the clinical outcomes of surgical repair of DeBakey type I and III aortic dissection (AD) by using the frozen elephant trunk (FET) technique, and to evaluate the postoperative behaviour of the residual aorta. METHODS: In total, 27 consecutive patients underwent treatment of the thoracic aorta for AD with the FET technique in a tertiary-care hospital in Vienna/Austria between 2005 and 2012, and were enrolled in this case series study. All operations were performed under circulatory arrest and bilateral antegrade cerebral perfusion. During the follow-up, a clinical examination was performed as well as aortic diameters and false lumen (FL) patency evaluated by computed tomography (CT) imaging at following levels: pulmonary bifurcation, diaphragm and coeliac trunk. RESULTS: The mean age of the patient cohort was 56 ± 12 years; 21 patients were male. Twenty-two (82%) and 5 (18%) patients presented with DeBakey type I and type III AD, respectively. The hospital mortality rate was 7% (2/28); 2 patients died due to non-aortic-related reasons during a follow-up period of 48 ± 26 months. Three (11%) patients had a stroke, and 2 (7%) a spinal cord injury. The follow-up CT scans revealed FL thrombosis in 96% of the patients at the level of the pulmonary bifurcation (P < 0.001). Distal to the stent graft, at the level of the diaphragm and coeliac trunk, FL patency was observed in 52% (P = 0.1) and 78% (P = 0.6) of the patients, respectively. The true lumen of all analysed aortic segments increased significantly while the mean aortic diameter remained stable. CONCLUSIONS: Compared with conventional surgery for extensive ADs, the FET technique provides a high rate of FL thrombosis of the thoracic aorta.
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Aorta/patologia , Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Prótese Vascular , Adulto , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/patologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/patologia , Aortografia , Implante de Prótese Vascular/instrumentação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
PURPOSE: The advantages of aortic valve-preserving surgery are still hampered by a higher rate of reoperations compared to root replacement with valved conduits. This study evaluates whether valve deterioration rate is related to the method or depends on stringent adherence to technical concepts, which might be lost once trainees perform this complex surgery on their own. METHODS: From 1991 to 2011, the David procedure was performed in 209 consecutive patients. Mean age was 57 ± 14 years. The patients were operated either by the senior author or trainees under his supervision (group 1, n = 130) or by surgeons on their own after training by the senior author (group 2, n = 79). Clinical and echocardiography data were evaluated pre- and postoperatively and at follow-up (mean 6.0 ± 4 years). RESULTS: In-hospital mortality was 1.5 % in group 1 and 5 % in group 2 (p = 0.29), and late mortality was 12 % (n = 12 in group 1 and n = 14 in group 2, p = 0.11), three were cardiac related. Nine patients (4.3 %) had to be reoperated; three for endocarditis in group 1, six for structural valve deterioration in group 2 (p = 0.14). The 9-year freedom from reoperation or aortic valve insufficiency (AI) ≥2° was 93 % in group 1 and 78 % in group 2 (p < 0.01). As groups showed differences in preoperative variables, results were compared also in a propensity matched subgroup. Despite no difference in perioperative results, long-term valve competence remained inferior in group 2. CONCLUSIONS: With stringent adherence to technical concepts, structural valve deterioration may virtually be considerably reduced in aortic valve reimplantation. Once performing this operation on their own, trainees-after training by the senior-achieved results as independent surgeons well comparable to published series. As long-term performance seems to depend more on judgment of the geometry achieved intraoperatively than on technical steps, a means of measurement of effective coaptation height with a caliper might facilitate evaluation of perfect repair.
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Aneurisma da Aorta Torácica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Competência Clínica , Mortalidade Hospitalar , Reimplante/métodos , Adulto , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/mortalidade , Estudos de Coortes , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Internato e Residência , Masculino , Corpo Clínico Hospitalar , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Radiografia , Reimplante/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
OBJECTIVES: To evaluate the feasibility and the outcomes of second-stage thoracoabdominal (TA) repair after previous frozen elephant trunk (FET) implantation. METHODS: Between 2005 and 2013, 41 patients underwent open TA aortic repair in our institution. Of these, 9 patients (78% male) underwent second-stage TA repair after previous FET implantation. Feasibility and outcomes were evaluated. RESULTS: The mean interval between FET implantation and second-stage TA repair was 423 days (19-1979 days). Indications for second-stage TA repair were progression in aortic diameter of atherosclerotic aneurysms in the downstream segments in 6 patients, diameter progression in post-dissection aneurysms in 2 patients and giant cell aortitis with aneurysm formation in another patient. There were no in-hospital deaths. The median intensive care unit stay was 3.5 days (range: 1-12 days) and median hospital stay was 22 days (range: 14-132 days). We did not observe symptomatic spinal cord ischaemia or stroke. One patient (11%) developed acute renal failure requiring haemodialysis. CONCLUSION: Second-stage TA aortic repair after previous frozen elephant implantation is a feasible and effective treatment modality for patients with various pathologies of downstream aortic segments. This approach adds additional value to the conventional elephant trunk technique by providing an excellent landing zone not only for additional stent graft procedures but also for subsequent open TA repair.
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Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Adulto , Idoso , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Torácica/epidemiologia , Prótese Vascular , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
A lesion of the circumflex artery (RCX) is one of the potential complications of mitral valve (MV) surgery. An intraoperative transoesophageal echocardiography (TEE) should be performed for early detection of potential myocardial damage. We report on an emergency PCI after minimally invasive mitral valve replacement in a redo operation. The patient had previously a mechanical aortic valve replacement. A TEE was performed at the end of the redo operation and showed significant signs of segmental myocardial lateral wall dysfunction. A coronary angiogram was performed immediately and a balloon angioplasty and implantation of two stents in the circumflex artery was necessary. In cases of suspected distortion of the RCX, a coronary angiography must be performed without delay to prevent myocardial necrosis.
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Oclusão Coronária/diagnóstico , Oclusão Coronária/etiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Intervenção Coronária Percutânea , Angioplastia Coronária com Balão/métodos , Oclusão Coronária/terapia , Emergências , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Reoperação , Stents , Resultado do TratamentoRESUMO
OBJECTIVES: 'The David technique' may provide an alternative to conduit implantation in patients with an aneurysm of the ascending aorta and aortic valve insufficiency. METHODS: From 1991 to 2013, the David technique was performed in 249 consecutive patients in our department. The patient mean age was 58 ± 14 years; 71 (29%) were female and 178 (71%) male. A modification of the David technique was performed by creating a pseudosinus in 43 patients (17%) and by creating a neosinus in 123 patients (49%). The mean follow-up was 6 ± 4.5 years. RESULTS: There were six in-hospital (2.4%) and 30 late deaths (2.4%/patient-year). Cardiac-related events were the cause of death in three patients. The Kaplan-Meier estimate for 10 years survival was 77%. Four patients had perioperative neurological events, and only eight neurological events occurred during follow-up (0.6%/patient-year). Ten patients (0.8%/patient-year) required aortic valve replacement; one because of combined aortic valve stenosis and insufficiency and nine because of severe aortic valve insufficiency as a result of leaflet prolapse (n = 3), leaflet perforation (n = 1), abridgement of the right coronary leaflet (n = 1) and because of endocarditis (n = 4). Three cases of bleeding were observed (0.24%/patient-year). Freedom from reoperation or aortic valve insufficiency ≥2° was 80% at 10 years. CONCLUSIONS: Aortic valve sparing to treat patients with an ascending aortic aneurysm with aortic valve insufficiency is a durable procedure. Aortic valve function remains stable for many years. Valve-related complications are rare, and the rate of reoperations is not increased in comparison to conduit root replacement.
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Aneurisma Aórtico/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Cirúrgicos Cardíacos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/complicações , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/mortalidade , Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Causas de Morte , Intervalo Livre de Doença , Feminino , Implante de Prótese de Valva Cardíaca , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
A 57-year-old man was admitted to our department with recent onset of chest pain. Computed tomography (CT) scans revealed an acute aortic syndrome manifested by a penetrating atherosclerotic ulcer and contained rupture at the level of origin of an aberrant right subclavian artery. A combined vascular and endovascular approach was selected. The entire arch was rerouted, a reversed bifurcated Dacron prosthesis was placed, and a bypass was created between the right common carotid artery and the lusorian artery, followed by thoracic endovascular aortic repair. The clinical course was uneventful. The CT scan obtained after the procedure revealed regular supra-aortic perfusion and complete exclusion of the complex lesion.
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Aneurisma/cirurgia , Doenças da Aorta/cirurgia , Ruptura Aórtica/cirurgia , Aterosclerose/cirurgia , Implante de Prótese Vascular , Anormalidades Cardiovasculares/cirurgia , Transtornos de Deglutição/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/anormalidades , Úlcera/cirurgia , Aneurisma/complicações , Aneurisma/diagnóstico , Aneurisma/fisiopatologia , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico , Doenças da Aorta/fisiopatologia , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/etiologia , Ruptura Aórtica/fisiopatologia , Aortografia/métodos , Aterosclerose/complicações , Aterosclerose/diagnóstico , Aterosclerose/fisiopatologia , Anormalidades Cardiovasculares/complicações , Anormalidades Cardiovasculares/diagnóstico , Anormalidades Cardiovasculares/fisiopatologia , Artéria Carótida Primitiva/cirurgia , Dor no Peito/etiologia , Transtornos de Deglutição/complicações , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Artéria Subclávia/fisiopatologia , Artéria Subclávia/cirurgia , Síndrome , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Úlcera/complicações , Úlcera/diagnóstico , Úlcera/fisiopatologiaRESUMO
OBJECTIVES: A prospective randomized multicentre trial was performed to analyse the efficacy of a vest (Posthorax support vest®) to prevent sternal wound infection after cardiac surgery, and to identify risk factors. METHODS: From September 2007 to March 2010, 2539 patients undergoing cardiac surgery via median sternotomy were prospectively randomized into those who received a Posthorax® vest and those who did not. Patients were instructed to wear the vest postoperatively for 24 h a day for at least 6 weeks; the duration of follow-up was 90 days. Patients who did not use the vest within a period of 72 h postoperatively were regarded as study dropouts. Statistical calculations were based on an intention-to-treat (ITT) analysis. Further evaluations comprised all subgroups of patients. RESULTS: Complete data were available for 2539 patients (age 67 ± 11years, 45% female). Of these, 1351 were randomized to receive a vest, while 1188 received no vest. No significant differences were observed between groups regarding age, gender, diabetes, body mass index, chronic obstructive pulmonary disease (COPD), renal failure, the logistic EuroSCORE and the indication for surgery. The frequency of deep wound complications (dWC: mediastinitis and sternal dehiscence) was significantly lower in vest (n = 14; 1.04%) vs non-vest (n = 27; 2.27%) patients (ITT, P < 0.01), but superficial complications did not differ between groups. Subanalysis of vest patients revealed that only 933 (Group A) wore the vest according to the protocol, while 202 (Group BR) refused to wear the vest (non-compliance) and 216 (Group BN) did not use the vest for other reasons. All dWC occurred in Groups BR (n = 7) and BN (n = 7), although these groups had the same preoperative risk profile as Group A. Postoperatively, Group BN had a prolonged intubation time, a longer stay in the intensive care unit, greater use of intra-aortic balloon pump, higher frequency of COPD and a larger percentage of patients who required prolonged surgery. CONCLUSIONS: Consistent use of the Posthorax® vest prevented deep sternal wounds. The anticipated risk factors for wound complications did not prove to be relevant, whereas intra- and postoperative complications appear to be very significant.
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Mediastinite/prevenção & controle , Dispositivos de Fixação Ortopédica , Esternotomia/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Áustria , Distribuição de Qui-Quadrado , Desenho de Equipamento , Feminino , Alemanha , Humanos , Análise de Intenção de Tratamento , Modelos Logísticos , Masculino , Mediastinite/diagnóstico , Mediastinite/etiologia , Pessoa de Meia-Idade , Razão de Chances , Pacientes Desistentes do Tratamento , Estudos Prospectivos , Fatores de Risco , Deiscência da Ferida Operatória , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The goal of the retrospective study was to relate the site of the primary entry tear in acute type B aortic dissections to the presence or development of complications. METHODS: A consecutive series of 52 patients referred with acute type B aortic dissection was analysed with regard to the location of the primary entry tear (convexity or concavity of the distal aortic arch) using the referral CT scans at the time of diagnosis. These findings were related to the clinical outcome as well as to the need for intervention. RESULTS: Twenty-five patients (48%) had the primary entry tear located at the convexity of the distal aortic arch, whereas 27 patients (52%) had the primary entry tear located at the concavity of the distal aortic arch. Twenty per cent of patients with the primary entry tear at the convexity presented with or developed complications, whereas 89% had or developed complications with the primary entry tear at the concavity (P < 0.001). Furthermore, in patients with complicated type B aortic dissection, the distance of the primary entry tear to the left subclavian artery was significantly shorter as in uncomplicated patients (8 vs. 21 mm; P = 0.002). In Cox regression analysis, a primary entry tear at the concavity of the distal aortic arch was identified as an independent predictor of the presence or the development of complicated type B aortic dissection. CONCLUSIONS: A primary entry tear at the concavity of the aortic arch as well as a short distance between the primary entry tear and the left subclavian artery are frequently associated with the presence or the development of complicated acute type B aortic dissection. These findings shall help us to further differentiate acute type B aortic dissections in addition to the common categorization in complicated and uncomplicated. These findings may therefore also have an impact on primary treatment.
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Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Doença Aguda , Idoso , Análise de Variância , Dissecção Aórtica/mortalidade , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/mortalidade , Estudos de Coortes , Intervalos de Confiança , Bases de Dados Factuais , Tratamento de Emergência/métodos , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Análise de Sobrevida , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
OBJECTIVES: Stent graft-induced retrograde type A dissection is a life-threatening complication after endovascular treatment of acute aortic type B dissections. METHODS: From August 2005 to February 2011, retrograde aortic dissection occurred in 4 of 29 patients (13.8%) undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated aortic type B dissection. Three patients underwent emergent surgical conversion immediately after TEVAR. The operative strategy was a combined surgical and endovascular approach (frozen elephant trunk technique) using a specially designed hybrid prosthesis (Jotec E-vita open). All operations were performed under moderate hypothermia (25-28°C) and selective bilateral antegrade cerebral perfusion. The mean duration of circulatory arrest was 56 ± 7 min. Operative data and the outcome of surgery were analysed retrospectively. Data were analysed retrospectively in the limited number of patients. RESULTS: All patients survived the surgical procedure. No stroke, paraplegia, renal failure or other major complications occurred. Postoperative CT scans revealed perigraft thrombus formation and stable aortic dimensions in all patients after 6 months. In one patient, the retrograde dissection remained primarily undetected and untreated. The patient died suddenly, with no clinical signs, within 7 days after stent graft implantation. Autopsy revealed cardiac tamponade due to retrograde type A aortic dissection. CONCLUSIONS: Retrograde aortic dissection type A is a serious complication of thoracic endovascular repair of acute aortic type B dissection. Despite the small number of patients investigated in this study, the frozen elephant trunk technique appears to be a feasible bail-out strategy for the treatment of these acute aortic events.
Assuntos
Angioplastia/efeitos adversos , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Morte Súbita Cardíaca/etiologia , Mortalidade Hospitalar/tendências , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Angioplastia/métodos , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/métodos , Causas de Morte , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Reoperação/métodos , Reoperação/mortalidade , Estudos Retrospectivos , Medição de Risco , Stents/efeitos adversos , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
We present a case of a 59-year old male with a Stanford type A aortic dissection (DeBakey type I) extending from the sinotubular junction to the abdominal aorta. The patient was treated by a combined surgical and endovascular repair (frozen elephant trunk technique) using a specially designed hybrid prosthesis (E-vita open, Jotec GmbH). This onstage hybrid procedure enables simultaneous treatment of the ascending aorta, the aortic arch and the descending aorta.
RESUMO
The increasing number of interventions for percutaneous aortic valve replacement (AVR) justify a renewed evaluation of one-year survival rates after open AVR with and without coronary artery bypass in octogenarians. Risk factors influencing mortality are compared, and the patients' quality-of-life (QoL) after one year is assessed. One hundred and fifty-four patients (102 females, 52 males) aged on average 82.9±2.5 years, who had undergone open bioprosthetic AVR with (n=80) and without (n=74) coronary artery bypass grafting (CABG) between January 2005 and December 2007 were reviewed retrospectively. Risk factors for mortality were analyzed. The patient's QoL after one year was evaluated by administering the Seattle Angina Questionnaire on the telephone. The mean in-hospital mortality rate was 7.8%. The 12-month survival rate was 81.8%. Preoperative risk factors revealed no difference between survivors and non-survivors: renal insufficiency, chronic obstructive pulmonary disease (COPD), diabetes, cerebrovascular disease (CVD), peripheral vascular disease, logistic EuroSCORE and concomitant CABG. Assessment of QoL revealed a substantial improvement of physical fitness in all 126 patients. Surgery in the aortic valve without CABG is associated with a good outcome. The improvement in QoL after one year supports the decision to operate on patients older than 80 years of age.
Assuntos
Valva Aórtica/cirurgia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Qualidade de Vida , Fatores Etários , Idoso de 80 Anos ou mais , Áustria , Bioprótese , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/psicologia , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/psicologia , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/psicologia , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/psicologia , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Near-infrared spectroscopy (NIRS) complements online monitoring of cerebral oxygenation during aortic arch surgery. Its addition targets at an increase of safety of a complex procedure employing bilateral antegrade cerebral perfusion (BACP) and circulatory arrest under tepid blood temperatures. We report the outcome of NIRS-guided aortic arch surgery using BACP with moderate hypothermic circulatory arrest (MHCA). METHODS: Between December 2006 and December 2008, NIRS was used in 13 patients (mean age: 67.5 ± 11.3 years) undergoing aortic arch repair using BACP combined with MHCA. The diagnosis was atherosclerotic thoracic aneurysms in eight and acute aortic dissection in five patients. Seven patients had a hemi-arch replacement, six underwent frozen stent-graft arch replacement and four patients had concomitant procedures such as coronary artery bypass grafting (CABG) or aortic valve surgery. Our regimen of employing an algorithm for adaptation of perfusion modalities included the threshold of the drop in regional cerebral oxygen saturation <55% and/or a drop in the total oxygen index (TOI) of 15-20% assessed by the means of NIRS. RESULTS: The mean MHCA was 35 ± 16min and lowest bladder temperature was 26 ± 1.2°C. The mean TOI pre-MHCA was 66 ± 6.5%. Twelve out of 13 patients underwent bilateral perfusion because of unilateral drops below the threshold level of TOI (mean: 44±7.9%). In three patients, an organic psychosyndrome was observed. No patient developed permanent neurological dysfunction. CONCLUSION: NIRS-guided BACP during MHCA allows a safe approach to complex aortic arch surgery. The drop of brain oxygenation values in the contralateral hemisphere during unilateral ACP strongly suggests the routine use of BACP, when circulatory arrest under tepid temperatures is used.
Assuntos
Aorta Torácica/cirurgia , Circulação Cerebrovascular , Monitorização Intraoperatória/métodos , Idoso , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Isquemia Encefálica/prevenção & controle , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Perfusão/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this study was to evaluate the alterations of the aorta by using a new combined surgical and endovascular technique for the treatment of aortic type A dissections. The diameter of the descending aorta, the implanted stent graft, and the false lumen were evaluated. METHODS: Between August 2005 and February 2009, 14 patients (aged 49 +/- 13 years; 11 men, 3 women) with type A dissection in the aorta were operated on the thoracic aorta by the frozen elephant trunk technique. The size dynamics of the false lumen were analyzed by deducting the diameter of the stent graft obtained on computed tomography from the maximum dimension of the aorta. RESULTS: The technical success rate was 100%. All patients survived during the follow-up period. The mean follow-up period was 21.4 months. No redisection or aortic rupture occurred during the follow-up period. Postoperative computed tomography scans showed complete thrombus formation of the false lumen in the perigraft space within the entire zone of the stented segment of the hybrid prosthesis during the first 2 weeks after surgery in 12 patients (86%), whereas all patients showed complete obliteration of the false lumen at the 3-month control. The follow-up computed tomography scan obtained after 12 months revealed shrinkage of the false lumen in 9 patients (64%). CONCLUSIONS: The combined surgical and endovascular technique described in this report proved effective for the treatment of extended aortic lesions. The perigraft space thrombosed completely and had shrunken after successful placement of the stent graft.