Aortic Arch-Clamping Technique in Hemiarch Replacement Without Circulatory Arrest.

The open anastomosis technique has become more popular since it was first used in hemiarch replacement; however, hypothermic circulatory arrest is unavoidable. This institution performed a novel surgical technique called the arch-clamping technique. It has been used in the treatment of patients with ascending aortic aneurysm extending to the proximal aortic arch and avoids the use of hypothermic circulatory arrest. Thirty patients had a hemiarch replacement with the arch-clamping technique from 2021 to 2022; all of them were discharged uneventfully.

Surgical management of aortic regurgitation secondary to Behcet's disease.

Background: Aortic regurgitation (AR) related to Behcet's disease (BD) is rare, but usually fatal. Perivalvular leakage (PVL) is high if AR related to BD treated with regular AVR. In this study, we report the surgical management of AR secondary to BD. Methods: Between September 2017 and April 2022, 38 patients with AR secondary to Behcet's disease had surgery in our center. 17 patients did not have a BD diagnosis before surgery, 2 of them were diagnosed during surgery and received Bentall procedure. The remaining 15 patients received conventional AVR. 21 patients were diagnosed as BD before surgery, all of them received modified Bentall procedures. All patients were followed up by regular outpatient visits, transthoracic echocardiogram and CT angiography were performed to evaluate the aorta and aortic valve. Results: Seventeen patients did not have a BD diagnosis at the time of surgery. Out of them, 15 patients received conventional AVR, and a total of 13 patients suffered PVL after surgery. Twenty-one patients had a BD diagnosis before surgery. They received modified Bentall procedures and IST and steroids were given both pre- and post-surgery. In this group treated with Bentall procedure no patient suffered PVL during follow up. Conclusions: PVL is a complex scenario after conventional AVR for AR in BD. Modified Bentall procedure seems superior to isolated AVR in these cases. The use of IST and steroids before and after surgery in combination with modified Bentall procedure could have a role in effectively reducing PVL.

Massive Bleeding After Surgical Repair in Acute Type A Aortic Dissection Patients: Risk Factors, Outcomes, and the Predicting Model.

Background: Massive bleeding throughout aortic repair in acute type A aortic dissection (ATAAD) patients is a common but severe condition that can cause multiple serious clinical problems. Here, we report our findings regarding risk factors, short-term outcomes, and predicting model for massive bleeding in ATAAD patients who underwent emergent aortic repair. Methods: A universal definition of perioperative bleeding (UDPB) class 3 and 4 were used to define massive bleeding and comprehensively evaluate patients. A total of 402 consecutive patients were enrolled in this retrospective study during 2019. Surgical strategies used to perform aortic arch procedures included total arch and hemiarch replacements. In each criterion, patients with massive bleeding were compared with remaining patients. Multivariable regression analyses were used to identify independent risk factors for massive bleeding. Logistic regression was used to build the model, and the model was evaluated with its discrimination and calibration. Results: Independent risk factors for massive bleeding included male sex (OR = 6.493, P < 0.001), elder patients (OR = 1.029, P = 0.05), low body mass index (BMI) (OR = 0.879, P = 0.003), emergent surgery (OR = 3.112, P = 0.016), prolonged cardiopulmonary bypass time (OR = 1.012, P = 0.002), lower hemoglobin levels (OR = 0.976, P = 0.002), increased D-dimer levels (OR = 1.000, P = 0.037), increased fibrin degradation products (OR = 1.019, P = 0.008), hemiarch replacement (OR = 5.045, P = 0.037), total arch replacement (OR = 14.405, P = 0.004). The early-stage mortality was higher in massive bleeding group (15.9 vs. 3.9%, P = 0.001). The predicting model showed a well discrimination (AUC = 0.817) and calibration (χ2 = 5.281, P = 0.727 > 0.05). Conclusion: Massive bleeding in ATAAD patients who underwent emergent aortic repair is highly associated with gender, emergent surgery, increased D-dimer levels, longer CPB time, anemia, and use of a complex surgical strategy. Since massive bleeding may lead to worse outcomes, surgeons should choose suitable surgical strategies in patients who are at a high risk of massive bleeding.

Management of aortobronchial fistula: Experience of 14 cases.

OBJECTIVES: Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF. METHODS: From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision. RESULTS: In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up. CONCLUSIONS: ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions.

OBJECTIVE: Aortoesophageal fistula (AEF) related to aortic aneurysm and dissection is an uncommon but life-threatening condition. We performed a systematic review of risk factors for mortality and factors associated with the prognosis of AEF. METHODS: A systematic search of the PubMed, Embase, and Cochrane Library databases was performed. Clinical characteristics, diagnostic methods, and treatments were assessed in terms of their ability to predict mortality. RESULTS: The systematic review identified 184 eligible articles including 219 patients with AEF. Multivariable Cox regression revealed positive correlations of hemorrhagic shock (hazard ratio (HR): 1.824, 95% CI: 1.217-2.735, P = 0.004), sepsis (HR: 1.714, 95% CI: 1.112-2.641, P = 0.015), multiorgan failure (HR: 3.060, 95% CI: 1.470-6.368, P = 0.003), and conservative treatment (HR: 5.257, 95% CI: 3.405-8.116, P < 0.001) with mortality and a negative correlation between combination therapy (aortic graft replacement and esophagectomy) and mortality (HR: 0.319, 95% CI: 0.125-0.813, P = 0.017). Kaplan-Meier survival analysis showed that the 1-year cumulative survival rate was 42.5 ± 3.8%. The overall fistula-related mortality rate was 47.0% (103/219). The most common causes of death were bleeding (54.9%) and infection (29.2%). CONCLUSIONS: We found that hemorrhagic shock, sepsis, and multiorgan failure were risk factors for death in patients with AEF. Additionally, conservative treatment was associated with a higher rate of mortality, while combined aortic graft replacement and esophagectomy improved the prognosis.

Thoracic aortic surgery: status and upcoming novelties.

Several novel technological developments and surgical approaches have characterized the field of aortic surgery in the recent decade. The progressive introduction of endovascular procedures, minimally invasive surgical techniques and hybrid approaches have changed the practice in aortic surgery and generated new trends and questions. Also, the advancements in the manufacturing of tissue engineered vascular grafts as substitutes for aortic replacements are enlightening new avenues in the treatment of aortic disease. This review will provide an overview of the current novel perspectives, debates and trends in major thoracic aortic surgery.

One-stage hybrid procedure for distal aortic arch disease: mid-term experience at a single center.

BACKGROUND: This study analyzes the outcomes of a one-stage hybrid procedure combining thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in patients with distal aortic arch disease. METHODS: This retrospective study collected 103 hybrid procedures combining TEVAR with extra-anatomic bypass (mean age, 62.2±9.3 years; 90 males) performed from January 2009 to January 2019 at Beijing Anzhen Hospital. We analyzed 30-day and mid-term outcomes including survival rate and the incidence of stroke, spinal cord injury (SCI), and endoleak. RESULTS: Five deaths (4.6%) occurred within 30 days, including type I endoleak in Zone 1 (n=1), hemorrhagic shock (n=1), stroke (n=2), and stent migration (n=1). Two patients developed SCI. The median follow-up time was 39.5 (interquartile range, 13.6-69.0) months. In all, 14 late deaths occurred; these were due to stroke (n=2), severe pneumonia (n=1), aortic rupture caused by type I endoleak (n=3), and sudden death (n=8). Six late endoleaks occurred including three type I and one type II in Zone 1 and two type I in Zone 2. In a competing risks analysis, the incidences of reintervention at 7 years, late death, and survival without reintervention were 8%, 22%, and 70%, respectively. In a Cox risk model, stroke (HR, 21.602; 95% CI: 2.798-166.796; P=0.003) was the only risk factor for 30-day mortality. Stroke (HR, 19.484; 95% CI: 5.245-72.380; P<0.001), SCI (HR, 15.548; 95% CI: 2.754-87.786; P=0.002), and endoleak (HR, 4.626; 95% CI: 1.068-20.040; P=0.041) were independent risk factors for long-term mortality. CONCLUSIONS: The one-stage hybrid procedure provides acceptable mid-term results with good mid-term patency of extra-anatomic bypass. Strict selection of patients suitable for hybrid repair can effectively improve the survival rate and reduce the incidence of complications. At the same time, close follow-up patients should receive close long-term follow-up after hybrid procedure.

Clinical study on relationship between renal artery involvement and renal function in acute Stanford A aortic dissection / 中国胸心血管外科临床杂志

@#Objective    To evaluate the involvement of renal artery in acute Stanford type A aortic dissection (TAAD) using CT angiography (CTA) and to analyze the difference of renal function among different types of renal artery involvement. Methods    From January 2016 to November 2017, 151 patients of acute TAAD with renal artery involvement were included in the study. There were 118 males and 33 females, with an average age of 47.93±10.53 years. All patients underwent aortic CTA to confirm the TAAD. According to CTA，involvement of one side of renal artery can be divided into four types: type A, large tear near renal artery orifice, difficult to distinguish true or false lumen; type B, the orifice of the renal artery originates entirely from the false lumen; type C, the orifice of the renal artery originates entirely from the true lumen; type D, renal artery dissection is observed, renal artery intima can be seen. The levels of serum creatinine (sCr) and creatinine clearance (CC) in all groups were analyzed and compared. Results    The results of one-way ANOVA analysis showed that there was no significant difference in sCr or CC among the groups (P>0.05). There was no significant difference in age, sex, proportion of hypertension history and onset time among the above groups (P>0.05). Conclusion    The three most common types of renal artery involvement were BC type, CC type, and AC type. The types of renal artery involvement do not affect renal function.

Surgical treatment of distal aortic arch lesions using stented elephant trunk implantation combined with transposition of left subclavian artery to left common carotid artery / 中国胸心血管外科临床杂志

@#Objective    To evaluate the short- and middle-term outcomes of surgical treatment for distal aortic arch lesions using stented elephant trunk implantation combined with transposition of left subclavian artery to left common carotid artery. Methods    The clinical data of 14 patients with distal aortic arch lesions undergoing stented elephant trunk procedure with left subclavain artery transposition under hypothermic cardiopulmonary bypass (CPB) with antegrade selective cerebral perfusion from May 2009 to November 2015 in our hospital were retrospectively reviewed. All of them were males with a mean age of 52±14 years ranging from 20 to 69 years. Hypertension was observed in nine patients, coronary artery disease in five and prior cerebral infarction in one. History of percutaneous coronary intervention was noted in one patient, history of Bentall operation in one, ligation of patent ductus arteriosus in one and endovascular aneurysm repair in one. Results    There was no hospital death. Concomitant procedures included coronary artery bypass grafting in two patients and plasty of the ascending aorta replacement in one. Mean duration of mechanical ventilation and ICU stay was 21±7 h and 43±19 h, respectively. All patients survived and were discharged. One patient was lost to follow-up and no patient died during the follow-up. Postoperative computed tomography revealed good patency of  the anastomotic site between the left subclavian artery and the left common carotid artery. Conclusion    Stented elephant trunk procedure with left subclavain artery transposition obtains satisfactory surgical results in patients with distal aortic arch lesions.

Thoracoabdominal aortic replacement for Crawford extent II aneurysm after thoracic endovascular aortic repair.

BACKGROUND: The surgical treatment of Crawford extent II aneurysms after thoracic endovascular aortic repair (TEVAR) remains challenging, because of the need to remove the failed endograft and the complexity of the aortic reconstruction. We retrospectively reviewed our experience with surgical management of Crawford extent II aneurysms after TEVAR using thoracoabdominal aortic replacement (TAAR). METHODS: Eleven patients (10 males, 1 female) with Crawford extent II aneurysm after TEVAR were treated with TAAR between August 2012 and May 2015. The indications included: diameter >5.0 cm; persistent pain; size increase >0.5 cm/year; and no suitable landing zone for re-TEVAR. Five patients underwent surgery under deep hypothermic cardiac arrest, two under mild hypothermic cardiopulmonary bypass, and four under direct aortic cross-clamping under normothermia. Two patients had Marfan syndrome. RESULTS: There were no in-hospital deaths. Continuous renal replacement therapy was required in three patients. One patient needed re-intubation, and two patients had prolonged intubation (>72 h). One patient sustained paraplegia after surgery but recovered during follow-up. Cerebrospinal fluid drainage were used in four patients (3 immediately in the operation room, and 1 in the intensive care unit when the patient suffered paraplegia). One patient died during follow-up. CONCLUSIONS: TAAR represents a feasible option for the treatment of Crawford extent II aneurysms after TEVAR, with acceptable surgical risks and favorable results.

A Successful Three-Stage Surgical Treatment for Aortoesophageal Fistula After Thoracic Endovascular Aortic Repair and Esophageal Stent Repair.

A 39-year-old man with Stanford B aortic dissection was treated by thoracic endovascular aortic repair (TEVAR) and experienced an aortoesophageal fistula (AEF). After repeated TEVAR and esophageal stent implantation, the hematemesis did not cease although the whole thoracic descending aorta was covered by stents. A three-stage operation was performed, and an AEF 9 cm long was found during the operation. To our knowledge, this may be the largest AEF ever reported. The patient survived without adverse events.

Eighty-six cases of laparoscopic vaginoplasty using an ileal segment.

BACKGROUND: The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. As the laparoscopy has been an important tool for the treatment of uterovaginal anomalies, we evaluated the feasibility of laparoscopic vaginoplasty using an ileal segment retrospectively. METHODS: Totally 86 patients who underwent laparoscopic vaginoplasty using an ileal segment in Beijing Anzhen Hospital during February 2004 to July 2007 were enrolled in this study. Of the 86 patients, 70 (81.4%) underwent primary operations and 16 (18.6%) secondary operations. Nineteen (22.1%) patients underwent total laparoscopic vaginoplasty and 67 (77.9%) patients underwent laparoscope-assisted vaginoplasty. The operation time, cost of hospitalization, and hospital duration were compared between the two laparoscopic groups. The Student's t test and the Mann-Whitney test were used to examine the differences. RESULTS: All the surgeries were successfully completed with no any intraoperative complication. There were three major surgical complications in the postoperative period: one case of intra-abdominal hemorrhage, one case of meatal stenosis, and one case of intestinal obstruction. The mean follow-up period of this series was 18 months. Seventy-eight patients were satisfied with their sexual lives after the surgeries except 5 women complaining of vaginal stenosis and 3 with no sexual partner during the follow-up. Significant differences were obtained between total laparoscopic and laparoscope-assisted vaginoplasty groups, such as the operation time, cost of hospitalization, and hospital duration (P < 0.01). There were no significant differences in sexual function between the two groups. CONCLUSIONS: The laparoscopic vaginoplasty using an ileal segment is satisfactory for cosmetic, functional, and anatomic results. Vaginoplasty with an ileal segment, performed by either total laparoscopic or laparoscope-assisted techniques, has a high success rate for a functional vagina.