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He K, Qin X, Li M, Bian L, Yue H, Liang W, Wu Z. Two surgical strategies (early carotid reperfusion vs. Central aortic repair-first) of acute type a aortic dissection complicated with cerebral malperfusion syndrome: a meta-analysis and systematic review. BMC Cardiovasc Disord 2024; 24:239. [PMID: 38714966 PMCID: PMC11075335 DOI: 10.1186/s12872-024-03910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Cerebral malperfusion (CM) is a common comorbidity in acute type A aortic dissection (ATAAD), which is associated with high mortality and poor neurological prognosis. This meta-analysis investigated the surgical strategy of ATAAD patients with CM, aiming to compare the difference in therapeutic effectiveness between the central repair-first and the early reperfusion-first according to clinical outcomes. METHODS The meta-analysis and systematic review was conducted based on studies sourced from the PubMed, Embase, and Cochrane literature database, in which cases of ATAAD with CM underwent surgical repair were included. Data for baseline characteristics, mortality, survival were extracted, and risk ratio (RR) values and the pooled mortality were calculated. RESULTS A total of 17 retrospective studies were analyzed, including 1010 cases of ATAAD with CM underwent surgical repair. The pooled early mortality in early reperfusion group was lower (8.1%; CI, 0.02 to 0.168) than that in the central repair group (16.2%; CI, 0.115 to 0.216). The pooled long-term mortality was 7.9% in the early reperfusion cohort and 17.4% the central repair-first cohort, without a statistically significant heterogeneity (I [2] = 51.271%; p = 0.056). The mean time of symptom-onset-to-the-operation-room in all the reports was 8.87 ± 12.3 h. CONCLUSION This meta-analysis suggested that early reperfusion-first may achieved better outcomes compared to central repair-first in ATAAD patients complicated with CM to some extent. Early operation and early restoration of cerebral perfusion may reduce the occurrence of some neurological complications. TRIAL REGISTRATION The meta-analysis was registered in the International Prospective Register of Systematic Reviews database (No. CRD CRD42023475629) on Nov. 8th, 2023.
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Affiliation(s)
- Kang He
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Xiaoli Qin
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Mei Li
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Longrong Bian
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Honghua Yue
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Weitao Liang
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Zhong Wu
- Department of Cardiovascular surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China.
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Jiang Q, Huang K, Wang D, Xia J, Yu T, Hu S. A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-marfan, type A aortic dissection. Perfusion 2023:2676591231161919. [PMID: 36898141 DOI: 10.1177/02676591231161919] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVES Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. METHODS A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. RESULTS The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296-0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194-0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16 mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008 pg/mL, p < 0.001) at 24 h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3 days, p < 0.001). CONCLUSIONS This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery.
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Affiliation(s)
- Qin Jiang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Keli Huang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Deliang Wang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Jiaqi Xia
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Tao Yu
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Shengshou Hu
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
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Sugiyama K, Watanuki H, Tochii M, Futamura Y, Ishizuka K, Matsuyama K. Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta. Ann Vasc Dis 2022; 15:295-300. [PMID: 36644259 PMCID: PMC9816034 DOI: 10.3400/avd.oa.21-00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/04/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.
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Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan,Corresponding author: Kayo Sugiyama, MD, PhD. Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195, Japan Tel: +81-561-62-3311, Fax: +81-561-63-6193, E-mail:
| | - Hirotaka Watanuki
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Masato Tochii
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Yasuhiro Futamura
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Koki Ishizuka
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Katsuhiko Matsuyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
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Wang C, Zhang L, Li T, Xi Z, Wu H, Li D. Surgical treatment of type A acute aortic dissection with cerebral malperfusion: a systematic review. J Cardiothorac Surg 2022; 17:140. [PMID: 35659278 PMCID: PMC9164494 DOI: 10.1186/s13019-022-01894-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Type A acute aortic dissection (TAAAD) complicated with cerebral malperfusion (CM) is a life-threatening condition associated with high mortality, poor outcomes, and the optimal surgical management remains controversial. The aim of this review was to report the current results of surgical interventions of these patients. METHODS A systematic review was performed using PubMed and MEDLINE search for cases underwent surgical repair for TAAAD with CM. Demographics, neurological symptom, the time from onset of symptoms to operation, operation data, mortality, neurological outcome, and follow-up were reviewed. RESULTS A total of 363 patients with mean age of 65.7 ± 13 years underwent surgical repair for TAAAD with CM were identified in 12 retrospective studies. In-hospital mortality was 20.1%. Mean duration of follow-up was 40.1 ± 37.6 months. The involved supra-aortic branch vessels were RCCA (n = 99), LCCA (n = 25), B-CCA (n = 52), CCA (n = 131), IA (n = 19), and LSA (n = 8). Time from onset of neurological symptoms to surgery was 13.3 h. Antegrade and/or retrograde cerebral perfusion were applied. Postoperatively, improved, unchanged and worsened neurological status was occurred in 54.3%, 27.1%, and 8.5%, respectively in 199 patients. CONCLUSION The outcomes of surgical treatment of TAAAD complicated with CM indicate acceptable early mortality and morbidity. It is reasonable to perform lifesaving surgery on these patients. Early central surgical repair and reperfusion of brain may improve the outcomes.
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Affiliation(s)
- Changtian Wang
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Lei Zhang
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Tao Li
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Zhilong Xi
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Haiwei Wu
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Demin Li
- Department of Cardiovascular Surgery, Jinling Hospital, Nanjing University, School Medicine, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
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Nemoto H, Uchida K, Minami T, Yasuda S, Cho T, Masuda M. A massive postoperative stroke caused by a carotid thrombus that occurred during the surgical repair of an aortic dissection. SAGE Open Med Case Rep 2021; 9:2050313X211025215. [PMID: 34178353 PMCID: PMC8202300 DOI: 10.1177/2050313x211025215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022] Open
Abstract
A 59-year-old man with no prior neurological deficits developed a massive stroke during the repair of a double-barreled acute type A aortic dissection with major entry in the ascending aorta and an occluded brachiocephalic artery. As right cerebral ischemia was alleviated by the circle of Willis, the patient was alert and conscious preoperatively. Nevertheless, the thrombus in the right carotid artery induced a severe postoperative right cerebral embolism. In conclusion, occlusion of the carotid artery is a risk factor of postoperative severe stroke, even in patients without neurological symptoms preoperatively.
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Affiliation(s)
- Hiroko Nemoto
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Tomoyuki Minami
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shota Yasuda
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Tomoki Cho
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Munetaka Masuda
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
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