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Lok YI, Villaquiran J, Kuo J. A challenging case of emergency redo surgery for acute type A aortic dissecting aneurysm of ascending and aortic arch with frozen elephant trunk following aortic root replacement. J Cardiothorac Surg 2024; 19:237. [PMID: 38627730 PMCID: PMC11020323 DOI: 10.1186/s13019-024-02653-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Redo ascending and aortic arch surgeries following previous cardiac or aortic surgery are associated with high risk of morbidity and mortality due to multiple factors included sternal re-entry injury, extensive aortic arch surgery, emergency aortic surgery, prolonged cardiopulmonary bypass duration, poor heart function, and patients with older age. Therefore, appropriate surgical strategies are important. We report a case of a 72-year-old gentleman with previous surgery of aortic root replacement who presented with acute Type A aortic dissecting aneurysm of ascending and aortic arch complicated with left hemothorax, which was successfully treated by emergency redo aortic surgery with frozen elephant trunk (FET) technique.
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Affiliation(s)
- Yuh Ing Lok
- Department of Cardiothoracic Surgery, Derriford Hospital, Derriford Road, Plymouth, PL6 8DH, UK.
| | - Jaime Villaquiran
- Department of Cardiothoracic Surgery, Derriford Hospital, Derriford Road, Plymouth, PL6 8DH, UK
| | - James Kuo
- Department of Cardiothoracic Surgery, Derriford Hospital, Derriford Road, Plymouth, PL6 8DH, UK
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Wu JL, Zhang L, Qiu JT, Yu CT. Morphological features of the thoracic aorta and supra-aortic branches in patients with acute Type A aortic dissection in China. Interact Cardiovasc Thorac Surg 2018; 27:555-560. [PMID: 29688450 DOI: 10.1093/icvts/ivy110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/12/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the morphological characteristics of the dissected thoracic aorta and brachiocephalic arteries within the Chinese population. METHODS A retrospective analysis of computed tomography scans of 387 patients with acute Type A aortic dissection was carried out. The dimensions of the thoracic aorta at multiple levels and other imaging characteristics were studied. RESULTS The patients with a maximum diameter ≥55 mm accounted for less than one-third of the population. Among those without Marfan syndrome (MFS) (n = 349), only 114 (32.8%) patients had a maximal aortic diameter ≥ 55 mm, whereas among those with MFS (n = 38), 20 (78.9%) had a maximal aortic diameter ≥ 45 mm. The predicted maximum aortic diameter is 88.46 - 0.81 × height (cm) + 63.02 × body surface area (m2) + 5.50 × (if diabetes, 1, if not, 0) - 6.63 × (if hypertension, 1, if not, 0). A positive correlation was established between a circular false lumen and the probability that brachiocephalic arteries were involved by dissection. The size ratio of false lumen to true lumen was greater in the circumferential group when compared with the crescent group. The independent predictors for the circumferential false lumen were age, atherosclerosis and smoking. CONCLUSIONS Herein, the morphological characteristics of the thoracic aorta among Chinese patients with acute Type A aortic dissection were described. The currently recommended criteria for prophylactic aorta surgery were applied to most patients with MFS but not to those without MFS within the Chinese population. Furthermore, the shape of the false lumen was identified as a putative risk factor that might affect the prognosis of the patients.
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Affiliation(s)
- Jin-Lin Wu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Liang Zhang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun-Tao Qiu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Cun-Tao Yu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Hage A, Ginty O, Power A, Dubois L, Dagenais F, Appoo JJ, Bozinovski J, Chu MWA. Management of the difficult left subclavian artery during aortic arch repair. Ann Cardiothorac Surg 2018; 7:414-421. [PMID: 30155421 PMCID: PMC6094016 DOI: 10.21037/acs.2018.03.14] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/13/2018] [Indexed: 11/06/2022]
Abstract
Management of the left subclavian artery (SCA) during aortic arch surgery is associated with several challenges, including preserving distal perfusion, achieving hemostasis and preventing posterior circulation stroke and spinal cord injury. The most common challenge remains its deep position in the chest, often exacerbated by posterior and apical displacement from an arch aneurysm. We discuss several management options consisting of pre-, intra- and post-operative strategies and their respective advantages, disadvantages and clinical outcomes. A clinical algorithm is proposed to help guide decision-making in managing the difficult left SCA during aortic arch repair.
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Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Olivia Ginty
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Adam Power
- Division of Vascular Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Jehangir J. Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Michael W. A. Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - on behalf of the Canadian Thoracic Aortic Collaborative (CTAC) Investigators
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
- Division of Vascular Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
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Surgical repair and reconstruction of aortic arch in debakey type I aortic dissection: recent advances and single-center experience in the application of branched stent graft. J Cardiothorac Surg 2017; 12:86. [PMID: 28974246 PMCID: PMC5627456 DOI: 10.1186/s13019-017-0649-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 09/20/2017] [Indexed: 11/17/2022] Open
Abstract
Background Aortic dissection (AD) represents a clinically uncommon aortic pathology which predicts a dismal prognosis if not promptly treated. In acute Debakey type I AD (ADIAD), aortic lesion extends from aortic root to even distal abdominal aorta among which aortic arch and its three main branches still remain a great surgical challenge for repair and reconstruction. Several decades have witnessed the painstaking efforts of cardiovascular surgeons across the globe for optimizing the surgical procedures, from total or hemi-arch replacement, “elephant trunk” technique to branched stent graft. However, operative mortality and morbidity still remain to be reduced and surgical strategy is to be advanced and simplified, particularly the repair and reconstruction of aortic arch and supra-aortic vessels. Methods In this paper, we reviewed the relevant literature concerning recent advances in surgical intervention of aortic arch and summarized our opinions in the application of branched stent graft in ADIAD. Results The operative strategy for acute Debakey type I aortic dissection still remain to be advanced and simplified, especially the repair and reconstruction of aortic arch and supra-aortic vessels. For selection of branched stent grafts, the anatomic features and pathological changes of diseased arch are the crucial factors for clinical decision making. Conclusions Branched stent graft is potentially an effective alternative for the treatment of type I AD with diseased aortic arch and supra-aortic vessels. The selection of branched stent grafts still remains to be further discussed in large-scale studies in the future.
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Hu X, Wang Z, Ren Z, Hu R, Wu H. Simplified total aortic arch replacement with an in situ stent graft fenestration technique for acute type A aortic dissection. J Vasc Surg 2017; 66:711-717. [DOI: 10.1016/j.jvs.2017.01.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 01/12/2017] [Indexed: 11/27/2022]
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Left Subclavian Artery Fenestration: A Novel Treatment Strategy for Acute Type A Aortic Dissection. Ann Thorac Surg 2015; 101:95-9. [PMID: 26347120 DOI: 10.1016/j.athoracsur.2015.06.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The optimal surgical strategy for the left subclavian artery (LSA) during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection remains a challenge. The objective of the study is to report a novel surgical technique aiming to simplify the revascularization procedure of total aortic arch replacement combined with stented elephant trunk implantation. METHODS We retrospectively reviewed the result of 167 patients who underwent total aortic arch replacement combined with stented elephant trunk implantation between January 2000 and December 2012. Of the 167 patients, 51 were selected to undergo the simplified revascularization, which is to fenestrate a stent graft of the descending aorta instead of performing reconstruction of the LSA. Before performing the new LSA revascularization, we had performed the elephant trunk procedure whereby the tubular material completely covered the LSA. The ensuing revascularization was modified by removing a patch of the polyester fabric of the elephant trunk that was located at the origin of the LSA. Both perioperative variables and postoperative outcome of the surgery were assessed. RESULTS The indication for adopting the LSA fenestration was under the circumstance of absence of dissection at the origin of the LSA. The nosocomial mortality of the 51 patients was 7.8% (multiorgan failure 2, renal failure 1, infection 1). During a mean follow-up period of 51.3 ± 27.6 months, the survival rate of the 47 patients was 100%, 90.8%, and 70.2% at 1, 5, and 10 years, respectively. No stroke and left limb ischemia were observed. No patients required reintervention because of anastomotic leak between the LSA and the descending aorta during follow-up. CONCLUSIONS The LSA fenestration technique during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection is reliable and effective for patients who have no dissection at the LSA. Furthermore, because the simplified surgical procedure largely shortens the time of operation, it effectively improves the patient's prognosis.
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Xiao Z, Meng W, Zhu D, Guo Y, Zhang E. Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation. J Thorac Cardiovasc Surg 2014; 147:639-43. [DOI: 10.1016/j.jtcvs.2013.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/27/2012] [Accepted: 02/12/2013] [Indexed: 10/27/2022]
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A combined branched stent grafting technique to reconstruct total aortic arch in the treatment of stanford A aortic dissection. Ann Thorac Surg 2013; 96:1888-90. [PMID: 24182490 DOI: 10.1016/j.athoracsur.2013.04.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 03/03/2013] [Accepted: 04/15/2013] [Indexed: 11/23/2022]
Abstract
Traditional total arch replacement technology and artificial blood vessels are designed for patients with Stanford A aortic dissection who have 3 branches (brachiocephalic trunk, left common carotid artery, and left subclavian artery) arising from the arch of the aorta. However, if there is anatomical variation of the aortic arch branches, the operation will be very difficult. The number of primary branches of the aortic arch can be reduced to 1 or 2 or increased to 4 to 6. Also, anastomoses of the graft to the left subclavian artery and descending aorta are usually very difficult because of the deep surgical field. Moreover, once bleeding occurs after the anastomoses, hemostasis in the deep field is difficult. Therefore, we applied a "combined branched" stent grafting technique for total arch reconstruction to reduce such problems.
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Chen CC, Tseng YC, Lin CC, Li CF, Yeh ML. A Modular Branched Stent-Graft System for Sutureless Anastomoses in Extensive Aortic Arch Replacement—A Porcine Study. Ann Vasc Surg 2012; 26:527-36. [DOI: 10.1016/j.avsg.2012.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/26/2012] [Accepted: 01/26/2012] [Indexed: 10/28/2022]
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