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Cavozza C, Scarongella R, Policastro G, Maj G, Cassinari A, Penpa S, Maconi A, Audo A. Direct Innominate Artery Cannulation for Thoracic Aortic Surgery. J Clin Med 2025; 14:2684. [PMID: 40283516 DOI: 10.3390/jcm14082684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2025] [Revised: 03/18/2025] [Accepted: 03/27/2025] [Indexed: 04/29/2025] Open
Abstract
Objectives: Direct innominate artery cannulation is a viable and effective alternative for arterial inflow during thoracic aorta surgery, applicable in elective and emergent cases. This technique ensures reliable circulatory control. Methods: A single-center retrospective study of 208 cases that underwent thoracic aortic surgery between January 2010 and December 2021 was performed. The primary outcomes were in-hospital and remote mortality and the secondary outcomes were adverse neurologic events. Results: The median age of the patients was 69 years. The male gender accounted for 63.9% of the cases. The most represented surgical interventions consisted of hemiarch replacement in 105 cases (50.5%) and ascending aorta and aortic valve replacement (wheat procedure) in 71 cases (34.1%). The operative mortality rate was 5.3%, with six cases attributed to aortic-type dissection. The overall remote mortality rate at five years was 7.7. Postoperatively, 70 patients experienced alterations in the level of consciousness, with 12 of these cases belonging to the dissection group. Six patients with permanent neurologic symptoms had a positive computed tomography scan. Of the eleven patients with negative brain computed tomography scans, nine experienced temporary neurological deficits, while two suffered from permanent neurological damage. Conclusions: Direct innominate artery cannulation represents a safe and effective method for providing arterial inflow during cardiopulmonary bypass, offering an outstanding alternative to traditional sites for both planned and urgent surgical interventions.
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Affiliation(s)
- Corrado Cavozza
- Cardiac Surgery Department, University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Rossella Scarongella
- Cardiac Surgery Department, University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Giulia Policastro
- Cardiac Anesthesia Department, University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Giulia Maj
- Cardiac Anesthesia Department, University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Antonella Cassinari
- Research and Innovation Department (DAIRI), University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Serena Penpa
- Research and Innovation Department (DAIRI), University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Antonio Maconi
- Research and Innovation Department (DAIRI), University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
| | - Andrea Audo
- Cardiac Surgery Department, University Hospital "SS. Antonio e Biagio e C. Arrigo", 15121 Alessandria, Italy
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Lin CY, Kao MC, Lee HF, Wu MY, Tseng CN. Analysis of outcomes and prognostic factor in acute type A aortic dissection complicated with preoperative shock: A single-center study. PLoS One 2024; 19:e0302669. [PMID: 38687702 PMCID: PMC11060600 DOI: 10.1371/journal.pone.0302669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/06/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a critical cardiovascular emergency that requires prompt surgical intervention for preserving life, particularly in patients with critical preoperative status. This retrospective study aimed to investigate the clinical features, early and late outcomes, and prognostic factors in patients undergoing aortic repair surgery for ATAAD complicated with preoperative shock. METHODS Between April 2007 and July 2020, 694 consecutive patients underwent emergency ATAAD repair at our institution, including 162 (23.3%) presenting with preoperative shock (systolic blood pressure <90 mm Hg), who were classified into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. The clinical demographics, surgical information, and postoperative complications were compared. Five-year survival and freedom from reoperation rates of survivors were analyzed using the Kaplan-Meier actuarial method. Multivariate logistic regression analysis was used to identify independent risk factors for in-hospital mortality. RESULTS The in-hospital surgical mortality rate in patients with ATAAD and shock was 22.8%. The non-survivor group showed higher rates of preoperative cardiopulmonary resuscitation, acute myocardial infarction, and cerebral infarction, and was associated with longer cardiopulmonary bypass time, higher rates of total arch replacement and intraoperative extracorporeal membrane oxygenation implementation. The non-survivor group had higher blood transfusion volumes and rates of malperfusion-related complications. Multivariate analysis revealed that preoperative cardiopulmonary resuscitation, prolonged cardiopulmonary bypass time, and total arch replacement were risk factors for in-hospital mortality. For patients who survived to discharge, the 5-year cumulative survival and freedom from aortic reoperation rates were 75.6% (95% confidence interval, 67.6%-83.6%) and 82.6% (95% confidence interval, 74.2%-91.1%), respectively. CONCLUSIONS Preoperative shock in ATAAD is associated with a high risk of in-hospital mortality, particularly in patients who undergo cardiopulmonary resuscitation and complex aortic repair procedures with extended cardiopulmonary bypass. However, late outcomes are acceptable for patients who were stabilized through surgical treatment and survived to discharge.
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Affiliation(s)
- Chun-Yu Lin
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiothoracic and Vascular Surgery, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Ming-Chang Kao
- Department of Anesthesiology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Hsin-Fu Lee
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Meng-Yu Wu
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Chi-Nan Tseng
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
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3
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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4
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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5
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Patel PM, Chen EPC. Optimal brain protection in aortic arch surgery. Indian J Thorac Cardiovasc Surg 2022; 38:36-43. [PMID: 35463699 PMCID: PMC8980966 DOI: 10.1007/s12055-021-01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022] Open
Abstract
There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.
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Choudhary SK, Reddy PR. Cannulation strategies in aortic surgery: techniques and decision making. Indian J Thorac Cardiovasc Surg 2022; 38:132-145. [PMID: 35463714 PMCID: PMC8980986 DOI: 10.1007/s12055-021-01191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022] Open
Abstract
Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.
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Affiliation(s)
- Shiv K. Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
| | - Pradeep R. Reddy
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
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Ibrahim M, Stevens LM, Ouzounian M, Hage A, Dagenais F, Peterson M, El-Hamamsy I, Boodhwani M, Bozinovski J, Moon MC, Yamashita MH, Atoui R, Bittira B, Payne D, Lachapelle K, Chu MW, Chung JCY, Canadian Thoracic Aortic Collaborative. Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada. CJC Open 2021; 3:1117-1124. [PMID: 34712938 PMCID: PMC8531226 DOI: 10.1016/j.cjco.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background To explore evolving surgical techniques and outcomes for aortic arch surgery. Methods A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. Results From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases. Conclusions Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.
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Affiliation(s)
- Marina Ibrahim
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Louis-Mathieu Stevens
- Centre Hospitalier de l'Université de Montreal, University of Montreal, Montreal, Quebec, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ali Hage
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Mark Peterson
- Division of Cardiac Surgery, St Micheal's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Mount Sinai Hospital, New York, New York, USA
| | - Munir Boodhwani
- Division of Cardiac Surgery, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Colombia, Victoria, British Columbia, Canada
| | - Michael C. Moon
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Michael H. Yamashita
- Division of Cardiovascular Surgery, St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rony Atoui
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Bindu Bittira
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Kevin Lachapelle
- Division of Cardiac Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Michael W.A. Chu
- Division of Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C.-Y. Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Jennifer C.-Y. Chung, Division of Cardiac Surgery, Toronto General Hospital, 200 Elizabeth St 4N-466, Toronto, Ontario M5G 2C4, Canada. Tel.: +1-416-340-4745; fax: +1-416-340-3498.
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8
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Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, Han H. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13:2551-2562. [PMID: 34012600 PMCID: PMC8107572 DOI: 10.21037/jtd-21-411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.
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Affiliation(s)
- Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Yong Cao
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Baodong Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongyun Qiu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maosheng Wang
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, The General Hospital of Northern Theater Command, Shenyang, China
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9
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Payabyab EC, Hemli JM, Mattia A, Kremers A, Vatsia SK, Scheinerman SJ, Mihelis EA, Hartman AR, Brinster DR. The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection. J Cardiothorac Surg 2020; 15:205. [PMID: 32736644 PMCID: PMC7393698 DOI: 10.1186/s13019-020-01249-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. METHODS A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. RESULTS Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). CONCLUSIONS This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.
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Affiliation(s)
- Eden C Payabyab
- Division of Cardiac Surgery, Virginia Commonwealth University Health Systems, Richmond, VA, USA.
- Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Allan Mattia
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital / Northwell Health, Manhasset, NY, USA
| | - Alex Kremers
- Division of Cardiac Surgery, Virginia Commonwealth University Health Systems, Richmond, VA, USA
- Rush University, Chicago, IL, USA
| | - Sohrab K Vatsia
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Efstathia A Mihelis
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | | | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
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10
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Bakshi A, Ghanta RK. Commentary: Protect the brain: An armamentarium of cerebral-protection strategies should be in the aortic surgeon's toolbox. JTCVS Tech 2020; 2:18-19. [PMID: 34317736 PMCID: PMC8298917 DOI: 10.1016/j.xjtc.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/06/2020] [Accepted: 03/08/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Ravi K. Ghanta
- Address for reprints: Ravi K. Ghanta, MD, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
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11
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Surgical rescues for critical hemopericardium complicated by acute type A aortic dissection: Emergent subxiphoid pericardiotomy or cardiopulmonary bypass first? PLoS One 2020; 15:e0229648. [PMID: 32119707 PMCID: PMC7051057 DOI: 10.1371/journal.pone.0229648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 02/11/2020] [Indexed: 12/31/2022] Open
Abstract
Background Hemopericardium is a common and hazardous complication of acute type A aortic dissection (ATAAD). This retrospective study aimed to clarify the short-term and mid-term outcomes in patients who underwent surgical rescues for hemopericardium complicated by ATAAD. Methods Between January 2007 and March 2019, 586 consecutive patients underwent ATAAD repair at our institution. According to preoperative computed tomography, hemopericardium was found in 191 patients (32.6%), 150 were stabilized with medical treatment, and 41 underwent surgical rescues for critical hemodynamics. The 41 patients were classified into groups according to their rescue procedures: emergent subxiphoid pericardiotomy (E-SXP group, n = 26, 63.4%) or emergent cardiopulmonary bypass (E-CPB group, n = 15, 36.6%). Clinical features, surgical information, postoperative complications, and 3-year survival were analyzed and compared. Results Demographics, comorbidities and aortic repair procedures were generally homogenous between the two groups, except for sex. The average systolic blood pressure was 62.4 ± 13.3 mmHg and 67.1 ± 13.1 mmHg in the E-SXP and E-CPB groups, respectively. A total of 29.3% of patients underwent cardiopulmonary resuscitation (CPR) before surgical rescues. The in-hospital mortality was similar (30.8% versus 33.3%, P = 0.865) in the two groups. Multivariate analysis revealed that preoperative CPR was an in-hospital predictor of mortality. For patients who survived to discharge, 3-year cumulative survival rates were 87.8% ± 8.1% and 60.0% ± 19.7% in the E-SXP and E-CPB groups, respectively (P = 0.170). Conclusions Patients who underwent surgical rescues for ATAAD-complicated hemopericardium are at a high risk of in-hospital mortality. The two rescue procedures revealed similar short-term and mid-term outcomes.
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Dolapoglu A, Avcı E, Bugra O. Cannulation of Innominate Artery During Proximal Aortic Aneurysm Repair. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.474696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Imasaka KI, Tomita Y, Nishijima T, Tayama E, Morita S, Toriya R, Shiose A. Pectoral Muscle Atrophy After Axillary Artery Cannulation for Aortic Arch Surgery. Semin Thorac Cardiovasc Surg 2019; 31:414-421. [PMID: 30654025 DOI: 10.1053/j.semtcvs.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 11/11/2022]
Abstract
To investigate postoperative pectoral atrophy in 141 patients undergoing aortic arch surgery involving bilateral axillary artery cannulations with side grafts. The depth from the skin to the axillary artery surrounding the thoracoacromial artery (zone 1), and the thicknesses of pectoralis major (zone 2) and pectoralis minor (zone 3) were measured by computed tomography before surgery, at 1 and 6 months after surgery, and at the most recent follow-up assessment (PostT2) (mean = 41 months, range 11-75 months). Based on the median value (47.4 mm) of zone 1, the preoperative pectoral thickness was categorized into 2 groups: pectoral thickness >47.4 mm (thick group) and ≤47.4 mm (thin group). Mean changes in the pectoral thickness from baseline were evaluated using the longitudinal mixed-effects model. Forty-three of 110 patients underwent total arch replacements and extra-anatomical bypasses for left subclavian artery anastomoses. In 3 patients, axillary artery grafts became infected. There was no obvious harm associated with muscle wasting. Mean changes from baseline in zones 1, 2, and 3 showed significant declines at PostT2 (-13.40 ± 9.73 mm [P < 0.0001], -7.00 ± 5.23 mm [P < 0.0001], and -7.23 ± 6.42 mm [P < 0.0001], respectively). In the thick group, the progression of pectoral atrophy in zones 1 and 3 was significantly more than that of the thin group (P < 0.0001 for both zones). Postoperative pectoral atrophy progressed rapidly. The preoperative pectoral size might be of no use in the prevention of pectoral atrophy. Further investigation to prevent the pectoral atrophy is needed.
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Affiliation(s)
- Ken-Ichi Imasaka
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - Yukihiro Tomita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takuya Nishijima
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Eiki Tayama
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Shigeki Morita
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ryohei Toriya
- Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan
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Rouchdy A, Abdelrahaman A. Cannulation of innominate artery as an alternative to axillary artery in repair for type A aortic dissection. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.jescts.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Bergeron EJ, Mosca MS, Aftab M, Justison G, Reece TB. Neuroprotection Strategies in Aortic Surgery. Cardiol Clin 2017; 35:453-465. [DOI: 10.1016/j.ccl.2017.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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16
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Hsu PS, Chen JL, Tsai CS, Tsai YT, Lin CY, Lee CY, Ke HY, Lin YC. Subclavian artery cannulation provides better myocardial protection in conventional repair of acute type A aortic dissection: experience from a single medical centre in Taiwan. Cardiovasc J Afr 2016; 27:143-146. [PMID: 27841900 PMCID: PMC5101431 DOI: 10.5830/cvja-2015-056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/02/2015] [Indexed: 11/26/2022] Open
Abstract
Background Although many reports have detailed the advantages and disadvantages between femoral and subclavian arterial cannulations for acute aortic dissection type A (AADA), the confounding factors caused by disease severity and surgical procedures could not be completely eliminated. We compared femoral and subclavian artery cannulation and report the results for reconstruction of only the ascending aorta. Methods From January 2003 to December 2010, 51 AADA cases involving reconstruction of only the ascending aorta were retrospectively reviewed and categorised on the basis of femoral (n = 26, 51%) or subclavian (n = 25, 49%) arterycannulation. Bentall’s procedures, arch reconstruction and hybrid operations with stent-grafts were all excluded to avoid confounding factors due to dissection severity. Surgical results, postoperative mortality, and short- and mid-term outcomes were compared between the groups. Results Subclavian cannulation had a lower incidence of cerebral and myocardial injury and lower hospital mortality than femoral cannulation (8 vs 34%, p = 0.04). Ventilation duration as well as intensive care unit (ICU) and hospital stay were also shorter with subclavian cannulation. Risk factors for hospital mortality included pre-operative respiratory failure (odds ratio: 12.84), peri-operative cardiopulmonary bypass (CPB) time > 200 minutes (odds ratio: 13.49), postoperative acidosis (pH < 7.2, odds ratio: 88.63), and troponin I > 2.0 ng/ml (odds ratio: 20.08). The overall hospital mortality rate was 21%. The 40 survivors were followed up for three years with survival of 75% at one year and 70% at three years. Conclusions Our results show that subclavian cannulation had a lower incidence of cerebral and myocardial injury as well as better postoperative recovery and lower hospital mortality rates for reconstruction of only the ascending aorta.
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Affiliation(s)
- Po-Shun Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Jia-Lin Chen
- Department of Anesthesia, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan; Division of Cardiovascular Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, National Defense Medical Centre, Taoyuan, Taiwan.
| | - Yi-Ting Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Chih-Yuan Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Chung-Yi Lee
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Hong-Yan Ke
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Yi-Chang Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
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Preventza O, Coselli JS. Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience. Ann Cardiothorac Surg 2016; 5:352-9. [PMID: 27563548 DOI: 10.21037/acs.2016.07.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection is a deadly disease with significant morbidity and mortality. We describe the differential aspects of the disease and the North American experience with its treatment.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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Stamou SC, Gartner D, Kouchoukos NT, Lobdell KW, Khabbaz K, Murphy E, Hagberg RC. Axillary Versus Femoral Arterial Cannulation During Repair of Type A Aortic Dissection?: An Old Problem Seeking New Solutions. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 4:115-123. [PMID: 28097193 DOI: 10.12945/j.aorta.2016.16.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/15/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation. METHODS A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary (n = 107) or femoral (n = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality. RESULTS Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001). CONCLUSIONS The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.
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Affiliation(s)
- Sotiris C Stamou
- Department of Cardiovascular Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Derek Gartner
- Department of Cardiovascular Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nicholas T Kouchoukos
- Division of Cardiothoracic Surgery, Missouri Baptist Medical Center, Saint Louis, Missouri, USA
| | - Kevin W Lobdell
- Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kamal Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward Murphy
- Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, Grand Rapids, Michigan, USA
| | - Robert C Hagberg
- Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA
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Linardi D, Faggian G, Rungatscher A. Temperature Management During Circulatory Arrest in Cardiac Surgery. Ther Hypothermia Temp Manag 2016; 6:9-16. [DOI: 10.1089/ther.2015.0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniele Linardi
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Alessio Rungatscher
- Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy
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Berretta P, Alfonsi J, Di Bartolomeo R, Di Eusanio M. Innominate artery cannulation during aortic surgery. Multimed Man Cardiothorac Surg 2015; 2015:mmv030. [PMID: 26658194 DOI: 10.1093/mmcts/mmv030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/14/2015] [Indexed: 11/14/2022]
Abstract
During aortic surgery, the cannulation of arteries preserving an antegrade flow in the thoracic aorta [ascending aorta, axillary artery, innominate artery (IA) and carotid artery] has been associated with superior survival and neurological outcomes compared with the cannulation of the femoral artery. However, the ideal site of cannulation for both cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion remains under debate. Here, we present our technique of IA cannulation for CPB and antegrade selective cerebral perfusion during surgery of the thoracic aorta.
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Affiliation(s)
- Paolo Berretta
- Department of Cardiac Surgery, G. Mazzini Hospital, Teramo, Italy
| | - Jacopo Alfonsi
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marco Di Eusanio
- Department of Cardiac Surgery, G. Mazzini Hospital, Teramo, Italy
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Seco M, Edelman JJB, Van Boxtel B, Forrest P, Byrom MJ, Wilson MK, Fraser J, Bannon PG, Vallely MP. Neurologic injury and protection in adult cardiac and aortic surgery. J Cardiothorac Vasc Anesth 2015; 29:185-95. [PMID: 25620144 DOI: 10.1053/j.jvca.2014.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Van Boxtel
- Columbia University Medical Center-New York Presbyterian Hospital, New York, New York
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Byrom
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, Weigang E, Hoffmann I, Blettner M, Carrel TP. The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry. J Am Coll Cardiol 2015; 65:2628-2635. [PMID: 26088302 DOI: 10.1016/j.jacc.2015.04.030] [Citation(s) in RCA: 275] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 03/23/2015] [Accepted: 04/14/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Malperfusion adversely affects outcomes in patients with acute type A aortic dissection, but reliable quantitative data are lacking. OBJECTIVES The aim of this study was to analyze the impact of various forms of malperfusion on early outcome. METHODS A total of 2,137 consecutive patients enrolled in GERAADA (German Registry for Acute Aortic Dissection Type A) who underwent surgery between 2006 and 2010, of whom 717 (33.6%) had any kind of pre-operative malperfusion, were retrospectively analyzed. RESULTS All-cause 30-day mortality was 16.9% and varied substantially according to the number of organ systems affected by malperfusion (none, 12.6%; 1 system, 21.3%; 2 systems, 30.9%; 3 systems, 43.4%; p < 0.001). Pre-operative cerebral malperfusion, comatose state, peripheral malperfusion, visceral malperfusion, involvement of supra-aortic branches, coronary malperfusion, and renal malperfusion were all independent predictors of developing any post-operative malperfusion syndrome. When survival was considered, age, peripheral malperfusion, involvement of supra-aortic branches, coronary malperfusion, spinal malperfusion, a primary entry in the descending aorta, and pre-operative comatose state were independent predictors, again with increasing significance. CONCLUSIONS Malperfusion remains a severe clinical condition with strong potential for adverse outcomes in patients undergoing surgery for acute type A aortic dissection. The GERAADA registry suggests that the impact of the number of organs involved and the type of malperfusion on outcome differs substantially. Introducing an appropriate classification system, such as "complicated" and uncomplicated" acute type A aortic dissection, might help predict individual risk as well as select a surgical strategy that may quickly resolve malperfusion.
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Affiliation(s)
- Martin Czerny
- University Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland, and University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | - Florian Schoenhoff
- University Clinic for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Christian Etz
- Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Lars Englberger
- University Clinic for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Nawid Khaladj
- Department for Cardiac Surgery, University Hospital Munich, Munich, Germany
| | - Andreas Zierer
- Division of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Ernst Weigang
- Department of Vascular and Endovascular Surgery, Clinic Hubertus Hospital, Berlin, Germany
| | - Isabell Hoffmann
- Institute for Medical Biostatistics, Epidemiology and Informatics, Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Maria Blettner
- Institute for Medical Biostatistics, Epidemiology and Informatics, Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thierry P Carrel
- University Clinic for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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Preventza O, Garcia A, Tuluca A, Henry M, Cooley DA, Simpson K, Bakaeen FG, Cornwell LD, Omer S, Coselli JS. Innominate artery cannulation for proximal aortic surgery: outcomes and neurological events in 263 patients. Eur J Cardiothorac Surg 2015; 48:937-42; discussion 942. [DOI: 10.1093/ejcts/ezu534] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/04/2014] [Indexed: 11/14/2022] Open
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Rylski B, Urbanski PP, Siepe M, Beyersdorf F, Bachet J, Gleason TG, Bavaria JE. Operative techniques in patients with type A dissection complicated by cerebral malperfusion. Eur J Cardiothorac Surg 2014; 46:156-66. [DOI: 10.1093/ejcts/ezu251] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ouzounian M, LeMaire SA, Coselli JS. Open aortic arch repair: state-of-the-art and future perspectives. Semin Thorac Cardiovasc Surg 2014; 25:107-15. [PMID: 24216527 DOI: 10.1053/j.semtcvs.2013.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 11/11/2022]
Abstract
Surgical procedures for the treatment of complex aortic arch pathology remain among the most challenging cardiovascular operations, incurring considerable risk for death and stroke. The purpose of this article is to describe the evolution of our approach to open repair of the aortic arch. Our arterial cannulation strategy has shifted from femoral and direct aortic to right axillary and more recently innominate artery cannulation. This transition has facilitated the administration of continuous antegrade cerebral perfusion and more moderate levels of hypothermia during complex repairs. Modifications in surgical technique, including arch reconstruction with the trifurcated graft, and the classical and frozen elephant trunk techniques have simplified the conduct of the operation. Experimental and clinical research supporting the evolution of our approach is discussed in this paper.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Cardiovascular Surgery Service, The Texas Heart Institute, St. Luke's Health System, Houston, Texas
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Acute Type A Dissection: Impact of Antegrade Cerebral Perfusion Under Moderate Hypothermia. Ann Thorac Surg 2013; 96:2135-41. [DOI: 10.1016/j.athoracsur.2013.06.085] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/19/2013] [Accepted: 06/20/2013] [Indexed: 11/22/2022]
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LeMaire SA, Weldon SA, Coselli JS. Total aortic arch replacement: current approach using the trifurcated graft technique. Ann Cardiothorac Surg 2013; 2:347-52. [PMID: 23977604 DOI: 10.3978/j.issn.2225-319x.2013.05.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/10/2013] [Indexed: 11/14/2022]
Abstract
Since the pioneering work of DeBakey, Cooley, and colleagues more than 50 years ago, surgical treatment of aneurysms involving the transverse aortic arch has been associated with substantial morbidity and mortality. Over the past 15 years, techniques for replacing the diseased aortic arch have evolved substantially. Previously, our approach to these operations involved femoral cannulation, profound-to-deep hypothermic circulatory arrest and retrograde cerebral perfusion, and the island technique for reattaching the brachiocephalic vessels. In contrast, we currently use innominate artery cannulation, deep-to-moderate hypothermic circulatory arrest with antegrade cerebral perfusion, bilateral cerebral monitoring with near-infrared spectroscopy, and the trifurcated graft (Y-graft) technique for reattaching the arch branches. Cannulating the innominate artery to provide an inflow site for cardiopulmonary bypass has facilitated the use of antegrade cerebral perfusion as a cerebral protection strategy; the left common carotid artery is additionally perfused to provide bilateral cerebral perfusion. Despite having a systemic circulatory arrest time that often exceeds 60 minutes, these improved perfusion strategies make it possible to consistently avoid cerebral circulatory arrest all together. A moderate temperature target of between 18 and 23 °C is now used; this appears to reduce the risk of hypothermic coagulopathy and improve hemostasis. Y-graft techniques, such as the trifurcated graft approach, have the advantages of eliminating residual aortic arch tissue and being easily tailored to the needs of the individual patient. This report describes total aortic arch replacement in patients with aneurysms that are confined to the ascending aorta and transverse aortic arch.
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Affiliation(s)
- Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; ; Cardiovascular Surgery Service, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas, USA
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Hajj-Chahine J. eComment: Brachial plexus injury in cardiac surgery. Interact Cardiovasc Thorac Surg 2013; 17:157-8. [PMID: 23785092 DOI: 10.1093/icvts/ivt179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France
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Orihashi K. Acute type a aortic dissection: for further improvement of outcomes. Ann Vasc Dis 2013; 5:310-20. [PMID: 23555530 DOI: 10.3400/avd.ra.12.00051] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/07/2012] [Indexed: 12/20/2022] Open
Abstract
Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.
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Affiliation(s)
- Kazumasa Orihashi
- Department of Surgery II, Kochi Medical School, Nankoku, Kochi, Japan
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Preventza O, Bakaeen FG, Stephens EH, Trocciola SM, de la Cruz KI, Coselli JS. Innominate artery cannulation: an alternative to femoral or axillary cannulation for arterial inflow in proximal aortic surgery. J Thorac Cardiovasc Surg 2012; 145:S191-6. [PMID: 23260457 DOI: 10.1016/j.jtcvs.2012.11.061] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 07/31/2012] [Accepted: 11/28/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of innominate artery cannulation in proximal aortic procedures, including those involving hypothermic circulatory arrest. METHODS A total of 68 patients underwent innominate artery cannulation with a side graft during proximal aortic surgery performed by way of a median sternotomy. The indications for surgery were proximal arch aneurysm in 43 patients (63.2%), aortic dissection in 11 patients (16.2%), total arch aneurysm in 10 patients (14.7%), and ascending aortic aneurysm in 4 patients (5.9%). Six patients (8.8%) had undergone previous sternotomy. Hypothermic circulatory arrest with antegrade cerebral perfusion was used in 64 patients (94.1%). Of the 68 patients, 63 (92.6%) received antegrade cerebral perfusion to both cerebral hemispheres. The median antegrade cerebral perfusion time was 20 minutes (range, 15.0-33.0 minutes). Seven patients had periods of circulatory arrest without antegrade cerebral perfusion for a median of 20 minutes (range, 6-33 minutes). RESULTS One patient died, for 30-day mortality of 1.5%. Three patients (4.4%) had strokes, two of whom had a partial recovery. Seven patients (10.3%) developed temporary postoperative confusion that resolved successfully in all cases. CONCLUSIONS Cannulating the innominate artery for arterial inflow is an alternative technique for proximal aortic surgery procedures. It is especially useful in cases requiring hypothermic circulatory arrest to deliver antegrade cerebral perfusion.
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Affiliation(s)
- Ourania Preventza
- Texas Heart Institute, St Luke's Episcopal Hospital, Houston, Tex 77030, USA.
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Krüger T, Conzelmann LO, Bonser RS, Borger MA, Czerny M, Wildhirt S, Carrel T, Mohr FW, Schlensak C, Weigang E. Acute aortic dissection type A. Br J Surg 2012; 99:1331-44. [DOI: 10.1002/bjs.8840] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges.
Methods
Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described.
Results
Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options.
Conclusion
AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.
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Affiliation(s)
- T Krüger
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - L O Conzelmann
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
| | - R S Bonser
- Department of Cardiac Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust and University of Birmingham, Birmingham, UK
| | - M A Borger
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - M Czerny
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - S Wildhirt
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - T Carrel
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - F W Mohr
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - C Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - E Weigang
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
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Tuncer A, Adademir T, Tuncer E, Tas SG, Donmez AA, Sunar H, Balkanay M. Midterm results of axilloaxillary cardiopulmonary bypass. Heart Surg Forum 2012; 15:E23-7. [PMID: 22360900 DOI: 10.1532/hsf98.20111094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Total axilloaxillary cardiopulmonary bypass (CPB) is an alternative peripheral cannulation technique that has the advantages of antegrade flow during CPB, monohemispherical brain perfusion in case of circulatory arrest, and achieving excellent decompression of the heart during sternotomy. The results of this strategy, particularly beyond the immediately postoperative period, are not well known. METHODS Eleven patients with huge aortic aneurysms (>80 mm) and/or acute-subacute ascending aorta dissections underwent surgery with totally axilloaxillary CPB. Short- and midterm outcomes, including survival and complications relating to axilloaxillary cannulation, were reported. RESULTS All attempts at axillary artery cannulation were successful. Ten of the 11 axillary vein cannulation attempts were successful, and the target pump flow was achieved via the axillary vein alone. Postoperatively, clinical examinations revealed no cases of arm ischemia or compartment syndrome. Three patients (27.3%) experienced ipsilateral brachial plexus neuropathy that produced right hand weakness. The neuropathy was transient in 2 patients, and the symptoms resolved completely. Hospital death occurred in 1 (9.1%) of the 11 patients. The mean (±SD) follow-up time was 956 ± 292 days. One of the survivors died on postoperative day 105 from subacute graft infection and sepsis. The right arms of all 9 of the living patients were examined physically and by Doppler ultrasonography. We found a chronic recanalized thrombotic change in the subclavian vein in 1 patient (11.1%), who had no complaints. CONCLUSIONS Axilloaxillary CPB is an alternative technique that can be used under certain conditions. Adding axillary venous cannulation to axillary artery cannulation at least does not increase the risk of a procedure that uses the axillary artery alone, either in the early or mid term.
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Affiliation(s)
- Altug Tuncer
- Department of Cardiovascular Surgery, Kartal Koşuyolu Heart and Research Hospital, Istanbul, Turkey
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Elmistekawy EM, Rubens FD. Deep hypothermic circulatory arrest: Alternative strategies for cerebral perfusion. A review article. Perfusion 2011; 26 Suppl 1:27-34. [DOI: 10.1177/0267659111407235] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep hypothermic circulatory arrest is an essential tool in the surgeon’s armamentarium. There are essentially three strategies to address cerebral ischemia during arrest periods. Early surgical case series pioneered the option of complete anoxia with deep hypothermia. Subsequent innovators introduced the concept of retrograde perfusion of the cerebral vessels through the venous system, and others have advocated the use of selective and non-selective antegrade perfusion of the cerebral arteries. Clinical studies assessing outcomes of the three approaches are compromised by small patient numbers, retrospective design and surgeon bias. In this review, the authors will briefly discuss the conceptual basis of these strategies and the literature comparing these approaches in terms of key neurologic outcomes. The importance of this topic will emphasize the key role the perfusion community plays in establishing guidelines for best practice in circulatory arrest to go forward with education and research in this area.
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Affiliation(s)
- E M Elmistekawy
- Division of Cardiac Surgery, the Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - F D Rubens
- Division of Cardiac Surgery, the Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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Neri E. Invited commentary. Ann Thorac Surg 2010; 90:737. [PMID: 20732487 DOI: 10.1016/j.athoracsur.2010.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 04/18/2010] [Accepted: 04/23/2010] [Indexed: 11/29/2022]
Affiliation(s)
- Eugenio Neri
- Unità Operativa di Chirurgia dell'Aorta Toracica, Policlinico Santa Maria alle Scotte, Viale M. Bracci, Siena, 53100 Italy.
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