1
|
Yu W, Liang Y, Gao J, Xie D, Xiong J. Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery. J Cardiothorac Surg 2024; 19:286. [PMID: 38734628 PMCID: PMC11088173 DOI: 10.1186/s13019-024-02790-z] [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: 09/30/2023] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality. Traditionally, urgent open aortic repair is performed after admission to prevent aortic rupture and death. However, when combined with malperfusion syndrome, the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis, significantly impacting the surgery's prognosis and potentially resulting in adverse consequences, bringing. This presents great significant challenges in treatment. Based on recent domestic and international research literature, this paper reviews the mechanism, current treatment approaches, and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection. The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery. The superior mesenteric artery can be windowed and (/or) stented, followed by delayed aortic repair. Priority should be given to revascularization of the superior mesenteric artery, followed by central aortic repair. During central aortic repair, direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery, leading to resulting in favorable therapeutic outcomes. The research results indicate that even after surgical aortic repair, intestinal ischemic necrosis may still occur. In such cases, prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.
Collapse
Affiliation(s)
- Wenbo Yu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Yuan Liang
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianfeng Gao
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Dilin Xie
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianxian Xiong
- First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
| |
Collapse
|
2
|
Bozso SJ, Nagendran J, Chu MWA, Kiaii B, El-Hamamsy I, Ouzounian M, Forcillo J, Kempfert J, Starck C, Moon MC. Three-year outcomes of the Dissected Aorta Repair Through Stent Implantation trial. J Thorac Cardiovasc Surg 2024; 167:1661-1669.e3. [PMID: 36220703 DOI: 10.1016/j.jtcvs.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/11/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study objective was to evaluate the clinical and radiographic outcomes of the Ascyrus Medical Dissection Stent in a prospective, nonrandomized, international study (Dissected Aorta Repair Through Stent Implantation) of patients with acute DeBakey type I aortic dissection. METHODS The Ascyrus Medical Dissection Stent was used in combination with the standard surgical management of acute DeBakey type I aortic dissection I to treat patients with (56.5%, 26/46) and without (43.5%, 20/46) preoperative clinical and radiographic malperfusion. All patients had a primary entry tear in the ascending aorta, and 97.8% (45/46) were treated with a hemiarch repair. Median follow-up was 3 years. RESULTS All 47 patients underwent emergency surgical repair with successful Ascyrus Medical Dissection Stent implantation. One patient was excluded from analysis due to use in iatrogenic dissection. Overall mortality at 30 days and 3 years was 13.0% (6/46) and 21.7% (10/46), respectively. Overall new stroke rate at 30 days was 15.2% (7/46). No devices were explanted at any time during the 3-year median follow-up. At 3 years, the total aortic diameter in zones 0, 1, and 2 decreased or remained stable in 91.7%, 72.7%, and 75.0%, respectively. The false lumen was completely or partially thrombosed in 90.5% in zone 0, 60.0% in zone 1, and 68.2% in zone 2 at 3 years. CONCLUSIONS The use of the Ascyrus Medical Dissection Stent in the treatment of acute DeBakey type I aortic dissection I holds promise as a simple technology that enables repair of the aortic arch and proximal descending aorta, while promoting positive aortic remodeling. Ongoing follow-up of the Dissected Aorta Repair Through Stent Implantation trial will provide long-term, prospective, clinical outcomes and radiographic data on positive remodeling of the aortic arch.
Collapse
Affiliation(s)
- Sabin J Bozso
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, Edmonton, Canada
| | - Bob Kiaii
- Division of Cardiac Surgery, Western University, Edmonton, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Canada
| | - Jessica Forcillo
- Centre Hospitalière de L Université de Montréal (CHUM), Montreal, Canada
| | | | | | - Michael C Moon
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada.
| |
Collapse
|
3
|
Huang LC, Chen SK, Peng H, Wu XJ. A visceral organ function-focused therapeutic strategy using a 6-hour time window for patients with acute type a aortic dissection complicated by mesenteric malperfusion. J Cardiothorac Surg 2024; 19:183. [PMID: 38580973 PMCID: PMC10996210 DOI: 10.1186/s13019-024-02634-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/11/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) complicated by mesenteric malperfusion is a critical and complicated condition. The optimal treatment strategy remains controversial, debate exists as to whether aortic dissection or mesenteric malperfusion should be addressed first, and the exact time window for mesenteric ischemia intervention is still unclear. To solve this problem, we developed a new concept based on the pathophysiological mechanism of mesenteric ischemia, using a 6-hour time window to divide newly admitted patients by the time from onset to admission, applying different treatment protocols to improve the clinical outcomes of patients with ATAAD complicated by mesenteric malperfusion. METHODS This was a retrospective study that covered a five-year period. From July 2018 to December 2020(phase I), all patients underwent emergency open surgery. From January 2021 to June 2023(phase II), patients with an onset within 6 h all underwent open surgical repair, followed by immediately postoperative examination if the malperfusion is suspected, while the restoration of mesenteric perfusion and visceral organ function was performed first, followed by open repair, in patients with an onset beyond 6 h. RESULTS There were no significant differences in baseline and surgical data. In phase I, eleven patients with mesenteric malperfusion underwent open surgery, while in phase II, our novel strategy was applied, with sixteen patients with an onset greater than 6 h and eleven patients with an onset less than 6 h. During the waiting period, none died of aortic rupture, but four patients died of organ failure, twelve patients had organ function improvement and underwent surgery successfully survived. The overall mortality rate decreased with the use of this novel strategy (54.55% vs. 18.52%, p = 0.047). Furthermore, the surgical mortality rate between the two periods showed even stronger statistical significance (54.55% vs. 4.35%, p = 0.022). Moreover, the proportions of patients with sepsis and multiorgan failure also showed differences. CONCLUSIONS Our novel strategy for patients with ATAAD complicated by mesenteric malperfusion not only improves the surgical success rate but also reduces the overall mortality rate.
Collapse
Affiliation(s)
- Ling-Chen Huang
- Department of Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167# Beilishi Road, Beijing, 100037, China
| | - Shuang-Kun Chen
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China
| | - Hua Peng
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China
| | - Xi-Jie Wu
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China.
| |
Collapse
|
4
|
Chandiramani A, Al-Tawil M, Rajasekar T, Elleithy A, Kakar S, Haneya A, Zeinah M, Harky A. Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type A Aortic Dissection Patients: An Epidemiologic Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00184-8. [PMID: 38644098 DOI: 10.1053/j.jvca.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening emergency that is associated with a high morbidity and mortality rate. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aims of this meta-analysis were to summarize the findings of observational studies investigating the utility of the Penn classification system and to analyze the incidence rates and mortality patterns within each class. The electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were filtered by multiple reviewers to give 10 studies that met the inclusion criteria. The extracted data included patient characteristics, and primary outcomes were the incidence rates of different Penn classes, along with the corresponding mortality for each class. Out of 1,512 studies identified during the initial search, 10 studies, including 4,494 patients, met the inclusion criteria. The pooled incidence of Penn A was highest at 0.55 (95% CI 0.52, 0.58), followed by Penn B at 0.21 (95% CI 0.17, 0.25), and finally Penn C at 0.14 (95% CI 0.11, 0.17). Patients with Penn BC were found to be at the highest risk of death, as their early mortality rates were 0.36 (95% CI 0.31, 0.41). Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 (95% CI 0.15, 0.27), followed by Penn B at 0.19 (95% CI 0.15, 0.23) and Penn A at 0.07 (95% CI 0.05, 0.10). Among patients presenting with ATAAD, class A was most frequently observed, followed by classes B, C, and BC. These findings indicate an incremental increase in mortality rates with the progression of Penn classification.
Collapse
Affiliation(s)
| | | | | | | | - Sahil Kakar
- Department of Ear, Nose, and Throat Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
| |
Collapse
|
5
|
Hashimoto O, Saito Y, Sasaki H, Yumoto K, Oshima S, Tobaru T, Kanda J, Sakai Y, Yasuda S. Treatment strategies and in-hospital mortality in patients with type A acute aortic dissection and coronary artery involvement. J Thorac Cardiovasc Surg 2024; 167:596-601.e3. [PMID: 35459537 DOI: 10.1016/j.jtcvs.2022.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Type A acute aortic dissection (AAD), especially that with coronary artery involvement and malperfusion, is a life-threatening disease. In the present study we aimed to investigate the association of surgical treatment and percutaneous coronary intervention (PCI) with in-hospital mortality in patients with type A AAD and coronary artery involvement. METHODS This retrospective multicenter registry in Japan included 225 patients with type A AAD and coronary artery involvement. Treatment strategies including surgical treatment and/or PCI were left to treating physicians. The primary end point was in-hospital death. RESULTS Of 225 patients, dissection extended into the right and left coronary arteries and both in 115 (51.1%), 105 (46.7%), and 5 (2.2%), respectively. Overall, 94 (41.8%) patients died during the hospitalization. Coronary angiography was performed in 53 (23.6%) patients, among whom 39 (73.6%) underwent PCI. Surgical repair was performed in 188 (83.6%) patients. In patients who received neither procedure, 33 of 35 (94.3%) died during the hospitalization. PCI was performed as a bridge to surgical repair in 37 of 39 (94.9%) patients, and in-hospital mortality of patients who underwent PCI and surgical procedures was 24.3%. Multivariable analysis identified PCI and surgical procedures as factors associated with lower in-hospital mortality rates. CONCLUSIONS Coronary artery involvement in type A AAD was associated with high in-hospital mortality of more than 40% in the current era. An early reperfusion strategy with PCI as a bridge to surgical repair might improve clinical outcomes in this fatal condition.
Collapse
Affiliation(s)
- Osamu Hashimoto
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Haruka Sasaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; Department of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Keita Yumoto
- Department of Cardiovascular Surgery, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Susumu Oshima
- Department of Aortic Surgery, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Tetsuya Tobaru
- Department of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Junji Kanda
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
| | - Yoshiaki Sakai
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
6
|
Manchev G, Gegouskov V, Kornovski V, Yankov G, Goranovska V, Ilieva V, Petrova V. Can Open Distal Repair Be Safely Used in All Patients with Type A Acute Aortic Dissection? Ann Thorac Cardiovasc Surg 2024; 30:n/a. [PMID: 37730310 PMCID: PMC10902668 DOI: 10.5761/atcs.oa.23-00086] [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] [Indexed: 09/22/2023] Open
Abstract
PURPOSE The distal suture line during aortic dissection repair can be performed by a closed technique or by an open technique. This study presents a retrospective comparison of both methods regarding their postoperative outcomes. PATIENTS AND METHODS 120 patients who underwent surgery for acute aortic dissection type A were divided into two groups. In group A (n = 81), open distal anastomosis was performed under hypothermic circulatory arrest and selective cerebral perfusion. In group B (n = 39), distal anastomosis was performed with the aorta cross-clamped under mildly hypothermic cardiopulmonary bypass. Primary outcomes were operative mortality, neurologic morbidity, and long-term survival. RESULTS Hospital mortality (17.3% for the open group vs. 12.8% for the closed group, p = 0.53), permanent neurologic dysfunction (8.7% vs. 8.3%, p = 1.0), and temporary neurologic dysfunction (31.9% vs. 22.2%, p = 0.298) were not significantly different between groups. No significant difference in actuarial 5- and 10-year survival was observed (88% vs. 86% and 53 vs. 73%, respectively, p = 0.396). After propensity-score adjustment, the technique of distal aortic repair was not found to be a predictor of the primary outcomes. CONCLUSION We conclude that the open repair can be used in most if not all cases of surgical repair of type A acute aortic dissection.
Collapse
Affiliation(s)
- Georgi Manchev
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vassil Gegouskov
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vladimir Kornovski
- Department of Cardiac Surgery, Heart and Brain University Hospital, Burgas, Bulgaria
| | - Georgi Yankov
- Department of Thoracic Surgery, Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Valya Goranovska
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vicktoria Ilieva
- Department of Anesthesia and Intensive Care, Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Vicktoria Petrova
- Department of Anesthesia and Intensive Care, Ivan Rilski University Hospital, Sofia, Bulgaria
| |
Collapse
|
7
|
Chen S, Peng H, Zhuang H, Wang J, Yan P, Zhang W, Zheng W, Li M, Wu X. Optimized strategy to improve the outcomes of acute type A aortic dissection with malperfusion syndrome. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00019-9. [PMID: 38218532 DOI: 10.1016/j.jtcvs.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution. METHODS Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (first stage) or an optimized strategy (second stage). In the second stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed, followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the first and second stages. RESULTS The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in the second stage vs 12.5% in the first stage; P < .01). In the second stage, the in-hospital mortality for MPS was decreased (10.2% vs 33.9%; P < .01). Moreover, the in-hospital mortality for MPS with symptom onset within 6 hours and beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in the second stage was comparable to that in patients without MPS (4.0% vs 2.4%; P > .05). CONCLUSIONS The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For patients with MPS symptom onset within 6 hours, immediate central repair is reasonable; for those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.
Collapse
Affiliation(s)
- Shuangkun Chen
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hua Peng
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hui Zhuang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Juxiang Wang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Pianpian Yan
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Weiqun Zhang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Weiliang Zheng
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Mingyu Li
- Fujian Provincial Key Laboratory of Innovative Drug Target Research, School of Pharmaceutical Sciences, Xiamen University, Xiamen, China
| | - Xijie Wu
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
| |
Collapse
|
8
|
Liu S, Ma J, Gao J, Zhang L, Liu W, Lin D, Yang Z. Risk Factors and Early Outcomes for Gastrointestinal Complications in Patients Undergoing Open Surgery for Type A Aortic Dissection. Am Surg 2023; 89:5450-5458. [PMID: 36788032 DOI: 10.1177/00031348231156768] [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] [Indexed: 02/16/2023]
Abstract
BACKGROUND Gastrointestinal complications need to be paid more attention, especially in critically ill patients. The purpose of this study was to identify the risk factors and short-term outcomes of gastrointestinal complications after open surgery for type A aortic dissection. METHODS A retrospective single-institutional study including patients who underwent open surgery for type A aortic dissection during 2012-2020 was conducted. Univariate analysis and logistic regression analysis were used to identify risk factors associated with gastrointestinal complications. The related clinical outcomes were compared between the patients with and without gastrointestinal complications. RESULTS Among the 2746 patients, 150 developed gastrointestinal complications. The development of gastrointestinal complications contributed to the higher rate of mortality (P = .008), longer stay in the intensive care unit (P < .001), and longer hospital stay (P < .001). Logistic regression analysis showed that age (odds ratio [OR] 1.020; 95% confidence interval [CI] 1.005-1.057; P = .011), American Society of Anesthesiologists classification greater than grade III (OR 1.724; 95%CI 1.179-2.521, P = .005), pre-induction mean arterial pressure (OR 0.978; 95%CI 0.965-0.990, P = .001), aortic cross-clamp time (OR 1.012; 95%CI 1.005-1.019, P = .001), cardiopulmonary bypass time (OR 1.007; 95%CI 1.002-1.011, P = .002), and intraoperative transfusion of red blood cells (OR 1.214; 95%CI 1.122-1.314, P = .001) were independent risk factors for gastrointestinal complications. CONCLUSIONS The incidence of gastrointestinal complications after open surgery for type A aortic dissection was 5.5%, resulting in increased mortality and prolonged hospital stay. It is necessary to take suitable strategies to reduce the incidence of gastrointestinal complications.
Collapse
Affiliation(s)
- Shuo Liu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
- Department of Anesthesiology, Aerospace Center Hospital, Beijing, People's Republic of China
| | - Jun Ma
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Junwei Gao
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Liang Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenjun Liu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Duomao Lin
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhanmin Yang
- Department of Anesthesiology, Aerospace Center Hospital, Beijing, People's Republic of China
| |
Collapse
|
9
|
Al-Tawil M, Salem M, Friedrich C, Diraz S, Broll A, Rezahie N, Schoettler J, de Silva N, Puehler T, Cremer J, Haneya A. Preoperative Imaging Signs of Cerebral Malperfusion in Acute Type A Aortic Dissection: Influence on Outcomes and Prognostic Implications-A 20-Year Experience. J Clin Med 2023; 12:6659. [PMID: 37892797 PMCID: PMC10607191 DOI: 10.3390/jcm12206659] [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: 08/20/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) continues to be a subject of active research due to its high mortality rates and associated complications. Cerebral malperfusion in ATAAD can have a devastating impact on patients' neurological function and overall quality of life. We aimed to explore the risk profile and prognosis in ATAAD patients presenting with preoperative imaging signs of cerebral malperfusion (PSCM). METHODS We obtained patient data from our Aortic Dissection Registry, which included 480 consecutive ATAAD cases who underwent surgical repair between 2001 and 2021. Primary endpoint outcomes included the in-hospital and 30-day mortality, postoperative new neurological deficit, mechanical ventilation hours, and intensive care unit (ICU) length of stay. RESULTS Of the total cohort, 82 patients (17.1%) had PSCM. Both groups had similar distributions in terms of age, sex, and body mass index. The patients in the PSCM group presented with a higher logistic EuroSCORE (47, IQR [31, 64] vs. 24, IQR [15, 39]; p < 0.001) and a higher portion of patients with a previous cardiac surgery (7.3% vs. 2.0%; p = 0.020). Intraoperatively, the bypass, cardioplegia, and aortic cross-clamp times were similar between both groups. However, the patients in the PSCM group received significantly more intraoperative packed red blood cells, fresh frozen plasma, and platelets transfusions (p < 0.05). Following the surgery, the patients who presented with PSCM had markedly longer ventilation hours (108.5 h, IQR [44, 277] vs. 43 h, IQR [16, 158], p < 0.001) and a significantly longer ICU length of stay (7 days, IQR [4, 13] vs. 5 days, IQR [2, 11]; p = 0.013). Additionally, the patients with PSCM had significantly higher rates of postoperative new neurological deficits (35.4% vs. 19.4%; p = 0.002). In the Cox regression analysis, PSCM was associated with significantly poorer long-term survival (hazard ratio (HR) 1.75, 95%CI [1.20-2.53], p = 0.003). Surprisingly, hypertension was shown as a protective factor against long-term mortality (HR: 0.59, 95%CI [0.43-0.82], p = 0.001). CONCLUSION PSCM in ATAAD patients is linked to worse postoperative outcomes and poorer long-term survival, emphasizing the need for early recognition and tailored management.
Collapse
|
10
|
Wang X, Ma J, Lin D, Dong X, Wu J, Bai Y, Zhang D, Gao J. The risk factors of postoperative hypoxemia in patients with Stanford type A acute aortic dissection. Medicine (Baltimore) 2023; 102:e34704. [PMID: 37603505 PMCID: PMC10443739 DOI: 10.1097/md.0000000000034704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/20/2023] [Indexed: 08/23/2023] Open
Abstract
Hypoxemia is one of the most common complications in patients after Stanford type A acute aortic dissection surgery. The aim of this study was to investigate the association of circulating ANG II level with postoperative hypoxemia and to identify the risk factors for postoperative hypoxemia in Stanford type A acute aortic dissection patients. In this study, 88 patients who underwent Stanford type A acute aortic dissection surgery were enrolled. Postoperative hypoxemia is defined by the oxygenation index (OI). Perioperative clinical data were collected and the serum ANG II and sACE2 levels were measured. The differences in the basic characteristics, intraoperative details, biochemical parameters, laboratory test data and clinical outcomes were compared between the hypoxemia group and the non-hypoxemia group by univariate analysis. Multivariate logistic regression analysis was performed on the variables with P < .1 in univariate analysis or that were considered clinically important to identify risk factors for postoperative hypoxemia. Twenty-five patients (28.4%) were considered to have postoperative hypoxemia (OI ≤ 200 mm Hg). The ANG II concentration remained a risk factor associated with postoperative hypoxemia [OR = 1.018, 95% CI (1.003-1.034), P = .022]. The other risk factors remaining in the logistic regression model were BMI [OR = 1.417, 95% CI (1.159-1.733), P = .001] and cTnI [OR = 1.003, 95% CI (1.000-1.005), P = .032]. Elevated levels of ANG II, BMI and cTnI are risk factors for postoperative hypoxemia in patients with Stanford type A acute aortic dissection.
Collapse
Affiliation(s)
- Xu’an Wang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jun Ma
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Duomao Lin
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiuhua Dong
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinjing Wu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Bai
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dongni Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junwei Gao
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
11
|
Bjurbom M, Olsson C, Geirsson A, Gudbjartsson T, Gunn J, Hansson EC, Hjortdal V, Jeppsson A, Mennander A, Ede J, Zindovic I, Ahlsson A, Wickbom A, Dalén M. Type A Aortic Dissection Repair in Patients With Prior Cardiac Surgery. Ann Thorac Surg 2023; 115:591-598. [PMID: 35688205 DOI: 10.1016/j.athoracsur.2022.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/21/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emergency surgery for acute type A aortic dissection in patients with previous cardiac surgery is controversial. This study aimed to evaluate the association between previous cardiac surgery and outcomes after surgery for acute type A aortic dissection, to appreciate whether emergency surgery can be offered with acceptable risks. METHODS All patients operated on for acute type A aortic dissection between 2005 and 2014 from the Nordic Consortium for Acute Type A Aortic Dissection database were eligible. Patients with previous cardiac surgery were compared with patients without previous cardiac surgery. Univariable and multivariable statistical analyses were performed to identify predictors of 30-day mortality and early major adverse events (a secondary composite endpoint comprising 30-day mortality, perioperative stroke, postoperative cardiac arrest, or de novo dialysis). RESULTS In all, 1159 patients were included, 40 (3.5%) with previous cardiac surgery. Patients with previous cardiac surgery had higher 30-day mortality (30% vs 17.8%, P = .049), worse medium-term survival (51.7% vs 71.2% at 5 years, log rank P = .020), and higher unadjusted prevalence of major adverse events (52.5% vs 35.7%, P = .030). In multivariable analysis, previous cardiac surgery was not associated with 30-day mortality (odds ratio 0.78; 95% CI, 0.30-2.07; P = .624) or major adverse events (odds ratio 1.07; 95% CI, 0.45-2.55, P = .879). CONCLUSIONS Major adverse events after surgery for acute type A aortic dissection were more frequent in patients with previous cardiac surgery. Previous cardiac surgery itself was not an independent predictor for adverse events, although the small sample size precludes definite conclusions. Previous cardiac surgery should not deter from emergency surgery.
Collapse
Affiliation(s)
- Markus Bjurbom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Christian Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut; Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jarmo Gunn
- Department of Surgery, Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ari Mennander
- Tampere University Heart Hospital, Tampere, Finland; Tampere University, Tampere, Finland
| | - Jacob Ede
- Department of Cardiothoracic Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Anders Ahlsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Cardiothoracic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Anders Wickbom
- Department of Cardiothoracic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
12
|
Persistent malperfusion after central aortic repair in acute type I aortic dissections. J Vasc Surg 2023; 77:1618-1624. [PMID: 36796591 DOI: 10.1016/j.jvs.2023.02.004] [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: 01/06/2023] [Revised: 01/28/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention. METHODS Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death. RESULTS There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion. CONCLUSIONS One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.
Collapse
|
13
|
Right versus left coronary artery involvement in patients with type A acute aortic dissection. Int J Cardiol 2023; 371:49-53. [PMID: 36257475 DOI: 10.1016/j.ijcard.2022.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Type A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. METHODS This multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. RESULTS Of 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. CONCLUSIONS The rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement.
Collapse
|
14
|
Shiiya N. Management of noncerebral malperfusion complicating acute type A dissection. Asian Cardiovasc Thorac Ann 2023; 31:26-31. [PMID: 35167355 DOI: 10.1177/02184923211069812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second-look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.
Collapse
Affiliation(s)
- Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
15
|
Kaufeld T, Martens A, Beckmann E, Rudolph L, Krüger H, Natanov R, Arar M, Korte W, Schilling T, Haverich A, Shrestha M. Onset of pain to surgery time in acute aortic dissections type A: a mandatory factor for evaluating surgical results? Front Cardiovasc Med 2023; 10:1102034. [PMID: 37180800 PMCID: PMC10172470 DOI: 10.3389/fcvm.2023.1102034] [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: 11/18/2022] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Objective An acute aortic dissection type A (AADA) is a rare but life-threatening event. The mortality rate ranges between 18% to 28% and mortality is often within the first 24 h and up to 1%-2% per hour. Although the onset of pain to surgery time has not been a relevant factor in terms of research in the field of AADA, we hypothesize that a patient's preoperative conditions depend on the length of this time. Methods Between January 2000 and January 2018, 430 patients received surgical treatment for acute aortic dissection DeBakey type I at our tertiary referral hospital. In 11 patients, the exact time point of initial onset of pain was retrospectively not detectable. Accordingly, a total of 419 patients were included in the study. The cohort was categorized into two groups: Group A with an onset of pain to surgery time < 6 h (n = 211) and Group B > 6 h (n = 208), respectively. Results Median age was 63.5 years (y) ((IQR: 53.3-71.4 y); (67.5% male)). Preoperative conditions differed significantly between the cohorts. Differences were detected in terms of malperfusion (A: 39.3%; B: 23.6%; P: 0.001), neurological symptoms (A: 24.2%; B: 15.4%; P: 0.024), and the dissection of supra-aortic arteries (A: 25.1%; B: 16.8%; P: 0.037). In particular, cerebral malperfusion (A 15.2%: B: 8.2%; P: 0.026) and limb malperfusion (A: 18%, B: 10.1%; P: 0.020) were significantly increased in Group A. Furthermore, Group A showed a decreased median survival time (A: 1,359.0 d; B: 2,247.5 d; P: 0.001), extended ventilation time (A: 53.0 h; B: 44.0 h; P: 0.249) and higher 30-day mortality rate (A: 25.1%; B: 17.3%; P: 0.051). Conclusions Patients with a short onset of pain to surgery time in cases of AADA present themselves not only with more severe preoperative symptoms but are also the more compromised cohort. Despite early presentation and emergency aortic repair, these patients show increased chances of early mortality. The "onset of pain to surgery time" should become a mandatory factor when making comparable surgical evaluations in the field of AADA.
Collapse
Affiliation(s)
- Tim Kaufeld
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Correspondence: Tim Kaufeld
| | - Andreas Martens
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Erik Beckmann
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, UnitedStates
| | - Linda Rudolph
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heike Krüger
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Morsi Arar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wilhelm Korte
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tobias Schilling
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
16
|
Singla A, De Silva R, Hawthorne JR, Hardstaff R, Lee T, Yeun L, Laurence J, Pleass H. Kidney Allograft Retrieval in Donations After Cardiac Death Following Type A0 Dissection Extending to Both Renal Origins. EXP CLIN TRANSPLANT 2022; 20:531-533. [PMID: 35620892 DOI: 10.6002/ect.2022.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Controlled organ retrieval in donors after cardiac death has been increasing in Australia to help bridge the gap in demand and supply. Donation of organs from donors with acute aortic syndrome has been scarcely reported. Several concerns exist related to ischemic insults before retrieval from malperfusion, systemic inflammatory state in dissection, and involvement of donor organ vessels that may preclude the ability of surgeons to perform successful anastomosis of healthy vessels. Here, we have described a case in which both kidneys were successfully retrieved from a donor after cardiac death who had a type A0 aortic dissection. Despite radiological malperfusion and concern about vessel integrity, donor organs were unaffected and had immediate graft function.
Collapse
Affiliation(s)
- Animesh Singla
- From the Transplant Surgery Department, Westmead Hospital, Westmead, Sydney, Australia.,From the Sydney University, Sydney, Australia
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Borsoi L, Armeni P, Donin G, Costa F, Ferini-Strambi L. The invisible costs of obstructive sleep apnea (OSA): Systematic review and cost-of-illness analysis. PLoS One 2022; 17:e0268677. [PMID: 35594257 PMCID: PMC9122203 DOI: 10.1371/journal.pone.0268677] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a risk factor for several diseases and is correlated with other non-medical consequences that increase the disease's clinical and economic burden. However, OSA's impact is highly underestimated, also due to substantial diagnosis gaps. OBJECTIVE This study aims at assessing the economic burden of OSA in the adult population in Italy by performing a cost-of-illness analysis with a societal perspective. In particular, we aimed at estimating the magnitude of the burden caused by conditions for which OSA is a proven risk factor. METHODS A systematic literature review on systematic reviews and meta-analyses, integrated by expert opinion, was performed to identify all clinical and non-clinical conditions significantly influenced by OSA. Using the Population Attributable Fraction methodology, a portion of their prevalence and costs was attributed to OSA. The total economic burden of OSA for the society was estimated by summing the costs of each condition influenced by the disease, the costs due to OSA's diagnosis and treatment and the economic value of quality of life lost due to OSA's undertreatment. RESULTS Twenty-six clinical (e.g., diabetes) and non-clinical (e.g., car accidents) conditions were found to be significantly influenced by OSA, contributing to an economic burden ranging from €10.7 to €32.0 billion/year in Italy. The cost of impaired quality of life due to OSA undertreatment is between €2.8 and €9.0 billion/year. These costs are substantially higher than those currently borne to diagnose and treat OSA (€234 million/year). CONCLUSIONS This study demonstrates that the economic burden due to OSA is substantial, also due to low diagnosis and treatment rates. Providing reliable estimates of the economic impact of OSA at a societal level may increase awareness of the disease burden and help to guide evidence-based policies and prioritisation for healthcare, ultimately ensuring appropriate diagnostic and therapeutic pathways for patients.
Collapse
Affiliation(s)
- Ludovica Borsoi
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | - Patrizio Armeni
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | - Gleb Donin
- Department of Biomedical Technology, Czech Technical University in Prague, Kladno, Czech Republic
| | - Francesco Costa
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS), Milan, Italy
| | | |
Collapse
|
18
|
Shetty V, Shetty DP, Rao PV, Hosabettu PK, Subramanian S, Vikneswaran G, Narayan P. Determinant of outcome in late presenting type A aortic dissection. J Card Surg 2022; 37:1654-1660. [DOI: 10.1111/jocs.16401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Varun Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Parachuri Venkat Rao
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Praveen Kumar Hosabettu
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Sendur Subramanian
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Gunaseelan Vikneswaran
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Pradeep Narayan
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| |
Collapse
|
19
|
Malperfusion in acute type A aortic dissection: how we handle the challenge? Indian J Thorac Cardiovasc Surg 2022; 38:122-131. [PMID: 35463696 PMCID: PMC8980967 DOI: 10.1007/s12055-021-01292-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
Malperfusion syndrome (MPS) complicating acute type A aortic dissection (ATAAD) poses a continuing challenge and management dilemma for cardiovascular surgeons. MPS may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral, and/or limb ischemia with varying frequency and severity. Despite the continuous improvement in diagnosis and management strategies for MPS with ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable. The present review aimed to assess current evidence on ATAAD patients with MPS and how best to handle the challenge.
Collapse
|
20
|
van Bakel PAJ, Henry M, Kim KM, Yang B, van Herwaarden JA, Alberto Figueroa C, Patel HJ, Williams DM, Burris NS. Imaging features of renal malperfusion in aortic dissection. Eur J Cardiothorac Surg 2022; 61:805-813. [PMID: 35019977 PMCID: PMC8947793 DOI: 10.1093/ejcts/ezab555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/08/2021] [Accepted: 11/20/2021] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection. METHODS In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion. RESULTS Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20-16.41, P = 0.03] and focal (OR 11.23; 1.12-112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion. CONCLUSIONS In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.
Collapse
Affiliation(s)
| | | | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - C Alberto Figueroa
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Nicholas S Burris
- Corresponding author. Department of Radiology, University of Michigan, 1500 E Medical Center Drive, CVC 5588, SPC 5030, Ann Arbor, MI 48109, USA. Tel: +1-734-768-7169; e-mail: (N.S. Burris)
| |
Collapse
|
21
|
Liang S, Liu Y, Zhang B, Dun Y, Guo H, Qian X, Sun X. OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6549205. [PMID: 35293587 DOI: 10.1093/ejcts/ezac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/14/2022] [Accepted: 03/12/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shenghua Liang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
22
|
Addressing malperfusion first before repairing type A dissection. JTCVS Tech 2021; 10:1-5. [PMID: 34977693 PMCID: PMC8690294 DOI: 10.1016/j.xjtc.2021.04.029] [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: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022] Open
|
23
|
Zhang H, Xie W, Lu Y, Pan T, Zhou Q, Xue Y, Wang D. Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: a retrospective study. J Cardiothorac Surg 2021; 16:326. [PMID: 34743732 PMCID: PMC8574002 DOI: 10.1186/s13019-021-01714-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Cannulation strategy in surgery for acute type A aortic dissection (ATAAD) remains controversial. We aimed to retrospectively analyze the safety and efficacy of double arterial cannulation (DAC) compared with right axillary cannulation (RAC) for ATAAD. Methods From January 2016 to December 2018, 431 ATAAD patients were enrolled in the study. Patients were divided into DAC group (n = 341) and RAC group (n = 90). Propensity score matching analysis was performed to compare the early and mid-term outcomes between these two groups. To confirm the organ protection effect by DAC, intraoperative blood gas results and cardiopulmonary bypass parameters were compared between the two groups. Results Demographics and preoperative comorbidities were comparable between two groups, while patients in DAC group were younger than RAC group (51.55 ± 13.21 vs. 56.07 ± 12.16 years, P < 0.001). DAC had a higher incidence of limb malperfusion (18.2% vs. 10.0%, P = 0.063) and lower incidence of coronary malperfusion (5.3% vs. 12.2%, P = 0.019). No significant difference in cardiopulmonary bypass and cross-clamp time was found between the two groups. The in-hospital mortality was 13.5% (58/431), while there was no difference between the two groups (13.5% vs. 13.3%; P = 0.969). Patients who underwent DAC had higher incidence of postoperative stroke (5.9% vs. 0%, P = 0.019) and lower incidence of postoperative acute kidney injury (AKI) (24.7% vs. 40.3%; P = 0.015). During a mean follow-up period of 31.8 (interquartile range, 25–45) months, the overall survival was 81.5% for DAC group and 78.0% for RAC group (P = 0.560). Intraoperative blood gas results and cardiopulmonary bypass parameters showed that DAC group had more intraoperative urine output volume than RAC group (P = 0.05), and the time of cooling (P = 0.04) and rewarming (P = 0.04) were shorter in DAC group. Conclusions DAC will not increase the surgical risks compared to RAC, but could reduce the incidence of postoperative AKI which may be benefit for renal protection. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01714-5.
Collapse
Affiliation(s)
- He Zhang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Wei Xie
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yuzhou Lu
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China.
| |
Collapse
|
24
|
Hashimoto O, Saito Y, Nakayama T, Okino S, Sakai Y, Nakamura Y, Fukuzawa S, Himi T, Ishibashi I, Kobayashi Y. Prognostic Impact of Branch Vessel Involvement on Computed Tomography versus Clinical Presentation of Malperfusion in Patients With Type a Acute Aortic Dissection. Am J Cardiol 2021; 152:158-163. [PMID: 34120705 DOI: 10.1016/j.amjcard.2021.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/01/2022]
Abstract
Type A acute aortic dissection (AAD) is a life-threatening disease. The use of contrast-enhanced computed tomography (CT) for diagnosing AAD has increased, and CT can provide pathophysiologic information on dissection such as intramural hematoma (IMH), longitudinal extent of dissection, and branch vessel involvement. However, the prognostic impact of these CT findings is poorly investigated. This multicenter registry included 703 patients with type A AAD. The longitudinal extent of dissection and IMH was determined on CT. Branch vessel involvement was defined as dissection extended into coronary, cerebral, and visceral arteries on CT. The evidence of malperfusion was defined based on clinical presentations. The primary endpoint was in-hospital death. Of 703 patients, 126 (18%) died during hospitalization. Based on contrast-enhanced CT findings, longitudinal extent of dissection was not associated with in-hospital death, while patients with IMH had lower in-hospital mortality than those without (13% vs 22%, p = 0.004). Coronary, cerebral, and visceral artery involvement on CT was found in 6%, 55%, and 32%. In patients with coronary artery involvement, 90% had clinical coronary malperfusion, while only 25% and 21% of patients with cerebral and visceral artery involvement had clinical evidence of corresponding organ malperfusion. Multivariable analysis showed evidence of malperfusion as a significant factor associated with in-hospital mortality. In conclusions, branch vessel involvement on CT was not always associated with end-organ malperfusion in patients with type A AAD, especially in cerebral and visceral arteries. Clinical evidence of malperfusion was significantly associated with in-hospital mortality beyond branch vessel involvement on CT.
Collapse
Affiliation(s)
- Osamu Hashimoto
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinichi Okino
- Department of Cardiology, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Yoshiaki Sakai
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Yoshitake Nakamura
- Division of Cardiology, Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
| | - Shigeru Fukuzawa
- Department of Cardiology, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Toshiharu Himi
- Division of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Iwao Ishibashi
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
25
|
Sultan I, Bianco V, Patel HJ, Arnaoutakis GJ, Di Eusanio M, Chen EP, Leshnower B, Sundt TM, Sechtem U, Montgomery DG, Trimarchi S, Eagle KA, Gleason TG. Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2021; 161:1713-1720.e1. [DOI: 10.1016/j.jtcvs.2019.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
|
26
|
Lu Z, Xue Y, Fan F, Cao H, Pan J, Zhou Q, Wang D. Malperfusion syndromes in acute type A aortic dissection do not affect long-term survival in Chinese population: A 10-year institutional experience. J Card Surg 2021; 36:1943-1952. [PMID: 33870559 DOI: 10.1111/jocs.15464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative malperfusion of acute type A aortic dissection (ATAAD) remains a catastrophic complication that is associated with high postoperative morbidity and mortality. The relationship between malperfusion and long-term survival in the Chinese population is unknown. METHODS A total of 771 patients who underwent ATAAD surgery between January 2009 and December 2018 at our center were included. In-hospital mortality, complications, morbidity, and long-term survival were analyzed. RESULTS Preoperative malperfusion was identified in 292 of 771 patients (37.9%), the in-hospital mortality rate was 20.9% in patients with preoperative malperfusion and 9.2% in those without. Independent predictors of in-hospital mortality included any malperfusion (odds ratio [OR], 5.132; p = .001), pericardial tamponade (OR, 1.808; p = .046), advanced age (OR, 1.028; p = .003), and cardiopulmonary bypass time (OR, 1.008; p = .001). Immediate emergency surgery (OR, 0.492; p = .007) and antegrade cerebral perfusion perioperatively (OR, 0.477; p = .020) were protective against postoperative mortality. The postoperative survival rates at 1, 3, and 5 years were 94.4% ± 1.5%, 91.9% ± 1.8%, and 83.0% ± 3.2% in patients with malperfusion and 94.7% ± 1.1%, 90.2% ± 1.7%, and 84.4% ± 2.7%, respectively, in those without. Preoperative malperfusion did not significantly affect the long-term outcomes of operative survivors (log-rank p = .601). CONCLUSION Malperfusion resulted in an unfavorable prognosis in the short term, but showed almost equal long-term survival in patients without malperfusion of ATAAD. Emergency central repair might be considered to further improve the outcomes of ATAAD with malperfusion.
Collapse
Affiliation(s)
- Zirun Lu
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| |
Collapse
|
27
|
Yamasaki M, Yoshino H, Kunihara T, Akutsu K, Shimokawa T, Ogino H, Kawata M, Takahashi T, Usui M, Watanabe K, Masuhara H, Yamamoto T, Nagao K, Takayama M. Risk analysis for early mortality in emergency acute type A aortic dissection surgery: experience of Tokyo Acute Aortic Super-network. Eur J Cardiothorac Surg 2021; 60:957-964. [PMID: 33829258 DOI: 10.1093/ejcts/ezab146] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/17/2020] [Accepted: 02/24/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES We investigated the various pre- and postoperative complications related to early (30-day) mortality after open surgery for acute type A aortic dissection. METHODS Data from the Tokyo Acute Aortic Super-network database spanning January 2015 to December 2017 were retrospectively reviewed. Pre- and postoperative factors related to early postoperative mortality were assessed in 1504 of 2058 (73.0%) consecutive patients [age: 66.6 (SD: 13.5) years, male: 52.9%] who underwent acute type A aortic dissection repair. RESULTS The early mortality rate following surgical repair was 8.9%. According to multivariable analysis, male sex [odds ratio (OR) 1.670, 95% confidence interval (CI) 1.063-2.624, P = 0.026], use of percutaneous circulatory assist devices (n = 116, 7.7%) including extracorporeal membrane oxygenators or intra-aortic balloon pumps (OR 4.857, 95% CI 2.867-8.228, P < 0.001), shock (n = 162, 10.8%) (OR 3.06, 95% CI 1.741-5.387, P < 0.001), cardiopulmonary arrest (n = 41, 2.7%) (OR 7.534, 95% CI 3.407-16.661, P < 0.001), coronary ischaemia (n = 36, 2.3%) (OR 2.583, 95% CI 1.042-6.404, P = 0.041) and cerebral ischaemia (n = 59, 3.9%) (OR 2.904, 95% CI 1.347-6.261, P = 0.007) were independent preoperative risk factors for early mortality, while cardiac tamponade (n = 34, 2.3%) (OR 10.282, 95% CI 4.640-22.785, P < 0.001), cerebral ischaemia (n = 80, 5.3%) (OR 2.409, 95% CI 1.179-4.923, P = 0.016) and mesenteric ischaemia (n = 15, 1.0%) (OR 44.763, 95% CI 13.027-153.808, P < 0.001) were independent postoperative risk factors. CONCLUSIONS Not only critical preoperative conditions but also postoperative cardiac tamponade and vital organ ischaemia are risk factors for early mortality after acute type A aortic dissection repair.
Collapse
Affiliation(s)
- Manabu Yamasaki
- Tokyo CCU Network Scientific Committee, Tokyo, Japan.,Department of Cardiovascular Surgery, St. Luke's International Hospital, Tokyo, Japan
| | | | | | - Koichi Akutsu
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | - Hitoshi Ogino
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | | | - Michio Usui
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | | | | | | - Ken Nagao
- Tokyo CCU Network Scientific Committee, Tokyo, Japan
| | | |
Collapse
|
28
|
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: 2.7] [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.
Collapse
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
| |
Collapse
|
29
|
Saran N, Pochettino A. Cannulation strategies & circulation management in type-A aortic dissection. J Card Surg 2021; 36:1793-1798. [PMID: 33728710 DOI: 10.1111/jocs.15456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
Type A aortic dissection most often requires emergent surgery to prevent malperfusion, stroke, and/or rupture of aorta. To achieve the structural goals of the operation, the conduct of the surgery is targeted from it inception at restoring true lumen flow. In this regard, institution of cardiopulmonary bypass and circulation management is key to allow adequate systemic flow, perfusion of brain and visceral organs and comprehensive systemic cooling to achieve circulatory arrest when needed. Different strategies have been used to establish adequate true lumen perfusion with varying success rates, with the most common still being femoral cannulation. More recently axillary and central cannulation strategies have shown satisfactory results by allowing more reliable true lumen flow. Cannulation approach should, therefore, depend on individual patient characteristics, presentation, and true lumen anatomy.
Collapse
Affiliation(s)
- Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
30
|
Nikolaos S, Vasilios P, Niki L, Argyriou EO, Theodoros K, Mihalis A. Arc of Buhler: A lifesaving anatomic variation. A case report. J Vasc Bras 2020; 19:e20200045. [PMID: 34211516 PMCID: PMC8218005 DOI: 10.1590/1677-5449.200045] [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] [Indexed: 11/29/2022] Open
Abstract
The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).
Collapse
Affiliation(s)
- Schizas Nikolaos
- Evangelismos General Hospital of Athens, Department of Cardio Thoracic and Vascular Surgery, Athens, Greece
| | - Patris Vasilios
- Evangelismos General Hospital of Athens, Department of Cardio Thoracic and Vascular Surgery, Athens, Greece
| | - Lama Niki
- Kapodistrian University of Athens, Research Unit of Radiology and Medical Imaging, Greece
| | | | - Kratimenos Theodoros
- Evangelismos General Hospital of Athens, Interventional Radiology Unit, Department of Radiology, Athens, Greece
| | - Argiriou Mihalis
- Evangelismos General Hospital of Athens, Department of Cardio Thoracic and Vascular Surgery, Athens, Greece
| |
Collapse
|
31
|
Liu X, Wang G, Zhang T. The analysis of the levels of plasma inflammation-related cytokines and endotoxins in patients with acute aortic dissection. Clin Hemorheol Microcirc 2020; 76:1-7. [PMID: 32116237 DOI: 10.3233/ch-190674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the changes in the levels of plasm interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9) and endotoxins in patients with acute aortic dissection (AAD). METHODS 55 AAD patients who were admitted and scheduled to undergo emergency surgery in our hospital from January 2017 to July 2017 were selected and retrospectively analyzed. They were divided into the survival group (n = 40) and the death group (n = 15). The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins at admission and at 6 h, 12 h and 24 h after admission (T0, T1, T2 and T3) were measured, and the correlations of inflammatory cytokines with endotoxins were analyzed. RESULTS At T1, T2 and T3, the levels of inflammatory cytokines and endotoxins were increased. The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins in the death group were significantly higher than those in the survival group at each time point (p < 0.05 in all comparisons). Neutrophil and platelet counts in the death group were higher than those in the survival group (p < 0.05). Correlation analyses indicated that the levels of IL-6, TNF-α, CRP and MMP-9 were positively correlated with the level of endotoxin. CONCLUSION Patients with AAD are often accompanied by systemic inflammatory responses, with inflammation-related cytokines (IL-6, TNF-α, CRP and MMP-9) and endotoxins levels significantly elevated. Combined monitoring of dynamic changes in inflammatory cytokines and endotoxins, as well as early interventions, has important clinical implications for evaluating the prognosis of AAD and reducing mortality.
Collapse
Affiliation(s)
- Xiaojun Liu
- Department of Cardiac Surgery, Qingdao Fuwai Cardiovascular Hospital, Qingdao, Shandong, China
| | - Gang Wang
- Department of Cardiac Surgery, Qingdao Fuwai Cardiovascular Hospital, Qingdao, Shandong, China
| | - Tao Zhang
- Department of Cardiac Surgery, Qingdao Fuwai Cardiovascular Hospital, Qingdao, Shandong, China
| |
Collapse
|
32
|
Xue Y, Pan J, Cao H, Fan F, Luo X, Ge M, Chen Y, Wang D, Zhou Q. Different aortic arch surgery methods for type A aortic dissection: clinical outcomes and follow-up results. Interact Cardiovasc Thorac Surg 2020; 31:254-262. [PMID: 32632444 DOI: 10.1093/icvts/ivaa095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/06/2020] [Accepted: 05/03/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to investigate the clinical outcomes and follow-up results among 5 main aortic arch surgery methods for type A aortic dissection in a single centre.
METHODS
From 2002 to 2018, 958 type A aortic dissection patients who received surgical repair were divided into 5 groups according to the arch surgery method: hemiarch replacement (n = 206), island arch replacement (n = 54), total arch replacement with frozen elephant trunk (n = 425), triple-branched stent (n = 39) and fenestrated stent (n = 234). The indications for the different arch methods were related to the patient’s preoperative status, the location and extent of the dissection and the surgical ability of the surgeons. A comparative study was performed to identify the differences in the perioperative data, and the Kaplan–Meier analysis was used to assess the long-term survival and reintervention rates. Thirty matched surviving patients that were included in each group completed Computed tomography angiography to determine long-term reshaping effect.
RESULTS
The 30-day mortality rate was 15.8%, and there was no difference among the 5 groups (P = 0.848). The follow-up survival rates were similar among the 5 groups (P = 0.130), and the same was true for patients without reintervention (P = 0.471). In the propensity matching study, patients with stents (frozen elephant trunk, triple-branched stent, fenestrated stent) had a slower aortic dilation rate and a higher ratio of thrombosis in the false lumen at the descending aortic and abdominal aortic levels than patients without stents.
CONCLUSIONS
No standard method is available for arch surgery, and indications and long-term effects should be identified with clinical data. In our experiences, simpler surgical procedures could reduce mortality in critically ill patients and stents in the distal aorta could improve long-term reshape effects.
Collapse
Affiliation(s)
- Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Xuan Luo
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Min Ge
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Yang Chen
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Jiangsu, China
| |
Collapse
|
33
|
Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary Surgical Strategies for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2020; 32:617-629. [PMID: 32615305 DOI: 10.1053/j.semtcvs.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.
Collapse
Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
| |
Collapse
|
34
|
Norton EL, Farhat L, Wu X, Kim KM, Fukuhara S, Khaja MS, Williams DM, Patel HJ, Deeb GM, Yang B. Managing Malperfusion Syndrome in Acute Type A Aortic Dissection With Previous Cardiac Surgery. Ann Thorac Surg 2020; 111:52-60. [PMID: 32569666 DOI: 10.1016/j.athoracsur.2020.04.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/03/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.
Collapse
Affiliation(s)
| | - Linda Farhat
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Minhaj S Khaja
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | | | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.
| |
Collapse
|
35
|
Qian SC, Ma WG, Pan XD, Liu H, Zhang K, Zheng J, Liu YM, Zhu JM, Sun LZ. Renal malperfusion affects operative mortality rather than late death following acute type A aortic dissection repair. Asian J Surg 2020; 43:213-219. [DOI: 10.1016/j.asjsur.2019.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/18/2019] [Indexed: 12/20/2022] Open
|
36
|
Leshnower BG, Keeling WB, Duwayri YM, Jordan WD, Chen EP. The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: Initial results compared with conventional algorithms. J Thorac Cardiovasc Surg 2019; 158:1516-1524. [DOI: 10.1016/j.jtcvs.2019.01.116] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 12/17/2018] [Accepted: 01/03/2019] [Indexed: 11/17/2022]
|
37
|
Bozso SJ, Nagendran J, Chu MW, Kiaii B, El-Hamamsy I, Ouzounian M, Kempfert J, Starck C, Shahriari A, Moon MC. Single-Stage Management of Dynamic Malperfusion Using a Novel Arch Remodeling Hybrid Graft. Ann Thorac Surg 2019; 108:1768-1775. [DOI: 10.1016/j.athoracsur.2019.04.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/06/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
|
38
|
Xue Y, Zhou Q, Pan J, Cao H, Fan F, Zhu X, Chong H, Wang D. Root reconstruction for proximal repair in acute type A aortic dissection. J Thorac Dis 2019; 11:4708-4716. [PMID: 31903260 DOI: 10.21037/jtd.2019.10.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Retrospective compared the results of root reconstruction and root replacement for acute type A aortic dissection (ATAAD) patients and observed the rate of aortic insufficiency (AI) and aortic root dilation in the midterm follow-up period. Methods From 2008-2016, 427 ATAAD patients received surgical therapy in our center. There were 328 male and 99 female patients, aging from 22 to 83 years with a mean age of (51.1±12.5) years. These patients were divided into two major groups: 298 cases with root reinforcement reconstruction (Root Reconstruction), 129 cases with Bentall procedure (Root Replacement). Results The 30-day mortality was 7.7% (33/427), while no difference between the 2 procedures (8.1% and 7.0%, P=0.844). Cross-clamp, cardiopulmonary bypass, and circulatory arrest times of all the patients were 252.5±78.1, 173.6±68.9, 30.7±9.5 minutes, respectively. In the average follow-up time of (34.5±26.1) months, midterm survival rates were similar between the 2 procedures (86.2% and 86.0%, P=0.957). Only one patient received redo Bentall procedure because of severe aortic regurgitation and dilated aortic root (50 mm) in the Root Reconstruction Group. Conclusions The indication of root management of ATAAD is based on the diameter of aortic root, structure of aortic root, and the dissection involvement. For most ATAAD patients, aortic root reinforcement reconstruction is a feasible and safe method.
Collapse
Affiliation(s)
- Yunxing Xue
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xiyu Zhu
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hoshun Chong
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| |
Collapse
|
39
|
Mukaiyama Y, Okada A, Kawakatsu Y, Akuzawa S, Suzuki K, Ishigami N, Yamamoto T. Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study. BMC Nephrol 2019; 20:368. [PMID: 31615429 PMCID: PMC6794814 DOI: 10.1186/s12882-019-1559-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI), which may progress to end-stage kidney disease (ESKD), is a potential complication of aortic dissection. Notably, in all reported ESKD cases secondary to aortic dissection, imaging evidence of static obstruction of the renal arteries always shows either renal artery stenosis or extension of the dissection into the renal arteries. CASE PRESENTATION We present the case of a 58-year-old man with hypertension who was diagnosed with a Stanford type B aortic dissection and treated with medications alone because there were no obvious findings indicative of dissection involving the renal arteries. He had AKI, which unexpectedly progressed to ESKD, without any radiological evidence of direct involvement of the renal arteries. Thus, we failed to attribute the ESKD to the dissection and hesitated to perform any surgical intervention. Nevertheless, the patient's hormonal levels, fractional excretion values, ankle brachial indices, and Doppler resistive indices seemed to indirectly suggest kidney malperfusion and implied renal artery hypo-perfusion. However, abdominal computed tomography imaging only revealed progressive thrombotic obstruction of the false lumen and compression of the true lumen in the descending thoracic aorta, despite the absence of anatomical blockage of renal artery perfusion. Later, signs of peripheral malperfusion, such as intermittent claudication, necessitated surgical intervention; a graft replacement of the aorta was performed. Post-operatively, the patient completely recovered after 3 months of haemodialysis, and the markers that had pre-operatively suggested decreased renal bloodstream normalised with recovery of kidney function. CONCLUSIONS To the best of our knowledge, this is the first report of severe AKI, secondary to aortic dissection, without direct renal artery obstruction, which progressed to "temporary" ESKD and was resolved following surgery. This case suggests that only coarctation above the renal artery branches following an aortic dissection can progress AKI to ESKD, despite the absence of radiological evidence confirming an obvious anatomical blockage. Further, indirect markers suggestive of decreased renal blood flow, such as ankle brachial indices, renal artery resistive indices, urinary excretion fractions, and hormonal changes, are useful for evaluating concomitant AKI and may indicate the need for surgical intervention after a Stanford type B aortic dissection.
Collapse
Affiliation(s)
- Yoshihiro Mukaiyama
- Department of Urology, Takashimadaira Chuo General Hospital, 1-73-1 Takashimadaira, Itabashi, Tokyo, 175-0082, Japan
| | - Akira Okada
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yutaro Kawakatsu
- Department of Nephrology, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Satoshi Akuzawa
- Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Kazuchika Suzuki
- Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Naoyuki Ishigami
- Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Tatsuo Yamamoto
- Department of Nephrology, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| |
Collapse
|
40
|
Yang B, Rosati CM, Norton EL, Kim KM, Khaja MS, Dasika N, Wu X, Hornsby WE, Patel HJ, Deeb GM, Williams DM. Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome. Circulation 2019; 138:2091-2103. [PMID: 30474418 DOI: 10.1161/circulationaha.118.036328] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. METHODS From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). RESULTS Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03). CONCLUSIONS Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.
Collapse
Affiliation(s)
- Bo Yang
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - Carlo Maria Rosati
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | | - Karen M Kim
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - Minhaj S Khaja
- Radiology (M.S.K., N.D., D.M.W.), Michigan Medicine, Ann Arbor
| | | | - Xiaoting Wu
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | | - Himanshu J Patel
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | - G Michael Deeb
- Departments of Cardiac Surgery (B.Y., C.M.R., K.M.K., X.W., H.J.P., G.M.D.), Michigan Medicine, Ann Arbor
| | | |
Collapse
|
41
|
Malperfusion in type A aortic dissection: results of emergency central aortic repair. Gen Thorac Cardiovasc Surg 2019; 67:594-601. [DOI: 10.1007/s11748-019-01072-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/19/2019] [Indexed: 12/25/2022]
|
42
|
Abstract
Acute aortic dissection is a life-threatening condition with the potential for serious complications such as myocardial infarction, heart failure, stroke, paraplegia, renal failure, mesenteric ischemia, and limb ischemia. Emergency department clinicians must be aware of the potential ischemic complications of aortic dissection and act quickly to prevent irreversible organ damage and death. This article highlights a case of a 49-year-old man who developed renal and lower extremity malperfusion secondary to Stanford Type A aortic dissection. Important historical clues and objective findings characteristic of acute aortic dissection and end-organ ischemia are discussed with the purpose of increasing reader knowledge of aortic dissection and signs of organ malperfusion with the hope that better awareness results in improved patient outcomes.
Collapse
|
43
|
Velayudhan BV, Idhrees AM, Mukesh K, Kannan RN. Mesenteric Malperfusion in Acute Aortic Dissection: Challenges and Frontiers. Semin Thorac Cardiovasc Surg 2019; 31:668-673. [DOI: 10.1053/j.semtcvs.2019.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022]
|
44
|
Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience. J Thorac Cardiovasc Surg 2018; 158:675-687.e4. [PMID: 30711274 DOI: 10.1016/j.jtcvs.2018.11.127] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 10/18/2018] [Accepted: 11/05/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS). METHODS Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n = 419) served as controls. RESULTS In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008-2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P = .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P = .016), and serum lactate ≥6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P = .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P = .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome. CONCLUSIONS In patients with acute type A aortic dissection with mesMPS, endovascular fenestration/stenting, and delayed open aortic repair achieved favorable short- and long-term outcomes. Surgeons should consider correcting mesenteric malperfusion before undertaking open aortic repair in patients with mesMPS, especially those with acute stroke, gross bowel necrosis at laparotomy, or serum lactate ≥6 mmol/L.
Collapse
|
45
|
Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion. J Thorac Cardiovasc Surg 2018; 156:483-489. [DOI: 10.1016/j.jtcvs.2018.02.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 01/03/2018] [Accepted: 02/02/2018] [Indexed: 11/19/2022]
|
46
|
Jassar AS, Sundt TM. How should we manage type A aortic dissection? Gen Thorac Cardiovasc Surg 2018; 67:137-145. [DOI: 10.1007/s11748-018-0957-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/08/2018] [Indexed: 02/06/2023]
|
47
|
Di Marco L, Leone A, Murana G, Castelli A, Alfonsi J, Di Bartolomeo R, Pacini D. Acute type A aortic dissection: Rationale and outcomes of extensive repair of the arch and distal aorta. Int J Cardiol 2018; 267:145-149. [PMID: 29880297 DOI: 10.1016/j.ijcard.2018.05.111] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/17/2018] [Accepted: 05/25/2018] [Indexed: 11/18/2022]
Abstract
Type A acute aortic dissection represents one of the most complex and life-threatening disorders of the cardiovascular system. Cardiac tamponade caused by ascending aorta rupture is the most common cause of death. In light of this, emergent surgery with ascending and partial arch replacement represents, in most of cases, the best and the faster therapeutic option. The natural history of aortic dissection, however, teaches us that in most cases there is a distal progression of the aortic disease that often requires further surgical and/or endovascular treatments. In light of this, it can be hypothesized that, by increasing the extent of aortic replacement during the first operation, it may improve the outcome of these patients by reducing the probability of a second surgery or, in selected cases and for appropriate indications, by treating with a single surgical step, the disease. In this short review of the literature, we focalized on the rationale and outcome of an extensive repair of the thoracic aorta.
Collapse
Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Castelli
- Cardio-Anesthesiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
48
|
Berretta P, Trimarchi S, Patel HJ, Gleason TG, Eagle KA, Di Eusanio M. Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD. J Vis Surg 2018; 4:65. [PMID: 29682475 DOI: 10.21037/jovs.2018.03.13] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 03/12/2018] [Indexed: 11/06/2022]
Abstract
Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.
Collapse
Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato, Italy
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, USA
| | - Thomas G Gleason
- Division of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, USA
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
49
|
The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg 2018; 155:897-904. [DOI: 10.1016/j.jtcvs.2017.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 10/15/2017] [Accepted: 11/01/2017] [Indexed: 11/20/2022]
|
50
|
Li ZD, Liu Y, Zhu J, Wang J, Lu FL, Han L, Xu ZY. Risk factors of pre-operational aortic rupture in acute and subacute Stanford type A aortic dissection patients. J Thorac Dis 2018; 9:4979-4987. [PMID: 29312702 DOI: 10.21037/jtd.2017.11.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Aortic rupture is one of the main causes of early death in acute and subacute Stanford type A aortic dissection (ATAAD) patients. This study aimed to analyze potential risk factors for pre-operational aortic rupture in ATAAD patients. Methods We retrospectively reviewed aortic dissection cases treated between May 2013 and May 2016 in Changhai Hospital, Shanghai. A total of 329 patients with ATAAD were included in the final analysis, and 31 patients died of aortic rupture before surgery. Clinical data on basic characteristics, clinical presentation, and biochemical measurements for all 329 patients were analyzed. Results The in-hospital aortic rupture rate was 9.4% (31/329), and the rupture accounted for 47% (31/66) of all in-hospital deaths of ATAAD patients. Patients who experienced rupture were significantly older (P<0.001), had lower systolic blood pressure (P=0.040), had more painful manifestation (P<0.001), had more systematic complications [shock (P=0.001), coma (P<0.001), hypoxemia (P=0.006), kidney and liver dysfunctions, and myocardial injury (higher troponin, P=0.009)], and had worse blood coagulability [lower platelet count (P=0.012), longer prothrombin time (P<0.001), and higher D-dimer (P=0.003)]. Multivariable analysis identified the following independent risk factors: shock [odds ratio (OR): 8.12; 95% confidence interval (CI), 1.10-59.85, P=0.040], pain requiring medication (OR: 12.67; 95% CI, 2.43-66.09; P=0.003), troponin level >0.7 ng/mL (OR: 9.28; 95% CI, 1.72-50.06; P=0.010), and D-dimer level ≥10 µg/mL (OR: 13.37; 95% CI, 2.18-81.97; P=0.005). Conclusions Aortic rupture accounted for 47% of all in-hospital deaths among patient with ATAAD. Shock, pain requiring medication, a troponin level >0.7 ng/mL and a D-dimer level ≥10 µg/mL are independent risk factors for aortic rupture in these patients.
Collapse
Affiliation(s)
- Zhuo-Dong Li
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yang Liu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Jiang Zhu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Jun Wang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Fang-Lin Lu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Lin Han
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhi-Yun Xu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| |
Collapse
|