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Kim LE, Park JH, Lee HC, Bae MJ, You JH. Midterm Clinical Outcomes of Endovascular Treatment for Acute Aortic Dissection with Malperfusion Syndrome. Vasc Specialist Int 2024; 40:17. [PMID: 38845442 PMCID: PMC11157333 DOI: 10.5758/vsi.240006] [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: 01/05/2024] [Revised: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 06/09/2024] Open
Abstract
Purpose There is limited data on the midterm results of endovascular treatment for acute type B aortic dissection (TBAD) with malperfusion syndrome (MS), particularly in Asia. This study aimed to investigate the clinical outcomes of endovascular treatment of acute TBAD with MS. Materials and Methods We retrospectively analyzed 27 patients who underwent endovascular treatment for acute TBAD with MS. Results Among the 27 patients with TBAD and MS, malperfusion was observed in the isolated renal (44.4%), visceral (7.4%) and iliofemoral (25.9%) arteries, as well as their combinations (22.2%). The patients underwent thoracic endovascular aortic repair (TEVAR) only (25.9%), selective stenting only in arteries affected by malperfusion (22.2%), or combined treatment with TEVAR and selective stenting (51.9%). Primary technical success was achieved in all the patients. No inhospital mortality or early death within 30 days after operation occurred. The rates of stroke, limb ischemia, acute kidney injury, and reintervention at 30 days were 7.4%, 3.7%, 25.9%, and 3.7%, respectively. The mean follow-up period was 4.3±3.1 years. During the follow-up, the rates of death, stroke, maintenance hemodialysis, aneurysmal change, and reintervention were 0%, 3.7%, 7.4%, 7.4%, and 7.4%, respectively. Two patients required reintervention due to limb ischemia and aneurysmal changes in the distal portion of the stent graft. Computed tomography scans revealed a significant increase in aortic diameters in patients who underwent selective stenting compared to those who underwent TEVAR over a 3-year period, with changes in aortic area measuring 878.9 mm2 vs. 188.4 mm2 at the middle of the lesion (P=0.037), 303.7 mm2 vs. 22.8 mm2 at the level of the celiac trunk (P=0.025), and 442.9 mm2 vs. 37.3 mm2 at the level of the renal artery (P=0.019). Conclusion The endovascular treatment of acute TBAD with MS demonstrated a high primary technical success rate and promising short- and midterm clinical outcomes.
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Affiliation(s)
- La Eun Kim
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Jong Ha Park
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Han Cheol Lee
- Division of Cardiology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Mi Ju Bae
- Department of Cardiovascular Surgery, Pusan National University Hospital, Pusan National University, Busan, Korea
| | - Ji Hoon You
- Department of Cardiothoracic Surgery, Veterans Health Service Medical Center, Seoul, Korea
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Qiu Z, Xiao J, Wu Q, Chai T, Zhang L, Li Y, Chen L. Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients. BMC Cardiovasc Disord 2022; 22:117. [PMID: 35313815 PMCID: PMC8939131 DOI: 10.1186/s12872-022-02511-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated. METHODS Between January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time. RESULTS Total early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87-155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53-375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64-0.91; P = 0.003), when compared with the FS group. CONCLUSIONS The early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.
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Affiliation(s)
- Zhihuang Qiu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Jun Xiao
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Qingsong Wu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Tianci Chai
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Li Zhang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Yumei Li
- Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China. .,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China. .,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China.
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Nakai Y, Yamada T, Ogawa S, Kamiya S, Saitoh Y, Suda H. Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians. Asian Cardiovasc Thorac Ann 2022; 30:772-778. [PMID: 35234053 DOI: 10.1177/02184923221083369] [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
BACKGROUND We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians. METHODS From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians. RESULTS The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23). CONCLUSION The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.
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Affiliation(s)
- Yosuke Nakai
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Toshiyuki Yamada
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shinji Ogawa
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shinji Kamiya
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yuhei Saitoh
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
| | - Hisao Suda
- Department of Cardiovascular Surgery, 38386Nagoya City University Graduate School of Medical Sciences, Japan
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Salem M, Salib M, Friedrich C, Salem M, Puehler T, Schoettler J, Schoeneich F, Cremer J, Haneya A. Influence of Age on Postoperative Neurological Outcomes after Surgery of Acute Type A Aortic Dissection. J Clin Med 2021; 10:jcm10081643. [PMID: 33921536 PMCID: PMC8068896 DOI: 10.3390/jcm10081643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute type A aortic dissection (AAAD) is considered a fatal disease which requires an emergent surgical intervention. This study focuses onthe neurological outcome after surgical repair in cases of AAAD in comparison between elderly and young patients. METHODS a retrospective analysis of 368 consecutive patients who underwent emergency surgery of ascending aorta in moderate hypothermic circulatory arrest (MHCA) (20-24 °C) and antegrade cerebral perfusion after AAAD between 2001 and 2016. Patients were divided into two groups: those aged 75 years and older (68 (18.5%)) and those younger than 75 years (300 (81.5%)). RESULTS Comparing both groups, average age was 79.0 ± 3.2 vs. 59.2 ± 10.7 years (p < 0.001); female gender represents 58.8% of elderly patients vs. 28.7% in younger patients (p < 0.001). Intraoperatively, cardiopulmonary bypass time (155 min (131; 187) vs. 171 min (137; 220); p = 0.012), cross-clamping time (79 min (60; 105) vs. 93 min (71; 134); p = 0.001] and circulatory arrest time (29 min (22; 40) vs. 33 min (26; 49); p = 0.011) were significantly shorter in elderly than younger group. Postoperatively, there was no significant difference in delirium (11.8% vs. 20.5%; p = 0.0968) or stroke (11.8% vs. 16.1%; p = 0.369). The 30-day mortality was satisfactory for both groups but significantly higher in the elderly group (27.9% vs. 14.3%; p = 0.007). CONCLUSION The current study concluded that surgical treatment of AAAD in elderly patients can be applied safely without increasing risk of neurological complication. However, minimizing operation time may help limit the occurrence of postoperative neurological complication.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
- Correspondence: ; Tel.: +49-431500-67089
| | - Michael Salib
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Christine Friedrich
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Mostafa Salem
- Department of Cardiology and Angiology, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany;
| | - Thomas Puehler
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Jan Schoettler
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Felix Schoeneich
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Jochen Cremer
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Assad Haneya
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
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Yang S, Xue Y, Liu J, Zhang H, Jiang W. Is fibrinogen plasma level a risk factor for the first 24-hour death of medically treated acute type A aortic dissection patients? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1015. [PMID: 32953815 PMCID: PMC7475496 DOI: 10.21037/atm-20-5466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The present study aims to assess the risk factors which affect the first 24-hour death of medical treatment in acute type A aortic dissection (ATAAD) patients. Methods This is a retrospective cohort study in a single center. From January 2009 to January 2018, 2,379 patients with type A aortic dissection were admitted to Beijing Anzhen Hospital, of which 243 patients who received medical intervention in ATAAD were involved in the final analysis. Fibrinogen plasma was obtained within 6 hours of admission and was assessed by using thrombin to convert fibrinogen to fibrin. Multivariable regressions were used to analyze the association of fibrinogen on in-hospital mortality and the first 24-hour mortality. Results The total in-hospital mortality rate was 92 (37.9%) in patients with ATAAD, and 33 (13.6%) of patients died within 24 hours of onset. We found no significant association between fibrinogen plasma level and in-hospital death (HR, 0.91; 95% CI, 0.78, 1.06; P=0.23), but a fibrinogen plasma level of ≤4.0 g/L was an independent risk factor for the first 24-hour mortality (HR, 5.92; 95% CI, 1.40, 25.08, P=0.02). Conclusions ATAAD patients with a fibrinogen plasma level of >4.0 g/L have lower first 24-hour mortality when treated medically, while patients with a fibrinogen plasma level of ≤4.0 g/L are more likely to die without surgery in the first 24 hours.
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Affiliation(s)
- Sheng Yang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Xue
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Wenjian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
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6
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Wang J, Wu LR, Xie X. Stanford type a aortic dissection with cerebral infarction: a rare case report. BMC Neurol 2020; 20:253. [PMID: 32576285 PMCID: PMC7313114 DOI: 10.1186/s12883-020-01832-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/18/2020] [Indexed: 01/16/2023] Open
Abstract
Background Aortic dissection (AoD) is a disease with a high mortality rate. Its clinical manifestations are diverse and covert, which makes diagnosis and treatment challenging. Here, we report a very rare case of aortic dissection leading to bilateral cerebral cortex ischaemia and epilepsy. Case presentation A 54-year-old man was admitted to the hospital with acute onset of right limb weakness accompanied by slurred speech. He had a history of hypertension as well as tobacco and alcohol use. The patient was found to have aphasia and right hemiplegia on physical examination. No bleeding was seen on the skull CT. Acute cerebral infarction was considered after admission, and rt-PA was administered for intravenous thrombolysis. During intravenous thrombolysis, the patient suddenly developed epilepsy, and diazepam was given immediately by intravenous injection to control the symptoms. Emergency skull diffusion-weighted imaging (DWI) was performed, and the results showed a small, patchy, high signal that was scattered throughout the left brain hemisphere, right frontal parietal lobe and centrum semiovale. Head and neck CT angiography (CTA) was performed; dissection was found in the ascending aorta, aortic arch, bilateral common carotid artery, proximal part of the internal carotid artery, and initial segment of the left external carotid artery. The laceration was located in the upper part of the ascending aorta. AoD complicated by acute cerebral infarction and epilepsy was considered, and the patient was immediately transferred to the cardiovascular surgery specialist hospital for surgical treatment. Conclusions Some aortic dissections have no typical manifestations of chest pain, and the onset is covert. Atypical clinical manifestations of epilepsy secondary to bilateral cerebral hemisphere infarction may appear. AoD with cerebral infarction is a contraindication for intravenous thrombolysis; surgical treatment is the best way to reduce mortality.
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Affiliation(s)
- Jie Wang
- Department of Neurology, Chongqing City Hospital of Traditional Chinese Medicine, No. 6, Seventh Branch Road, Panxi, Jiangbei District, Chong qing, 400021, China.
| | - Li-Rong Wu
- Department of Neurology, Chongqing City Hospital of Traditional Chinese Medicine, No. 6, Seventh Branch Road, Panxi, Jiangbei District, Chong qing, 400021, China
| | - Xin Xie
- Department of Neurology, Chongqing City Hospital of Traditional Chinese Medicine, No. 6, Seventh Branch Road, Panxi, Jiangbei District, Chong qing, 400021, China
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Salem M, Friedrich C, Thiem A, Huenges K, Puehler T, Cremer J, Haneya A. Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years. Thorac Cardiovasc Surg 2020; 69:322-328. [PMID: 32559807 DOI: 10.1055/s-0040-1710002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients. PATIENTS AND METHODS This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016. RESULTS The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality. CONCLUSION Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Alexander Thiem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
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Funakoshi Y, Imamura H, Tokunaga S, Murakami Y, Tani S, Adachi H, Ohara N, Kono T, Fukumitsu R, Sunohara T, Omura Y, Matsui Y, Sasaki N, Fujiwara S, Fukuda T, Akiyama R, Horiuchi K, Yoshida K, Kajiura S, Shigeyasu M, Koyama T, Sakai N. Carotid artery stenting before surgery for carotid artery occlusion associated with acute type A aortic dissection: Two case reports. Interv Neuroradiol 2020; 26:814-820. [PMID: 32397860 DOI: 10.1177/1591019920925690] [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] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes.Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient's neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1. CONCLUSIONS In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.
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Affiliation(s)
- Yusuke Funakoshi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - So Tokunaga
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasutaka Murakami
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomoyuki Kono
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihiro Omura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuichi Matsui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazufumi Horiuchi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazufumi Yoshida
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shinji Kajiura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masashi Shigeyasu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Moeller E, Nores M, Stamou SC. Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 7:155-162. [PMID: 32272487 PMCID: PMC7145439 DOI: 10.1055/s-0039-3401810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.
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Affiliation(s)
- Ellie Moeller
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Marcos Nores
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, FL
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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.
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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
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Sirota DA, Khvan DS, Lyashenko MM, Alsov SA, Chernyavsky AM. [Djumbodis stent migration in a patient with aortic dissection]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:163-166. [PMID: 31503261 DOI: 10.33529/angio2019321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Treatment of patients presenting with type I aortic dissection is known to be a surgical challenge. The Djumbodis bare metal stent was developed to ease the burden of a reconstructive intervention on the aortic arch, to decrease the duration of the operation, and to minimize complications associated with artificial circulation. Currently, insufficiently explored remains the problem of complications occurring due to the technological fatigue of the metal and possible stent migration. Described herein is a clinical case report regarding migration of a Djumbodis stent, diagnosed 6 months after implantation for DeBakey type I acute aortic dissection. We revealed dislocation of the stent's distal portion with fenestration of the membrane of the true channel and perfusion of the false channel, as well as fractured fragments of the stent. The patient underwent repeat 'open' intervention.
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Affiliation(s)
- D A Sirota
- Centre for Surgery of the Aorta, Coronary and Peripheral Arteries, National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - D S Khvan
- Centre for Surgery of the Aorta, Coronary and Peripheral Arteries, National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - M M Lyashenko
- Centre for Surgery of the Aorta, Coronary and Peripheral Arteries, National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - S A Alsov
- Centre for Surgery of the Aorta, Coronary and Peripheral Arteries, National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A M Chernyavsky
- Centre for Surgery of the Aorta, Coronary and Peripheral Arteries, National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
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12
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Al-Adhami A, Harky A, Bashir M, Kolvekar S. Replacing the ascending aorta in the elderly: do or do not. Indian J Thorac Cardiovasc Surg 2019; 35:106-111. [PMID: 33061074 DOI: 10.1007/s12055-018-0734-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY UK
| | - Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, CH1 2UL UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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13
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Evangelista A, Maldonado G, Gruosso D, Gutiérrez L, Granato C, Villalva N, Galian L, González-Alujas T, Teixido G, Rodríguez-Palomares J. The current role of echocardiography in acute aortic syndrome. Echo Res Pract 2019; 6:R53-R63. [PMID: 30921764 PMCID: PMC6454227 DOI: 10.1530/erp-18-0058] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndrome (AAS) comprises a range of interrelated conditions caused by disruption of the medial layer of the aortic wall, including aortic dissection, intramural haematoma and penetrating aortic ulcer. Since mortality from AAS is high, a prompt and accurate diagnosis using imaging techniques is paramount. Both transthoracic (TTE) and transoesophageal echocardiography (TEE) are useful in the diagnosis of AAS. TTE should be the first imaging technique to evaluate patients with thoracic pain in the emergency room. Should AAS be suspected, contrast administration is recommended when images are not definitive. TEE allows high-quality images in thoracic aorta. The main drawback of this technique is that it is semi-invasive and the presence of a blind area that limits visualisation of the distal ascending aorta near. TEE identifies the location and size of the entry tear, secondary communications, true lumen compression and the dynamic flow pattern of false lumen. Although computed tomography (CT) is the most used imaging technique in the diagnosis of AAS, echocardiography offers complementary information relevant for its management. The best imaging strategy for appropriately diagnosing and assessing AAS is to combine CT, mainly ECG-gated contrast-enhanced CT, and TTE. Currently, TEE tends to be carried out in the operating theatre immediately before surgical or endovascular therapy and in monitoring their results. The aims of this review are to establish the current role of echocardiography in the diagnosis and management of AAS based on its advantages and limitations.
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Affiliation(s)
- Arturo Evangelista
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Giuliana Maldonado
- Cardiovascular Imaging Department, Instituto del Corazon, Quironsalud Teknon, Barcelona, Spain
| | - Domenico Gruosso
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Laura Gutiérrez
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Chiara Granato
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Nicolas Villalva
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Laura Galian
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Teresa González-Alujas
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Gisela Teixido
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Jose Rodríguez-Palomares
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
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Shimamura J, Yamamoto S, Oshima S, Ozaki K, Fujikawa T, Sakurai S, Hirai Y, Hirokami T, Moriya N, Hase S, Nakagawa T, Yamasaki M, Takayama W, Sasaguri S. Surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection. Eur J Cardiothorac Surg 2019; 54:369-374. [PMID: 29420717 DOI: 10.1093/ejcts/ezy014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/04/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection. METHODS Between 2008 and 2015, a total of 300 patients with acute Type A aortic dissection underwent emergency surgery, consisting of 271 hemiarch repairs and 29 total aortic arch replacements, using transapical cannulation and the adventitial inversion technique at a distal anastomosis. The mean follow-up periods were 31.7 ± 25.2 months. Overall, 18% (54/300) of the patients were octogenarians, and 21.7% (65/300) had cardiac tamponade; 25% (75/300) had preoperative malperfusion. RESULTS The in-hospital and 30-day mortality rates were 8.3% (25/300) and 6.7% (20/300), respectively. The 30-day mortality rate was 2.7% (6/225) among patients without preoperative malperfusion and 18.7% (14/75) among patients with malperfusion (P < 0.0001), 7.4% (4/54) among octogenarians and 6.5% (16/246) among patients aged less than 80 years (P = 0.81), and 6.3% (17/271) among patients treated with hemiarch repair and 10.3% (3/29) among patients treated with total aortic arch replacement (P = 0.403). Preoperative malperfusion was an independent predictor of perioperative mortality in a multivariable analysis. During the follow-up period, distal reintervention was performed in 11% (33/300) of the patients. The rates of freedom from reintervention at 1, 3 and 5 years were 95.9%, 88.9% and 80.0%, respectively. The overall survival rates at 1, 3 and 5 years were 88.7%, 86.7% and 82.0%, respectively. The in-hospital mortality rate for elective reintervention was 3.0% (1/33). CONCLUSIONS Aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection provides good early and mid-term results. The safety of elective distal reintervention can be guaranteed. To obtain better operative outcomes, effective treatment for cases with malperfusion is mandatory.
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Affiliation(s)
- Junichi Shimamura
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Shin Yamamoto
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Susumu Oshima
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Kensuke Ozaki
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Takuya Fujikawa
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Shigeru Sakurai
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Yuki Hirai
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Tomohiro Hirokami
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Nobukazu Moriya
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Soichiro Hase
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Tassei Nakagawa
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Motoshige Yamasaki
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Wataru Takayama
- Department of Anesthesiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Shiro Sasaguri
- Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
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15
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Suzuki T, Asai T, Kinoshita T. Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians Without Patient Selection. Ann Thorac Surg 2019; 107:1146-1153. [DOI: 10.1016/j.athoracsur.2018.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
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Does Interhospital Transfer Influence the Outcomes of Patients Receiving Surgery for Acute Type A Aortic Dissection? Type A Aortic Dissection: Is Transfer Hazardous or Beneficial? Emerg Med Int 2019; 2019:5692083. [PMID: 31011453 PMCID: PMC6442438 DOI: 10.1155/2019/5692083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/03/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction The progression of acute type A aortic dissection may cause immediate death, such that, in the event of its diagnosis, emergency surgery is indicated. Relatedly, an interhospital transfer may prolong the time from diagnosis to surgery. This study therefore investigated how interhospital transfers impact surgical outcomes for acute type A aortic dissection. Materials and Methods After excluding those patients who received deferred surgery for acute type A aortic dissection, 112 patients who received emergency surgery for the condition at our hospital from January 2011 to January 2018 were enrolled. These patients were divided into two groups, one consisting of the patients who were sent directly to our emergency department (group 1) and the other consisting of the patients who were transferred from another hospital after first being diagnosed with type A aortic dissection (group 2). The collected data included the patient demographics, clinical characteristics, operative findings and methods, postoperative outcomes, latest follow-up time, and most recent status. Results There were 59 patients in group 1 and 53 patients in group 2. Univariate analysis revealed that group 1 had significantly more patients with a previous stroke (p = 0.007). Moreover, the average length of time from receiving a computed tomography (CT) scan to entering the operating room (OR) was shorter for the group 1 patients (p < 0.001). However, except for the incidence of postoperative acute kidney injury (14.5% versus 33.3%, p = 0.024), there was no statistical difference between the groups in terms of the operative findings and outcomes, such as hypotension before cardiopulmonary bypass, hemopericardium, other complications, and survival rate. Multivariate analysis showed that the independent predictors of hospital mortality included age > 61.5 years (p = 0.017), respiratory rate upon admission > 18.5 breaths/minute (p = 0.046), and total bypass time > 265.6 minutes (p = 0.015). For the patients who survived to discharge, log-rank analysis demonstrated similar cumulative survival rates for the two groups (p = 0.62). Further multivariate analysis showed that the risk of death after discharge was associated with the interval between the CT scan and OR entry (hazard ratio = 0.97 per minute; 95% confidence interval, 0.950–0.998; p = 0.037). Conclusion In this study, it was found that interhospital transfer did not influence the surgical outcomes of patients with acute type A aortic dissection. As such, it can be concluded that the transfer of the patients with type A aortic dissection to tertiary hospitals with experienced cardiac surgical teams may not increase the surgical risk.
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Kodama H, Takahashi S, Okazaki T, Morita S, Go S, Watanabe M, Yamane Y, Katayama K, Kurosaki T, Sueda T. Association between false lumen segmental arteries and spinal cord ischemia in type A acute aortic dissection. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:226-233. [PMID: 30465415 DOI: 10.23736/s0021-9509.18.10639-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen). METHODS The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated. RESULTS The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184). CONCLUSIONS In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.
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Affiliation(s)
- Hiroshi Kodama
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan -
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Shohei Morita
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Seimei Go
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Masazumi Watanabe
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Yoshitaka Yamane
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Tatsuya Kurosaki
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Taijiro Sueda
- Department of Cardiovascular Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
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Acute ischemic stroke as a complication of Stanford type A acute aortic dissection: a review and proposed clinical recommendations for urgent diagnosis. Gen Thorac Cardiovasc Surg 2018; 66:439-445. [PMID: 29948797 DOI: 10.1007/s11748-018-0956-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Stanford type A acute aortic dissection requires emergency surgery. Because patients with ischemic stroke as a complication of Stanford type A acute aortic dissection do not often complain of chest or back pain, probably due to consciousness disturbance, amnesia, or aphasia, a fatal course following inappropriate intravenous rt-PA therapy and delay of appropriate surgical treatment sometimes occur. REVIEW AND PROPOSED RECOMMENDATIONS When treating any suspected stroke patients, emergency services and initial urgent care doctors should always suspect aortic dissection. Even in the absence of chest or back pain, the initial urgent care doctor needs to immediately perform chest contrast CT if suspecting aortic dissection from blood pressure laterality or upper mediastinal widening on chest X-ray. Whenever aortic dissection cannot be ruled out from initial clinical information, the initial urgent care doctor should evaluate the common carotid artery (CCA). Dissection extension to the CCA or flow abnormality of the CCA is often detected if aortic dissection is a cause of ischemic stroke or transient ischemic attack. Head CT or MRI including vascular imaging is preferable. D-dimer should be measured in hospitals where available. As soon as aortic dissection is identified, the initial urgent care doctor needs to consult with cardiovascular surgeons or cardiologists for appropriate treatment.
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Zhou T, Li J, Sun Y, Gu J, Zhu K, Wang Y, Lai H, Wang C. Surgical and early outcomes for Type A aortic dissection with preoperative renal dysfunction stratified by estimated glomerular filtration rate. Eur J Cardiothorac Surg 2018; 54:940-945. [PMID: 29672685 DOI: 10.1093/ejcts/ezy157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/21/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tianyu Zhou
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongxin Sun
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiawei Gu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Zhu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yulin Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
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Hata M, Orime Y, Wakui S, Umeda T, Akiyama K, Tanaka M. Efficacy of modified less invasive quick replacement using mild hypothermic arrest and partial retrograde cerebral perfusion for type A acute aortic dissection. Gen Thorac Cardiovasc Surg 2017; 66:33-37. [PMID: 29080092 DOI: 10.1007/s11748-017-0844-3] [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: 07/07/2017] [Accepted: 09/27/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We previously reported a unique technique called "less invasive quick replacement (LIQR)" for treating type A acute aortic dissection with moderate hypothermic arrest (28 °C). This study examines the modified LIQR using mild hypothermic arrest (30 °C) with partial retrograde cerebral perfusion (RCP). METHODS 187 patients were divided into 2 groups: group L consisted of 130 patients underwent LIQR without any cerebral perfusion; group M consisted of 57 patients who were treated with modified LIQR. In modified LIQR, circulatory arrest was commenced under the 30 °C for open distal aortic stamp fixation. RCP was used during final half anastomosis of the prosthesis and then rapid re-warming was initiated. RESULTS The incidence of additional valve or coronary surgeries was significantly higher in group M (28.1%) than in group L (9.2%). The average rectal temperature was significantly higher in group M (29.5 °C) than in group L (27.4 °C). The durations of brain ischemia (M 7.7 min; L 18.6 min), cardiopulmonary bypass (M 82.0 min; L 93.3 min), and overall operation (M 145.2 min; L 154.2 min) were significantly shorter in group M. The incidence of postoperative brain damage was 6 patients (4.6%) in group L, but none in group M. The hospital mortality rate was 3 patients in group L (2.3%). All group M patients were discharged from the hospital without any complications. CONCLUSION Modified LIQR is safe and effective. It makes the surgery much quicker and is a less invasive procedure. The surgical outcome was also favorable.
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Affiliation(s)
- Mitsumasa Hata
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan. .,Department of Cardiovascular Surgery, Nihon University Hospital, 1-6 Kanda Surugadai Chiyoda-ku, Tokyo, 101-8309, Japan.
| | - Yukihiko Orime
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shinji Wakui
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tomofumi Umeda
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kenji Akiyama
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
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Sultan I, Wallen TJ, Habertheuer A, Siki M, Arnaoutakis GJ, Bavaria J, Szeto WY, Milewski R, Vallabhajosyula P. Concomitant antegrade stent grafting of the descending thoracic aorta during transverse hemiarch reconstruction for acute DeBakey I aortic dissection repair improves aortic remodeling. J Card Surg 2017; 32:581-592. [DOI: 10.1111/jocs.13192] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ibrahim Sultan
- University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | | | | | - Mary Siki
- University of Pennsylvania Medical Center; Philadelphia Pennsylvania
| | | | - Joseph Bavaria
- University of Pennsylvania Medical Center; Philadelphia Pennsylvania
| | - Wilson Y. Szeto
- University of Pennsylvania Medical Center; Philadelphia Pennsylvania
| | - Rita Milewski
- University of Pennsylvania Medical Center; Philadelphia Pennsylvania
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22
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Castaño M, Gualis J, Martínez-Comendador JM, Martín E, Maiorano P, Castillo L. Emergent aortic surgery in octogenarians: is the advanced age a contraindication? J Thorac Dis 2017; 9:S498-S507. [PMID: 28616346 DOI: 10.21037/jtd.2017.04.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.
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Affiliation(s)
- Mario Castaño
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Javier Gualis
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | | | - Elio Martín
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Pasquale Maiorano
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Laura Castillo
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
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23
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Evangelista A, Rabasa JM, Mosquera VX, Barros A, Fernández-Tarrio R, Calvo-Iglesias F, Ferrera C, Rozado J, López-Ayerbe J, Garrote C, San román JA, Nistal F, Sanchez V, García Robles JA, Valera F, Ballester C, Gil-Albarova O, Domínguez F, Vivancos R, Mateo-Martinez A, Gallego P, González-Molina M, Fernández-Golfin C, Josa M, Hurlé A, Rodríguez-Sanchez I, Rodríguez-Palomares J. Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II). EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 7:602-608. [DOI: 10.1177/2048872616682343] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. Methods: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22–92), 443 type A (70.4%) and 186 type B (29.6%). Results: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th–75th percentiles, 2.7–15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1–3, 2.5–11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. Conclusion: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.
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Affiliation(s)
| | | | | | | | | | | | | | - Jose Rozado
- Hospital Universitario de Asturias, Oviedo, Spain
| | | | | | | | - Francisco Nistal
- Hospital de Valdecilla, Universidad de Cantabria, Santander, Spain
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24
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Zierer A, El-Sayed Ahmad A, Papadopoulos N, Detho F, Risteski P, Moritz A, Diegeler A, Urbanski PP. Fifteen years of surgery for acute type A aortic dissection in moderate-to-mild systemic hypothermia†. Eur J Cardiothorac Surg 2016; 51:97-103. [DOI: 10.1093/ejcts/ezw289] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 05/27/2016] [Accepted: 06/01/2016] [Indexed: 11/14/2022] Open
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25
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Preventza O, Coselli JS. Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience. Ann Cardiothorac Surg 2016; 5:352-9. [PMID: 27563548 DOI: 10.21037/acs.2016.07.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection is a deadly disease with significant morbidity and mortality. We describe the differential aspects of the disease and the North American experience with its treatment.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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26
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Berretta P, Patel HJ, Gleason TG, Sundt TM, Myrmel T, Desai N, Korach A, Panza A, Bavaria J, Khoynezhad A, Woznicki E, Montgomery D, Isselbacher EM, Di Bartolomeo R, Fattori R, Nienaber CA, Eagle KA, Trimarchi S, Di Eusanio M. IRAD experience on surgical type A acute dissection patients: results and predictors of mortality. Ann Cardiothorac Surg 2016; 5:346-51. [PMID: 27563547 DOI: 10.21037/acs.2016.05.10] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Type A acute aortic dissection (TAAD) is a disease that has a catastrophic impact on a patient's life and emergent surgery represents a key goal of early treatment. Despite continuous improvements in imaging techniques, medical therapy and surgical management, early mortality in patients undergoing TAAD repair still remains high, ranging from 17% to 26%. In this setting, the International Registry of Acute Aortic Dissection (IRAD), the largest worldwide registry for acute aortic dissection, was established to assess clinical characteristics, management and outcomes of TAAD patients. The present review aimed to evaluate and comment on outcomes of TAAD surgery as reported from IRAD series.
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Affiliation(s)
- Paolo Berretta
- Division of Cardiac Surgery, G. Mazzini Hospital, Teramo, Italy
| | - Himanshu J Patel
- Cardiac Surgery, University of Michigan Health System, Ann Arbor, USA
| | - Thomas G Gleason
- Division of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Thoralf M Sundt
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, USA
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, Tromsø University Hospital, Tromsø, Norway
| | - Nimesh Desai
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Antonello Panza
- Department of Cardiology and Cardiac Surgery, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Joe Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Ali Khoynezhad
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Elise Woznicki
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, USA
| | - Dan Montgomery
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, USA
| | | | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Rossella Fattori
- Interventional Cardiology Unit, San Salvatore Hospital, Pesaro, Italy
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, London, UK
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato, Italy
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27
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Deplano V, Boufi M, Boiron O, Guivier-Curien C, Alimi Y, Bertrand E. Biaxial tensile tests of the porcine ascending aorta. J Biomech 2016; 49:2031-2037. [DOI: 10.1016/j.jbiomech.2016.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/25/2016] [Accepted: 05/02/2016] [Indexed: 11/26/2022]
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28
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Yu PJ, Cassiere HA, Kohn N, Dellis SL, Manetta F, Esposito RA, Hartman AR. Utility of Established Risk Models to Predict Surgical Mortality in Acute Type-A Aortic Dissection. J Cardiothorac Vasc Anesth 2016; 30:39-43. [DOI: 10.1053/j.jvca.2015.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Indexed: 11/11/2022]
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29
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Tochii M, Takami Y, Hattori K, Ishikawa H, Ishida M, Higuchi Y, Takagi Y. Early and Late Outcomes of Surgical Repair for Stanford A Acute Aortic Dissection in Octogenarians. Circ J 2016; 80:2468-2472. [DOI: 10.1253/circj.cj-16-0918] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masato Tochii
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Koji Hattori
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Michiko Ishida
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yoshiro Higuchi
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University
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30
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Ascending aortic replacement for acute type A aortic dissection in octogenarians. Gen Thorac Cardiovasc Surg 2015; 64:138-43. [DOI: 10.1007/s11748-015-0613-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022]
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31
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El-Sayed Ahmad A, Papadopoulos N, Detho F, Srndic E, Risteski P, Moritz A, Zierer A. Surgical Repair for Acute Type A Aortic Dissection in Octogenarians. Ann Thorac Surg 2015; 99:547-51. [DOI: 10.1016/j.athoracsur.2014.08.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/28/2014] [Accepted: 08/06/2014] [Indexed: 11/28/2022]
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32
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Imasaka KI, Tayama E, Tomita Y. Preoperative renal function and surgical outcomes in patients with acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2014; 20:470-6. [DOI: 10.1093/icvts/ivu430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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33
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Göbölös L, Ugocsai P, Foltan M, Philipp A, Thrum A, Miskolczi S, Malvindi PG, di Gregorio V, Pousios D, Navaratnarajah M, Ohri SK. Central cannulation by Seldinger technique: a reliable method in ascending aorta and aortic arch replacement. Med Sci Monit 2014; 20:2386-93. [PMID: 25416498 PMCID: PMC4251545 DOI: 10.12659/msm.890813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery. Material/Methods Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch. Results There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6–33.3) min vs. 43±22 (28.0–78.0) min (p=0.058) and 32±8 (23.6–40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels. Conclusions Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.
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Affiliation(s)
- Laszlo Göbölös
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Peter Ugocsai
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Andrea Thrum
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Szabolcs Miskolczi
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Pietro G Malvindi
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Vincenzo di Gregorio
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Dimitrios Pousios
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Manoraj Navaratnarajah
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Sunil K Ohri
- Department of Cardiothoracic Surgery, University Hospital Southampton NHS Trust, Southampton, United Kingdom
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34
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Tokuda Y, Miyata H, Motomura N, Oshima H, Usui A, Takamoto S. Brain Protection During Ascending Aortic Repair for Stanford Type A Acute Aortic Dissection Surgery. Circ J 2014; 78:2431-8. [DOI: 10.1253/circj.cj-14-0565] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | | | | | - Hideki Oshima
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
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35
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The Role of Age in Complicated Acute Type B Aortic Dissection. Ann Thorac Surg 2013; 96:2129-34. [DOI: 10.1016/j.athoracsur.2013.06.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 06/09/2013] [Accepted: 06/14/2013] [Indexed: 11/21/2022]
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36
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Olsson C, Franco-Cereceda A. Impact of organ failure and major complications on outcome in acute Type A aortic dissection. SCAND CARDIOVASC J 2013; 47:352-8. [PMID: 24131200 DOI: 10.3109/14017431.2013.845307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Organ failure and major complications after operations for acute Type A aortic dissection impair outcomes. The objective was to analyze the prevalence of organ failure and major complications, their interrelationship and predictors, and their impact on early and late survival. DESIGN All operative survivors 1990-2009 (n = 335) were retrospectively reviewed. Predictors of organ failure and major complications (bleeding, infection, renal or respiratory failure, neurological dysfunction, and multisystem organ failure) and their influence on in-hospital and long-term mortality were analyzed with multivariable statistical methods. RESULTS Major complication(s) occurred in 153 patients (46%), most frequently bleeding and permanent neurological dysfunction (19% each). Increasing organ system failure index increased in-hospital mortality markedly: zero (2.9%), one (14%), two (33%), three or more (43%), p = 0.002. Reoperation for bleeding (odds ratio [95% confidence interval]) 2.6 [1.1-6.3], multisystem organ failure 4.3 [1.4-13], and permanent neurological dysfunction 14 [6.2-32] were related to in-hospital mortality. The latter two and respiratory failure also entailed increased long-term mortality. CONCLUSIONS Organ failure and major complications were common and impacted negatively on both in-hospital and long-term survival. Strategies to avoid or treat organ failure and major complications should improve early and late survival after surgery for acute Type A aortic dissection.
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Affiliation(s)
- Christian Olsson
- Department of Molecular Medicine and Surgery, Cardiovascular Surgery Unit, The Karolinska Institute and Karolinska University Hospital , Stockholm , Sweden
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37
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Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection. J Thorac Cardiovasc Surg 2013; 146:647-55.e1. [DOI: 10.1016/j.jtcvs.2012.07.072] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/17/2012] [Accepted: 07/26/2012] [Indexed: 11/18/2022]
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38
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Grabenwoger M, Weiss G. Type A aortic dissection: the extent of surgical intervention. Ann Cardiothorac Surg 2013; 2:212-5. [PMID: 23977585 DOI: 10.3978/j.issn.2225-319x.2013.02.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 02/19/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Martin Grabenwoger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
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39
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Easo J, Weigang E, Hölzl PPF, Horst M, Hoffmann I, Blettner M, Dapunt OE. Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection - analysis of the German Registry for Acute Aortic Dissection type A (GERAADA). Ann Cardiothorac Surg 2013; 2:175-80. [PMID: 23977579 DOI: 10.3978/j.issn.2225-319x.2013.01.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 01/14/2013] [Indexed: 12/28/2022]
Affiliation(s)
- Jerry Easo
- Department of Cardiothoracic and Vascular Surgery, Klinikum Oldenburg, Germany
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40
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Unosawa S, Hata M, Niino T, Shimura K, Shiono M. Prognosis of patients undergoing emergency surgery for type A acute aortic dissection without exclusion of the intimal tear. J Thorac Cardiovasc Surg 2013; 146:67-71. [DOI: 10.1016/j.jtcvs.2012.05.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/18/2012] [Accepted: 05/17/2012] [Indexed: 11/29/2022]
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41
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Lee SJ, Kim JH, Na CY, Oh SS, Kim YM, Lee CK, Lim DS. Eleven years of experience with the neurologic complications in Korean patients with acute aortic dissection: a retrospective study. BMC Neurol 2013; 13:46. [PMID: 23692963 PMCID: PMC3664074 DOI: 10.1186/1471-2377-13-46] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 05/16/2013] [Indexed: 11/16/2022] Open
Abstract
Background This study attempts to explore the clinical features, possible mechanisms and prognosis of the neurologic complications in patients with acute aortic dissection (AD). Methods Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT findings, neurologic complications and outcome. Neurologic complications were classified into early-onset or delayed-onset complications. Independent t-test or Chi-square test (or Fisher exact test) was used for comparing the different groups. Multivariable logistic regression analysis was performed to determine the independent association between variables. Results The mean age of the included patients (145 male and 133 female) was 59.4 years (range 19–91 years). 41 patients (14.7%) had a neurologic complication, which included 21 with early-onset complication and 23 with delayed-onset complication, including 3 with both. Advanced age and classic type of dissection were independently associated with the neurologic complication in patients with type A dissection. The most frequent manifestation was ischemic stroke (26 patients, 9.4%), followed by hypoxic encephalopathy (9, 3.2%), ischemic neuropathy (5, 1.8%), spinal cord ischemia (5, 1.8%), seizure (2, 0.7%), hoarseness (1, 0.4%) and septic encephalopathy (1, 0.4%). Overall in-hospital mortality was 10.1%, whereas the complicated group had a mortality rate of 43.9%. Renal impairment, pulse deficit, neurologic complication and nonsurgical treatment were independent variables for determining in-hospital mortality in patients with type A dissection. Conclusions The dominance of neurologic symptom in the early stage of AD may make its early diagnosis difficult. Besides chest pain and widened mediastinum in chest x-ray, variable neurologic symptoms including left hemiparesis with asymmetric pulse and hypotension may suggest underlying AD.
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42
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Management of acute Type A aortic dissection. Med J Armed Forces India 2013; 70:73-5. [PMID: 24623952 DOI: 10.1016/j.mjafi.2013.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/06/2013] [Indexed: 11/20/2022] Open
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43
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Krüger T, Conzelmann LO, Bonser RS, Borger MA, Czerny M, Wildhirt S, Carrel T, Mohr FW, Schlensak C, Weigang E. Acute aortic dissection type A. Br J Surg 2012; 99:1331-44. [DOI: 10.1002/bjs.8840] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges.
Methods
Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described.
Results
Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options.
Conclusion
AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.
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Affiliation(s)
- T Krüger
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - L O Conzelmann
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
| | - R S Bonser
- Department of Cardiac Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust and University of Birmingham, Birmingham, UK
| | - M A Borger
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - M Czerny
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - S Wildhirt
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - T Carrel
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland
| | - F W Mohr
- Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany
| | - C Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - E Weigang
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of Johannes Gutenberg University Mainz, Mainz, Germany
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Recommendations for haemodynamic and neurological monitoring in repair of acute type a aortic dissection. Anesthesiol Res Pract 2011; 2011:949034. [PMID: 21776255 PMCID: PMC3137975 DOI: 10.1155/2011/949034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 03/16/2011] [Accepted: 06/07/2011] [Indexed: 11/18/2022] Open
Abstract
During treatment of acute type A aortic dissection there is potential for both pre- and intra-operative malperfusion. There are a number of monitoring strategies that may allow for earlier detection of potentially catastrophic malperfusion (particularly cerebral malperfusion) phenomena available for the anaesthetist and surgeon. This review article sets out to discuss the benefits of the current standard monitoring techniques available as well as desirable/experimental techniques which may serve as adjuncts in the monitoring of these complex patients.
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In-hospital mortality and three-year survival after repaired acute type A aortic dissection. Neth Heart J 2011; 17:226-31. [PMID: 19789684 DOI: 10.1007/bf03086252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background. The results of acute type A dissection (AAD) surgery in the Netherlands are largely unknown, as was recently stated in a report by the Health Council of the Netherlands. In order to gain more insight into the Dutch situation we investigated predictors of in-hospital mortality of surgically treated AAD patients and assessed threeyear survival.Methods. 104 consecutive patients undergoing surgery for AAD in a 16-year period (1990-2006) were evaluated. Preoperative and intraoperative variables were analysed to identify predictors of early mortality.Results. Preoperative malperfusion (limb ischaemia or mesenteric ischaemia) was present in 15.4%, shock in 18.3%, and 6.7% were operated under cardiac massage. Marfan syndrome was present in four patients and four patients had a bicuspid aortic valve. In-hospital mortality was 22.1%. Seven patients died intraoperatively; other causes of inhospital mortality were major brain damage in ten patients, multiple organ failure in three patients, low cardiac output in two patients and sudden cardiac death in one patient. Multivariate logistic regression revealed preoperative malperfusion (p=0.004) to be the only independent predictor of in-hospital mortality. Three-year survival was 68.8+/-4.7% (including hospital mortality). Hospital survivors had a three-year survival of 88.3+/-3.9%.Conclusion. In-hospital mortality of our patients (22.1%) is comparable with the results of larger case series published in the literature. Prognosis after successful surgical treatment is relatively good with a three-year survival of 88.3% in our series. (Neth Heart J 2009;17:226-31.).
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The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition. Eur J Cardiothorac Surg 2011; 40:1078-84. [DOI: 10.1016/j.ejcts.2011.03.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Revised: 03/03/2011] [Accepted: 03/07/2011] [Indexed: 11/23/2022] Open
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Kaul P. Spontaneous retrograde dissection of ascending aorta from descending thoracic aorta - a case review. Perfusion 2011; 26:215-22. [DOI: 10.1177/0267659110395804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A 56-year-old man with sudden onset chest pain, absent right lower limb pulses and ECG changes suggestive of inferior ST elevation MI underwent coronary angiogram through the right radial artery with a view to primary percutaneous coronary intervention (PCI). The left coronary angiogram demonstrated severe proximal stenotic disease in the left anterior descending and circumflex coronary arteries, but the right coronary artery could not be selectively cannulated. An ascending aortogram to visualise the right coronary artery not only failed to demonstrate it, but revealed, instead, a dissection flap in the ascending aorta, arch and descending thoracic aorta, with moderately severe aortic regurgitation. At operation, the patient was found to have an acute dissection of the ascending aorta, arch and descending aorta with an entry tear in the descending aorta below the left subclavian artery origin. Triple coronary artery bypass grafting with re-suspension of the aortic valve, supracoronary replacement of the ascending aorta and hemiarch and transaortic repair of the descending aortic tear was performed. The patient made an uncomplicated recovery, with the re-appearance of right limb pulses. A postoperative magnetic resonance (MR) scan revealed complete thrombosis of the false channel in the residual arch and a considerably shrunken false channel in the descending aorta and no aortic regurgitation. Retrograde dissection of the ascending aorta from the descending aorta has been reported infrequently in the past. We believe the scale of the problem has been underestimated because of the failure to adopt open distal anastomosis routinely in the past and, hence, failure to inspect the arch and the descending aorta routinely, particularly when the intimal tear was not identified in the ascending aorta. Retrograde dissection of the ascending aorta from an intimal tear in the descending aorta, when identified as such, has been managed, either on the principle of exclusion of the tear in the descending aorta by various elephant trunk procedures and their variants or, alternatively, on the principle of excision of the tear by extended one-stage aortic replacement, usually combined with an elephant trunk procedure. Neither of these procedures is widely adopted, owing to procedural, institutional and outcome considerations. We describe a transaortic repair of the intimal tear in the descending aorta with supracoronary interposition graft replacement of the ascending aorta and hemiarch with excellent clinical and radiological result. We also review the diagnostic and therapeutic approaches to this incompletely understood lethal disease.
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Affiliation(s)
- Pankaj Kaul
- Department of Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, UK,
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Montalvo J, Razzouk A, Wang N, Bansal R, Rasi A, Hasaniya N, Floridia R, Bailey L. Aortic Root Surgery Does Not Increase the Operative Risk of Acute Type A Aortic Dissection. Am Surg 2011. [DOI: 10.1177/000313481107700128] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 ( P = NS). By multivariate analysis, preoperative shock ( P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias ( P = 0.002, OR = 4.62), and packed red blood cell transfusion ( P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.
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Affiliation(s)
- Jose Montalvo
- Loma Linda University Medical Center, Loma Linda, California
| | - Anees Razzouk
- Loma Linda University Medical Center, Loma Linda, California
| | - Nan Wang
- Loma Linda University Medical Center, Loma Linda, California
| | - Ramesh Bansal
- Loma Linda University Medical Center, Loma Linda, California
| | - Alfredo Rasi
- Loma Linda University Medical Center, Loma Linda, California
| | - Nahidh Hasaniya
- Loma Linda University Medical Center, Loma Linda, California
| | | | - Leonard Bailey
- Loma Linda University Medical Center, Loma Linda, California
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Abstract
Acute aortic dissection remains the most common of all aortic catastrophes and is associated with significant morbidity and mortality. Urgent surgical intervention should be considered in all patients with acute type A aortic dissection. Immediate repair is performed for those who are hypotensive due to rupture and tamponade and who exhibit malperfusion of the coronary, cerebrovascular, visceral, or peripheral arterial systems. Selective delayed management with eventual repair may be assumed in patients with type A intramural hematoma and in those with coma (potential neurologic devastation), assuming that neurologic status improves. Urgent repair should not be precluded in patients presenting with active stroke, older age, and previous cardiac surgery. Ultimately, each patient should be individualized and the decision to intervene left to the surgeon.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School, Memorial Hermann Heart and Vascular Institute, 6400 Fannin Street Suite 2850, Houston, TX 77030, USA.
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