The New Delivery Method for Cardioplegic Solution in Type A Aortic Dissection.

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

To explore the safety and feasibility of endograft repair in refractory aortic dissection and dissecting aneurysm. The clinical data of 13 refractory cases of aortic dissection and dissecting aneurysm, 11 males and 2 females, aged 52 (38-82), out of the 68 consecutive patients with aortic dissection and dissecting aneurysm who underwent endograft repair from Jan 2001 to Oct 2004, were analyzed. Nine of the 13 cases were diagnoses as with aortic dissection and dissecting aneurysm of Stanford type A, 3 of which had tears in the ascending aorta (DeBakey type I), 3 had tears in aortic arch, and 3 had tears on the distal aortic arch with ascending aorta involved; and the other four out of the 13 cases were diagnosed as Stanford type B, one with Marfan's syndrome. Eight of the 13 cases had more than 2 entries, 3 of which had suffered from shock and hemathorax due to rupture preoperatively. Follow-up ranging 2 months to 3 years was carried out after the operation. Transluminal placement of stentgratf was technically successful in all patients. Three patients with DeBakey type I dissections received stent-grafts introduced through the left common carotid or right femoral artery, of which one case died from gastrointestinal hemorrhage 1 month postoperatively. For the patients with tears in aortic arch preliminary Y type bypass from ascending aorta to left common carotid artery and left subclivian artery was performed in 2 cases, and carotid-carotid artery bypass was performed in one case, and then stent-grafts were deployed through right femoral artery. The 3 cases with tears in the distal arch and ruptured aneurysm, received stent-grafts implantation through the femoral artery emergently, and closed thoracic drainage and anti-shock treatment, one of which died from another aneurysm rupture 27 hours postoperatively. Out of the 4 cases with Stanford type B dissection with multiple tear entries, 3 underwent multiple stent-grafts repair and 1 underwent emergent abdominal-bilateral iliac arteries Y-type graft bypass due to rupture of iliac dissecting aneurysm. During the follow-up CT, MRI and color Doppler sonography showed that all 11 patients remained healthy with the former tears well closed and thrombosis in the false lumen. Endograft repair for refractory aortic dissecting aneurysm is feasible and technically successful, especially for the patients with tears in the ascending aorta or aortic arch.

Acute aortic dissection (AD) is the most common life-threatening disorder affecting the aorta. Neurological symptoms are present in 17-40% of cases. The management of these patients is controversial. We presented a 37-year-old man admitted for complaining of left-sided weak-ness. Symptoms appeared two hours before admission. The patient had no headache, neither thoracic pain. Neurological examination showed mild confusion, left-sided hemiplegia, National Institutes of Health Stroke Scale (NIHSS) score was 10. Ischemic stroke was suspected, brain multislice computed tomography (MSCT) and angiography were performed and right intrapetrous internal carotid artery dissection noted. Subsequent color Doppler ultrasound of the carotid arteries showed dissection of the right common carotid artery (CCA). The patient underwent thoracic and abdominal MSCT aortography which showed ascending aortic dissection from the aortic root, propagating in the brachiocephalic artery and the right CCA. Digital subtraction angiography was performed subsequently and two stents were successfully implanted in the brachiocephalic artery and the right CCA prior to cardiac surgery, only 6 hours after admission. The ascending aorta was reconstructed with graft interposition and the aortic valve re-suspended. The patient was hemodynamically stable and with no neurologic deficit after surgery. Unfortinately, at the operative day 6, mediastinitis developed and after intensive treatment the patients died 35 days after admission. In young patients with suspected stroke and oscillatory neurological impairment urgent MSCT angiography of the brain and neck and/or Doppler sonography of the carotid and vertebral artery are mandatory to exclude carotid and aortic dissection. The prompt diagnosis permits urgent carotid stenting and cardiosurgery. To the best of our knowledge, this is the first published case of immediate carotid stenting in acute ischemic stroke after the diagnosis of carotid and aortic dissection and prior to cardiac surgery

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Aortic dissection (AD) is a rare but often lethal condition if not properly and urgently treated. Most often, patients arrive with acute hemodynamic instability and ripping chest agony. The patient'slife depends critically on a correct diagnosis made as soon as possible. We describe a 60-year-old man who arrived at the emergency room with symptoms of a brain stroke, including poor consciousness, left-sided weakness, and speech disturbance associated with hemodynamic instability, and chest pain. Thoracic aortic arch dissection was observed on CT angiography (CTA).In addition, CTA revealed that the dissection extends proximally into the left common carotid artery, left subclavian artery, brachiocephalic trunk, and right common carotid artery and distally to the left common iliac artery, coupled with significant stenosis of the left common iliac artery. Proper management of blood pressure (BP) parameters is life-saving for the patient. Since our hospital did not offer cardiothoracic surgery services, the patient was transferred to a different institution, where he received medical care immediately from an expert team and had surgery.

Commentary: Warm versus cold cardioplegia: The devil is in the details

Traditionally aortic arch anomalies have been viewed as a "normal" and clinically insignificant; therefore, they are often overlooked by radiologists and go unreported. Arch anomalies have been reported to occur in 7% to 15% of patients without thoracic aortic aneurysm or dissection. This study aims to define the incidence of aortic arch anomalies in patients with a thoracic aortic dissection (TAD). We retrospectively reviewed all patients from 2006 to 2010 with a TAD admitted to a single institution. Thoracic computed tomography images of 176 patients with dissected thoracic aortas and 179 consecutive, unselected age-matched patients without dissection as controls were reviewed to determine the incidence of bovine arch and other arch anomalies. Statistical analysis of demographic data and clinical outcomes was performed to evaluate significant differences between the groups. Arch anomalies occurred in 34% of patients with TAD compared to controls (19%, p = 0.0017). The most common variant was a common origin of the innominate and left common carotid arteries ("bovine" arch) found in 31% of dissection patients compared to 15% in the control group (p = 0.0004). Overall arch anomalies occurred in 27% of all Type A dissections and 39% (p = 0.1409) of all Type B dissections. The association was statistically significant in patients ages 50 to 79 with TAD (36.4%, p = 0.0011) and in African Americans collectively (43.2%, p = 0.0033). Aortic arch anomalies occur frequently in patients with TAD and therefore may represent a proclivity for this life threatening condition.

Cardiovascular disease is the leading cause of death in most Western societies and is increasing steadily in many developing countries. Aortic diseases constitute an emerging share of the burden. New diagnostic imaging modalities, longer life expectancy in general, longer exposure to elevated blood pressure, and the proliferation of modern noninvasive imaging modalities have all contributed to the growing awareness of acute and chronic aortic syndromes. Despite recent progress in recognition of both the epidemiological problem and diagnostic and therapeutic advances, the cardiology community and the medical community in general are far from comfortable in understanding the spectrum of aortic syndromes and defining an optimal pathway to manage aortic diseases.1–13 This comprehensive review is organized in two parts, with a focus on the etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II. Both parts may help to better integrate the complexities of acute aortic syndromes.

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Stroke in Patients with Common Carotid Artery Dissection Secondary to Dissecting Aortic Aneurysm: an Observational Vascular Imaging Study

Outcome of Endovascular Treatment of Acute Type B Aortic Dissection

Aim. Assessment of normal and variant aortic arch anatomy in patients with type A aortic dissection and aneurysm of the arch and descending thoracic aorta.Methods. We retrospectively studied computer tomography (CT) data of chest organs with contrast in patients who underwent reconstruction of the aortic arch in type I aortic dissection according to DeBakey classification (n = 61) and resection of the aortic arch and descending thoracic aorta aneurysm (n = 14) at the Meshalkin National Medical Research Center, Novosibirsk, Russian Federation. The control group included patients without aortic arch pathology (n = 52). To identify relationships between the anatomical type of aortic arch and the risk of aortic pathology development, univariate and multivariate binary logistic regression analyses were used.Results. Our analysis revealed four types of aortic arch anatomy. Normal aortic arch anatomy occurred in 66.1 % of patients (n = 84), the proportion of abnormalities of the left common carotid artery was 30 % (bovine aortic arch occurred in 15 %, and the same site of origin of left common carotid artery and brachiocephalic trunk occurred in 15 %). Divergence of the left vertebral artery from the aortic arch between the left common carotid and left subclavian arteries occurred in 3.1 % (n = 4), and the combination of “bovine trunk” and divergence of the left vertebral artery from the aortic arch was detected in 0.8 % patients (n = 1). Logistic regression analyses revealed no statistically significant relationships between variant aortic arch anatomy and the development of type A aortic dissections and aortic arch aneurysms. The presence of the common origin of brachiocephalic trunk and left common carotid artery was associated with a reduced risk of acute aortic dissection type I by 89 %, or an OR of 0.11 (95% CI: 0.03–0.46) (p = 0.002).Conclusion. Our data will help with future planning surgical interventions on the aortic arch and descending thoracic aorta. Received 17 June 2020. Revised 16 July 2020. Accepted 17 July 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: A.A. ShadanovData collection and analysis: A.A. Shadanov, T.A. BergenStatistical analysis: D.A. Sirota, A.A. ShadanovDrafting the article: A.A. ShadanovCritical revision of the article: D.A. Sirota, M.M. Lyashenko, A.M. ChernyavskiyFinal approval of the version to be published: A.A. Shadanov, D.A. Sirota, T.A. Bergen, M.M. Lyashenko, A.M. Chernyavskiy

OBJECTIVE To evaluate the effects of endovascular stent-graft repair for Stanford type A aortic dissection combined with extra-anatomic bypass. To perform endovascular repair for Stanford type A aortic dissection, we tried to extend the landing zone by extra-anatomic bypass to reconstruct the innominate artery, the left common carotid artery or the left subclavian artery, and then achieved the process immediately or at a secondary stage via either the carotid or the femoral approach. Thirty-four patients with ascending aortic dissection (n=8) and aortic arch dissection (n=26) were treated with this technique. Thirty three patients were successfully done aortic endovascular repair, only one died during the operation. The thirty-day mortality rate was 8.8% (3/34), endoleak incidence rate was 11.8% (4/34) and incidence rate of cerebral infarction was 5.9% (2/34). Twenty-nine patients were followed-up for 6-70 months (mean, 24. 5 months). Complete (n=16) and partial (n=13) thrombosis of the false lumen were showed with CT angiography and/or vascular color Doppler ultrasound scanning. Endovascular stent-graft repair combined with extra-anatomic bypass can be a novel option for Stanford type A aortic dissection; it is safe, less invasive, and with fewer complications. Nevertheless, indications need further consideration.

Type B Aortic Dissection Involving an Isolated Right-Sided Aortic Arch

BACKGROUNDCardiac transplantation is considered the standard treatment for refractory end-stage heart failure. Worldwide, 5074 heart transplantations were performed in 2015. About 100 heart transplants are performed at the authors’ center each year. The usual complications of heart transplantation include graft rejection, infection, and graft dysfunction. Aortic dissection after heart transplantation is very rare and is a serious complication that requires a hybrid procedure.CASE SUMMARYA 58-year-old female patient was admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in July 2020 because of unprovoked low back pain without precipitating causes. Magnetic resonance imaging and computed tomography angiography showed type A aortic dissection with an aberrant right subclavian artery. After admission, urapidil was used to control blood pressure. Ten days later, the patient underwent ascending aortic and aortic arch replacement, subclavian artery reconstruction, and endovascular repair of abdominal and thoracic aortic aneurysms. A cardiopulmonary bypass was established through the right femoral artery and femoral vein. The aberrant right subclavian artery, innominate artery, left common carotid artery, and left subclavian artery were blocked, and the left and right common carotid arteries were cannulated for bilateral cerebral perfusion.CONCLUSIONThe right axillary artery could not be selected for cardiopulmonary bypass intubation because of aberrant right subclavian artery.