Aortic Dissection Repair Research Articles

Initial Study of the Extended STABILISE Technique for Complete Remodeling in Aortic Dissection

Thoracic endovascular aortic repair (TEVAR) is the standard treatment for acute complicated type B aortic dissection (TBAD). However, long-term results reveal that TEVAR does not achieve a complete aortic remodeling and poses a risk of aneurysmal aortic degeneration. Distal re-entry treatment at the abdominal level seems to be necessary to obtain a complete remodeling in TBAD. Moreover, it is necessary to treat the aortoiliac bifurcation in patients with persistent true lumen collapse or limb ischemia. Between January 2018 and October 2019, 11 patients with acute or sub-acute complicated TBAD or non-A non-B aortic dissection were treated in our institution in an endovascular fashion. We performed the stent-assisted, balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique in all cases, but 2 cases required complementary treatment of the aortoiliac bifurcation with a bifurcated AFX endograft system for limb ischemia due to true lumen collapse. Technical success was obtained in all patients. No procedural complications occurred. No postoperative deaths, stroke, paraplegia, mesenteric, or renal ischemia were observed, and no secondary intervention was necessary. Satisfactory aortic re-modeling was obtained after the follow-up periods with a 57.5% mean true lumen expansion. Our initial experience using the extended STABILISE (e-STABILISE) technique using a bifurcated AFX endograft did not result in any postoperative mortality or complications. Without additional data, this technique should be reserved for specific patients who require revascularization of the aortoiliac bifurcation.

Perioperative Outcomes of Acute Type-A Aortic Dissection Repair was Unaffected by COVID-19 Testing Delay

Background:This study assesses impact of COVID-19 testing delay on perioperative outcomes of Acute Type A Aortic Dissection (ATAAD) repair at a single institution.Methods:From January 2010 – May 2021, 539 ATAAD patients underwent open aortic repair at our institution. Sixty-five of these patients had open aortic repair during COVID (March 2020 – May 2021) and 474 patients were pre-COVID (January 2010 – February 2020).Results:Compared to the pre-COVID group, patients During-COVID had a higher proportion of previous myocardial ischemia [9/65 (14%) vs 28/474 (5.9%), p=0.03], chronic obstructive pulmonary disease [14/65 (22%) vs 55/474 (12%), p=0.02], and renal malperfusion syndrome [11/65 (17%) vs 30/474 (6.4%), p=0.01]. There was no significant difference in surgical outcomes between groups, including operative mortality (7.6% vs 9.2%, p=0.64). The median admission-to-Operating Room (OR) time was 107 minutes in the During-COVID group compared to 87 minutes in pre-COVID group, p=0.88. During COVID, the median admission-to-OR time was significantly longer in the Waiting group compared to the No-waiting group (209 min vs 75min, p=0.0009). Only one patient had positive COVID test. There were no aortic ruptures while awaiting COVID testing results. There was a total of 6 reported deaths in the During-COVID group: 1 patient died post-surgery due to ARDS caused by COVID, and others due to ischemic stroke (3 patients) and organ failure (2 patients).Conclusions:Perioperative outcomes of ATAAD patients were similar during-COVID compared to pre-COVID. Waiting for COVID testing results did not significantly affect the perioperative outcomes among ATAAD patients after repair.

Thromboembolic events from the intraoperative use of topical gelatin and albumin-glutaraldehyde haemostatic agents

BackgroundAn under-recognised complication of gelatin-based [GBA] and albumin-glutaraldehyde-based haemostat agents [AGA] is their potential to embolise. This review aims to collate and analyse cases reported in the literature of perioperative thromboembolic phenomena secondary to locally applied GBA and AGA agents. Methods An electronic search was performed on databases Embase, Ovid Medline, Proquest, Scopus and Pubmed. 8875 articles were reviewed from title and abstract. After exclusion criteria and duplicates were removed, 13 articles with 18 cases were included for analysis. Data extracted from each of the articles included patient demographics, surgery type, the haemostatic agent used, clinical features, radiology and pathological findings, and associated morbidity and mortality. ResultsThromboembolic events reported included fourteen secondaries to GBA and four from AGA. Cases included twelve pulmonary emboli, three peripheral emboli, two cerebral emboli and one coronary embolus. Embolic phenomena were most common following spinal orthopaedic surgery in GBA patients [43%], and Type A Aortic dissection repair in AGA patients [100%]. The application of 10ml or more of GBA was frequently reported in cases [64%]. Six cases were fatal. The time course of each event ranged from occurring intraoperatively to 45 days post-operation. ConclusionGBA and AGA agents are associated with venous and arterial embolisation and high overall mortality. GBA application over an unclear bleeding site poses a risk of arterial embolisation. Surgical fields should be dried before the application of AGA. Quantities of GBA > 10mL were frequently reported. GBA and AGA embolisation can occur anywhere from immediate to 45 days postoperatively.

Surgical outcomes of acute type A aortic dissection in dialysis patients: lessons learned from a single-center\u2019s experience

There is a paucity of data describing the safety and efficacy of acute type A aortic dissection (ATAAD) repair surgeries in dialysis patients. Our study aimed to investigated the influence of dialysis on early and late outcomes in end-stage renal disease (ESRD) patients who received repair surgery for ATAAD. A total of 882 ATAAD patients who received emergency aortic dissection repair at our center from January 2015 to December 2019 were retrospectively screened in this study and divided into the dialysis group (n = 16) and the non-dialysis group (n = 866), depending on whether they required dialysis for preoperative ESRD. No significant difference of age, preoperative hemodynamics, organ ischemia conditions, operative variables as well as the 30-Day mortality and in-hospital complications was discovered between two groups. However, the survival rates and the proportion of late aortic event (sudden death and reoperation) free population at 1 and 3 years after surgery were significantly decreased in dialysis patients compared to non-dialysis patients. Our study indicated that the short-term surgical outcomes of ATAAD in dialysis patients were comparable to non-dialysis patient. However, the dialysis patients were associated with a worse long-term prognosis.

Impact of after-hours surgery on outcomes of acute type A aortic dissection repair.

To establish whether emergency surgery performed outside working hours (after hours) contributed to adverse outcomes for patients with acute type A aortic dissection (ATAAD). We reviewed the operation records of ATAAD repair in our institution from 2004 to 2019 (n = 187). Emergency surgery was performed by one of a few teams of experienced surgeons, regardless of the time of day. Patients were divided into two groups based on the surgery start time: during working hours (n = 65) and after hours (n = 122). A propensity score-matched analysis was performed for 58 pairs of patients. The overall in-hospital mortality was 6.9% for the working-hours group and 13.8% for the after-hours group. There were no significant differences between the groups in the relatively limited study population (n = 187). Surgeon experience and aortic interventions did not differ remarkably between the groups. After-hours repair was not associated with postoperative complications. There were no significant differences in the long-term survival or aortic event-free rates between the groups. After-hours surgery did not affect the short- or long-term outcomes of ATAAD repair under our backup system, which supports the recommendation of immediate surgical repair. Efforts to minimize the discrepancies between working hours and after hours could help to improve the surgical outcomes of patients undergoing ATAAD repair.

Determinant of outcome in late presenting type A aortic dissection

Early repair is recommended in type A aortic dissection repair, however, this is not often possible. The aim of this study was to assess the time delays, examine the effect of timing and malperfusion on outcomes, and identify other independent risk factors for mortality. This was a retrospective study on data collected prospectively. Primary outcome was 30-day mortality. Secondary outcome was adverse postoperative outcomes. All patients who arrived at the hospital with a type A aortic dissection, irrespective of the timing, were included in the study. Univariate as well as multivariate analysis was carried out. A total of 81 patients presented to our institution during the study period. Half the patients got operated within 86 h of symptom onset and 75% were operated within 183 h. With regards to malperfusion, 6 (8.8%) patients had cerebral malperfusion, 10 (14.7%) had features of myocardial ischemia, and 13 (19.1%) had renal malperfusion. One (1.5%) patient had mesenteric ischemia and 9 (13.2%) had limb ischemia. The duration between symptom onset and operative repair was longer in survivors (152 ± 167 vs. 75 ± 102, p = .29). A total of 29 (42.6%) patients presented with features of one or more organ malperfusion and the mortality in these patients was significantly higher at 10 (34.5%) versus 5 (12.5%); p = .04. Multivariable logistic regression identified CPB time as an independent risk factor in our cohort for 30-day mortality (odds ratio: 1.03; 95% confidence interval: 1.007-1.06). In cases of predominantly delayed presentation and operative repair, the outcome is significantly influenced by presence of malperfusion. Surgical repair still produces satisfactory outcomes and should be undertaken at the earliest in most cases.

Comparative review of large animal models for suitability of proximal aortic endovascular repair

Background
 The advent of TEVAR heralds a paradigm shift in treating descending aortopathies and is viewed as a potential option for ascending aortic dissection (AD) repair too. Currently, TEVAR’s usage for ascending aortopathies remains limited. Consequently, an urgent requirement exists to choose appropriate animal models to better contemporary understanding of endovascularly treating Type-A ADs.
 This review article provides a summary of current literature on this topic. Two broad sections are covered, including the macroscopic differences between adult swine, ovine and porcine species versus that of their human counterparts, as well as the valvular, aortic and coronary vasculature variances.
 
 Methods 
 A narrative review was conducted to integrate current findings of anatomical differences in valvular and ascending aortic anatomy amongst the aforementioned species. An electronic search of PubMed and Ovid Medline databases from January 1965 to June 2020 was performed, limited to articles published in English. 
 
 Results
 Whilst macroscopic anatomy remains grossly similar, differences in valvular leaflet shape are present, with swine and porcine models possessing anatomic characteristics that are comparable to their human counterparts. Research into inter-species ascending aortic anatomy has not been extensively performed, highlighting a literature gap. Conversely, multiple morphological studies have highlighted that swine coronary vasculature is closely resemblant to that of man.
 
 Conclusion
 Both swine and ovine species are suitable as appropriate animal models in examining the feasibility of endovascular stent-grafts for ascending ADs. However, given the similarities in coronary and aortic valve anatomy to their human analogues, porcine models are better suited for this purpose.

Institutional practice in sizing of the hybrid prosthesis in frozen elephant trunk surgery.

The frozen elephant trunk (FET) technique for total arch replacement (TAR) is widely used for repair of aortic arch dissections and aneurysms. Despite its widespread adoption, there are no international or regional guidelines for the sizing of FET prostheses in TAR. We seek to highlight the heterogeneity thereof and pave the way for evidence-based guidelines to advise FET prosthesis sizing in TAR. An online questionnaire was sent to 22 specialist aortic surgeons from 13 different countries across North America, Europe, Asia, and Australia, inquiring about each surgeon's approach to FET prosthesis sizing. The results were then pooled for frequency analysis. All 22 surgeons responded to the questionnaire. Zone 2 is preferred implantation zone for AAD, CAD, and TAA (selected by 72.7%, 72.7%, and 68.2% respectively). The maximal diameter of the true lumen in the DTA is the most common index measurement for AAD and CAD (40.9% and 59.1%, respectively). Stent-graft diameters equal to the index measurement is the most common approach for AAD and CAD (77.3% and 45.5%, respectively) while 59.1% of surgeons oversize the index diameter by 10% for TAA; 100 mm is the preferred length for 50.0%, 27.3%, and 40.9% of surgeons in AAD, CAD, and TAA respectively. There is considerable heterogeneity in sizing practices for FET prostheses internationally, with variable evidence for its impact on clinical outcomes. This issue would be aided by the development of evidence-based guidelines to inform clinical decision making.

Safety Time and Optimal Temperature of Unilateral Antegrade Cerebral Perfusion in Acute Type A Aortic Dissection: A Single-Center 15-Year Experience.

The optimal level of hypothermia and safe time of unilateral antegrade cerebral perfusion (uACP) in acute type A aortic dissection (ATAAD) repair remain controversial. To analyze the association of uACP time and circulatory arrest temperature with surgical outcomes of ATAAD. We retrospectively analyzed 263 patients who had undergone ATAAD repair between 2006 and 2020 using uACP. The patients were stratified by three chronologically equivalent periods (period 1, 2006 to 2010; period 2, 2011 to 2015; period 3, 2016 to 2020) to demonstrate the decade-long evolution of surgical strategy and outcomes. The mean age of the patients was 59.4 ± 12.5 years, and 68.8% were male. The hospital mortality rates were 15.1%, 12.9%, and 11.0% from period 1 to 3 (p = 0.740). The median circulatory arrest temperatures were 20, 23, and 25 °C (p < 0.001), respectively, and the median uACP times were 72, 59, and 41 minutes (p < 0.001). The incidence rates of postoperative permanent neurologic deficits were 13.2%, 10.9%, and 18.3% (p = 0.312), and those of transient neurologic deficits were 9.4%, 10.9%, and 11.9% (p = 0.936), respectively. Multivariate logistic regression analysis showed that uACP time ≥ 60 minutes was an independent predictor of hospital mortality rather than postoperative stroke. ROC curve analysis estimated an optimal cutoff value of 52 minutes of uACP time when the circulatory arrest temperature was ≥ 25 °C to predict hospital mortality (area under the curve: 0.72). Unilateral antegrade cerebral perfusion time was associated with hospital mortality after ATAAD surgery. A safe threshold of 50 to 60 minutes of uACP should be considered.

Comparison of Single Axillary vs. Dual Arterial Cannulation for Acute Type a Aortic Dissection: A Propensity Score Matching Analysis

BackgroundThe optimal arterial cannulation site for acute aortic dissection repair is unclear, especially for complex arch surgery. Axillary artery cannulation is widely accepted but adding femoral artery cannulation to it was considered to potentially improve perfusion and early outcomes. To clarify this point, a comparison of perioperative outcomes for these two different cannulation strategies was conducted regarding the pathological features of dissection.MethodsFrom January 2010 to December 2019, 927 consecutive patients underwent a total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data, including detailed pathological features, were retrospectively collected and analyzed. Propensity score matching and multivariate logistic regression analysis were used for adjusting confounders that are potentially related to the outcome.ResultsA total of 523 patients (56.3%) accepted a dual arterial cannulation (DAC group), and 406 patients (43.7%) received a single axillary artery cannulation (SAC group). In total, 388 pairs of patients were well-matched. Whether before or after adjusting the preoperative characteristics by matching, there were no significant differences in operative mortality (6.7 vs. 5.4%, P = 0.420 before matching; 5.4 vs. 5.4%, P = 1 after matching), stroke (6.7 vs. 5.4%, P = 0.420 before matching; 6.4 vs. 5.2%, P = 0.435 after matching), spinal cord injury (5 vs. 5.7%, P = 0.640 before matching; 5.4 vs. 5.7%, P = 1. After matching), and acute renal failure requiring dialysis (13.8 vs. 9.6%, P =0.050 before matching; 12.6 vs. 9.5%, P = 0.174) between the two groups. Dual arterial cannulation was not an independent protective factor of operative mortality (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.55–1.86), stroke (OR 1.17, 95% CI 0.65–2.11), spinal cord injury (OR 1.17, 95% CI 0.65–2.11), and acute renal failure requiring continuous renal replacement therapy (CRRT) (OR 1.24, 95% CI 0.78–1.97) after adjusting for confounding factors by multivariable logistic regression analysis. In the subgroup analysis, no advantage of dual arterial cannulation was found for a particular population.ConclusionsSingle axillary artery cannulation was competent in the complex arch repair for acute aortic dissection, presenting with a satisfactory result as dual arterial cannulation. Adding femoral artery cannulation was necessary when a sufficient flow volume could not be achieved by axillary artery cannulation or when a lower limb malperfusion existed.

Stent Graft-induced Aortic Wall Injury: Incidence, Risk Factors, and Outcomes

BackgroundStent graft-induced new entry has been described in thoracic endovascular aortic repair for aortic dissection. The incidence of stent graft-induced aortic wall injury (SAWI) related to iatrogenic injury in nondissections is incompletely described. We describe incidence, risk factors, and outcomes of SAWI. MethodsAll post-thoracic endovascular aortic repair computed tomography angiograms (January 2005 to December 2018) were reviewed for radiographic evidence of SAWI. Endograft-induced aortic dissections were likewise considered SAWI. Patient characteristics, time to SAWI, and need for reintervention were noted. Cox proportional hazards modeling was used to identify risk factors for SAWI. ResultsWithin the study cohort (n = 430), 38 patients (9%) had SAWI during a median follow-up of 2.3 years (interquartile range, 4.8); 42% (n = 16) were proximal, 53% (n = 20) distal, and 5% (n = 2) both proximal and distal. Nine (23%) were distal intimal flap injuries in dissection cases, thus subclassifying them as stent graft-induced new entry. Twenty-nine percent of SAWI (n = 11) required reintervention. Of these, 45% (n = 5) were open, and 55% (n = 6) were endovascular. Thoracic endovascular aortic repair for acute dissection had a higher incidence of SAWI development (hazard ratio 4.6; 95% confidence interval, 2.4 to 9; P < .001) as compared with other indications. Use of devices with proximal bare springs or barbs was also associated with increased SAWI incidence (hazard ratio 5.3; 95% confidence interval, 2.6 to 11.0; P < .001). ConclusionsThe rate of SAWI after thoracic endovascular aortic repair is low (9%), but nearly one third will require reintervention. Thoracic endovascular aortic repair in the setting of acute dissection and use of devices with proximal bare springs or barbs were associated with an increased incidence of SAWI.

Does systemic immune-inflammation index predict the short outcomes after an acute type A aortic dissection repair? Promising biomarker for acute aortic syndrome.

The retrospectively presented by Xu et al. assessed the value of the systemic immune-inflammation index (SII) in the prediction of short-term outcomes in patients undergoing surgery for acute type A aortic dissection (ATAAD). The authors concluded that SII is a reliable biomarker that can predict postoperative short-term outcomes and this marker could be potentially applied to stratification and patient selection with ATAAD. Although the study is retrospective, it is well-matched and conducted in a large volume center and the surgical technique was standard for all procedures. In addition, there was no statistical difference in cardiopulmonary bypass, aortic cross-clamp and deep hypothermic time, comorbidities, blood and blood products transfusion between the study groups. In addition, 90.7% of patients underwent elephant trunk technique for ATAAD repair, while the 30-day mortality and postoperative temporary and permanent neurological dysfunctions were 14.8% and 11.1%, respectively. Randomized controlled and prospective studies are warranted to clarify these well-documented results to apply this useful biomarker in clinical practice for patients with the acute aortic syndrome.

Prediction of aortic dilatation in surgically repaired type A dissection: A longitudinal study using computational fluid dynamics

ObjectiveTo examine the role of a key hemodynamic parameter, namely the true and false lumen pressure difference, to predict progressive aortic dilatation following type A aortic dissection (TAAD) repair. MethodsFour patients with surgically repaired TAAD with multiple follow-up computed tomography angiography scans (4-5 scans per patient; N = 18) were included. Through-plane diameter of the residual native thoracic aorta was measured in various aortic segments during the follow up period (mean follow-up: 49.6 ± 31.2 months). Computational flow analysis was performed to estimate true and false lumen pressure difference at the same locations and the correlation with aortic size change was studied using a linear mixed effects model. ResultsGreater pressure difference between the true and false lumen was consistent with greater aortic diameter expansion during the follow up period (linear mixed effects analysis; coefficient, 0.26; 95% confidence interval, 0.15-0.37; P < .001). Based on our limited data points, a pressure difference higher than 5 mm Hg might cause unstable aortic growth. ConclusionsComputational fluid dynamic assessment of standard aortic computed tomography angiography offers a noninvasive technique that predicts the risk of aortic dilatation following TAAD. The technique may be used to plan closer observation or intervention in high-risk patients.

Transapical cannulation for surgical repair of chronic type B aortic dissection.

Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.

Endovascular Repair In Patients With Heritable Thoracic Aortic Disease

<h3>INTRODUCTION AND OBJECTIVES</h3> In patients with heritable thoracic aortic disease (HTAD), endovascular repair of aortic aneurysm and dissection may be lifesaving but is associated with increased risk of complications. This study reports our experience with endovascular aortic and branch vessel repair in patients with HTAD. <h3>METHODS</h3> A retrospective analysis of patients with HTAD at our institution who underwent endovascular aortic and/or branch vessel repair was performed. <h3>RESULTS</h3> Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent 37 endovascular procedures between 2006-2020. Indications for repair were acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and 8 chronic aneurysms). Six procedures repaired branch vessel aneurysms or dissections. Twenty-five (68%) proximal landing zones were in the native vessel, 11 (30%) were in a surgical graft or elephant trunk and 1 was in an endograft. Outcomes are listed in Table I. Thirty-six (97%) procedures were technically successful and none required surgical conversion. Two patients (7%) died: one from sepsis (33 days post-procedure) and one from presumed pseudoaneurysm rupture (116 days post-procedure). Two procedures were complicated by stroke and one patient developed paraparesis. Six aortic endografts (16%) developed stent-induced new entry tears (SINEs) identified 20 ± 15 days post-procedure. Seven endografts (19%) developed a Type I endoleak and 9 (24%) developed a Type II endoleak. Within 30 days, 2 (5%) endografts required reintervention. After 30 days, 15 additional endografts (41%) required reintervention. <h3>CONCLUSIONS</h3> Endovascular repair in select patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection at relatively low risk. However, risk of endoleaks, SINEs, and reinterventions is high.

Preoperative Spinal Drain Placement Is Associated With Reduced Risk Of Spinal Cord Ischemia In Patients Undergoing Thoracic Endovascular Aortic Repair For Aortic Dissection

<h3>INTRODUCTION</h3> Spinal cord ischemia (SCI) is a rare but serious complication of TEVAR. A number of measures including spinal drain (SD) placement have been proposed to reduce the risk of SCI in TEVARs performed for aneurysms. However, there is no specific data on potential benefits of SD placement in aortic dissection (AD). We aimed to assess the impact of preoperative SD placement on preventing SCI during TEVARs performed for AD. <h3>Methods</h3> We included all TEVAR cases performed for AD in VQI from 2012 to 2021. Patients with connective tissue disease, open conversion, rupture, proximal disease > zone 5, or SCI on presentation were excluded. One-to-one propensity score matching was used to balance patients on 37 dimensions by the nearest neighbor principle to compare patients based on preoperative SD placement. The primary outcome was SCI. Secondary outcomes included 30-day and 90-day mortality, perioperative complications, and 90-day re-intervention. <h3>RESULTS</h3> A total of 2970 TEVARs were performed for AD with 1373 (44.9%) undergoing preoperative SD placement. Propensity matching produced 924 well-matched pairs. In the matched cohort, SD placement was not associated with significant reduction in temporary SCI (2.7 vs. 1.9%, p=0.28). However, SD placement was associated with significant reduction of the risk of permanent SCI at discharge (1.4% vs. 2.7%, p=0.049). SD was also associated with lower risk of 30-day mortality (3.6% vs 6.0%, p=0.016) and longer length of stay but not perioperative complication or 90-day mortality or 90-day re-intervention. <h3>CONCLUSION</h3> Our study suggests that preoperative SD placement in patients undergoing TEVAR for AD is beneficial in reducing the risk of permanent SCI without increasing risks of perioperative complications. Further prospective studies are necessary to confirm these findings.

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

ObjectiveTo evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair.MethodsFrom 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries.ResultsThe aortic cannulation group was younger (59 vs 62 years; P = .02), more likely to be men (76% vs 60%; P = .02), and had more peripheral vascular disease (60% vs 37%; P = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%; P = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes; P = .01), less utilization of antegrade cerebral perfusion (93% vs 98%; P = .04), and received less blood transfusion (0 vs 1 U; P = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%; P = 1.0) and operative mortality (4.2% vs 6.3%; P = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94; P = .91) or operative mortality (odds ratio, 0.70; P = .64). Short-term survival was similar between central and ABV cannulation groups.ConclusionsBoth aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.

Aortic Arch Management During Acute and Subacute Type A Aortic Syndromes

BackgroundThe purpose of this study was to compare the outcomes of no arch intervention, hemiarch replacement, and total arch replacement during type A aortic syndromes in a contemporary series. MethodsFrom 2004 to 2019, 634 patients have required acute type A dissection repair; these patients were divided into three groups based on type of arch intervention performed: no arch (n = 130), hemiarch (n = 397), and total arch (n = 107). The primary endpoint was mortality; a multivariable risk factor analysis was performed. Secondary endpoints were reoperation and early and late complications. ResultsOperative age was 55 ± 14 years for the cohort and was similar between groups (P = .34). The incidence of peripheral artery disease, heart failure, and prior coronary artery bypass graft surgery differed between the groups (P < .05). Median cardiopulmonary bypass time, aortic cross-clamp time, and length of stay were longest for the total arch group (P < .0001). Early mortality was 20%, 10%, and 10% for the no-arch, hemiarch, and total arch groups, respectively (P = .01). Ten-year survival was 54%, 66%, and 65% for the no-arch, hemiarch, and total arch groups, respectively (P = .01). There was no difference in incidence or timing of redo aortic interventions (P > .05). For the entire cohort, risk factors for late mortality included preoperative peripheral artery disease (hazard ratio 2.3; 95% confidence interval, 1.2 to 4.4; P = .009) and preoperative dialysis (hazard ratio 2.8; 95% confidence interval, 1.3 to 6.1; P = .01). ConclusionsDespite longer cardiopulmonary bypass and aortic cross-clamp times, arch intervention was not associated with worse operative or long-term outcome in this series. Patients with peripheral vascular disease and preoperative renal failure remain at highest risk for mortality after type A aortic dissection repair.

Prevention and management of difficult hemostasis in acute type A aortic dissection repair.

Postoperative bleeding after surgery for acute aortic dissection is one of the most common complications and has an important influence on mortality and morbidity. Therefore, various methods have been introduced to prevent or manage postoperative bleeding. In this article, we investigated the causes of bleeding after surgery for acute aortic dissection, and introduce appropriate transfusion or pharmacologic treatment, topical hemostatic agents, and local compressive maneuver to manage it.

Left Subclavian Artery Sacrifice in Acute Aortic Dissection Repair using the Frozen Elephant Trunk.

Surgery of acute aortic dissection using the frozen elephant trunk (FET) can be complicated when the origin of the left subclavian artery (LSA) is dissected and sacrifice by ligation is a viable option. However, the LSA is supposed to play a role in neuroprotection as a major collateral. We, therefore, analyzed our results of LSA sacrifice in this cohort. We identified a total of 84 patients from our prospectively collected database who underwent FET repair of acute aortic dissection between October 2009 and April 2018. LSA was sacrificed in 19 patients (22.6%). Results were analyzed and compared with regard to neurological outcomes. New postoperative stroke was seen in two patients (2.4%) and spinal cord injury in three patients (3.6%) overall, none in the LSA-sacrifice group. We observed a temporary neurological deficit in five patients (6.0%) overall, none in the LSA-sacrifice group. None of the patients developed acute ischemia of the left arm. Only two patients (12.5%) came back for carotid-subclavian artery bypass due to exertion-induced weakness of the left arm 3 to 4 months after the initial surgery. In-hospital mortality was 15.5% overall, with no difference between groups. LSA sacrifice was not associated with elevated postoperative risk of either central or spinal neurological injury. Thus, it can facilitate FET repair of acute aortic dissection in selected cases when the left subclavian origin cannot be preserved. Carotid-subclavian artery bypass became necessary in only a small fraction of these patients and can be performed as a second-stage procedure.