Level Of Pulmonary Bifurcation Research Articles

Application of Different Types of Hybrid Aortic Arch Repair: Toward to Solve Dissection Involving the Aortic Arch

To investigate the outcomes and effectiveness of different types of hybrid aortic arch repair for aortic dissection involving the aortic arch. From 2013 to 2020, 168 patients underwent hybrid aortic arch repair for dissection involving the aortic arch. We collected data from our electronic medical records, including the presenting pathology, perioperative details, and postoperative outcomes. We included the following types of hybrid aortic arch repair: classic type I, type II, and type III hybrid aortic arch repair, as well as the new type IV hybrid aortic repair. We defined type IV hybrid aortic arch repair as revascularization of supra-aortic branches through extra-anatomy bypass without sternotomy, followed by stent-graft placement. There were 23, 82, and 63 patients who underwent type I, type II, and type IV hybrid aortic arch repair, respectively. There were no type III hybrid aortic repairs performed. Forty-nine cases were performed urgently. The technical success rate was 99.4%. The early mortality rates of the total group, type I group, type II group, and type IV group were 6.5%, 4.3%, 8.5%, and 4.8%, respectively. Postoperative complications mainly included tracheotomy (8.9%), stroke (6%), wound infection (4.2%), renal insufficiency (8.9%), and endoleak (7.7%). With a mean follow-up of 45.1 ± 28.5 months, the total 1-year and 5-year actual survival rates were 93.5% and 89.0%, respectively. At 6 months, the aortic diameter at the level of the diaphragm decreased significantly (30.8 ± 4.9 mm vs. 28.5 ± 6.3 mm, P=0.012), and the rate of thrombosis of the false lumen at the level of pulmonary bifurcation and diaphragm were 95.7% and 83.1%. Ten patients underwent reintervention of the aorta, including 7 endovascular reinterventions, 2 total thoracoabdominal aortic aneurysm repairs, and 1 open total arch replacement. For the total group, the free from aorta reintervention rate at 5 years was 91.4%. Our results with hybrid aortic arch repair for aortic dissection involving the aortic arch are acceptable. The hybrid aortic arch repair could promote thrombosis of the distal false lumen while excluding intimal tears in the aortic arch.

Thoracic Endovascular Aortic Repair for Retrograde Type A Aortic Intramural Hematoma.

Objectives: To evaluate the effects of thoracic endovascular aortic repair (TEVAR) in descending aorta for retrograde type A aortic intramural hematoma (re-TAIMH).Methods: From January 2013 to September 2019, 65 consecutive patients diagnosed with re-TAIMH and treated by TEVAR were enrolled in this retrospective cohort study, of whom 44 patients presented with entry tear in descending aorta (Group A) and 21 with penetrating atherosclerotic ulcer (Group B). The clinical data, including baseline characteristics, adverse events, aortic remolding, and overall survival were reviewed.Results: The mean age of all the patients was 52.0 ± 8.3 years, and 54 (83.1%) patients were men. The mean maximal ascending aortic diameter (MAAD) was 43.1 ± 5.4 mm, and the mean maximal ascending aortic hematoma thickness (MAAHT) was 9.6 ± 4.7 mm. TEVAR was performed under general anesthesia in 53 (81.5%) patients, while 12 (18.5%) patients were treated under local anesthesia. There were two deaths during hospitalization (one with rupture and another with multiple organ dysfunction syndrome), and overall survival at 1, 4, and 7 years for all 65 patients was 93.8, 92.0, and 87.4%, respectively. The MAAD and MAATH decreased significantly after TEVAR (p < 0.05) in the two groups, so did the mean descending aortic diameter at the pulmonary bifurcation level. Type I endoleak, dialysis, progression to type A aortic dissection, and enlargement in MAAHT and MAAD were more common complications, which occurred in four, three, two, and two patients, respectively.Conclusion: Patients with retrograde TAIMH treated by TEVAR had a favorable prognosis including late survival and aortic remolding. However, some post-intervention complications were not negligible.

Distal Remodeling After Operations for Extensive Acute Aortic Dissection

The clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood. From 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n= 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n= 25), and total endovascular repair (n= 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up. At 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up. After distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management.

Associations Between Cardio-Ankle Vascular Index and Aortic Structure and Sclerosis Using Multidetector Computed Tomography.

Aortic pulse wave velocity (PWV) has been accepted as the gold standard for arterial stiffness measurement. However, PWV depends on blood pressure (BP). To eliminate the BP dependency of PWV, the cardio-ankle vascular index (CAVI) was developed. This study aimed to define the relationship between CAVI and aortic atherosclerosis or structure on multidetector computed tomography (MDCT). Patients with (n = 49) or without (n = 49) coronary artery disease were studied. The lumen and vessel diameters and wall thickness were calculated from the cross-sectional area at the pulmonary bifurcation level by 64-slice MDCT. The CAVI was measured within 3 days before MDCT. Multivariate analysis showed that the vessel diameter of the ascending and descending aorta on MDCT depends on age, body surface area, and diastolic BP. The CAVI significantly correlated with the vessel diameter ( r = .453) and wall thickness ( r = .387) of the thoracic descending aorta ( P < .001, respectively). The CAVI was an independent predictor of the descending aortic wall thickness on multiple stepwise regression analysis. These data suggest that CAVI, a simple index, is useful for evaluating thoracic aortic atherosclerosis.

Effects of Postoperative Pericardial Effusion on Coronary Artery Bypass Grafts: A Study with X-ray Computed Tomography.

The aim of this study was to evaluate the effects of pericardial effusion on coronary artery bypass grafts and their patency using X-ray computed tomography (CT). Uncontrasted CT of horizontal sections from the lower margin of the aortic arch to the left ventricle was done at 5-mm intervals. In one cross-section of the pulmonary bifurcation level, 30 ml of a contrast media (lohexol 350) was injected at a rate of 3 ml/second into the antecubital vein. All slices of uncontrasted CT were analyzed for the presence or absence of effusion. The severity was expressed as the maximum value of the thickness of effusion. CT was repeated about every 6 months postoperatively under the same conditions. Selective angiography was also performed 7.1 +/- 3.9 months postoperatively. A total of 46 patients (mean age 57 years) underwent CT and angiography. A total of 95 grafts were implanted: 90 saphenous veins and 5 internal thoracic arteries. Selective angiography revealed that 79 grafts were patent and 16 were occluded. The first postoperative CT (at 2.6 +/- 2.1 months) showed the retention of effusion in all patients. The mean maximum value was 1.0 +/- 0.5 cm; there were no significant differences between patent grafts (1.0 +/- 0.5 cm) and occluded grafts (1.0 +/- 0.5 cm). Occlusion was found in 10 grafts by the first CT (2.9 +/- 2.7 months postoperatively) and another 6 grafts by the second CT (11.3 +/- 4.2 months). Thereafter, all grafts were patent. Previously occluded grafts showed no cross-section images on uncontrasted or contrasted CT. Except for two grafts, all patent grafts could be observed even without contrast enhancement. The remaining two grafts were masked with effusion, but patency was confirmed by a contrast media. In conclusion, retention of effusion does not affect the patency of grafts. Occlusion occurs early after surgery, and grafts cannot be imaged on CT. Patent grafts can be observed by uncontrasted CT, as well as contrasted CT, except where a large amount of effusion is present.

Aortopulmonary Window and Anomalous Coronary Artery: An Exceptional Association

Aortopulmonary window is rarely associated with other cardiac anomalies, such as anomalous origin of one coronary artery. This exceptional association has been reported in 15 patients, with different surgical solutions. We describe 2 patients with aortopulmonary window with anomalous origin of the right coronary artery, one of which presented with tetralogy of Fallot-pulmonary atresia. A neonatal modified Blalock-Taussig shunt and ligature of the distal pulmonary artery at the level of pulmonary bifurcation was performed in the first patient, and the second patient underwent aortopulmonary window division with anomalous coronary artery reimplantation. Both patients had an uneventful postoperative course.

A new surgical technique for one-stage repair of interrupted aortic arch with valvular aortic stenosis

Clinical Summary A male neonate weighing 3100 g was referred to our hospital with cyanosis and respiratory distress. Two-dimensional echocardiography showed type B IAA, patent ductus arteriosus, subarterial VSD, and valvular aortic stenosis. The aortic valve was bicuspid and the annular diameter measured 3.0 mm. The infundibular septum was deviated posteriorly. Because aortic flow was decreased because of a left-to-right shunt through VSD, a significant pressure gradient across the aortic valve and subaortic portion was not detected by Doppler echocardiogram.