Surgery For Acute Aortic Dissection Research Articles

Completion Bentall procedure for a huge aortic root pseudoaneurysm after surgery for acute aortic dissection: A case report

A 56-year-old man with a history of emergency ascending aortic and aortic valve replacement for acute type A aortic dissection 6 months previously developed a huge pseudoaneurysm arising from the sinus of Valsalva due to recurrent aortic root dissection. The patient urgently underwent the completion Bentall procedure with coronary artery reconstruction using interposing grafts. During surgery, the non-coronary sinus of Valsalva was repeatedly dissected and ruptured, where surgical glue was applied in the previous operation. The 25-mm REGENT mechanical valve® from the previous operation was left in place, and 2-0 bladed mattress sutures were circumferentially placed in the sewing ring of the prosthesis. A 28-mm Valsalva graft® was cut at the middle of its skirt portion, through which these sutures were passed and tied, and was seated to completely cover the valve cuff. The completion Bentall procedure is considered a feasible technique for reoperative aortic root replacement in patients with a prosthetic aortic valve following acute type A aortic dissection repair. It is important to accurately measure the outer diameter of the prosthetic valve to ensure proper fit of the graft and to minimize the risk of bleeding.

Endovascular aortic arch repair under monitored anaesthesia care: maximizing microinvasiveness.

Patients with aortic arch pathologies after surgery for type-A acute aortic dissection represent a challenging population since open surgery is associated with a non-negligible rate of mortality and complications. Microinvasive endovascular aortic arch repair Arch-Thoracic EndoVascular Aortic Repair (Ar-TEVAR) has shown promising results in high-risk patients. Ar-TEVAR is usually performed under general anaesthesia. We report the case of an 83-year-old man with a history of ascending aorta replacement for type-A acute aortic dissection who was referred for an anastomotic pseudoaneurysm. Ar-TEVAR using an off-the-shelf single-branch aortic arch stent graft was chosen. In order to further minimize procedural invasiveness, monitored anaesthesia care (local anaesthesia with sedation and analgesia) was performed since it provides less stress on the cardiovascular and respiratory systems and overall leads to a faster recovery especially in elderly patients.

Influence of Clinical Status and Dissection Morphology on Transfusion Volume in Acute Aortic Dissection Surgery

Influence of Clinical Status and Dissection Morphology on Transfusion Volume in Acute Aortic Dissection Surgery

The risk factors of postoperative hypoxemia in patients with Stanford type A acute aortic dissection.

Hypoxemia is one of the most common complications in patients after Stanford type A acute aortic dissection surgery. The aim of this study was to investigate the association of circulating ANG II level with postoperative hypoxemia and to identify the risk factors for postoperative hypoxemia in Stanford type A acute aortic dissection patients. In this study, 88 patients who underwent Stanford type A acute aortic dissection surgery were enrolled. Postoperative hypoxemia is defined by the oxygenation index (OI). Perioperative clinical data were collected and the serum ANG II and sACE2 levels were measured. The differences in the basic characteristics, intraoperative details, biochemical parameters, laboratory test data and clinical outcomes were compared between the hypoxemia group and the non-hypoxemia group by univariate analysis. Multivariate logistic regression analysis was performed on the variables with P < .1 in univariate analysis or that were considered clinically important to identify risk factors for postoperative hypoxemia. Twenty-five patients (28.4%) were considered to have postoperative hypoxemia (OI ≤ 200 mm Hg). The ANG II concentration remained a risk factor associated with postoperative hypoxemia [OR = 1.018, 95% CI (1.003-1.034), P = .022]. The other risk factors remaining in the logistic regression model were BMI [OR = 1.417, 95% CI (1.159-1.733), P = .001] and cTnI [OR = 1.003, 95% CI (1.000-1.005), P = .032]. Elevated levels of ANG II, BMI and cTnI are risk factors for postoperative hypoxemia in patients with Stanford type A acute aortic dissection.

Time-of-day discrepancy for the long term surgical outcome of patients with aortic dissection.

It has been suggested that the time of day when cardiovascular surgery is performed may affect the surgery outcomes. This study investigated whether there was a difference in risk-adjusted mortality and morbidity outcomes between patients undergoing acute aortic dissection during the day or the night. Consecutive patients who had undergone Stanford A acute aortic dissection surgery were enrolled between 2016 and 2020. In the daytime group, surgery was performed between 08:00 and 20:00, and in the nighttime group between 20:00 and 8:00. The primary outcome was in-hospital overall mortality, and the secondary outcomes were overall mortality within a median follow-up time of 35.2 (17.0,53.5) months and the occurrence of re-entry tears and major bleeding. A total of 925 patients were enrolled. The primary outcome of in-hospital overall mortality did not differ significantly between patients who received daytime or nighttime surgery. Similarly, the secondary outcomes of overall mortality during the follow-up and incidence of re-entry tears and major bleeding did not differ significantly between the groups. Subgroup analysis was also performed according to the surgery type (modified triple-branched stent-graft implantation or frozen elephant trunk implantation), and surgical approach (partial upper sternotomy or full median sternotomy) confirming that the time of surgery did not significantly influence the outcomes. Cox regression analysis showed that time from onset to admission (P = 0.036), and time from the onset to surgery (P = 0.045) were significant risk factors for increased mortality during follow-up. The time of day when thoracotomy was performed did not significantly affect the clinical outcome and is therefore not a consideration for the improvement of outcome in Stanford A acute aortic dissection patients.

Cardiovascular surgery during the first wave of COVID-19 pandemic.

In this study, we aimed to evaluate primary outcomes and main characteristics of emergency and elective/urgent cardiovascular surgeries which were performed in the first three months of the novel coronavirus disease 2019 (COVID-19) pandemic in our center. Between March 11th, 2020 and June 11th, 2020, a total of 209 patients (44 males, 165 females; mean age: 57.3±12.8 years; range, 20 to 80 years) who underwent emergency or elective/urgent surgery with cardiovascular pathologies were retrospectively analyzed. The patients were classified as emergency and elective/urgent according to the level of necessity of the surgical procedure at the time of hospital admission. Pre-, intra-, and postoperative data of the patients were recorded. During the study period, 156 elective/urgent and 74 emergency cardiovascular surgeries were performed. Six COVID-19 (+) patients were operated emergently. The number of acute aortic dissection and peripheral vascular surgery was higher in the emergency group (p<0.05). Two patients who were COVID-19 (-) preoperatively became COVID-19 (+) in the postoperative period. In these patients, acute respiratory distress syndrome developed, and extracorporeal membrane oxygenation support was needed. Four patients who needed post-cardiotomy extracorporeal membrane oxygenation support due to low cardiac output were COVID-19 (-) both in the pre- and postoperative periods. The overall in-hospital mortality rate was 9.1%. Even during pandemic such as COVID-19, referral centers with experienced personnel can provide non-pandemic healthcare with a quality close to the daily routine.

Concomitant Coronary Artery Bypass Grafting in Acute Type-A Aortic Dissection Repair: Early and Long-Term Outcomes

This study analysed incidence, indications, and impact of concomitant coronary artery bypass grafting (cCABG) on early and long-term outcomes of acute type-A aortic dissection (ATAAD) surgery using 17-year multicentre data.

A Single-Centre Experience With Direct True Lumen Aortic Cannulation in Acute Type-A Aortic Dissection Surgery: Fast, Effective, and Safe

Direct true lumen cannulation of the aorta (DTLC) enables effective antegrade perfusion and is a potentially advantageous technique for cardiopulmonary bypass (CPB) in acute Type-A aortic dissection (ATAAD) scenarios. This report presents results with this cannulation technique.

An Australian Multi-Centre Validation of the GERAADA Score for Prediction of 30-Day Mortality After Acute Type-A Aortic Dissection Surgery

The German Registry of Acute Aortic Dissection Type A (GERAADA) score is a novel risk calculator designed to predict 30-day mortality in ATAAD surgery. Input variables include age, critical status, malperfusion, aortic insufficiency, redo, entry tear location, and extent of dissection. We evaluated this risk score using multi-centre data.

Three Cases of Compartment Syndrome Following Stanford Type-A Acute Aortic Dissection Surgery

Stanford type-A acute aortic dissection can cause lower limb ischaemia with malperfusion syndrome or femoral artery cannulation. Some reports suggest that muscular men aged <60 years may have risk factors for compartment syndrome and myonephropathic metabolic syndrome. This paper describes three cases of compartment syndrome after aortic dissection surgery.

Variability of blood pressure and risk of postoperative acute kidney injury in patients undergoing surgery for acute aortic dissection: A 11-year single-center study.

In patients receiving surgery, increased blood pressure variability may contribute to the onset of acute kidney injury (AKI). However, the extent and significance of blood pressure variability in patients undergoing aortic dissection surgery have yet to be determined. The authors analyzed all patients operated for aortic dissection at Peking University Shenzhen Hospital from January 1, 2011 to December 31, 2021. Preoperative blood pressure variability was expressed as standard deviation, coefficient of variation (CV), and range. The primary outcome was postoperative AKI. After multivariate analysis, systolic blood pressure variability was found to be independently associated with AKI after aortic dissection surgery. The odds ratios and 95% confidence intervals for standard deviation, CV, and systolic blood pressure range were 1.232 (1.011-1.500), 1.451 (1.058-1.991), and 1.138 (0.986-1.288) for postoperative AKI, respectively. However, there was no significant relationship between diastolic blood pressure variability and AKI after aortic dissection surgery. Finally, in patients undergoing surgery for aortic dissection, the variability of systolic blood pressure is actually an important factor in the development of AKI.

High preoperative bradykinin level is a risk factor for severe postoperative hypoxaemia in acute aortic dissection surgery.

What is the central question of this study? Hypoxaemia can lead to increased postoperative mortality in patients: what are the independent risk factors for severe hypoxaemia after acute Stanford type A aortic dissection? What is the main finding and its importance? Severe postoperative hypoxaemia was found in 36.4% of patients, and it was determined that high preoperative bradykinin levels and increased BMI were independent predictors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. For obese patients with high preoperative bradykinin levels, more attention should be paid to preventing severe postoperative hypoxaemia. Severe hypoxaemia after cardiac surgery is associated with serious complications and a high risk of mortality. The purpose of this study is to investigate the independent risk factors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. We collected 77 patients with acute Stanford type A aortic dissection who underwent surgical treatment. The primary outcome was severe postoperative hypoxaemia (PaO2 /FiO2 ≤100mmHg), and a multivariate logistic regression analysis was performed to assess the independent predictors of risk for this. A mixed-effects analysis of variance model and a receiver operating characteristic (ROC) curve were generated to evaluate the predictive probabilities of risk factors for severe postoperative hypoxaemia. A total of 36.4% of patients developed severe postoperative hypoxaemia. The multivariate logistic regression analysis identified high preoperative bradykinin level (odds ratio (OR)=55.918, P<0.001) and increased body mass index (BMI; OR=1.292, P=0.032) as independent predictors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. The mixed-effect analysis of variance model and ROC curve indicated that high preoperative bradykinin level and BMI were significant predictors of severe postoperative hypoxaemia (area under the ROC curve=0.834 and 0.764, respectively). High preoperative bradykinin levels and obesity were independent risk factors for severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. For obese patients with high levels of bradykinin before surgery, clinicians should actively take measures to block bradykinin-mediated inflammatory reactions.

Investigation of the Effect of Acute to Chronic Glycemic Ratio on the Development of Postoperative Pneumonia After Stanford Type A Acute Aortic Dissection Surgery

Aim: A critical clinical condition called acute Type A aortic dissection (ATAAD) necessitates quick surgical action. Other significant issues include the emergence of postoperative pneumonia and various organ failures. We sought to determine how well the ratio of admission blood glucose (ABG) to estimated average glucose (eAG) might be used to anticipate postoperative pneumonia following ATAAD surgery. Materials and Methods: The study comprised patients who underwent ATAAD surgery between January 2016 and January 2022. In the postoperative phase, patients were divided into two groups: Group 1 for those who did not acquire pneumonia and Group 2 for those who did.Results: The study involved 124 patients in total. Group 1 [N = 92, median age = 51 (32 to 80) years] consisted of those who did not acquire postoperative pneumonia, but Group 2 [N = 32, median age = 53 (30 to 77)] did. ABG/eAG ratio and ventilation time were found to be independent predictors of postoperative pneumonia by multivariate analysis [(OR: 0.886, CI 95%: 0.695-0.990, P=0.009) and (OR: 1.114, 1.030-1.542, P=0.023)].Conclusion: We demonstrated that ABG/eAG ratio, calculated at admission time, is a significant predictor of the development of postoperative pneumonia.

Outpatient management of patients after surgical operations for acute aortic dissection of type A

Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.

A prospective, controlled study on the utility of rotational thromboelastometry in surgery for acute type A aortic dissection

To evaluate the hemostatic system with ROTEM in patients undergoing surgery for acute type aortic dissection (ATAAD) using elective aortic procedures as controls. This was a prospective, controlled, observational study. The study was performed at a tertiary referral center and university hospital. Twenty-three patients with ATAAD were compared to 20 control patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM (INTEM, EXTEM, HEPTEM and FIBTEM) was tested at 6 points in time before, during and after surgery for ATAAD or elective aortic surgery. The ATAAD group had an activated coagulation coming into the surgical theatre. The two groups showed activation of both major coagulation pathways during surgery, but the ATAAD group consistently had larger deficiencies. Reversal of the coagulopathy was successful, although none of the groups reached elective baseline until postoperative day 1. ROTEM did not detect low levels of clotting factors at heparin reversal nor low levels of platelets. This study demonstrated that ATAAD is associated with a coagulopathic state. Surgery causes additional damage to the hemostatic system in ATAAD patients as well as in patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM does not adequately catch the full coagulopathy in ATAAD. A transfusion protocol in ATAAD should be specifically created to target this complex coagulopathic state and ROTEM does not negate the need for routine laboratory tests.

Perioperative Risk Factors for Post-operative Pneumonia after Type A Acute Aortic Dissection Surgery.

Type A acute aortic dissection (TAAAD) is a dangerous and complicated condition with a high death rate before hospital treatment. Patients who are fortunate to receive prompt surgical treatment still face high in-hospital mortality. A series of post-operative complications further affects the prognosis. Post-operative pneumonia (POP) also leads to great morbidity and mortality. This study aimed to identify the prevalence as well as the risk factors for POP in TAAAD patients and offer references for clinical decisions to further improve the prognosis of patients who survived the surgical procedure. The study enrolled 89 TAAAD patients who underwent surgical treatment in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei province, China from December 2020 to July 2021 and analyzed the perioperative data and outcomes of these patients. Logistic regression analyses were used to identify the risk factors for POP. In the study, 31.5% of patients developed POP. Patients with POP had higher proportions of severe oxygenation damage, pneumothorax, reintubation, tracheotomy, renal replacement therapy, arrhythmia, gastrointestinal bleeding, and longer duration of mechanical ventilation, fever, ICU stay, and length of stay (all with P<0.05). The in-hospital mortality was 2.3%. Smoking, preoperative white blood cells, and intraoperative transfusion were the independent risk factors for POP in TAAAD. Patients who underwent TAAAD surgery suffered poorer outcomes when they developed POP. Furthermore, patients with risk factors should be treated with caution.

Is Exercise Blood Pressure Putting the Brake on Exercise Rehabilitation after Acute Type A Aortic Dissection Surgery?

(1) Background: Exercise is recommended to improve physical fitness in patients recovering from acute type A aortic dissection (ATAAD). However, surgery corrects the diseased blood vessels and reduces the risk of ATAAD, but it does not redefine a safe exercise blood pressure (BP) threshold. This review aimed to discuss whether the safe threshold of exercise BP can be upregulated after ATAAD surgery to increase exercise intensity with additional benefits. (2) Data sources: The PubMed databases were searched with the keywords “type A acute aortic dissection surgery”, “exercise”, “BP”, “stress”, and variations of these terms. (3) Study selection: Data from clinical trials, guidelines, and recent reviews were selected for review. (4) Results: Regular exercise can be considered a cardioprotective intervention for aortic dissection patients by attenuating hemodynamic responses at rest and during exercise. Previous studies have mainly focused on moderate-intensity aerobic exercise. In practice, the exercise systolic BP of some patients was higher than 160 mm Hg without adverse events, which indicates that the training intensity may be underestimated for patients after ATAAD surgery. Limited studies suggest a light-to-moderate resistance training for selected patients because it may cause a greater increase in BP. (5) Conclusions: Moderate-intensity continuous aerobic exercise supplemented by low-intensity resistance training is appropriate for cardiac rehabilitation after ATAAD surgery. The BP increase based on the normal exercise BP response, corresponding to the moderate-intensity is relatively safe. For high-risk post-ATAAD patients, considering the overall volume of training, personalizing the exercise regimen to remain within “safe” BP limits, and avoiding excessive fluctuations in BP should be the primary considerations for exercise training.

Preoperative Nomogram and Risk Calculator for Postoperative Hypoxemia and Related Clinical Outcomes Following Stanford Type A Acute Aortic Dissection Surgery.

BackgroundHypoxemia is a common complication after Stanford type A acute aortic dissection surgery (AADS), however, few studies about hypoxemia after AADS exist. The aims of this study were to identify independent risk factors for hypoxemia after AADS and to clarify its association with clinical outcomes.MethodsPatients undergoing AADS from 2016 to 2019 in our hospital were identified and used as a training set. Preoperative variables were first screened by univariate analysis and then entered into a multivariate logistic regression analysis to identify independent risk factors. A nomogram and an online risk calculator were constructed based on the logistic model to facilitate clinical practice and was externally validated in an independent dataset.ResultsSevere hypoxemia developed in 119 of the 492 included patients (24.2%) and poorer clinical outcomes were observed in these patients. Five independent risk factors for severe hypoxemia after AADS were identified by multivariate analysis, including older age, smoking history, renal insufficiency, higher body mass index, and white blood cell count. The model showed good calibration, discrimination, and clinical utility in the training set, and was well validated in the validation set. Risk stratification was performed and three risk groups were defined as low, medium, and high risk groups. Hypertension was identified as an independent risk factor for moderate hypoxemia besides the five predictors mentioned above, and renal insufficiency was not significant for mild hypoxemia by multivariate analysis. In addition, although frozen elephant trunk was associated with increased risk of postoperative hypoxemia in the univariate analysis, frozen elephant trunk was also not identified as an independent risk factor for postoperative hypoxemia in the multivariate analysis.ConclusionHypoxemia was frequent following AADS, related to poorer clinical outcomes. Predictors were identified and a nomogram as well as an online risk calculator predicting severe hypoxemia after AADS was developed and validated, which may be helpful for risk estimation and perioperative management.

False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report

BackgroundAcute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen.Case presentationThe patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism.ConclusionsWe experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis.

Development and validation of a risk prediction model for postoperative pneumonia in adult patients undergoing Stanford type A acute aortic dissection surgery: a case control study

BackgroundPneumonia is a common complication after Stanford type A acute aortic dissection surgery (AADS) and contributes significantly to morbidity, mortality, and length of stay. The purpose of this study was to identify independent risk factors associated with pneumonia after AADS and to develop and validate a risk prediction model.MethodsAdults undergoing AADS between 2016 and 2019 were identified in a single-institution database. Patients were randomly divided into training and validation sets at a ratio of 2:1. Preoperative and intraoperative variables were included for analysis. A multivariate logistic regression model was constructed using significant variables from univariate analysis in the training set. A nomogram was constructed for clinical utility and the model was validated in an independent dataset.ResultsPostoperative pneumonia developed in 170 of 492 patients (34.6%). In the training set, multivariate analysis identified seven independent predictors for pneumonia after AADS including age, smoking history, chronic obstructive pulmonary disease, renal insufficiency, leucocytosis, low platelet count, and intraoperative transfusion of red blood cells. The model demonstrated good calibration (Hosmer–Lemeshow χ2 = 3.31, P = 0.91) and discrimination (C-index = 0.77) in the training set. The model was also well calibrated (Hosmer–Lemeshow χ2 = 5.73, P = 0.68) and showed reliable discriminatory ability (C-index = 0.78) in the validation set. By visual inspection, the calibrations were good in both the training and validation sets.ConclusionWe developed and validated a risk prediction model for pneumonia after AADS. The model may have clinical utility in individualized risk evaluation and perioperative management.