Partial Cardiopulmonary Bypass Research Articles

Outcome of Open Repair of Thoracoabdominal Aortic Aneurysm in Takayasu Arteritis: A Retrospective Analysis

Takayasu Arteritis (TA) is an immune mediated arteritis causing inflammation of the aorta and its branches, which can result in aortic aneurysms. Our aim is to describe the outcome of surgical management in these patients who presented with Thoracoabdominal aortic aneurysm (TAAA). Between 2003 and 2023, 40TA patients with TAAA underwent operative repair. There were 24 females and 16 males, in the age group of 19-53years, with hypertension in 20 patients. Raised Erythrocyte sedimentation Rate was present in 13 patients. According to Crawford classification, there were 2 patients with type I, 2 with type II, 17 with type III, 12 patients with type IV and 7 with type V aneurysm. Multiple steno-occlusive lesions of aortic branches were present in 21 patients, with majority affecting the renal artery. Femoral Artery Femoral Vein Partial cardiopulmonary bypass was used for types I, II, III and V. Separate bypass to visceral branches was done in eight patients, of whom five had multiple bypasses and three patients only had renal bypass. Twelve patients underwent reimplantation of branches, out of which nine had multiple vessel reimplantation. Four patients underwent staged repair of the aneurysm, which included visceral debranching in the first day, followed by repair of the aneurysm in the next day. In the immediate postoperative period, ten patients developed acute kidney injury and two required dialysis. Other morbidities included acute respiratory distress syndrome (ARDS), spinal cord dysfunction, bleeding, and wound complications. Three patients expired in the immediate postoperative period. Mean duration of intensive care unit stay was 4.1days and hospital stay was 12.7days. Comparison of disease activity with morbidity and mortality was statistically insignificant. Patients were on follow-up for a range of 6months to 14years and median follow-up of 25months. Over this time period four patients expired and four developed anastomotic pseudoaneurysm requiring intervention. On comparing the disease activity at the time of surgery with the long-term arteritis related complications that required intervention, the P value was 0.653 and hence statistically not significant. The 10-year survival rate is 84.4%. Surgical repair has good and satisfactory outcome, with low early and late mortality rates. Progression of disease can occur at any stage of the disease, hence indicating the need for long term follow-up and frequent imaging.

Hydrogen attenuates endothelial glycocalyx damage associated with partial cardiopulmonary bypass in rats.

Cardiopulmonary bypass (CPB) causes systemic inflammation and endothelial glycocalyx damage. Hydrogen has anti-oxidant and anti-inflammatory properties; therefore, we hypothesized that hydrogen would alleviate endothelial glycocalyx damage caused by CPB. Twenty-eight male Sprague-Dawley rats were randomly divided into four groups (n = 7 per group), as follows: sham, control, 2% hydrogen, and 4% hydrogen. The rats were subjected to 90 minutes of partial CPB followed by 120 minutes of observation. In the hydrogen groups, hydrogen was administered via the ventilator and artificial lung during CPB, and via the ventilator for 60 minutes after CPB. After observation, blood collection, lung extraction, and perfusion fixation were performed, and the heart, lung, and brain endothelial glycocalyx thickness was measured by electron microscopy. The serum syndecan-1 concentration, a glycocalyx component, in the 4% hydrogen group (5.7 ± 4.4 pg/mL) was lower than in the control (19.5 ± 6.6 pg/mL) and 2% hydrogen (19.8 ± 5.0 pg/mL) groups (P < 0.001 for each), but it was not significantly different from the sham group (6.2 ± 4.0 pg/mL, P = 0.999). The endothelial glycocalyces of the heart and lung in the 4% hydrogen group were thicker than in the control group. The 4% hydrogen group had lower inflammatory cytokine concentrations (interleukin-1β and tumor necrosis factor-α) in serum and lung tissue, as well as a lower serum malondialdehyde concentration, than the control group. The 2% hydrogen group showed no significant difference in the serum syndecan-1 concentration compared with the control group. However, non-significant decreases in serum and lung tissue inflammatory cytokine concentrations, as well as in serum malondialdehyde concentration, were observed. Administration of 4% hydrogen via artificial and autologous lungs attenuated endothelial glycocalyx damage caused by partial CPB in rats, which might be mediated by the anti-inflammatory and anti-oxidant properties of hydrogen.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Abstract 11924: Nicorandil Attenuates Ventricular Dysfunction in a Piglet Model of Cardiopulmonary Bypass and Cardioplegic Arrest

Introduction: Nicorandil is a coronary vasodilator for treatment of ischemia-induced angina. Studies suggest nicorandil may offer myocardial protection against regional ischemia-reperfusion (IR) injury during coronary artery bypass grafting in adults. The impact of nicorandil on global IR-induced myocardial injury and left ventricular (LV) dysfunction after cardiopulmonary bypass (CPB) and cardioplegic arrest (CA) has not been investigated in children. Hypothesis: Nicorandil attenuates myocardial IR injury and LV dysfunction after CPB and CA in an immature animal model. Methods: Anesthetized piglets (4-5 weeks-old, 8.8±0.4 kg) were cannulated via the right atrium and ascending aorta for initiation of full-flow CPB (100 mL/kg/min). Following 30 mins of aortic cross-clamp (ACC) and CA, hearts were reperfused on full CPB for 60 mins, followed by partial CPB for 30 mins, and separation from CPB for 30 mins. Nicorandil (0.2 mg/kg IV bolus + 0.02 mg/kg/min IV continuous infusion) or saline (N=6 per group) was initiated 5 mins before ACC and continued throughout the protocol. Temperature, ECG, mean arterial pressure (MAP), and LV function (via high-fidelity Millar pressure catheter) were continuously recorded. Serial plasma samples were collected for measurement of oxidant stress, inflammation, and multi-organ injury (heart, lung, kidney, and brain). Results: Temperature, heart rate, and MAP were similar between nicorandil- and saline-treated groups. However, 120 mins after ACC removal, nicorandil treatment significantly improved LV contractility [LV +dP/dt: 2,962±678 mmHg/sec (nicorandil) vs. 1,278±332 mmHg/sec (saline), p=0.004] and LV relaxation [LV -dP/dt: -2,670±454 mmHg/sec (nicorandil) vs. -1,347±339 mmHg/s (saline), p=0.002]. Also, nicorandil significantly attenuated the IR-induced increase in circulating biomarkers for oxidant stress, inflammation, and multi-organ injury. Conclusions: In a piglet model of CPB with CA, nicorandil attenuates LV systolic and diastolic dysfunction and improves oxidant stress, inflammation, and multi-organ injury. These results suggest that nicorandil may prove beneficial to mitigate IR injury and accelerate LV functional recovery after open heart surgery in infants and children.

Results of post-infarction left ventricular aneurysms surgical planning using magnetic resonance imaging and three-dimensional modeling

Aim. To evaluate the results of surgical intervention planning using three-dimensional models based on magnetic resonance imaging in patients with postinfarction left ventricular aneurysms.Material and Methods. Two groups of patients with postinfarction left ventricular aneurysm (PLVA) were included in the study, totaling 41 patients. The first (experimental) group included 17 patients diagnosed with PLVA by magnetic resonance imaging (MRI), and surgical intervention planning was performed using a 3D model of the heart. The control group comprised 24 patients in whom PLVA was diagnosed by echocardiography (TTE) or ventriculography, and surgical intervention planning was performed using traditional two-dimensional slice images.Results. Comparison of full perfusion under cardiopulmonary bypass (CPB) showed statistically significant differences between the groups: this parameter was 60 [56; 68] min in group 1 vs. 71 [61; 84] min in group 2, which was significantly higher (p = 0.043). There were no significant differences in total operation time (280 [265; 320] min in group 1 vs. 263 [248; 283] min in group 2, p = 0.055), overall CPB time (93 [86; 109] min in group 1 vs. 104 [83; 109] min in group 2, p = 0.653), and partial CPB time (31 [26; 39] min in group 1 vs. 27 [21; 32] min in group 2, p = 0.127).Conclusion. The use of 3D models to support surgeons for PLVA correction makes it possible to determine the type of reconstructive surgery, practice the main stages of the upcoming intervention, and reduce the time of full perfusion under CPB during its implementation.

Myocardial electrophysiological and mechanical changes caused by moderate hypothermia-A clinical study.

Moderate hypothermia has been used to improve outcomes in comatose out‐of‐hospital cardiac arrest survivors during the past two decades, although the effects remain controversial. We have recently shown in an experimental study that myocardial electrophysiological and mechanical relationships were altered during moderate hypothermia. Electromechanical window positivity increased, and electrical dispersion of repolarization decreased, both of which are changes associated with decreased arrhythmogenicity in clinical conditions. Mechanical dispersion, a parameter also linked to arrhythmic risk, remained unaltered. Whether corresponding electrophysiological and mechanical changes occur in humans during moderate hypothermia, has not been previously explored. Twenty patients with normal left ventricular function were included. Measurements were obtained at 36 and 32°C prior to ascending aortic repair while on partial cardiopulmonary bypass and at 36°C after repair. Registrations were performed in the presence of both spontaneous and comparable paced heart rate during standardized loading conditions. The following electrical and mechanical parameters were explored: (1) Electromechanical window, measured as time difference between mechanical and electrical systole, (2) dispersion of repolarization from ECG T‐wave, and (3) mechanical dispersion, measured as segmental variation in time to peak echocardiographic strain. At moderate hypothermia, mechanical systolic prolongation (425 ± 43–588 ± 67 ms, p < 0.001) exceeded electrical systolic prolongation (397 ± 49–497 ± 79 ms, p < 0.001), whereby, electromechanical window positivity increased (29 ± 30–86 ± 50 ms, p < 0.001). Dispersion of repolarization and mechanical dispersion remained unchanged. Corresponding electrophysiological and mechanical relationships were present at comparable paced heart rates. After rewarming, the increased electromechanical window was reversed in the presence of both spontaneous and paced heart rates. Moderate hypothermia increased electromechanical window positivity, while dispersion of repolarization and mechanical dispersion remained unchanged. This impact of hypothermia may be clinically relevant for selected groups of patients after cardiac arrest.

Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center

Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center

A Ten-year Single-center Surgical Experience With Symptomatic Complete Vascular Rings

Limited data exist on the management of complete vascular rings (CVR) in adults. We reviewed our institution's surgical experienceinthe managementof these patients. Between 2010 and 2019, all adult patients that underwent a thoracotomy for a CVR repair were identified. We performed a retrospective medical record review of these patients to characterize their demographics and outcomes. Among the 5 patients identified (3 females, 2 males; Mean age 50 ± 9 years), anatomic variants were right arch and Kommerell diverticulum (KD) in 3 (60%) and double aortic arch in 2 (40%) patients. Indications for operation included dysphagia in 4 (80%), respiratory symptoms in 3 (60%) and aneurysmal KD in 1 (20%) patient. Two right aortic arch exclusion, 1 ligamentum arteriosum (LA) division, 1 LA division combined with a KD resection and 2 aortic reconstructions with interposition Dacron graft under partial cardiopulmonary bypass, were performed. Two carotid-subclavian artery transpositions prior to the thoracotomy were done. The postoperative length of stay was 10.0 (IQR 7.3-14.8) days. One reoperation for chylothorax and 1 for symptoms recurrence were performed for the same patient. Over a follow-up period of 1.4 (IQR 0.4-7.0) years, no mortality or majorpostoperative complications occurred. At their last follow-up visit, all patients reported no related remaining symptoms, except for persisting mild asthma in 1 patient. Open repair of CVR in adults can be performed safely with low complication rate. Symptoms improved in all patients after definitive repair.

Open anatomical repair for primary coarctation of the aorta in adults.

Although endovascular repair has become an alternative treatment for coarctation of the aorta (CoA) in adults, open repair provides concomitant repair of other cardiac complications, including post-stenotic aneurysm, ascending aortic aneurysm, and intracardiac diseases. We evaluated open anatomical repair for CoA repair in adults. Eleven patients (6 men, age range 21-63years) underwent primary CoA repair. Complicating conditions included post-stenotic aortic aneurysm in the descending aorta in 5 patients (45.5%) and ascending aortic aneurysm in 3 (27.3%). Two patients (18.2%) had a bicuspid aortic valve, and one (9.1%) had a quadricuspid aortic valve. Ventricular septal defect was detected in 1 patient (9.1%). Eight patients (72.7%) underwent descending aorta replacement through a left thoracotomy, comprising partial cardiopulmonary bypass in 4 and deep hypothermic circulatory arrest in 4. Of those, the left subclavian artery was reconstructed in 4 patients. The remaining 3 patients (27.3%) underwent total arch replacement, through a median sternotomy in 1 and using a combination of median sternotomy and thoracotomy in 2. No in-hospital mortality was observed. No spinal cord ischemia or neurological events were encountered, but 1 patient (9.1%) who underwent CoA repair via median sternotomy and thoracotomy required prolonged ventilatory support for more than 48h. During the follow-up of 90months (interquartile range 65-124months), no patient died or required reintervention for the repaired segment. CoA in adults could be anatomically repaired with graft replacement both through the median sternotomy, the left thoracotomy, and the combination of both approaches, according to the complicated aortic or intracardiac lesions.

Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges

Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.

Abstract 15149: Aortic Total Clamp Increases Post Coronary Artery Bypass Grafting Stroke: A Multinomial Multifactor Model

Introduction: We performed a multinomial multifactor propensity-score based analysis on stroke in patients undergoing CABG. The unique model allowed us to test all the potential technical risk related to aortic manipulation alone or in combination. Methods: The study population included 16,255 consecutive patients undergoing isolated CABG between 1997 and 2017. Patients were divided into 7 groups: 1) No Proximal Anastomoses-Off-pump (NPA-OFF) group, 2) Side Biting Clamp-Off-pump (SBCL-OFF) group, 3) No Proximal Anastomoses-Beating Heart-On-Pump (NPA-BH-ON) group, 4) Side Biting Clamp-Beating Heart-On-Pump (SBCL-BH-ON) group, 5) No Proximal Anastomoses-Aortic Total Clamp-On-pump (NPA-ATC-ON) group, 6) Aortic Total Clamp-On-pump (ATC-ON) group, 7) Aortic Total Clamp-Side Biting Clamp-On-pump (ATC-SBCL-ON) group. The main end-point was the incidence of postoperative stroke within 30 days of the procedure. Statistical significance was set for p-values&lt; 0.05 (*). Results: The optimal balance with the balance table, effect size plot and Q-Q plot, allowed us to conclude that the groups were similar to support causal estimation of the treatment estimand. As shown in Figure 1, there was no difference between a total no-touch (NPA-OFF group) vs. the same technique on pump (NPA-BH-ON group, p&gt;0.05) and or adding a side biting clamp to these two procedures (SBCL-OFF group and SBCL-BH-ON group, both p&gt;0.05). All procedures including the use of a total clamp (NPA-ATC-ON, ATC-ON and ATC-SBCL-ON groups) had a significantly higher incidence of stroke (all p&lt;0.001). However, the latter procedures did not show difference between them (p&gt;0.05). Conclusions: Aortic total clamp is the main factor increasing the incidence of stroke. In contrast, the use of side biting partial clamping, off-pump techniques or cardiopulmonary bypass without aortic clamp and cardioplegic arrest, does not affect the incidence of stroke.

Anesthetic Management of Surgical Repair of Descending Thoracic Aortic Aneurysm

Anesthetic management of surgical repair of descending thoracic aortic aneurysm is a difficult mission for anesthesiologists. The surgical approach is best achieved through left postero-lateral thoracotomy with the use of one lung ventilation. The post-operative outcome is affected by the presence of associated co morbidities such as cardiac and renal diseases, the severe intra-operative hemodynamic fluctuations and the use of mechanical circulatory assisted devices. The severe hemodynamic fluctuations that result from clamping and declamping the descending thoracic aorta require an experienced cardiac anesthesiologist for the proper perioperative management of these patients. The aim of this review is to give new insights on the anesthetic management and the techniques of distal perfusion using partial cardiopulmonary bypass. Anesthetic goals are directed to provide spinal cord and renal protection with controlling the proximal hypertension.

Inflammatory Effects of Blood-Air Interface in a Porcine Cardiopulmonary Bypass Model.

Cardiopulmonary bypass (CPB) causes a systemic inflammatory response syndrome (SIRS) associated with multiorgan injury. A model was developed to test whether a blood-air interface (BAI) in the CPB circuit causes blood element activation and inflammation. Ten healthy swine were placed on partial CPB for 2 hours via the cervical vessels and monitored for 96 hours postoperatively. Five pigs (control group) had minimal air exposure in the circuit, while five were exposed to a BAI simulating cardiotomy suction. There were no significant differences in bypass flow or hemodynamics between the groups. In the BAI group, there was an increase in hemolysis after bypass (plasma-free hemoglobin 5.27 ± 1.2 vs. 0.94 ± 0.8 mg/dl; p = 0.01), more aggressive platelet consumption (28% vs. 83% of baseline; p = 0.009), leukocyte consumption (71% vs. 107% of baseline; p = 0.02), and increased granulocyte CD11b expression (409% vs. 106% of baseline; p = 0.009). These data suggest the inflammatory pattern responsible for the CPB-SIRS phenomenon may be driven by blood-air interaction. Future efforts should focus on BAI-associated mechanisms for minimizing blood trauma and inflammation during CPB.

Replacement of the descending thoracic aortic aneurysm with partial cardiopulmonary bypass in the era of endovascular repair.

Although the advent of thoracic endovascular aortic repair (TEVAR) has provided an alternative treatment option for descending thoracic aortic aneurysm (DTAA), open repair still plays a crucial role in DTAA repair. The purpose of this study was to re-evaluate the operative and long-term outcomes of open repair with partial cardiopulmonary bypass, compared to the results of TEVAR with a proximal landing zone of 3 or 4. Between 2007 and 2017, open repair was performed for 44 patients and TEVAR for 282 patients. Acute aortic dissection and open proximal anastomosis under circulatory arrest were excluded. Perioperative and long-term follow-up data were analyzed. In-hospital mortality rate (4.5% vs 3.2%, p = 0.42), and frequencies of spinal cord injury and neurological deficit showed no significant differences between the open repair and TEVAR groups (p = 0.41, 0.25, respectively). The propensity score-matched analysis showed similar cumulative survival (p = 0.23), but significantly higher reintervention rates for the repaired segment in the TEVAR group than in the open repair group (p = 0.0054). Twenty-two (7.8%) TEVAR patients required re-interventions for the repaired segment. Of those, 17 patients underwent additional TEVAR and 5 patients needed open conversion surgery with partial cardiopulmonary bypass. Reintervention rates for the repaired segment were significantly higher in the TEVAR group than in the open repair group (p = 0.012). Open repair DTAA using partial cardiopulmonary bypass showed operative outcomes comparable to TEVAR and lower reintervention rates, and thus remains an acceptable procedure for selected patients in this era of endovascular repair.

Correlation between perioperative thromboelastogram and coagulation test in patients undergoing cardiac surgery

Objective To investigate the correlation among preoperative and postoperative thromboelastography (TEG) and routine coagulation tests in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB), and detect the changes of TEG and coagulation test pre-CPB and post-CPB and the values in perioperative management of cardiac surgery. Methods In the current study, TEG, routine coagulation test and platelet count of hemoglobin (Hb) and blood platelet (PLT) were measured before and after cardiac surgery under CPB. The correlation between reaction time (R), clotting time (K), α-Angle (Angle), maximum amplitude (MA), coagulation index (CI) and prothrombin time (PT), international standard ratio (INR), activated partial coagulation time (APTT), thrombin time (TT), fibrinogen (Fib), Hb, PLT, CPB time and aortic occlusion (OA) time was analyzed. Results Forty-seven patients were enrolled in the study. Postoperative K value and Fib were statistically significantly increased compared with the preoperative levels (P<0.05). Postoperative Hb and PLT were decreased significantly compared with the preoperative levels (P<0.05). The correlations analysis among pre-operation (pre) items and post-operation (po) items including TEG, routine coagulation test, Hb and PLT showed that correlations were existed in these following indicators: MApre and PLTpre, INRpre and PTpre, Rpre and Kpre, Rpre and Anglepre, Rpre and CIpre, Kpre and Anglepre, Kpre and MApre, Kpre and CIpre, Anglepre and MApre, Anglepre and CIpre, MApre and CIpre, Kpo and Kpre, Kpo and Anglepre, Kpo and MApre, Anglepo and Kpre, Anglepo and Anglepre, Anglepo and MApre, Anglepo and Kpo, CIpo and Rpo, CIpo and Kpo, CIpo and Anglepo, MApo and CPB, CPB and OA, Hbpo and Hbpre, PTpo and Hbpre, INRpo and Hbpre, INRpo and PTpo, among which Rpre and Anglepre, Rpre and CIpre,Kpre and Anglepre, Kpre and MApre, Kpre and CIpre, Kpo and Anglepre, Kpo and MApre, Anglepo and Kpre, Anglepo and Kpo, CIpo and Rpo, CIpo and Kpo, MApo and CPB, PTpo and Hbpre, INRpo and Hbpre were negatively correlated, and the others were positively correlated. Conclusions TEG, coagulation test, Hb and PLT are widely correlated after CPB in patients undergoing cardiac valve surgery. TEG and coagulation test play an important role in monitoring coagulation function during perioperative period. Key words: Cardiac surgery; Cardiopulmonary bypass; Thromboelastography; Coagulation test

Right aortic arch with an aberrant left subclavian artery and aortic coarctation including a descending aortic aneurysm

BackroundThe right aortic arch and aortic coarctation are rare congenital anomalies with the incidence of 0.1% and 0.03–0.04%. We present a case report of a 51-year-old woman with the right aortic arch with aberrant left subclavian artery and coarctation of the aorta with post-stenotic aneurysm.Case presentationResection of the coarctation and aneurysm with replacement by tubular prosthesis was performed on partial cardiopulmonary bypass via femoral vessels.ConclusionPartial cardiopulmonary bypass is an applicable method for ensuring the perfusion of the distal part of the body and an aberrant left subclavian artery is not a contraindication of this technique.

Impact of preservation of the latissimus dorsi muscle through a left anteroaxillary thoracotomy on spinal cord protection in descending thoracic and thoraco-abdominal aortic operations†.

The presence of collateral network circulation to the spinal cord, which is reflected in the repair of a descending thoracic aortic aneurysm (dAo) and a thoraco-abdominal aortic aneurysm (TAAo), has been demonstrated in clinical and animal experimental data. The latissimus dorsi muscle (LDM) including the thoracodorsal artery might be one of the major sources of this collateral network. The objective of this study was to evaluate the impact on spinal cord safety of a left anteroaxillary thoracotomy with minimal muscle division including preservation of the LDM in surgery for dAo and TAAo. Sixty-nine patients [64 (23-85) years old; 56 men] who underwent surgical repair for dAo and TAAo were divided into 2 groups: 29 [65 (23-84) years old] with an anteroaxillary thoracotomy with LDM preservation (PL group) and 40 [61 (28-85) years old] with a lateral thoracotomy without LDM preservation (NL group). Aortic repairs were performed at the dAo in 30 patients including 14 in the PL group vs 16 in the NL group and at the TAAo in 39 patients including 15 in the PL group vs 24 in the NL group. There were 2 (2.9%) 30-day deaths; 2 (7.9%) in the PL group vs none in the NL group (P = 0.173). No strokes occurred. In patients with a femoro-femoral partial cardiopulmonary bypass with mild hypothermia, the incidence of loss of signal of motor-evoked potentials (>50%) was significantly lower in the PL group; 5.6% vs 31.8% (P = 0.039). The frequency of signal reduction of the remaining motor-evoked potential after surgery was also significantly lower in the PL group: 3.7% vs 25% (P = 0.040). Subsequently, the rate of spinal cord complications were lower in the PL group: 3.4% vs 12.5% (P = 0.188). The left anteroaxillary thoracotomy with minimal incision of the muscles including the LDM might have potential advantages for spinal cord protection via preserved intramuscular collateral circulations to the spinal cord in dAo/TAAo open repairs.

Stent graft as a bridge to allograft to treat a septic thoracic aortic pseudoaneurysm after spinal fusion

A 29-year-old woman was admitted to our institution for severe septic syndrome. Her medical history included a T6-T8 posterior spinal fusion 7 years earlier for tuberculous spondylodiscitis. Contrast-enhanced computed tomography (CT) revealed a 70- × 58-mm pseudoaneurysm of the descending thoracic aorta extending from T6 to T8 level, surrounding the left T6 screw (A/Cover). A T6-T8 spondylodiscitis and bilateral paraspinal collections were also observed. Blood and T7 bone biopsy specimens grew Escherichia coli. To prevent an imminent pseudoaneurysm rupture and to allow cryopreserved aortic allograft (CAA) delivery, the patient first underwent conformable TAG 26- × 26- × 100-mm (W. L. Gore & Associates, Flagstaff, Ariz) thoracic aortic stent graft implantation under general anesthesia through a small left femoral incision. The procedure was uncomplicated. Exclusion of the pseudoaneurysm was assessed by final angiography and postoperative CT scan (B). Five days later, T2-T10 spinal fusion was conducted after infected hardware removal through a posterior approach along with drainage of the paraspinal collections. Aortic replacement using a 10-cm-long thoracic CAA was performed through a left posterolateral thoracotomy in the same operative course. A partial cardiopulmonary bypass at normothermia was established through a left femoral incision. An arterial perfusion cannula was positioned in the abdominal aorta and a venous cannula to the right atrium. During aortic replacement, a fistula was observed at the bottom of the aortic pseudoaneurysm communicating with the former location of the left T6 screw. The final step consisted of implantation in the vertebral defect of a titanium mesh cage containing autologous bone graft. Transdiaphragmatic epiploplasty was performed to isolate the CAA (C). The culture specimens of the removed orthopedic hardware and stent graft grew E. coli. Antibiotic treatment initially consisted of intravenous administration of cefotaxime and gentamycin switched postoperatively to intravenous administration of ceftriaxone for 12 weeks. Follow-up included visits at 1 month and 6 months postoperatively, and follow-up should be continued twice a year. Six months postoperatively, the patient was asymptomatic. The CT scan showed satisfactory coverage of the allograft by the omentum and the absence of allograft pseudoaneurysm or residual collection (D). Vascular injury after spinal instrumentation is a rare but life-threatening condition. Treatment of such injuries is not standardized. Previous studies have reported the use of stent grafts with good outcomes.1Zerati A.E. Leiderman D.B. Teixeira W.G. Narazaki D.K. Cristante A.F. Wolosker N. et al.Endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal: case report and literature review.Ann Vasc Surg. 2017; 39: 285.e17-285.e21Abstract Full Text Full Text PDF Scopus (5) Google Scholar In our case, we believed that simple endovascular treatment was not possible because of the high risk of stent graft infection. We believed that CAA represented the best option in a septic field, as is the case with aortic graft infections.2Corvera J.S. Blitzer D. Copeland H. Murphy D. Hess Jr., P.J. Pillai S.T. et al.Repair of thoracic and thoracoabdominal mycotic aneurysms and infected aortic grafts using allograft.Ann Thorac Surg. 2018; 106: 1129-1135Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Potential postoperative CAA pseudoaneurysm formation requires close and lifelong follow-up. The patient consented to the use of related medical history and images for educational purposes.

Open surgery for descending thoracic aorta in an endovascular era

BackgroundThoracic endovascular aortic repair has become the preferred treatment for a variety of descending thoracic aortic pathologies. However, there are unresolved issues such as morphologic appearance of chronic dissection, persistent false lumen perfusion, and adequacy of landing zone. Enthusiasm for improving the technique of open aortic repair and perioperative management is fading. In this study, we would like to demonstrate how we improve our surgical outcomes by establishing a dedicated aortic multidisciplinary team at the Kawasaki Aortic Center. MethodWe performed a single-center retrospective study from January 2015 to December 2016. All patients with open descending thoracic aortic replacement were recruited. Preoperative patient demographic data, bypass strategies, operative details, and postoperative outcomes were reviewed. ResultFrom January 2015 to December 2016, we treated 168 cases of descending thoracic aortic repair using a left thoracotomy. Median age was 69.0 ± 21.8 years old, and 63.1% were aortic dissection (acute, 4.8%; chronic, 58.3%); 81.3% patients underwent elective operations. Left heart bypass, deep hypothermic circulatory arrest, and partial cardiopulmonary bypass were performed in 88.6%, 9.0%, and 2.4% of patients, respectively. Mean operative time was 312 ± 94 minutes. In-hospital mortality in total was 0.6%. The rate of transient spinal cord injury was 4.7%. ConclusionsUnder a dedicated aortic multidisciplinary team, we demonstrated that open descending thoracic aorta replacement can be performed with excellent early outcomes with low reintervention rates, regardless of the nature of the aortic pathologies.

Anomaly of Haughton type D left cervical aortic arch in combination with type B dissection: case report and literature review

BackgroundThe anomaly of cervical aortic arch is a rare phenomenon first described by Reid in 1914 and categorized by Haughton in 1975. The left cervical aortic arch Type D consisting of an ipsilateral descending aorta and coarctation or aneurysmatic formation of the arch demonstrates a complicated form requiring surgical management. Because of its rarity and unspecific symptoms only few cases are documented with the focus on surgical management.Case presentationA 43-year old, asymptomatic woman presented with a mediastinal mass overlapping the aortic arch region in a routine x-ray. For verification, a computed tomography was performed and revealed incidentally a type B dissection originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Surgical access was performed through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space. Simultaneously to the preparation, partial cardiopulmonary bypass was installed in the left groin. After preparation of the recurrent and phrenic nerve and the supraaortic branches, the descending aorta was clamped. Before the distal anastomosis to a straight graft, we performed a fenestration of the dissection membrane about a length of 5 cm to preserve the perfusion of both lumina. Then, the straight graft was sutured to the proximal part of descending aorta. The left axillary artery originated directly from the aneurysm and was dissected and reimplanted with a separate 8 mm sidegraft to the straight graft between the distal arch and proximal descending aorta. The patient was extubated on first postoperative day and recovered well.ConclusionThe left cervical aortic arch type D is a rare disease, which is prone to aneurysm formation due to abnormal flow patterns and tortuosity of the aorta. The difficulty lays in the identification of the pathology, especially in the physical examination, since a pulsating mass or cervical murmur seem to be the most specific symptoms in the majority of young, female patients. If diagnosed, surgical therapy with resection of the aneurysm and reimplantation of the axillary artery under cardiopulmonary bypass demonstrates the treatment of choice.