Selective Cerebral Perfusion Time Research Articles

Contemporary Single-Center Experience of Complete Aortic Arch Replacement Employing the Frozen Elephant Trunk Technique in Patients with Extensive Aortic Disease

Objective: This study aimed to examine contemporary results of the frozen elephant trunk (FET) procedure in an all-comers patient cohort. Methods: Between January 2017 and May 2024, a total of 132 consecutive patients with either aortic aneurysm (n = 32), acute aortic dissection (n = 32), or chronic aortic dissection (n = 68) underwent total aortic arch replacement employing the FET technique. In-hospital data were collected prospectively and included preoperative characteristics, intraoperative data, and follow-up results. Results: The median cardiopulmonary bypass time, cardiac ischemia time, and selective antegrade cerebral perfusion time were 180 (161–205), 89 (70–113), and 45 (38–54) min, respectively. Total 30-day mortality rate was 7.6% (n = 10). The rate of major postoperative neurological complications was 6.8% (n = 9) for perioperative stroke and 2.3% (n = 3) for permanent spinal cord injury. Five patients (3.8%) required hemofiltration at the time of discharge due to postoperative kidney injury. Rates of subsequent endovascular and open aortic repair following primary FET were 40.9% (n = 54) and 3.8% (n = 5), respectively. The median time to reintervention was 86 (30–439) days. The median follow-up time was 25 (8–52) months, and overall survival rates at 1, 2, and 3 years were 89%, 89%, and 87%, respectively. Conclusions: Our data are consistent with current reports, indicating that the FET technique is a valuable adjunct in treating extensive aortic arch pathologies. The procedure provides an increasingly safe and effective option for complete aortic arch replacement, even in patients requiring a redo procedure.

Early outcomes of total arch replacement in the treatment of aortic dissection

Abstract: Overview: Aortic dissection are severe pathologies with high mortality and complication rates post-surgery despite significant advancements in both diagnosis and surgical treatment. Aortic arch replacement surgery is a classic and highly effective treatment method at Cho Ray Hospital. Objectives: Describe clinical, paraclinical characteristics, postoperative results, general complications and early hospital mortality. Methods: Descriptive cross sectional study. Results: 102 patients underwent aortic arch replacement surgery due to aortic dissection. Males predominated at 72.5%. The male:female ratio was 2.5:1. The average age was 56.45 ± 11.79 years. A history of hypertension was present in 81.4% of cases. Most patients with aortic dissection were admitted in an acute condition, accounting for 95%. Patients with type A aortic dissection accounted for 87.3%, with the entry tear in the ascending aorta at 27.5%. Isolated aortic arch replacement was performed in 46.1% of patients, while 53.9% underwent aortic arch replacement with frozen elephant trunk technique. 7 patients required aortic root replacement, 7 needed aortic valve surgery, and 10 required CABG. Most patients were cooled to 25 degrees C with cerebral perfusion to three branches. Ascending aorta cannulation was established in 45.2% of cases. The average cardiopulmonary bypass time was 257.7 minutes, with selective cerebral perfusion time at 115.9 minutes and lower body circulatory arrest time averaging 57.2 minutes. Postoperative neurological complications occurred in 10.8%, and the rate of renal failure requiring dialysis was 17.8%. The mortality rate was 9.6%. Longer cardiopulmonary bypass times and body temperatures above 25 degrees significantly increased the rate of postoperative renal failure requiring dialysis. Patients with postoperative renal failure requiring dialysis had a statistically significant increase in postoperative mortality rates. Aortic root intervention surgery combined with arch replacement did not affect the rate of postoperative complications. Aortic arch replacement with frozen elephant trunk technique did not affect cardiopulmonary bypass time, clamping time, or the rate of postoperative complications. Conclusions: Total arch replacement at Cho Ray Hospital initially showed a safe and effective with acceptable mortality rate.

The results of single–stage repair for coarctation with ventricular septal defect in neonates

Background: The association of coarctation of the aorta (CoA) with a ventricular septal defect (VSD) in neonates is seriously who needs to surgery if not control heart failure by medicine in neonates. There are 2 procedures for repair includes: Two-stage repair (the repair coarctation and closure of the concomitant VSD as a secondary procedure), One-stage repair (the repair coarctation and closure of the concomitant VSD). Methods: We retrospectively reviewed patients (in neonate) undergoing repair of CoA with closure of VSD from 1/2015 to 12/2023. There were sixteens patients who underwent one-stage repair. The mean of age and body’s weight were 21 days (range from 14 days to 29 days) and 3,3 kilograms (range from 2,9 to 3,6). All patients had severe heart failure, lager VSD and gradient through aortic isthmus that was 54 mmHg. Results: The time of cardiopulmonary bypass, aortic clamping and selective cerebral perfusion time were: 126 mins; 87 mins and 18 mins. There were 5 patients with open chest. One patient died at ICU by multiple organ failure and one patient with cerebral haemorrhage. The gradient postopration of aortic arch was 7 mmHg with no residual VSD. During follow-up time 57 months after surgery, there was no late death. The mean gradient of aortic arch was 12 mmHg and one patient with 25 mmHg Conclusion: The results of single–stage repair for coarctation with ventricular septal defect in neonates was good with low re-coarctation.

Aortic arch repair with extended end-to-side anastomosis in neonates and infants with transverse arch hypoplasia

Background/Aim: The use of patches to repair the aortic arch is believed to have a positive effect on long-term morbidity. In this study, perioperative and follow-up data of patients who underwent transverse arch repair with a patch were compared with the data of patients who underwent end-to-end anastomosis (ESA). Methods: In this retrospective cohort study, the data of 27 patients (including 18 newborns) who underwent aortic arch repair at the Gazi Yasargil Education and Research Hospital between January 2018 and April 2023 were analyzed. The inclusion criteria included a diagnosis of proximal and distal transverse aortic arch hypoplasia, an age younger than 12 months of age, and the completion of aortic arch repair using cardiopulmonary bypass. Patients who underwent recoarctation repair due to residual obstruction, patients with single ventricular physiology, and patients who underwent aortic arch repair via a lateral thoracotomy without undergoing cardiopulmonary bypass were excluded from the study. The patients were divided into two groups. Group 1 included individuals who underwent aortic anterior wall expansion with autologous pericardium in addition to ESA; Group 2 included patients who underwent ESA only. Results: The median age of the patients was 21 days (range: 6–365 days), and the median body weight of the cohort was 3.5 kilograms (range: 2.4–8.9 kilograms). Enlargement with autologous pericardial patch was applied to 11 patients (40.7%). Surgical procedures performed in addition to arch repair included eight ventricular septal defect closures, six instances of pulmonary banding, three atrial septal defect closures, and one subvalvular pulmonary stenosis repair. The in-hospital mortality rate was 11.1% (n=3). Those three patients died due to sepsis. The median follow-up period was 152 days (range: 10–1316 days). Recoarctation requiring re-intervention did not occur in any of the studied patients. The antegrade selective cerebral perfusion time was statistically significantly longer in patients who underwent aortic arch repair using a patch (P=0.03). Conclusion: Repair of the arch with a patch may contribute to a reduction in long-term mortality and morbidity. However, there is a need for more comprehensive and long-term follow-up studies to verify these findings.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies.

Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.

Normothermic Versus Hypothermic Norwood Procedure.

Either deep hypothermia with circulatory arrest or hypothermic perfusion with antegrade selective cerebral perfusion is used during the Norwood procedure for hypoplastic left heart syndrome. Normothermic perfusion has been described for pediatric patients. The aim of this study was to compare the early outcomes of patients undergoing the Norwood procedure with antegrade selective cerebral perfusion under hypothermia with the procedure under normothermia. From 2005 to 2020, 117 consecutive patients with hypoplastic left heart syndrome underwent the Norwood procedure: 68 (58.2%) under hypothermia and 49 (41.8%) under normothermia. Antegrade selective cerebral perfusion flow was adjusted to maintain right radial arterial pressure above 50 mm Hg, and a flow rate of 40 to 50 mL kg-1 min-1. Baseline characteristics, operative data, and postoperative outcomes including lactate recovery time were compared. The baseline characteristics and cardiovascular diagnosis were similar in both groups. The normothermic group had a significantly shorter bypass time (in minutes) of 90.31 (±31.60) versus 123.63 (±25.33), a cross-clamp time of 45.24 (±16.35) versus 81.93 (±16.34), and an antegrade selective cerebral perfusion time of 25.61 (±13.84) versus 47.30 (±14.35) (P < .001). There were no statistically significant differences in the immediate postoperative course, or in terms of in-hospital mortality, which totaled 9 (18.4%) in the normothermic group, and 10 (14.9%) in the hypothermic group (P = .81). The normothermic Norwood procedure with selective cerebral perfusion is feasible and safe in terms of in-hospital mortality and short-term outcomes. It is comparable to the standard hypothermic Norwood with selective cerebral perfusion.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients

ObjectivesThe partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated.MethodsBetween January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time.ResultsTotal early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87–155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53–375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64–0.91; P = 0.003), when compared with the FS group.ConclusionsThe early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.

Effect on surgery outcomes owing to the interval between onset of symptoms and surgery of patients with acute type A aortic dissection

Abstract Background: This study aimed to identify whether the interval from onset of symptoms to surgery affects the outcomes of surgery in patients with acute type A aortic dissection (AAAD). Methods: This study retrospectively examined 249 patients with AAAD who underwent Sun's procedure. All patients were divided into 2 groups, hyperacute and acute, according to the interval from onset of symptoms to surgery. The primary endpoint was all-cause early mortality, and the secondary endpoint was early reoperation. Results: The surgery time, cardiopulmonary bypass time, clamp time, and selective cerebral perfusion time were not significantly different between the 2 groups. The intensive care unit length of stay and duration of mechanical ventilation of the 2 groups were 185.50 hours versus 185.00 hours (P = 0.970) and 41.50 hours versus 44.00 hours (P = 0.678), respectively. There were 52 early deaths: 29 in the hyperacute group and 23 in the acute group (21.6% vs. 20.0%, P = 0.751). The incidence of reoperation was 0.7% and 0.9% (P &gt; 0.999), respectively. The incidence rates of postoperative acute heart failure (AHF), acute respiratory failure (ARF), nervous dysfunction, and acute kidney injury were 37.3% versus 25.2% (P = 0.041), 51.5% versus 51.3% (P = 0.976), 13.4% versus 7.0% (P = 0.096), and 37.3% versus 37.4% (P = 0.990), respectively. Multivariable analysis indicated that surgery in the hyperacute phase might be an independent risk factor for AHF (OR: 1.765; 95% CI: 1.021–3.052; P = 0.042). Conclusion: Surgery in the hyperacute phase of AAAD was associated with postoperative AHF. Therefore, early medical management or interventional therapy for complications before surgery performed by experienced surgeons is recommended, especially in the hyperacute phase.

Extensive Arch Repair with a Novel Two-Branched Stent Graft in Acute Type A Aortic Dissection.

Purpose: In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.Methods: Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).Results: The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.Conclusion: Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.

Total aortic arch replacement using the thoraflex hybrid prosthesis: early- and medium-term results from a Scandinavian center

Objective. The purpose of this study was to assess our early experience with the Thoraflex hybrid prosthesis. Design. This was a retrospective, single-center cohort study. Results. Between December 2014 and December 2019, 34 patients underwent total aortic arch replacement with the Thoraflex hybrid prosthesis. Fifteen of the patients had pre-operative chronic aortic dissection. The mean cardiopulmonary bypass time was 200 ± 35 min, aortic cross clamp time 114 ± 34 min, deep circulatory arrest time to the lower body 60 ± 22 min, and selective antegrade cerebral perfusion time 67 ± 24 min. The rate of stroke was 11.7% (4/34), paraparesis was 8.8% (3/34) and renal failure was 11.7% (4/34). No patient required permanent dialysis. Three (8.8%) patients died within the first 30 days postoperatively. All early deaths were due to stroke or spinal cord complications. During follow-up, an additional four patients died. Average follow-up was 32.4 ± 19.4 months (1102 patient-months) and was 100% complete. Survival at 12 months and 36 months was 88% ± 7.2% and 75% ± 12.7%, respectively. Conclusions. The Thoraflex hybrid prosthesis can be used in the setting of total aortic arch replacement with good early- and medium-term results. Stroke and spinal cord complications remain an important source of early mortality.

Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair

BackgroundThe optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection.MethodsWe performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated.ResultsFemoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure.ConclusionFemoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.

Single-stage repair for coarctation with ventricular septal defect: results of 100 cases at a single centre.

The outcomes of the single-stage surgical repair of aortic arch hypoplasia (AAH) and/or coarctation of the aorta (CoA) associated with ventricular septal defect (VSD) remain controversial, especially in a lower middle-income country. This study reports the results of a single-stage repair protocol at our institution for AAH/CoA with VSD using selective cerebral perfusion. This retrospective study included 100 consecutive patients who underwent single-stage repair via median sternotomy using selective cerebral perfusion for AAH/CoA with VSD from July 2010 to March 2017. The patients consisted of 65 males and 35 females. The median age of the patients was 67 days (range 4-2266 days); the median weight was 3.8 kg (range 2.1-15 kg). The average cardiopulmonary bypass time was 132 ± 28 min, the aortic cross-clamp time was 92 ± 23 min and the selective cerebral perfusion time was 33 ± 10 min. The survival rate of all patients was 94.7 ± 2.3%, with an in-hospital mortality of 5% and no late mortality at a median follow-up of 37 months (range 4-96 months). Four patients required reoperation due to recoarctation. The overall event-free survival rate following surgery was 87.1%. The median pressure gradient across the anastomosis at the last follow-up was 8.3 ± 2.8 mmHg. Multivariate logistic regression analysis revealed proximal aortic arch obstruction as a predictor of mortality (odds ratio = 3.8). The aortic isthmus diameter was identified as a predictor for reintervention by Cox regression (hazard ratio = 6.7). Single-stage repair for AAH/CoA with VSD is safe and feasible in a developing country.

The surgical management of type IA endoleak after thoracic endovascular aortic repair

Our goal was to investigate the surgical strategy for type Ia endoleak after thoracic endovascular aortic repair (TEVAR) by reporting our experiences. From November 2012 to September 2019, a total of 23 patients received surgical management for type Ia endoleak after TEVAR. The operations included total arch replacement with the frozen elephant trunk technique in 15 patients, direct closure of the endoleak in 2 patients, hybrid aortic arch repair in 4 patients, arch debranching with TEVAR in 1 patient and left common carotid artery to left subclavian artery bypass with TEVAR in 1 patient. Among 21 patients with cardiopulmonary bypass (CPB), the mean CPB and aortic cross-clamp times were 146.7 ± 42.2 and 81.0 ± 43.3 min, respectively. The selective cerebral perfusion time was 18.8 ± 8.2 min in 17 patients with hypothermic circulatory arrest. The in-hospital mortality was 8.7% (2/23). Type Ia endoleak was sealed successfully after surgery in 95.5% (21/22) of patients. The follow-up data were available for all 21 survivors. The median follow-up period was 18 months (range 1-84 months). During the follow-up period, a total of 8 patients died or had aortic events, including 5 deaths and 6 aortic events. Different surgical strategies could be selected to treat patients with type Ia endoleak after TEVAR, with acceptable early and late outcomes.

Application of the modified stented elephant trunk procedure in type B aortic dissection.

BackgroundConsidering the progressive nature of complicated Stanford type B aortic dissection (TBAD), operation must anticipate the need for later interventions. Recently we have used a modified stent elephant trunk (SET) procedure to treat these patients. And we review the indications, considerations for planning, and operative details for this this modified SET procedure.MethodsTen patients (seven males and three females) with complicated TBAD underwent a modified SET procedure in Anzhen Hospital, Beijing in the period between January 2019 and December 2019. The patients, whose ages ranged from 29–52 (42±7.23), suffered complications with hypertension. Under deep hypothermic circulatory arrest, all the patients received SET implantation via an incision of the aortic arch. Before the patients were discharged, a computed tomography angiography (CTA) was performed to ensure the safety and accuracy of the procedure.ResultsThe average surgery time was 4.0–5.5 (4.65±0.47) hours, cardiopulmonary bypass (CPB) time was 115–163 (138.6±15.64) minutes, aortic cross-clamping time was 32–59 (42±7.72) minutes, and selective cerebral perfusion (SCP) time was 15–32 (21.7±5.56) minutes. The SCP flow and nasopharyngeal temperature were 5–8 (6.8±1.23) mL/kg/min and 23.5–26.8 (25.22±0.96) °C, respectively. During SCP, the blood pressure of the left upper limb was 20–31 (25.5±3.81) mmHg. Aorta cannulation position: vascular graft was anastomosed to the innominate artery (IA) and left subclavian artery (LSA) in seven cases, and with IA, LSA, and the right femoral artery in three cases. Ventilation time was 5–15 (8.8±2.94) h, retention time in ICU was one day, and post-operative hospitalization time was 6–8 (6.9±0.74) days. None of the patients died, or experienced endoleakage or neurological complications.ConclusionsThe application of a modified stented elephant trunk procedure in the treatment of TBAD is safe and efficient.

The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.

Our goal was to review the surgical treatment of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) in our centre. From January 2014 to April 2018, 22 patients with RTAD after TEVAR were operated on in our centre. The mean age at operation was 52.0 ± 8.0 years old. The median interval between the primary TEVAR procedure and RTAD was 4.6 months (range 0-120 months). The postoperative mortality and morbidity rates were calculated to evaluate the early and long-term results. Twenty patients received total arch replacement with the frozen elephant trunk technique and 2 patients received total arch replacement alone. The mean cardiopulmonary bypass time, aortic cross-clamp time and selective cerebral perfusion time were 172.4 ± 39.3, 100.1 ± 30.3 and 19.7 ± 10.5 min, respectively. The incidence of major adverse events was 18.6% (4/22), including stroke in 1 patient, myocardial dysfunction in 1 patient and renal failure necessitating dialysis in 3 patients. Death within 30 days was 13.6% (3/22 patients). The follow-up data were available for all 19 survivors. The mean follow-up period was 32.2 ± 16.2 months (range 10-62 months). No deaths or aortic-related events occurred during the follow-up period. Total arch replacement with or without the frozen elephant trunk technique was suitable for the management of RTAD after TEVAR, with acceptable early and long-term results.

Fenestrated Stent for Arch Repair for Acute Stanford Type A Aortic Dissection – A Conservative Solution for Complex Condition

Introduction: The best surgical strategy for acute Stanford type A aortic dissection (aTAAD) involving the arch is controversial. We have used a novel method that antegrade implanting a previously fenestrated stent for arch repair, which have revealed acceptable results. Methods: From December 2014 to December 2016, 81 aTAAD patients (52 male, 29 female) underwent ascending aorta replacement and fenestrated stent graft implantation. The fenestrated stent graft was implanted into the true lumen of aortic arch during the hypothermia circulation arrest period. The proximal descending aorta with the fenestration opening at the ostia of three head vessels in the arch. The proximal end of the stent graft was anastomosed to the distal end of the Dacron tube graft that replaced the proximal ascending aorta. All patients had contrast enhanced computed tomography angiography before discharge and during follow up. Results: The cardiopulmonary bypass time was 213 ± 49 minutes, aortic cross-clamp time was 133 ± 39 minutes, and selective cerebral perfusion and lower body arrest time was 27 ± 8 minutes. There were 5 in-hospital deaths due to circulation failure, multiple organ dysfunction and pulmonary infection (with the mortality of 6.2%). 5 patients died during follow-up period, the main causes of follow-up mortality were cerebral events and aortic rupture. The surviving patients had contrast enhanced CT scans in the 3rd, 6th, and 12th months. The morbidity of complication of endoleak from supraarch vessels was 5.6% (4/71), but all 4 patients were under follow-up without intervention because no dilation were discovered. The flow up CT revealed increasing false lumen thrombosis. Conclusion: In patients with aTADD, the previously fenestrated stent graft results in excellent aortic remodeling of the aortic arch and descending aorta without increasing morbidity and mortality. The risk of endoleak is maybe the underlying complication. But it will be a conservative solution for arch repair in aTAAD, especially concomitant with severe conditions. Disclosure: Nothing to disclose

Aortic dissection patients mimic acute coronary syndrome with preoperative antiplatelet therapy.

Acute Stanford type A aortic dissection (ATAAD) is often misdiagnosed as an acute coronary syndrome (ACS), and antiplatelet therapy (APT) for ACS will influence the timing and outcome of ATAAD. We reviewed the surgical outcome of these misdiagnosed ATAAD patients. From January 2011 to December 2015, 309 ATAAD patients received surgical therapy in our department, among whom 15 patients were misdiagnosed as ACS and took oral APT. We retrospectively reviewed the data of the perioperative and follow-up period. The average age of these 15 patients was 60.6±8.7 years old (9 males, 6 females). Five patients took aspirin orally, and 10 took aspirin and clopidogrel. Operations were performed 7, 3, and 1 day after stopping the agents in 2, 3, and 1 patient, respectively; the other 5 patients received emergency operation without stopping the agents. The cardiopulmonary bypass (CPB) time was 259.7±64.8 minutes, aortic cross-clamp time was 181.0±51.7 minutes, and selective cerebral perfusion and lower body arrest time were 34.9±8.1 minutes. There were two in-hospital deaths due to circulation failure (mortality 13.3%). The average drainage volume in the first 24 h after operation was 800.7±598.8 mL. During a mean follow-up period of 20.6±17.4 months, one patient had a sudden death. ATAAD misdiagnosed as ACS is not rare, and APT will increase the risk of bleeding in ATAAD patients. The decision of operation time relies on considering the balance between the rupture risk of aortic dissection and the hemorrhage risk of APT. The emergency operation for these patients will increase bleeding and transfusion.

Risk Factors for Postoperative Delirium in Type A Aortic Dissection Patients: A Retrospective Study.

BackgroundPostoperative delirium (POD) is a common complication in cardiac surgery among adult patients. This retrospective study was designed to identify the risk factors associated with POD of type A aortic dissection patients.Material/MethodsClinical data of 148 patients with type A aortic dissection in the Department of Critical Care Medicine was retrospectively analyzed. All these patients underwent Sun’s procedure with anesthetic treatment. The confusion assessment method for intensive care unit (CAM-ICU) was adapted to evaluate the delirium status of these patients. They were divided into 2 groups: the delirium group and the control group. Univariate analysis and multivariate logistic regression were performed in succession to determine the independent risk factors for POD.ResultsThe average age of these patients was 54.41±11.676 years old. Among the 148 patients, POD was detected in 68 patients, with an incidence of 45.95%. According to univariate analysis, age, irritability, alcohol use, extracorporeal circulation duration (cardiopulmonary bypass, CPB time), antegrade selective cerebral perfusion (ASCP) time, lowest partial pressure of oxygen (lowest PO2), mechanical ventilation time, blood loss, low PO2 and oxygenation index, hemoglobin (Hb), Intensive Care Unit (ICU) stay, and dihydroxyphenylalanine (DEX) were associated with higher odds of POD among type A aortic dissection patients. According to further analysis of multivariate logistic regression, ASCP time and irritability were confirmed as the independent factors for POD of type A aortic dissection patients.ConclusionsWe determined 2 independent risk factors for POD: ASCP time and irritability. Identifying and adjusting these risk factors are very important in reducing the incidence of POD among type A aortic dissection patients.