Surgical Repair Of Aortic Dissection Research Articles

Asymptomatic Aorto-Atrial Fistula Secondary to Surgical Repair of Ascending Aortic Dissection: When to Do Nothing

Secondary aorto-atrial fistula is a rare but potentially life-threatening complication of ascending aortic dissection surgical repair. Secondary aorto-atrial fistulas commonly lead to symptomatic heart failure requiring emergent repair. We present a rare case of secondary aorto-atrial fistula after surgical repair of aortic dissection that remained asymptomatic for a decade. (Level of Difficulty: Intermediate.)

High-Dose Tranexamic Acid in Patients Underwent Surgical Repair of Aortic Dissection Might Reduce Postoperative Blood Loss: A Cohort Analysis.

IntroductionWhile tranexamic acid (TXA) is widely used in patients with acute type A aortic dissection (ATAAD) who undergo surgical repair to reduce blood loss and transfusion requirement, the optimal dosage of TXA is unknown in these patients.Materials and MethodsThis was a retrospective cohort study that compared high-dose (>50 mg/kg) and low-dose TXA (≤50 mg/kg) in patients with ATAAD who underwent surgical repair. Propensity score matching (PSM) was performed between the two groups and results were analyzed in matched cases. The primary outcome was postoperative blood loss within 3 days after surgery. The secondary outcomes were total blood loss after surgery and perioperative blood transfusion, and safety outcomes were also assessed.ResultsThrough medical record screening, 529 patients were identified. After PSM, 196 patients in the high-dose group and 196 patients in the low-dose group were matched and included in the final analysis. Postoperative blood loss in 3 days after surgery was 940 mL (710–1,010 mL) in the low-dose group and 695 mL (620–860 mL) in the high-dose group. The difference was statistically significant (P < 0.001). Total postoperative blood loss was also statistically less in the high-dose group compared to the low-dose group (1,890 mL (1,410–2,100 mL) vs. 2,040 mL (1,460–2,320 mL), P = 0.032). No difference was found between the two groups in transfusion and safety outcomes.ConclusionIn ATAAD patients who underwent surgical repair, high-dose TXA significantly reduced postoperative blood loss compared to low-dose TXA, while no difference in transfusion or adverse events was found.

Partially Resorbable Mesh Inclusion between Dissected Layers during Surgical Repair of Aortic Dissection.

Surgical management of aortic dissection is technically challenging for different reasons. Reapproximation of dissected layers because of fragility of the dissected aortic wall layers is of major concern. Many techniques have been described to restore the integrity of aortic wall. Inclusion of a partially resorbable mesh fixed with glue, between the dissected layers, may be a simple and effective method for providing a secure and viable end-to-end anastomosis between aortic stump and a Dacron graft.

It is a medical emergency! Act fast: a case report of painless aortic dissection.

BackgroundA painless presentation of aortic dissection is rare in about 5% of cases. A few case reports discussed about involvement of coronary arteries causing bradycardia. In our case, we are presenting a rare presentation of aortic dissection with initial presentation as bradycardia without involvement of coronary arteries and without cardiac symptoms.Case summaryA 56-year-old man with history of hypertension presented with acute onset of altered mental status and right hand numbness. Initial vital signs were remarkable for bradycardia with heart rate 36/min. Physical exam was only significant for decreased sensation for light touch on right hand. Electrocardiogram showing marked sinus bradycardia. Initial computed tomography (CT) head did not show any acute abnormalities. On Day 2, patient complained of new weakness in left upper extremity. On exam, he had dysmetria, left upper extremity drift and cold to touch. Blood pressure was significantly different in both arms with 141/83 mmHg on right and 44/23 mmHg on left. He underwent immediate CT angiography chest showing Type 1 aortic dissection with extension into the brachiocephalic artery and right common carotid artery (RCCA) with thrombosis in RCCA. Patient was emergently taken for surgical repair of aortic dissection and resuspension of aortic valve.DiscussionIn our case, the initial presentation of aortic dissection included isolated sinus bradycardia without cardiac symptoms and no evidence for atrioventricular block. The mechanism may have been involvement in the arterial supply of the carotid body receptors. Patients with coexisting symptoms such as bradycardia and neurological deficits should be evaluated for aortic dissection.

Hospital outcomes of antegrade versus retrograde arterial cannulation in type A aortic dissection: A single center experience

Backgroundthe aim of our study was to evaluate the impact of different cannulation strategies, retrograde and antegrade, on outcome of type A aortic dissection (TAAD) surgery and to identify the predictors of perioperative transient & permanent neurologic dysfunction. MethodsBetween March 2014 and September 2017, 50 patients with TAAD who underwent surgical repair of aortic dissection at Kasr Alainy Hospital, Cardiothoracic Surgery Department were divided into two equal groups: The first group had retrograde (femoral) cannulation, while the second group had antegrade cannulation (central, right axillary, and innominate artery). Resultsthe mean age was 52.6 ± 7.55 years in the retrograde group and 46.5 ± 10.53 years in the antegrade group. There were 3 deaths in the retrograde group (12%) and 2 deaths in the antegrade group (8%). Transient neurologic dysfunction was observed in 4 patients (16%) in the first group and 0 patients (0%) in the second group. A total of 3 patients (12%) in the first group suffered from a permanent neurologic dysfunction to 2 patients (8%) in the second group. ConclusionsThe cannulation site in an aortic dissection should be carefully chosen on a case-by-case basis and larger study is recommended to better evaluate optimal cannulation technique.

Abstract P226: Aggressive Blood Pressure Control Status Post-acute Aortic Dissection May be Associated With Acute Kidney Injury: A Pilot Study

Management of acute aortic dissection includes appropriate blood pressure control (120/80 mmHg per AHA guidelines) but this is not based on evidence. Excessive lowering of blood pressure may contribute to organ malperfusion. The kidneys are the most commonly affected organs, causing refractory hypertension and acute kidney injury (AKI). Recent landmark blood pressure trials with intensive pressure goals have a significant incidence of AKI. This pilot study tested the hypothesis that achieved systolic blood pressure less than 120 mmHg has a higher incidence of AKI than those treated systolic pressures &gt; 120 mmHg. Methods: Patients were identified via surgical log. Retrospective chart review was performed on patients in the acute setting following dissection. Daily average blood pressures were calculated. Patients were included if they underwent surgical repair of aortic dissection and survived the first 24 hours. Patients were excluded if they demonstrated shock physiology or required renal replacement therapy in the first 24 hours. Serum creatinine and clinical course (including anti-hypertensive regimen) were recorded. The primary endpoint was in-hospital occurrence of AKI (defined per KDIGO criteria) in the acute setting status post aortic dissection in patients receiving anti-hypertensive therapy. An unadjusted odds ratio was calculated. Data on potential confounders and covariates (baseline sCR, contrast exposure etc) were also collected. Results: From 2013-2017, 37 cases of surgically repaired aortic dissection were identified and 16 cases met inclusion/exclusion criteria. The incidence of AKI in patients treated to an average systolic blood pressure less than 120mmHg was 75% compared with 50% in those with pressure greater than 120 mmhg. OR =3.0 [95% CI 0.3612-24.9];p=0.3019. Covariates and potential confounders were balanced between groups but given the small numbers additional statistical adjustments were not performed. Conclusion: The incidence of AKI was numerically higher in the group of patients achieving more intensive blood pressure targets. Our study was limited by small sample size and selection bias. Both of these issues can be addressed if we apply similar methodologies to address the same question on a lager sample size.

In Memoriam: Jimmy Frank Howell (1932–2014)

In Memoriam: Jimmy Frank Howell (1932–2014)

A case of carotid artery dissection after surgical repair of aortic dissection successfully treated with endovascular therapy using intravascular ultrasound

A 71-year-old woman developed the dissection from right brachiocephalic trunk (BCT) to internal carotid artery 6days after the operation of ascending aortic dissection. Since no improvement of symptoms was observed despite conservative therapy, we performed endovascular therapy (EVT). Although a balloon-expandable stent was implanted in the BCT to seal the entry point of the dissection, the true lumen of the carotid artery was still compressed. Thus, we covered the dissected lesion completely with multiple stents, and her neurological findings improved. This case demonstrates that EVT using multiple stents is an effective strategy to manage dissection of supra-aortic branches.

Acute coronary syndrome in a patient with Marfan syndrome following emergent surgical repair of aortic dissection

We report a case of acute coronary syndrome in a patient with suspect Marfan syndrome, 25 days after emergent modified Bentall-De Bono intervention for acute type I peripartum aortic dissection. She was admitted to our intensive care unit because of unstable angina, caused by critical blood flow reduction in a large portion of the myocardium, according to the severity of the symptoms and the electrocardiographic alterations. Coronary angiography showed a sub-occlusive stenosis of the left main coronary artery as a result of the dissection extension to the coronary ostium. Because of the high risk related to heart surgery, the patient was successfully treated by unprotected angioplasty and drug-eluting stent positioning. Short- and mid-term outcomes were favourable. Subsequent tests confirmed the diagnosis of Marfan syndrome. After 2 years of follow-up, the patient remains asymptomatic and in good health. To our knowledge, this is the first report of a successful percutaneous intervention of the left main coronary artery in a patient with Marfan syndrome who had already undergone ascending aortic root and valve replacement by the Bentall-De Bono procedure for acute dissection.

Extended repair of aortic dissection with an integrated stentgraft dacron prosthesis: The fate of the false lumen

Objective: Standard surgical repair of aortic dissection leaves the descending aorta untreated. The hybrid approach using an integrated stentgraft Dacron prosthesis allows for extended repair including the descending aorta. It was investigated whether this has an impact on the fate of the false lumen.

Detection and Monitoring of Complications Associated With Femoral or Axillary Arterial Cannulation for Surgical Repair of Aortic Dissection

Femoral arterial perfusion can be associated with complications, and axillary arterial perfusion is not free from risk. The purpose of this study was to describe the incidence and complications of femoral versus axillary artery cannulation for surgical repair of aortic dissection and to devise a strategy for early detection and monitoring of complications using transesophageal echocardiography, near-infrared spectroscopy, and orbital Doppler. Retrospective and observational. University hospital. Seventy-five consecutive patients with aortic dissection who underwent aortic repair between 1995 and 2004. Aortic surgery. Among the 44 cases with femoral arterial perfusion, sudden onset of hypotension occurred in 3 cases but was immediately treated based on the TEE diagnosis (collapse of true lumen in the descending aorta). In another case, myocardial ischemia occurred because of occlusion of the coronary artery. These four cases comprised 57.1% of 7 patients with type III dissection with retrograde extension in whom femoral arterial perfusion was used. However, malperfusion was not encountered in 3 cases of the same type of dissection but with axillary arterial perfusion. Axillary artery perfusion (29 cases) led to malperfusion of the right frontal lobe and coronary artery in 1 case each. Flexible management guided by real-time information is essential. Upon initiating femoral arterial perfusion, malperfusion should first be checked for in the descending aorta and then in the coronary and visceral arteries, especially in cases of type III dissection with retrograde extension. Attention should be paid to cerebral and coronary malperfusion when initiating axillary arterial perfusion.

INVITED COMMENTARY

Surgical repair of aortic dissection in previously operated patients is quite challenging. The Cleveland Clinic reports superb results in this quite infrequent population: early mortality rate is minimal and long-term survival remarkable. The relatively small number of patients in a very unstable situation does not by itself explain these rewarding results. However, the low mortality reflects the quality of patient management both in the preoperative period (proper stabilization of the clinical condition and thorough evaluation) and during surgery (adequate arterial perfusion, fine surgical techniques, and adequate medical management). The major limitation of the paper is that it does not address the mechanism of aortic dissection following cardiac surgery. Every patient category is pooled and the study population includes patients operated for very different pathological lesions: coronary artery disease, aortic valve disease, or ascending aorta pathology, including chronic aneurysms and acute aortic dissections. The mechanism of the aortic dissection developing during long-term follow-up of these operations may be the consequence of a surgical problem during the first operation (eg, abnormality either on the suture line in saphenous vein bypass surgery or on the aortic suture after valve replacement; or weakening of the media at the site of the aortic cross clamping). The mechanism may also relate to the use of “tricks”, like application of gelatin-resorcin-formalin glue to the tissues [1Kirsch M. Ginat M. Lecerf L. Houël R. Loisance D. Aortic wall alterations after use of gelatin-resorcinol-formalin glue.Ann Thorac Surg. 2002; 73: 642-644Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], to minimize the risk of tears and bleeding. Finally, the mechanism may relate to some biological abnormalities of the aortic wall, which are responsible for extreme weakness of the mural structure. These abnormalities sometimes may be present at the time of the first operation, like in a bicuspid aortic valve, ascending aorta enlargement, or a previous acute aortic dissection; or sometimes may develop after cardiac surgery in poorly managed patients who continue to smoke or who have uncontrolled hypertension. The aortic wall structure results from a balance between proteolytic activity mainly controlled by proteolytic enzymes and metalloproteinases-tissue inhibitors of MPs (MMP-TIMPs) interactions and permanent synthesis of new structural proteins, partly controlled by tissue growth factors [2Allaire E. Muscatelli-Groux B. Guinault A. et al.Vascular smooth muscle cell endovascular therapy stabilizes already developed aneurysms in a model of aortic injury elicited by inflammation and proteolysis.Ann Surg. 2004; 239: 417-427Crossref PubMed Scopus (70) Google Scholar]. Loss of this balance, either genetically controlled or as the consequence of an abnormal inflammatory process, will increase the risk of intramural hemorrhage and/or intimal fracture. Recognition of this situation at the time of the first operation should have an impact on the initial repair itself (eg, aortic root replacement in a bicuspid orifice, extensive surgery of the aorta in aortic dissection, etc). In the mean time the more liberal use of modern imaging techniques like magnetic resonance and helicoidal scanners should permit earlier detection of an abnormal risk of aortic dissection. Aortic Dissection After Previous Cardiovascular SurgeryThe Annals of Thoracic SurgeryVol. 78Issue 6PreviewRisk of repairing aortic dissection after previous cardiovascular surgery has not been described clearly. This study assesses early and late outcomes of such reoperations. Full-Text PDF

Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection.

In patients undergoing surgical repair of aortic dissection, false lumen perfusion during cardiopulmonary bypass may produce central nervous system damage, myocardial ischemia, aortic rupture, and death. We describe a method to detect false lumen perfusion at the beginning of retrograde aortic perfusion that may prevent these complications. Sonicated albumin microbubbles (8 mL) were injected through a side branch of the extracorporeal circulation line to detect true lumen and/or false lumen perfusion of the thoracic aorta at the beginning of cardiopulmonary bypass. Transesophageal echocardiography was used to image aortic perfusion. The study was performed in a cardiac surgery theater. A total of 27 consecutive patients undergoing operation for Type I aortic dissection were studied. All patients underwent surgical repair of aortic dissection and retrograde aortic perfusion through one femoral artery. Patients were divided into three groups: Group I, those having adequate true lumen perfusion: brisk appearance and washout of contrast in the true lumen with no, poor, or delayed opacification of the false lumen; Group II, those having mixed true lumen and false lumen perfusion: simultaneous opacification of both lumens; Group III, those having inappropriate false lumen perfusion: same criteria as for adequate true lumen perfusion applied to the false lumen. The true lumen was perfused in 13 patients, both lumens in 11 patients, and false lumen alone in three patients. In these three patients, cannulation was repeated through the contralateral femoral artery with restoration of true lumen perfusion; the first patient died of diffuse cerebral ischemic damage and renal failure, another one experienced temporary postoperative monoparesis, and the last had no neurologic sequelae. Contrast echocardiography allows immediate detection of retrograde aortic perfusion during cardiopulmonary bypass and may help prevent neurologic complications and death in patients with Type I dissection.

Visualization of Pattern Flow in Abdominal Arteries by Transgastric Echocardiography After Aortic Dissection Repair

The persistence of false lumen after surgical repair of aortic dissection is frequent. This event has a negative impact on the prognosis and is secondary to the persistence of unrepaired entry sites and of dissected major aortic branches. We describe three cases in which visualization of a dissected celiac trunk with an anomalous flow pattern was possible with transesoghageal echocardiography. Two of these cases died in the early postoperative period and the echo findings were confirmed at necropsy. We suggest that visualization of anomalous pattern flow in the celiac trunk is of prognostic relevance because it plays a major role in mantaining the false lumen persistence and, therefore, should be part of the routine examination after surgical repair of aortic dissection.

Postoperative Thrombus Formation in the False Lumen Following Surgical Repair of Aortic Dissection

During the period 1980 to 1990, 65 patients with aortic dissection underwent surgical treatment. The authors have mainly been using the entry closure proce dures to enclose the false lumen with thrombus for dissecting aortic aneurysm. The survival rate was 75%. In 36 long-surviving patients who have been able to be followed up postoperatively, angiography and/or computed tomography (CT) with contrast enhancement was used to evaluate the aortic and any resid ual false lumen during a mean follow-up of sixty months. Complete thrombotic closure of the false lumen was obtained in only 5 cases; 18 of the remaining 31 patients have developed almost complete thrombus for mation, and only local remaining false lumens were noted. In the other 13 pa tients (36%), an extensive residual false lumen was observed, mainly in the patients with an aneurysm of larger diameter where the preoperative CT im ages showed the false lumen to be larger than the true lumen, indicating the requirement for extensive aortic graft replacement or secondary operation.

MR imaging of the aorta after surgery for aortic dissection.

MR imaging is known to be an effective technique for the noninvasive diagnosis of thoracic aortic disease, but it has not been used to monitor the appearance of the aorta or the fate of the false lumen after surgery for aortic dissection. This study describes our initial experience with postsurgical MR imaging of aortic dissection (nine type A and two type B) to evaluate prognostically important features, including the status of residual false lumen. The most notable findings were (1) aneurysmal dilatation beyond the interposed graft (11/11 cases), (2) residual intimal flap (10/11 cases) with at least partial patency of the false lumen (10/10 cases), and (3) origin of a visceral vessel from the false lumen in persistently dissected abdominal aorta (6/9 cases). Evaluation of residual false lumen by double-spin-echo-intensity and phase-display techniques showed evidence of slow blood flow with variable amounts of thrombus in eight of 10 cases. Differentiation between signal within the false lumen due to slow flow and signal due to thrombus was facilitated by phase display. MR imaging can be used for noninvasive monitoring of the aorta after surgical repair of aortic dissection. Since the false lumen usually remains patent after surgical repair, such follow-up of its status seems necessary for identifying potential complications of the original dissection and/or the therapy.

Aortic Dissection Presenting as Pericarditis

In five patients with aortic dissection, signs and/or symptoms of pericarditis were part of the early manifestations of the aortic disease. Signs of inflammatory pericarditis were noted clinically in four patients and were found at autopsy in one. In the three nonoperated patients who died of aortic rupture leading to fatal hemopericardium, symptoms of pericarditis preceded fatal rupture of the aorta by four to five days. A fourth patient died after surgical repair of aortic dissection 35 days after the onset of pericarditis. In the fifth patient, manifestations of chronic constrictive pericardial disease occurred over a period of seven months after which old aortic dissection was first identified. In each case, the internal tear of classic aortic dissection was located in the ascending aorta. Microscopic evidence of cystic medial necrosis of the aorta was present in each case. In each of two cases, there was a congenital bicuspid aortic valve. The phenomenon observed represents acute aortic dissection in which slow penetration of blood into the pericardial space caused inflammatory pericarditis. The interval between the onset of pericarditis and rupture of the aorta may allow sufficient time for appropriate diagnosis and potentially lifesaving treatment of the aortic disease.