Surgical Treatment Of Acute Type Research Articles

Late aortic root redissection following surgical treatment for acute type A aortic dissection using Gelatin-Resorcin-Formalin glue.

Although Gelatin-Resorcin-Formalin (GRF) glue is widely used in surgery for acute aortic dissection, late complications possibly due to the glue, such as late aortic root redissection, have also been reported. We have experienced similar complications, some of which required redo surgeries, and these cases are reviewed. Twenty-six consecutive patients who underwent surgery for acute type A aortic dissection using GRF glue, from December 1996 to February 2001, were retrospectively studied, with a special focus on any late complications and any reoperation. Of the 21 patients who survived and were followed as outpatients, false aneurysms were found in 5 patients (21%) at 24-42 (mean 34) months following the initial surgery. Of these, 2 patients required resternotomy because of the increasing aneurysm diameter. In both cases, the aortic root was redissected at the site of the GRF glue use where the anastomosis between the aortic root and the prosthesis had widely opened and had become the aneurysm entry point. Significant aortic regurgitation was noticed in 3 patients (14%, 1 of whom showed a false aneurysm), and 2 of these underwent reoperation for aortic root redissection. A high incidence of aortic root redissection with false aneurysm and/or aortic insufficiency was found following the surgery for acute aortic dissection using GRF glue. These patients should be carefully followed for years after surgery.

New paradigms and improved results for the surgical treatment of acute type A dissection.

To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.

Changing predictors of postoperative mortality in acute type A aortic dissection. Is only coronary artery compromise significant?

Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.

Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection

Background. The aim of this study was to determine the durability of aortic valve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root. Methods. From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 ± 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 ± 46 months. Results. The operative mortality was 21.5% (n = 26). Actuarial survival was 72% ± 4%, 64% ± 5%, and 53% ± 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% ± 2% at 1 year, 89% ± 4% at 5 years, and 69% ± 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation. Conclusions. Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.

Surgery for acute type A aortic dissection

Background. Several innovative approaches have been introduced in the surgical treatment of acute type A aortic dissection. This study examines the effects of these new techniques on the early and late outcomes of patients with this disease. Methods. The records of patients who had surgery for acute type A aortic dissection during an 18 year interval were reviewed. There were 109 patients: 81 men and 28 women, with a mean age of 57 years, range 23 to 80. Most patients were acutely ill and 15 were in shock at the time of surgery. Operations were performed under cardiopulmonary bypass with femoral artery and right atrial cannulation. In 55 patients, the aorta was clamped and retrograde femoral perfusion was used throughout the procedure (group I). In 54 patients, no clamp was used; under circulatory arrest the primary tear was resected whether in the ascending aorta or transverse arch, and antegrade cardiopulmonary bypass was started after completion of the distal anastomosis (group II). Postoperative computed tomographic or magnetic resonance scans were completed annually. Results. There were 16 operative deaths (15%): 11 (20%) in group I, and 5 (9.2%) in group II ( p = 0.10). There were 10 strokes: 8 (14.5%) in group I and 2 (3.7%) in group II ( p = 0.05). After a mean follow-up time of 59 ± 45 months for group I, 31 (56%) patients were alive, and after a mean follow-up time of 45 ± 26 months for group II, 44 (81%) patients were alive. The actuarial survival of group II was higher than group I, but the difference was not significant ( p = 0.09). Postoperatively, a patent false lumen was found in 91% of group I patients and in 59% of group II ( p = 0.01). Conclusions. This study suggests that avoidance of aortic clamping, resection of the primary tear in the ascending aorta or transverse arch, and antegrade perfusion after completion of the distal anastomosis improve the early and late outcomes of surgery for acute type A aortic dissection.

Acute type a aortic dissection with leg ischemia

The incidence of lower extremity ischemia secondary to acute aortic dissection is relatively low, however, the presenting symptoms are variable in term of severity. We report here in two cases of such circumstances who were successively differently treated. Case one was a 60 years old male presented with severe left leg pain. Even after the initiation of cardiopulmonary bypass, the leg ischemia did not improve, therefore selective leg perfusion was additionally performed through direct left femoral artery cannulation. The surgery toward dissection was completed by mean of simultaneous graft replacement of ascending aorta and aortic arch. The leg ischemia after the aortic procedure however had persisted, femorofemoral bypass was created to relieve the mal-perfusion. Case two was a 37 years old male admitted with severe left leg pain associated with sensory-motor nerve dysfunction with muscle rigidity. In this particular patient, femoro-femoral bypass was firstly reconstructed as the mean of leg salvage procedure. After we learned there was no serious reperfusion symptom manifested, we performed radical surgery toward the aorta. We believe that the decision making of surgical treatment for acute type A dissection complicated with the presence of lower extremity ischemia is based on the severeness of mal-perfusion.

Early and late risk factors in surgical treatment of acute type A aortic dissection

Background. Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. Methods. A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. Results. The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% ± 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. Conclusions. Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection.

This study was performed to evaluate the effects of a residual dissection on coagulation, fibrinolysis, and platelet function after surgical treatment of acute type A aortic dissection. Between 1987 and 1995, 48 consecutive patients underwent emergency surgery for acute type A aortic dissection. Thirty-five of 41 survivors were followed-up for periods ranging from 6 to 112 months (median, 30.3 months). These survivors were classified into three groups by computed tomographic scanning and angiography. Fifteen patients had no residual dissection (group I). Of the 20 patients who had residual dissection, nine had an enlarged aorta greater than 45 mm in maximal diameter (group II), and 11 had an aorta less than 45 mm in maximal diameter (group III). For all patients, blood samples were collected for coagulation, fibrinolysis, and platelet function studies on the same day that the computed tomographic scanning had been performed. beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and alpha 2 plasmin inhibitor-plasmin complex concentrations were significantly higher in group II than in the other two groups. Strong correlations between the maximal diameter of the dissected aorta and beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and plasmin inhibitor-plasmin complex concentrations were evident. In contrast, correlations between the length of the dissected aorta and coagulation/fibrinolysis measurements were weak. Our findings suggest that the coagulopathy worsened in proportion to the degree of dilatation of the dissected aorta.

Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase.

In patients with Stanford type B dissection who have been treated successfully with medical hypotensive therapy during the acute phase, a large number have incurred the risk of surgery during their chronic phases because of enlargement of the dissected aorta. The purpose of this study was to determine the indications for surgical treatment of acute type B dissection by studying chronic-phase enlargements of aortic dissections in patients treated successfully with medical hypotensive therapy during the acute phase. In 41 patients with type B dissection who had been treated medically during the acute phase, univariate and multivariate factor analyses were made to determine the predominant predictors for chronic-phase enlargement (> or = 60 mm) of the dissected aorta. Computed tomography was performed every 4 to 14 months to observe whether there was enlargement of the maximum aortic diameter. The predominant predictors for aortic enlargement in the chronic phase were the existence of a maximum aortic diameter of > or = 40 mm during the acute phase (P < .001) and a patent primary entry site in the thoracic aorta (P = .001). The values of actuarial freedom from aortic enlargement for the patients with a large aortic diameter (> or = 40 mm) during the acute phase and a patent primary entry site in the thorax at 1, 3, and 5 years were 70%, 29%, and 22%, respectively. No aortic enlargement was observed in the other patients throughout the entire follow-up period. These data suggest that patients with acute type B dissection who have a large aortic diameter (> or = 40 mm) and a patent primary entry site in the thorax should be treated surgically during the acute phase on the condition that the surgical risk in this phase is limited.

Early failure of aortic valve conservation in aortic root aneurysm

Early failure of aortic valve conservation in aortic root aneurysm

肩鎖関節脱臼（Ｔｏｓｓｙ ＩＩＩ度）に対する手術療法の検討

肩鎖関節脱臼（Ｔｏｓｓｙ ＩＩＩ度）に対する手術療法の検討

Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue

We present an analysis of 59 patients operated on between 1983 and 1987 for acute type A dissecting aneurysm with aortic valve insufficiency. The ascending aorta was replaced with a Dacron tube, the layers of the dissection were unified with gelatin-resorcine-formaldehyde glue, and the natural aortic valve was preserved. Follow-up every 6 months was subject to actuarial analysis. The hospital mortality rate was 22%. The survivors were studied for 35.9 +/- 18.6 months (mean +/- standard deviation). Eight patients died (six of cardiovascular causes, one of cancer of the colon, and one of an unknown cause). Seventeen (36.9%) had aortic insufficiency, eight mild and nine moderate to severe. Four patients with severe insufficiency had reoperation with valve replacement. Excluding patients who have died or undergone reoperation, 29 of the remainder (90.6%) are free of symptoms. The follow-up survival rate is 61% +/- 6.93% (standard error) including hospital mortality. It is 55.4% +/- 7% (standard error) excluding reoperation and 44.2% +/- 7.1% (standard error) additionally excluding modest or severe aortic insufficiency. The use of gelatin-resorcine-formal glue allowed preservation of the native aortic valve, obviating the need for anticoagulants, and no embolic or hemorrhagic episodes were registered.

Extended and Total Aortic Resection in the Surgical Treatment of Acute Type A Aortic Dissection: Experience with 54 Patients

Fifty-four patients with acute type A aortic dissection were surgically treated with extended aortic resection. The age of the patients ranged from 22 to 75 years, and all of them were in very critical condition. In 50 patients, the resection extended from the aortic valve (included in 33) to the beginning of the descending thoracic aorta and in 4, from the valve (included in 3) to the aortic bifurcation. Deep hypothermia and circulatory arrest were employed during the aortic arch resection; inclusion of the graft at the end of procedure was done in 44 patients; in the others, the diseased aortic wall was excised. Early mortality was 20 ± 6% (11/54). Nine deaths were due to persistence of the distal dissection. Acute type A aortic dissection with aortic valve insufficiency should be treated as an emergency with extended aortic resection. As far as control of bleeding and closure of distal dissection are concerned, the best results have been achieved when the diseased aortic wall has been completely excised.

Duplex scanner study of carotid artery dissection following surgical treatment of aortic dissection type A.

In patients suffering from aortic dissection, persistent perfusion of the false lumen distal to the implanted graft is frequent. Postoperative follow-up examinations of the carotid arteries of these patients were performed by duplex scanner and correlated with clinical symptoms. Thirty-nine patients who survived the surgical treatment of acute type A aortic dissection had duplex sonography of both common carotid arteries after an average postoperative follow-up of 53 months. In 21 cases a composite graft and in 18 cases a supracoronary prosthetic vascular graft were implanted. No sign of residual dissection of the common carotid arteries was seen in 23 patients; in nine there was a dissection of both common carotid arteries, and seven patients had a unilateral carotid dissection (five right, two left). There were nine symptomatic patients with the following symptoms: transient ischemic attack (four), amaurosis fugax (four), stroke with incomplete recovery (one). Two symptomatic patients had a corresponding dissection. The generally good prognosis of all these patients suggests a conservative nonoperative treatment.