Objective To summarize the characteristics and management of pregnancy complicated with aortic dissection, and to explore the reasonable diagnosis and treatment plan. Methods The clinical data of 10 patients of pregnancy complicated with aortic dissection in Wuhan Tongji Hospital from January 2011 to June 2017 were collected. Their age was 25.2 (21-29) years. Results In the 10 patients, the majority (8 patients) were primipara, and most of them were in the late stages of pregnancy (5 patients) and puerperal (4 patients). Among them, 1 patient had gestational hypertension, and the blood pressure of the left and right upper extremities was significantly abnormal (initial blood pressure: left upper limb blood pressure: 90/60 mm Hg, right upper limb blood pressure: 150/90 mm Hg). The major clinical manifestations were severe chest and back pain which happened suddenly, with D-dimmer and C-creative protein increased which may be associated with inflammatory reaction. All patients were diagnosed by thoracoabdominal aortic CTA, including 5 patients of Stanford type A dissection and 5 patients of Stanford type B dissection. In the 10 patients, 1 patient refused surgery and eventually died of aortic rupture with the death of fetus before birth. And the remaining 9 patients underwent surgical treatment, 3 patients of endovascular graft exclusion for thoracic aortic stent graft, 2 patients underwent Bentall operation, 1 patient with Bentall + total aortic arch replacement + vascular thoracic aortic stent graft, 1 patient with Bentall operation combined with endovascular graft exclusion for thoracic aortic stent graft, 1 patient with Bentall + coronary artery bypass grafting, 1 patient of thoracoabdominal aortic vascular replacement. Among them, 1 patient underwent endovascular graft exclusion for thoracic aortic stent graft died of severe postoperative infection, and the remaining 8 patients were discharged from hospital. Nine patients were single birth, among them 5 newborn patients had severe asphyxia, 4 patients had mild asphyxia. Finally, 3 neonates died of severe complications, and the remaining 6 survived. Conclusion The ratio of pregnancy with Stanford type A aortic dissection is far higher than in the general population, the possibility of fetal intrauterine asphyxia is larger, but through active and effective surgical and perioperative treatment, we can effectively save the life of mother and fetus.
Acute Stanford type A aortic dissection has the characteristics of acute onset, severe condition and high mortality. Once making a definite diagnosis, surgical treatment is needed as soon as possible. It is difficult for cardiac surgeons to treat the acute aortic dissection involving the aortic sinus, which is an important risk factor for death. Improving the surgical treatment for the aortic sinus can be a key to improving the prognosis. In this review, we will introduce the modified sandwich technique for acute Stanford type A aortic dissection and the prognosis, and summarize the experiences of different modified sandwich techniques. However, there is still no unified standardized technique in aortic root repair, and there is a lack of large studies with long-term follow-up, so it is necessary to further improve the aortic root repair techniques.
ObjectiveTo evaluate the short-term result of proximal lengthening grafted stent and modified innominate artery cannula for Stanford A aortic dissection. Method We retrospectively analyzed the clinical data of 21 patients with Stanford A aortic dissection in our hospital between December 2012 and January 2015. There were 16 males and 5 females at a mean age of 57 years. All 21 patients underwent total arch replacement with proximal lengthening grafted stent and modified innominate artery cannula invented by our center. Result The mean operation time of 21 patients was 187.0±31.1 minutes, the mean cardiopulmonary bypass time was 116.0±32.0 minutes, the mean aortic block time was 87.0±23.0 minutes, the mean selective cerebral perfusion (SCP) time was 23.0±3.9 minutes, the mean breathing machanical ventilation time was 19.0±6.0 hours, and the mean intensive care unit stay time was 3.0±0.9 days. All patients had a good recovery after surgery. There was no death or severe complications. ConclusionThe technique of total arch replacement with proximal lengthening grafted stent and modified innominate artery cannula for Stanford A aortic dissection is effective, easy, and safe. The short-term result is satisfying.
ObjectiveTo investigate the effect of in vitro fenestration on reconstruction of left subclavian artery in endovascular treatment of aortic dissection.MethodsA total of 89 patients with aortic dissection involving left subclavian artery were treated by endovascular treatment in the Second Affiliated Hospital of Fujian Medical University from February 2017 to January 2020. There were 44 patients in the test group, including 36 males and 8 females, with an average age of 58.02±13.58 years. There were 45 patients in the control group, including 35 males and 10 females, with an average age of 54.10±12.32 years. The left subclavian artery was reconstructed by in vitro fenestration in the test group and by chimney technique in the control group. The clinical data were compared between the two groups.ResultsThe operation time of the test group was longer than that of the control group (126.16±7.53 min vs. 96.49±6.52 min, P<0.01). The median follow-up time was 31 (13-48) months. The incidence of endoleak in the test group (4.7%) was lower than that in the control group (18.6%, P=0.04) during the follow-up. There was no statistical difference in the incidence of stroke, myocardial infarction, false lumen thrombosis, retrograde aortic dissection or left subclavian artery occlusion between the two groups (P>0.05).Conclusion In vitro fenestration for reconstructing left subclavian artery in thoracic endovascular aortic repair of aortic dissection is safe and feasible, which is worthy of further clinical promotion.
ObjectiveTo systematically review mortality risk prediction models for acute type A aortic dissection (AAAD). MethodsPubMed, EMbase, Web of Science, CNKI, WanFang Data, VIP and CBM databases were electronically searched to collect studies of mortality risk prediction models for AAAD from inception to July 31th, 2021. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Systematic review was then performed. ResultsA total of 19 studies were included, of which 15 developed prediction models. The performance of prediction models varied substantially (AUC were 0.56 to 0.92). Only 6 studies reported calibration statistics, and all models had high risk of bias. ConclusionsCurrent prediction models for mortality and prognosis of AAAD patients are suboptimal, and the performance of the models varies significantly. It is still essential to establish novel prediction models based on more comprehensive and accurate statistical methods, and to conduct internal and a large number of external validations.
Objective To evaluate the value of 16slice spiral computed tomography (SCT) and its threedimensional reconstruction in diagnosis of aortic dissection (AD). Methods Fortyfive cases with AD underwent 16slice SCT, performed with unenhanced, contrastenhanced scanning and threedimensional reconstructions. Emphasis was placed on the true and false lumen, intimal flap, the entry and reentry tear and the involvement of branches of AD. Eleven cases were confimed by operation. Results True and false lumen and intimal flap of AD could be shown in all 45 cases (100%), the entry and reentry tears were revealed in 44 cases (97.8%) and 33 cases (73.3%), respectively. The right common iliac arteries were most easily involved by AD, 21 cases (46.7%). The thrombi in false lumen were shown in 29 cases (64.4%). Compared with surgery, the location and size of initial entry sites of 11 cases were consistent with the former. Conclusion 16slice SCT can exactly and completely diagnose AD, and provide detailed imaging information for clinical therapy. It’s very important for the selection of treatment methods and the observation of curative effect of patients.
Abstract： Objective To evaluate the clinical safety and neurological outcomes of right axillary artery cannulation with a side graft compared with a direct approachin aortic arch replacement for patients with acute Stanford type A aortic dissection. Methods Between July 2008 and July 2010， 280 consecutive patients with acute Stanford type A aortic dissection underwent right axillary artery cannulation for cardiopulmonary bypass （CPB） in total arch replacement and stented “elephant trunk” implantation in our hospital.These 280 patients were divided into two groups according to the method of axillary artery cannulation in operation:direct arterial cannulation was used in 215 patients（direct arterial cannulationgroup， DG group， mean age of 43.1±9.5 years）， while cannulation with a side graft was used in 65 patients（ indirect cannulation group， IG group， mean age of 44.7±8.3 years）. Clinical characteristics of both groups were similar except their axillary artery cannulation method. Patient outcomes were compared as to the prevalence of clinical complications， especially neurological deficits and postoperative morbidity. Results The overall hospital mortality was 3.6% （10/280）， 3.3% （7/215） in DG group and 4.6% （3/65） in IG group respectively.Right axillary artery cannulation was successfully performed in all cases without any occurrence of malperfusion. Postoperatively， 25 patients（8.9%）developed temporaryneurological deficits， 19 cases in DG group（8.8%）， and 6 cases in IG group （9.2%）， and all these patients were cured after treatment. The incidence of postoperative complications directly related to axillary artery cannulation was significantly lower in IG group than that in DG group（1 case vs. 19 cases， P=0.045）. There were no statistical differences in arterial perfusion peak flow， peak pressure，antegrade cerebral perfusion time， deep hypothermic circulatory arrest time， and CPB time between the two groups（P ＞ 0.05）. Conclusion Right axillary artery cannulation with a side graftcan significantly reduce the postoperative complications of axillary artery cannulation. It is a safe and effective method for patients undergoing surgery for acute Stanford type A aortic dissection.
Objective To study surgical indication, technique for treating acute Stanford type A aortic dissection involving repair of the aortic arch using Sun’s procedure with preservation of autologous brachiocephalic artery. Methods We retrospectively analyzed the clinical data of 28 consecutive patients (23 males, 5 females) who underwent operations on acute Stanford type A aortic dissection using Sun’s procedure with preservation of autologous brachiocephalic artery in our hospital between August 2011 and October 2013. The mean age was 29-62 (47±8) years. There were 26 patients with hypertension and 2 patients with Mafan syndrome. Sun’s procedure with preservation of autologous brachiocephalic artery was performed in all patients, concomitant procedure included aortic root replacement (Bentall) in 4 patients, aortic root replacement (Bentall) and mitral valve replacement (MVR) in 1 patient, aortic valsalva sinus plasty in 6 patients. Results The cardiopulmonary bypass time was 167±37 min. The cross clamp time was 80±22 min. Selective cerebral perfusion time was 29±5 min. One patient died postoperatively from acute hepatic failure. Two patients suffered from transient neurologic deficit and recovered after treatment during follow-up. Computed tomography angiography (CTA) of aorta was performed in each patient before discharged from the hospital. The patency of the anastomotic site at brachiocephalic artery was identified. Descending aortic true lumen was significantly expanded. There was only 2 patients with endoleak and total thrombosis of false lumen was found near stent graft with 25 patients. The 27 patients were followed up for 47 (36-62) months. One patient with descending thoracic aortic dilatation underwent thoracoabdoninal aortic replacement. One combined with acute endometrial tear underwent thoracic endovascular aortic repair. Conclusion Sun’s procedure with preservation of autologous brachiocephalic artery is safe and effective in the treatment of acute Stanford type A dissection in patients without brachiocephalic artery involved. Low mortality and complication rate are achieved, but the long-term results need the further follow-up.
Objective To analyze the surgical effect of total aortic arch replacement and stented elephant trunk (Sun’s procedure) for acute or chronic Stanford type A aortic dissection, and to investigate the optimal surgical timing for Stanford type A aortic dissection involving aortic arch. Methods We retrospectively reviewed the clinical data of 327 patients with acute or chronic Stanford type A aortic dissection treated by Sun's procedure from June 2010 to June 2014 in Guangdong Cardiovascular Institute. Patients were divided into two groups according to whether the time from onset to operation was longer than 2 weeks: an acute group with 229 patients (≤2 weeks, the average time of onset to operation 5.70±3.50 d) and a chronic group with 98 patients (>2 weeks, the average time of onset to operation 21.60±15.70 d). There were 186 males and 43 females with a mean age of 47.47±11.19 years in the acute group, and 76 males and 22 females with a mean age of 45.62±12.92 years in the chronic group. The patients discharged from hospital were followed up for one year. Results There was no significant difference between the two groups in preoperative data. The rate of coronary artery bypass grafting, cardiopulmonary bypass time, aortic cross-clamping time, intraoperative and postoperative 24 h red blood cell intake were higher or more in the acute group than those in the chronic group (P<0.05). The in-hospital morality, ICU stay, mechanical ventilation time, the incidence of neurological dysfunction, low cardiac output syndrome, acute renal failure with continuous renal replacement therapy, hepatic insufficiency, poor wound healing were higher or more in the acute group than those in the chronic group (P<0.05). During one year follow-up, the survival rate of the acute and chronic groups was 97.0% and 97.6% respectively (P>0.05). No new complications were found in the two groups. The irreversible neurological dysfunction, paraplegia and renal failure showed no significant difference between the two groups. Conclusion The short-term mortality and complications of acute Stanford A aortic dissection involving aortic arch treated by Sun’s procedure are significantly higher or more than those of chronic Stanford type A aortic dissection. The risk of surgical treatment in acute phase is high.
ObjectiveTo achieve a better early clinical result by modifying the total arch replacement and optimi-zing the procedure of operation. MethodWe retrospectively analyzed the clinical data of 38 patients patients with stanford a aortic dissection underwent the modifed total arch replacement in our hospital from September to December 2014. There were 26 males and 12 females with a mean age of 52.5 years ranging from 21-76 years. Three artery conduits were adopted during the surgical procedure. Right axillary artery and femoral artery cannulation were performed for cardiopulmonary bypass. The artificial graft and the left common carotid artery was anastomosed to provide simultaneous perfusion. Low rate bilateral brain perfusion began when circulation arrested at 26℃. Reperfusion restoration was obtained after the four-branch vascular graft anastomosed to the stent and aortic wall and completed the implantation of the elephant trunk. Then the aortic root and the vascular graft anastomosis were performed to reconstruct the ascending aorta. At last, the left subclavian artery and innominate artery were anastomosed to the branch of the vascular graft under the beating heart. ResultAll 38 operations were successful. The mean hypothermic circulatory time of the whole group was 18.8±4.2 min, the time of ascending aorta blocking was 86.1±14.2 min, the time of cardiopulmonary bypass was 178.4±71.4 min, the time of postoperative awakening was 4.7±2.0 h, the time of assisted mechanical ventilator was 38.7±19.9 h. One patient died because of multiple organ dysfunction syndrome (MODS), 3 patients accepted the hemodialysis, 6 patients suffered from transient neurological dysfunction, 1 patient suffered from paraparesis. There was no further complication during the follow-up of 1-3 months. ConclusionThe modified total aortic arch replacement can shorten the circulatory arrest time, cardiac arrest time and cardiopulmonary time, provide effective organ perfusion, and reduce the neurological complication and visceral damage.