Objective To analyze the etiologies, surgical treatment and outcomes of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. Methods The clinical data of patients with RTAD after TEVAR for Stanford type B aortic dissection receiving operations in Changhai Hospital from March 2014 to August 2018 were analyzed. All patients were followed-up by clinic interview or telephone. Results A total of 16 patients were enrolled, including 13 males and 3 females with a mean age of 49.1±12.2 years. The main symptoms of RTAD were chest pain in 12 patients, headache in 1 patient, conscious disturbance in 1 patient, and asymptomatic in 2 patients. All the 16 patients received total arch replacement with the frozen elephant trunk technique. Bentall procedure was used in 2 patients, aortic root plasticity in 10 patients and aortic valve replacement in 1 patient. The primary tear in 10 patients was located in the area which were anchored by bare mental stent, and in the other 6 patients it was located in the anterior part of ascending aorta. The mean cardiopulmonary bypass time was 152.2±29.4 min, aortic cross-clamping time was 93.6±27.8 min and selective cerebral perfusion time was 29.8±8.3 min. There was no death in hospital or within postoperative 30 days. The follow-up period was 32-85 (57.4±18.3) months. No death occurred during the follow-up period. One patient underwent TEVAR again 3 years after this operation and had an uneventful survival. Conclusion Total arch replacement with the frozen elephant trunk technique is a suitable strategy for the management of RTAD after TEVAR for Stanford type B aortic dissection.
ObjectiveTo evaluate the effectiveness and safety of proximal aortic repair (PAR) versus total arch replacement (TAR) for treatment of acute type A aortic dissection (ATAAD). Methods An electronic search was conducted for clinical controlled studies on PAR versus TAR for patients with ATAAD published in Medline via PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang Database and CNKI since their inception up to April 30, 2022. The quality of each study included was assessed by 2 evaluators and the necessary data were extracted. STATA 16 software was used to perform statistical analysis of the available data. ResultsA total of 28 cohort studies involving 7 923 patients with ATAAD were included in this meta-analysis, of whom 5 710 patients received PAR and 2 213 patients underwent TAR, and 96.43% of the studies (27/28) were rated as high quality. The meta-analysis results showed that: (1) patients who underwent PAR had lower incidences of 30 d mortality [RR=0.62, 95%CI (0.50, 0.77), P＜0.001], in-hospital mortality [RR=0.64, 95%CI (0.54, 0.77), P＜0.001], and neurologic deficiency after surgery [RR=0.84, 95%CI (0.72, 0.98), P=0.032] than those who received TAR; (2) the cardiopulmonary bypass time [WMD=–52.07, 95%CI (–74.19, –29.94), P＜0.001], circulatory arrest time [WMD=–10.14, 95%CI (–15.02, –5.26), P＜0.001], and operation time [WMD=–101.68, 95%CI (–178.63, –24.73), P＜0.001] were significantly shorter in PAR than those in TAR; (3) there was no statistical difference in mortality after discharge, rate of over 5-year survival, renal failure after surgery and re-intervention, volume of red blood cells transfusion and fresh-frozen plasma transfusion, or hospital stay between two surgical procedures. Conclusion Compared with TAR, PAR has a shorter operation time and lower early and in-hospital mortality, but there is no difference in long-term outcomes or complications between the two procedures for patients with ATAAD.
ObjectiveTo explore the optimal preoperative management strategy in patients with acute type A aortic dissection and pericardial tamponade.MethodsA total of 197 patients with acute type A aortic dissection were admitted to the Cardiovascular Center at the Second Affiliated Hospital of Nanjing Medical University from 2017 to 2019, among whom 26 patients suffered from cardiac tamponade, including 20 males and 6 females with an average age of 59.27±10.76 years. The clinical data of the patients were analyzed.ResultsAll patients underwent surgical repair of the aorta. The median cardiopulmonary bypass time and aortic cross clamping time were 174.5 min and 121.5 min, respectively. Postoperative complications included kidney failure in 3 patients, respiratory failure in 2 patients and disturbance of consciousness in 3 patients. Postoperative death occurred in 5 (19.2%) patients. The other 21 patients were successfully followed up for 2 years, during which 1 patient died with a survival rate of 95.2%, and no re-intervention was indicated.ConclusionAdequate preoperative management is crucial in patients with acute type A aortic dissection complicated with cardiac tamponade. A cardiac surgery team with round-the-clock availability, an integrated cardiac surgery ward and a rational algorithm that can shorten the time from disease onset to surgery treatment are the keys to improve survival rate.
ObjectiveTo investigate the application of ascending aorta cannulation and brachiocephalic trunk cannulation in acute type A aortic dissection.MethodsWe screened 183 patients with acute type A aortic dissection from January 2017 to January 2020 in our hospital. They were divided into 2 groups according to the cannulation strategy: ascending aorta cannulation and brachiocephalic trunk cannulation (a DAC group, n=42, 33 males and 9 females with a median age of 50 years) and the single axillary artery cannulation (an AAC group, n=141, 116 males and 25 females with a median age of 51 years). The general clinical data, intraoperative data and early postoperative results of the two groups before and after matching with propensity scores were compared.ResultsBefore propensity-score matching, the operation time, cardiopulmonary bypass time, aortic occlusion time and ICU stay in the DAC group were all shorter than those in the AAC group (P<0.05). The early postoperative mortality, and rates of brain complications, renal failure and pulmonary complications in the DAC group were significantly lower than those in the AAC group. After propensity-score matching, the operation time in the DAC group was significantly shorter than that in the AAC group (P<0.05). The early postoperative mortality, and rates of brain complications and pulmonary complications in the DAC group were significantly lower than those in the AAC group.ConclusionAscending aorta cannulation and brachiocephalic trunk cannulation can provide a safe, fast and effective method of establishing cardiopulmonary bypass for some acute type A aortic dissection patients, and significantly shorten the operation time without increasing surgical complications.
The treatment of acute Stanford type A aortic dissection has always been extremely challenging. Organ malperfusion syndrome is a common severe complication of acute aortic dissection, which can cause organ ischemia and internal environment disorder. Malperfusion increases early mortality, and impacts the long-term prognosis. In recent years, many scholars have done some studies on aortic dissection complicated with malperfusion. They explored the pathogenesis, proposed new classification, and innovated new treatment strategies. However, at present, the treatment strategies of acute Stanford type A aortic dissection complicated with organ malperfusion are different at different centers and consensus on its treatment is still lacking. Therefore, this review summarized the pathogenesis, classification, treatment strategy, and prognosis of acute Stanford type A aortic dissection complicated with malperfusion.
ObjectiveTo systematically evaluate the risk factors for postoperative delirium after surgery for Stanford type A aortic dissection. MethodsWe searched the CNKI, SinoMed, Wanfang data, VIP, PubMed, Web of Science, EMbase, The Cochrane Library database from inception to September 2022. Case-control studies, and cohort studies on risk factors for postoperative delirium after surgery for Stanford type A aortic dissection were collected to identify studies about the risk factors for postoperative delirium after surgery for Stanford type A aortic dissection. Quality of the included studies was evaluated by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by RevMan 5.3 software and Stata 15.0 software. ResultsA total of 21 studies were included involving 3385 patients. The NOS score was 7-8 points. The results of meta-analysis showed that age (MD=2.58, 95%CI 1.44 to 3.72, P＜0.000 01), male (OR=1.33, 95%CI 1.12 to 1.59, P=0.001), drinking history (OR=1.45, 95%CI 1.04 to 2.04, P=0.03), diabetes history (OR=1.44, 95%CI 1.12 to 1.85, P=0.005), preoperative leukocytes (MD=1.17, 95%CI 0.57 to 1.77), P=0.000 1), operation time (MD=21.82, 95%CI 5.84 to 37.80, P=0.007), deep hypothermic circulatory arrest (DHCA) time (MD=3.02, 95%CI 1.04 to 5.01, P=0.003), aortic occlusion time (MD=8.94, 95%CI 2.91 to 14.97, P=0.004), cardiopulmonary bypass time (MD=13.92, 95%CI 5.92 to 21.91, P=0.0006), ICU stay (MD=2.77, 95%CI 1.55 to 3.99, P＜0.000 01), hospital stay (MD=3.46, 95%CI 2.03 to 4.89, P＜0.0001), APACHEⅡ score (MD=2.76, 95%CI 1.59 to 3.93, P＜0.000 01), ventilation support time (MD=6.10, 95%CI 3.48 to 8.72, P＜0.000 01), hypoxemia (OR=2.32, 95%CI 1.40 to 3.82, P=0.001), the minimum postoperative oxygenation index (MD=−79.52, 95%CI −125.80 to −33.24, P=0.000 8), blood oxygen saturation (MD=−3.50, 95%CI −4.49 to −2.51, P＜0.000 01), postoperative hemoglobin (MD=−6.35, 95%CI −9.21 to −3.50, P＜0.000 1), postoperative blood lactate (MD=0.45, 95%CI 0.15 to 0.75, P=0.004), postoperative electrolyte abnormalities (OR=5.94, 95%CI 3.50 to 10.09, P＜0.000 01), acute kidney injury (OR=1.92, 95%CI 1.34 to 2.75, P=0.000 4) and postoperative body temperature (MD=0.79, 95%CI 0.69 to 0.88, P＜0.000 01) were associated with postoperative delirium after surgery for Stanford type A aortic dissection. ConclusionThe current evidence shows that age, male, drinking history, diabetes history, operation time, DHCA time, aortic occlusion time, cardiopulmonary bypass time, ICU stay, hospital stay, APACHEⅡ score, ventilation support time, hypoxemia and postoperative body temperature are risk factors for the postoperative delirium after surgery for Stanford type A aortic dissection. Oxygenation index, oxygen saturation, and hemoglobin number are protective factors for delirium after Stanford type A aortic dissection.
Objective To investigate the ultrasonographic characteristics of acute Stanford type A aortic dissection (ATAAD) involving the renal arteries and their relationship with renal function. Methods Patients with ATAAD admitted to Deyang People's Hospital from February 2013 to May 2023 were selected for the study. Based on whether the renal arteries were involved in the dissection, the patients were divided into two groups: a renal artery involvement group and a renal artery non-involvement group. General data and ultrasound characteristics of the two groups were compared. Logistic regression analysis and model correction were performed to analyze the relationship between ultrasound characteristics and renal function involvement in ATAAD patients. Receiver operating characteristic (ROC) curves were used to evaluate the predictive value of ultrasound characteristics for renal artery involvement in ATAAD patients. Additionally, patients in the renal artery involvement group were divided into normal renal function and abnormal renal function subgroups based on serum blood urea nitrogen (BUN) and serum creatinine (Scr) levels. Clinical data of the two subgroups were compared, and a log-binomial model was used to analyze the risk effects of ultrasound characteristics for abnormal renal function. Pearson correlation analysis was performed to assess the correlation between ultrasound characteristics of renal artery involvement and renal function indicators. Results A total of 163 patients were included, consisting of 106 males and 57 females, with a mean age of (50.06±10.46) years (ranging from 20 to 85 years). Significant differences in gender, Scr, and BUN were observed between the renal artery involvement group and the renal artery non-involvement group (P<0.001). Compared to the renal artery non-involvement group, the renal artery involvement group had an increased ascending aorta diameter, a greater proportion of ascending aortic dilation and poor renal perfusion (P<0.05). Logistic regression analysis indicated that ascending aorta diameter, ascending aortic dilation, and poor renal perfusion were independent factors for renal artery involvement (P<0.05). Ultrasonographic characteristics showed good predictive ability for renal artery involvement in ATAAD patients. Furthermore, the combination of the three characteristics yielded a higher predictive value for renal artery involvement. Compared to the normal renal function group, the abnormal renal function group had higher BUN and Scr levels, increased ascending aortic diameter, a greater proportion of ascending aortic dilation and poor renal perfusion (P<0.05). The log-binomial model analysis revealed that the risk ratios for ascending aortic diameter, ascending aortic dilation, and poor renal perfusion were statistically significant both before and after adjustment (P<0.05). Pearson correlation analysis revealed that ascending aortic diameter, ascending aortic dilation, and poor renal perfusion were strongly correlated with renal function parameters (P<0.05). ConclusionUltrasound characteristics of ATAAD involving the renal arteries are associated with renal function. Ascending aorta diameter, ascending aortic dilation, and poor renal perfusion are independent risk factors for abnormal renal function.
ObjectiveTo summarize our experience and clinical effect of surgical treatment of Stanford type A aortic dissection (TAAD) involving an aberrant right subclavian artery (ARSA). MethodsFrom March 2009 to January 2016, 14 patients with TAAD involving an ARSA (acute TAAD, n=10; chronic TAAD, n=4) underwent operation under hypothermic cardiopulmonary bypass combined with selective antegrade cerebral perfusion in our center. There were 11 male and 3 female patients with a mean age of 46.07±8.45 years. A total of 13 patients (13/14, 92.86%) underwent stented elephant trunk procedure combined with total arch replacement (Sun's procedure). The remaining patient (1/14, 7.14%) underwent partial aortic arch replacement combined with Bentall procedure without ARSA revascularization. ResultsThe average operation time, cardiopulmonary bypass time, aortic cross-clamping time and selective cerebral perfusion time was 7.89±1.80 h, 208.43±28.84 min, 117.64±23.30 min, and 30.50±10.15 min, respectively. No operation-related deaths occurred. However, two (14.29%) patients died on postoperative 5 d, 7 d, respectively in hospital. One patient required repeat thoracotomy for bleeding, one suffered temporary renal dysfunction and one renal failure (this patient had renal failure before surgery). The mean follow-up was 28.42±22.52 months with a follow-up rate of 100.00% (12/12). One patient died of heart failure and renal failure at 64 months after operation. The others were free from any aortic complications during follow-up. ConclusionsTAAD involving an ARSA should be clearly diagnosed before surgery, and treated by the optimal arterial cannulation and cerebral perfusion during operation. Repair of aortic dissection with Sun's procedure and revascularization of the ARSA can obtain satisfactory clinical outcomes in patients with TAAD involving an ARSA.
Objective To investigate the risk factors for early in-hospital death in patients with acute Stanford type A aortic dissection and emergency surgical treatment. MethodsWe retrospectively analyzed the clinical data of 189 patients with acute Stanford type A aortic dissection who underwent surgery in the First Affiliated Hospital of Xinjiang Medical University between January 2017 and January 2020. There were 160 males and 29 females with an average age of 46.35±9.17 years. All patients underwent surgical treatment within 24 hours. The patients were divided into a survival group (n=160) and a death group (n=29) according to their outcome (survival or death) during hospitalization in our hospital. Perioperative clinical data were analyzed and compared between the two groups. Results The overall in-hospital mortality was 15.34% (29/189). There was a statistical difference between the two groups in white blood cell count, blood glucose, aspartate aminotransferase (AST), bilirubin, creatinine, operative method, operation time, aortic occlusion time, or cardiopulmonary bypass time (P<0.05). Multivariate regression identified white blood cell count [OR=1.142, 95%CI (1.008, 1.293)], bilirubin [OR=0.906, 95%CI (0.833, 0.985)], creatinine [OR=1.009, 95%CI (1.000, 1.017)], cardiopulmonary bypass time [OR=1.013, 95%CI (1.003, 1.024)] as postoperative risk factors for early in-hospital death in the patients undergoing acute Stanford type A aortic dissection surgery (P<0.05). Conclusion Our study demonstrated that white blood cell, bilirubin, creatinine and cardiopulmonary bypass time are independent risk factors for in-hospital death after acute Stanford type A aortic dissection surgery.
Objective To systematically evaluate the risk factors for hypoxemia after Stanford type A aortic dissection (TAAD) surgery. Methods Electronic databases including PubMed, EMbase, The Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP and CBM were searched by computer to collect studies about risk factors for hypoxemia after TAAD published from inception to November 2021. Two authors independently assessed the studies' quality, and a meta-analysis was performed by RevMan 5.3 software. ResultsA total of 19 case-control studies involving 2 686 patients and among them 1 085 patients suffered hypoxemia, included 21 predictive risk factors. The score of Newcastle-Ottawa scale≥7 points in 16 studies. Meta-analysis showed that: age (OR=1.10, 95%CI 1.06 to 1.14, P＜0.000 01), body mass index (OR=1.87, 95%CI 1.49 to 2.34, P＜0.000 01), preoperative partial pressure of oxygen in arterial blood/fractional concentration of inspiratory oxygen (PaO2/FiO2)≤300 mm Hg (OR=7.13, 95%CI 3.48 to 14.61, P＜0.000 01), preoperative white blood cell count (OR=1.34, 95%CI 1.18 to 1.53, P＜0.000 1), deep hypothermic circulatory arrest time (OR=1.33, 95%CI 1.14 to 1.57, P=0.000 4), perioperative blood transfusion (OR=1.89, 95%CI 1.49 to 2.41, P＜0.000 01), cardiopulmonary bypass time (OR=1.02, 95%CI 1.00 to 1.03, P=0.02) were independent risk factors for hypoxemia after TAAD surgery. Preoperative serum creatinine, preoperative myoglobin, preoperative alanine aminotransferase were not associated with postoperative hypoxemia. Conclusion Current evidence shows that age, body mass index, preoperative PaO2/FiO2≤300 mm Hg, preoperative white blood cell count, deep hypothermic circulatory arrest time, perioperative blood transfusion, cardiopulmonary bypass time are risk factors for hypoxemia after TAAD surgery. These factors can be used to identify high-risk patients, and provide guidance for medical staff to develop perioperative preventive strategy to reduce the incidence of hypoxemia. The results should be validated by higher quality researches.