Comprehensive treatment of acute Stanford type A aortic dissection with limb malperfusion / 中华胸心血管外科杂志

Objective:To explore different strategies of central repair first or malperfusion first to treat type A aortic dissection complicated with limb malperfusion.Methods:From January 2020 to December 2021, 302 patients were diagnosed with acute type A aortic dissection, and 17 consecutive patients were diagnosed as type A acute aortic dissection complicated with limb malperfusion and underwent Sun’s procedure. There were 16 males and 1 female with an average of(52.6±4.2)years. Surgical strategies were as follows: immediate central repair-Sun’s procedure in 14 patients, endovascular stenting followed by central repair in 3 patients, endovascular stenting after central repair in 1 patient.Results:The incidence rate of limb malperfusion of acute Stanford A aortic dissection was 5.6%(17/302). Average extracorporeal circulation time was(271.8±38.9)min, average aortic cross-clamp time was (186.3±31.8)min, and the average circulatory arrest time was (48.75±11.3)min. Early mortality rate was 17.6%(3/17). Two patients were left hospital voluntarily because of cerebral infarction. One patient underwent leg incision osteofascial compartment syndrome and discharged unevently. Five patients underwent continuous renal replacement therapy and hemoperfusion. Follow-up results showed that patients with serious limb malperfusion have symptoms of nerve dysfunction including amyosthenia and sensory disturbance, but recovered gradually with rehabilitation.Conclusion:Sun’s procedure is safe and feasible for type A acute aortic dissection complicated with mild limb malperfusion. For serious limb malperfusion, endovascular stent followed by Sun’s procedure is a good choice with CRRT and hemoperfusion.

Clinical treatment of acute type-A aortic dissection with lower limb malperfusion / 中华胸心血管外科杂志

Objective To explore the treatment experience of acute type-A aortic dissection with lower limb malperfusion.Methods From December 2012 to December 2016,479 cases of acute type A aortic dissection were treated surgically,including 39 patients with lower limb ischemia,including 27 males and 12 females,with mean age of(5 1.4 ± 12.4) years.All patients were treated with deep hypothermic circulatory arrest and were treated with single pump,double-tube and double-injected limbs.According to the patient's lower limb ischemia time,symptoms and signs,limb ischemia was assessed.If necessary,femoral artery-femoral arterial bypass was performed.For patients undergoing femoral arterial-femoral prosthetic bypass during the same period,postoperative follow-up monitoring,if necessary,secondary femoral-femoral arterial vascular bypass or osteofascial decompression.Results Early mortality rate was 17.9％ (7/39).32 cases of postoperative survival.The follow-up rate was 93.8％ (30/32),3 months to 3 years after the operation,the results were satisfactory.The over lower limb malperfusion recovery rate of follow-up patients was 96.7％ (29/30).Conclusion Positive operation for acute type-A aortic dissection with lower limb malperfusion is safe,feasible and effective.Concomitant or secondary bypass procedures are also possible to restore distal perfusion when necessary.Comprehensive evaluation of patient' s status is strongly recommended for optimal surgical decision making.

A Case of Stanford Type A Acute Aortic Dissection with Occlusion of Prosthesis Implanted in the Abdominal Aorta / 日本心臓血管外科学会雑誌

A 54-year-old woman underwent abdominal aortic replacement for abdominal aortic aneurysm in March 2012. Approximately 6 months after surgery, she was taken by ambulance to hospital due to thoracodorsal pain, lower limb paralysis and pain. Emergency computed tomography indicated acute aortic dissection involving the ascending aorta, aortic arch, and descending aorta. The outline of the prosthesis implanted in the abdominal aorta was absent, and emergency surgery was performed immediately by median sternotomy to treat suspected complete obstruction. Following confirmation of brachiocephalic artery dissection, extracorporeal circulation was started with drainage of blood from the vena cava and the return via left axillary artery, plus perfusion in both lower limbs. However, the level of regional oxygen saturation declined as the flow of extracorporeal circulation increased. To solve this problem, an incision was made in the ascending aorta, and an aortic cannula was inserted directly into the true lumen. Aortic arch replacement was then performed, but this central repair failed to improve blood flow in both the left and right femoral artery. Proximal thrombectomy successfully removed a large amount of thrombi, but did not improve blood circulation. Left axillobifemoral bypass was subsequently performed, and improved lower limb blood circulation, but with residual motor impairment. Since the patient regained somatosensory sensation and was able to perform simple exercises, rehabilitation was started. Hemodialysis was required after abnormal increases in muscle enzyme levels and white blood cell count, but this was later discontinued following improvement of renal function. The patient was transferred to a rehabilitation clinic 54 days after surgery.