The risk factors of postoperative continuous renal replacement therapy application in Stanford type A acute aortic dissection / 中华胸心血管外科杂志

Objective:To investigate the risk factors of postoperative continuous renal replacement therapy application in Stanford type A acute aortic dissection.Methods:This retrospective study included 527 patients with Stanford type A acute aortic dissection from November 2015 to February 2018 in Beijing Anzhen Hospital. They were divided into 2 groups according to whether or not needed postoperative continuous renal replacement therapy, group CRRT(78 cases) and group None CRRT(449 cases). Binary logistic regression analysis was used to analyze the risk factors of continuous renal replacement therapy. Results:Of all the patients, the percentage of using continuous renal replacement therapy was 14.8%(78/527), and the mortality of 30 days after surgery was 8.5%(45/527). The independent risk factors associated with CRRT were preoperative serum creatinine(sCr)( OR=1.012, 95% CI: 1.005-1.019, P<0.001), transfusion of red blood cell in surgery( OR=1.141, 95% CI: 1.071-1.216, P<0.001), transfusion of platelet in surgery( OR=1.307, 95% CI: 1.084-1.576, P=0.005), the total amount of drainage( OR=1.000, 95% CI: 1.000-1.000, P=0.036), and the time of extubation after surgery( OR=1.004, 95% CI: 1.001-1.008, P=0.013). Conclusion:The risk factors of CRRT after emergency surgery of Stanford type A acute aortic dissection are preoperative serum creatinine, transfusion of red blood cell in surgery, transfusion of platelet in surgery, the total amount of drainage and the time of tracheal extubation after surgery. We need to focus on those risk factors in our daily job and manage them timely and properly, in order to improve patients’ prognosis.

Endovascular Repair Prior to Total Aortic Arch Replacement for Stanford A Acute Aortic Dissection with Abdominal Organ Ischemia / 日本心臓血管外科学会雑誌

A 47-year-old man was admitted to our hospital complaining of chest and back pain. Enhanced CT scan revealed Stanford type A acute aortic dissection. The celiac artery (CA) was not enhanced and the superior mesenteric artery (SMA) appeared on the delayed phase. There was a small amount of pericardial effusion. Blood gas analysis showed metabolic acidosis. To treat mesenteric malperfusion, we initially performed thoracic endovascular aortic repair (TEVAR) by the PETTICOAT technique and stenting to CA and SMA. The acidosis gradually normalized after TEVAR. We then performed surgical central repair (total arch replacement). He temporarily showed paraplegia after the operation but soon recovered by treatment for spinal ischemia. He was discharged 68 days post operatively without any complication. Surgical central repair is not always effective for treating organ ischemia, so endovascular repair before surgical operation is sometimes taken into consideration.

Acute Type A Aortic Dissection with Left Main Coronary Malperfusion / 日本心臓血管外科学会雑誌

A 77-year-old woman was admitted to our hospital with a decreased level of consciousness and left hemiplegia. Contrast-enhanced CT showed acute type A aortic dissection and right common carotid artery occlusion. Electrocardiogram findings showed ST segment elevation in the anterolateral wall. The results suggested that the aortic dissection had extended to the left main trunk and caused acute myocardial infarction. Percutaneous coronary intervention (PCI) was performed preoperatively to improve myocardial ischemia reperfusion. After a successful PCI, the patient underwent ascending aorta replacement immediately. In cases of acute aortic dissection involving the left main artery, preoperative PCI prevents extensive myocardial damage and serves as a bridge to surgery.

A Case of Stanford Type A Acute Aortic Dissection after Surgery for Esophageal Cancer / 日本心臓血管外科学会雑誌

A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.

Open Stent Grafting for Stanford Type A Acute Aortic Dissection Originating from an Aberrant Right Subclavian Artery / 日本心臓血管外科学会雑誌

<p>An aberrant right subclavian artery (ARSA) is a relatively rare congenital anomaly of arch branches, occurring in 0.5-2.0% of the population. Stanford type A acute aortic dissection involving an ARSA is rare, and is associated with difficult surgical planning in an emergency situation. We report a case of Stanford type A acute aortic dissection originating from an ARSA in a 50-year-old man. He was referred to our hospital with a chief complaint of chest and back pain. Contrast enhanced CT scan revealed type A aortic dissection involving an ARSA, with the entry located near the ARSA. Given the possible difficulty of performing distal anastomosis over the ARSA and ARSA reconstruction, total arch replacement was performed using the open stent-grafting technique. The postoperative course was uneventful, and a CT scan revealed a thrombosed false lumen and ARSA. The false lumen of the aorta next to the stent graft eventually disappeared at 1 year postoperatively. The open stent-grafting technique might be an effective alternative in the management of Stanford type A acute aortic dissection with ARSA.</p>

Total Arch Replacement in a Patient with Type A Acute Aortic Dissection and Situs Inversus Totalis / 日本心臓血管外科学会雑誌

<p>We report a case of type A acute aortic dissection in a patient with situs inversus totalis. A 51-year-old man was hospitalized with sudden-onset back pain. Contrast-enhanced computed tomography revealed Stanford type A acute aortic dissection and situs inversus totalis. Total arch replacement using selective cerebral perfusion and mild hypothermic circulatory arrest was successfully performed. He was discharged home 23 days after the operation.</p>

A Case of Acute Type A Aortic Dissection with Acute Coronary Syndrome : Left Main Stenting as a Bridge to Surgery / 日本心臓血管外科学会雑誌

<p>A 45-year-old man was hospitalized with sudden-onset chest pain. He was in cardiogenic shock with a systolic pressure of 68 mmHg. His electrocardiogram (ECG) showed ST segment elevation in leads I, aVL, and V2-5. An emergency coronary angiogram (CAG) showed that the true lumens of bilateral coronary arteries were compressed, showing acute Stanford type A aortic dissection involving bilateral coronary artery. A bare metal stent was promptly implanted in the left main trunk (LMT) to restore coronary blood flow because of his hemodynamic instability. Soon afterwards, the ischemic changes on ECG disappeared and he was transferred to the operating room in a stable hemodynamic condition. We performed emergency graft replacement of the ascending aorta and coronary artery bypass grafting. The postoperative CAG showed patent bypass grafts. Implantation of LMT stent, as a bridge to surgery, should be the treatment of choice for acute type A dissection involving LMT.</p>

A Case of Type A Acute Aortic Dissection in an Elderly Woman with Immune Thrombocytopenia Who Underwent Replacement of the Ascending Aorta and Aortic Arch and Later Required Aortic Root Replacement for Redissection of the Aortic Root / 日本心臓血管外科学会雑誌

We report a case of type A acute aortic dissection in an elderly woman with immune thrombocytopenia (ITP) who underwent replacement of the ascending aorta and aortic arch and later required aortic root replacement for redissection of the aortic root one month after her initial surgery. She was an 86-year-old woman with severe mitral regurgitation, and surgery was contraindicated because of her age and ITP. In October 2014, the patient presented with back pain. Computed tomography confirmed the diagnosis of her condition as type A acute aortic dissection, and she was immediately transferred to our hospital. Because echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and moderate tricuspid regurgitation, we performed replacement of the ascending aorta and aortic arch, mitral valve repair, and tricuspid annuloplasty. We used Bioglue to fuse the false lumen of the type A acute aortic dissection and used a Teflon felt sandwich for the proximal anastomosis technique. Respiratory support was discontinued 91 h after her first operation ; however, 30 days after surgery, she developed a to-and-fro murmur-a sign of the progression of heart failure. Echocardiography showed aggravation of aortic regurgitation, and computed tomography showed aortic root redissection ; therefore, 39 days after the initial surgery, we performed aortic root replacement. During the operation, we found the entry under the proximal anastomosis with an almost semicircle form at the right coronary cusp to the noncoronary cusp, and the dissection extended close to the right coronary artery ; thus, we performed bypass to the right coronary artery. Pathologic findings did not establish a causal association between the redissection and Bioglue, and we believed the fragility of the tissue and the selection of the surgical procedure to be the cause of redissection. The patient was transferred to another hospital when she was able to walk and eat, which was 121 days after her first operation. The patient required 50 units of platelet transfusion during her first and second operations, but her bleeding was easily controlled during surgery. She needed two procedures of pericardium drainage for pericardiac effusion and cardiac tamponade, which may relate to ITP. The diagnosis of redissection of the aortic root was made 30 days after the patient's first operation, on the basis of exacerbation of the to-and-fro murmur. Here, we emphasize the clinical importance of basic observations over time, such as auscultation, that are liable to be overlooked in the intensive care unit.

Surgical Treatment of Proximal Aortic Dissection in Patients with Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

<b>Objective</b> : Although dissection extending to the aortic root is a common finding, it is potentially fatal in patients with acute type A aortic dissection. The purpose of this study was to evaluate surgical results of acute type A aortic dissection with proximal involvement. The proximal extension of dissection, types of aortic root procedure and its feasibility were investigated. <b>Methods</b> : Between 1997 and 2011, 80 patients with acute type A aortic dissection underwent emergent operation. <b>Results</b> : Dissection reaching around the coronary artery orifice was observed in 28 patients. In 11 patients, both left and right coronary arteries were involved with aortic dissection. Aortic root replacement was performed in 4 patients. In 7 patients, the dissected aortic root was reinforced by GRF glue and proximal aorta was replaced with a graft. Among these patients, postoperative aortic root redissection with severe aortic regurgitation was observed in 5 patients during postoperative long-term periods. All of them required surgical re-intervention of the aortic root. In 17 patients, dissection was extended to the right coronary artery. Aortic root reconstruction was performed in 2 patients due to pre-existing annulo-aortic ectasia. The remaining 15 patients underwent proximal reinforcement with GRF glue. No patient showed dissection extending to the left coronary artery alone. Operative mortality was 11% and other types of complications concerning the aortic root was not observed. <b>Conclusion</b> : An acceptable outcome was demonstrated with our surgical strategy of proximal aortic dissection. For patients, in particular, with proximal involvement to both the left and right coronary arteries, redissection of the aortic root should be noticed as a late complication with considerable frequency. Special care should be taken for precise recognition of the proximal extension of dissection and appropriate surgical procedure including simultaneous aortic root replacement.

Stanford Type A Acute Aortic Dissection with Left Extra-pleural Hematoma and Lung Hemorrhage / 日本心臓血管外科学会雑誌

A 68-year-old woman with a sudden onset of back pain was brought to our hospital by ambulance. Computed tomography (CT) showed Stanford type A (DeBakey type II) acute aortic dissection, left hemothorax, and hematoma extending along the pulmonary artery ; therefore, the patient underwent emergency operation. We performed a median sternotomy. Pericardial effusion was not observed ; however, a hematoma was found around the ascending aorta. Preoperative CT showed left hemothorax, but pleural effusion was not observed in the left pleural cavity. The left hemothorax, which was detected on preoperative CT, was diagnosed as an extrapleural hematoma. The dissection entry site was located at the proximal aortic arch ; therefore, ascending aorta-hemiarch replacement was performed. After weaning from cardiopulmonary bypass, the patient experienced sudden airway bleeding. The bleeding was attributed to the hematoma extending along the pulmonary artery. Here, we have reported a rare case of Stanford type A acute aortic dissection with the left extrapleural hematoma and lung hemorrhage.

A Case of Postoperative Paraparesis after Ascending Aortic Replacement for Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

Although paraplegia following descending thoracic and thoracoabdominal aortic repair is well known, paraplegia after repairing ascending aorta has been rarely reported. We describe a very rare case of postoperative paraparesis after repairing type A acute aortic dissection. A 64-year-old man with type A acute aortic dissection whose aortic false lumen was all thrombosed, was treated with rest and his blood pressure was strictly controlled. The follow-up computed tomography revealed that blood flow in the false lumen was recognized in the ascending aorta 8 days after admission. At the same time the diameter of the ascending aorta was enlarged. We performed emergency ascending aortic replacement under deep-hypothermic circulatory arrest and selective cerebral perfusion. We recognized that he showed paraparesis 4 days after operation and magnetic resonance imaging showed high signals in the spinal cord, which indicated spinal cord infarction. He received rehabilitation for 5 months, and fully recovered neurologically. The causes of paraplegia after repairing type A acute aortic dissection have not been clarified. In our case, we presumed the causes included over 60 min circulatory arrest which invoked low spinal perfusion, the anterior spinal artery was thrombosed by selective cerebral perfusion, some intercostals arteries were occluded by postoperative change of the descending aortic false lumen pressure. This case is very rare, and we had to take all possible precautions.

A Case of Emergency Ascending Aorta Replacement for Paraplegia Caused by Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

We report a rare case of type A acute aortic dissection with paraplegia which was cured immediately after an emergency operation. A 79-year-old woman was transferred to our institution with sudden back pain and paraplegia. Computed tomographic scans revealed a cardiac tamponade with an acute type A aortic dissection. She went into shock soon after arrival, and about 4 hours from onset we performed an emergency replacement of the ascending aorta. Three hours after the operation, her neurological deficit gradually resolved and could walk by postoperative day 3. This case suggests that early restoration of the blood flow to the spinal cord is mandatory to relieve paraplegia caused by type A aortic dissection.