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ABSTRACT Introduction: According to recent data, thoracic aortic surgery has reduced morbidity and mortality including ascending aortic aneurysm treatment; however, women are at increased postoperative risk of adverse outcomes. Objective: Our aim was to evaluate early and late outcomes in male and female patients who underwent pre-emptive ascending aortic replacement (AAR). Methods: From January 2013 to September 2021, 91 patients (56 [61.5%] men and 35 [38.5%] women) underwent AAR for small (ranged from 5.0 to 5.5 cm) non-syndromic aneurysms. A propensity score-based adjustment of the groups was performed. We compared clinical outcomes between males and females. Results: Preoperative normalized aortic diameters were significantly larger in females (2.9 [2.7; 3.2] cm/m2) than in males (2.5 [2.3; 2.6] cm/m2, P<0.001), without differences in absolute values (51 [49; 53] mm vs. 52 [50; 53] mm, P=0.356). There were no significant differences in neurological, cardiac, pulmonary, and renal complications in both groups before and after matching. In-hospital mortality was 1 (1.8%) and 2 (5.7%) (P=0.307) in male and female patients in unmatched groups and 1 (2.9%) and 2 (5.7%) (P=0.553) in matched groups, respectively. Univariate logistic regression analysis revealed that the only risk factor for in-hospital mortality was age (odds ratio 1.117, 95% confidence interval 1.003-1.244; P=0.04). The overall survival rate was 83.5±0.06% in men and 94.3±0.04% in women at 36 months (P=0.404). Conclusion: Ascending aortic surgery for aneurysms ranged from 5.0 to 5.5 cm seems to have tolerable early and late outcomes in men and women.
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Thalassemia is an inherited hemoglobin disorder characterized by hemolytic anemia. Reportedly, cardiopulmonary bypass (CPB) causes hemolysis; therefore, extreme caution is warranted during CPB. However, few studies have reported open heart surgery in patients with thalassemia. We report successful surgery for aortic stenosis and regurgitation (ASR) and an ascending aortic aneurysm (AsAA) in a patient with thalassemia. A 69-year-old woman was referred to our hospital for surgical management of ASR and AsAA. Comprehensive evaluation of microcytic anemia led to diagnosis of beta-thalassemia minor. We performed aortic valve and ascending aorta replacement; we used a biologic valve and performed open distal anastomosis under hypothermic circulatory arrest (25°) combined with retrograde cerebral perfusion. Non-pulsatile flow circulation was maintained using a centrifugal pump during CPB. The suction and ventilatory pressures were decreased, and we performed dilutional ultrafiltration. A spare artificial lung was connected to the CPB to avoid complications in the event of artificial lung blockage. We did not observe any hemolysis-induced adverse event during the clinical course, and the patient was discharged 20 days postoperatively. Careful preoperative evaluation is essential to confirm thalassemia before cardiovascular surgery to establish an optimal surgical strategy and avoid the risk of CPB-induced hemolysis in patients with the hematological disorder.
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Objective:To summarize the experience of 15 cases of balloon endovascular occlusion assisted aortic replacement.Methods:15 patients who needed reoperation after aortic surgery underwent endovascular balloon occlusion assisted aortic replacement by DSA guidance in the hybrid OR. Main inclusion criteria: The target vessel to be blocked cannot be directly blocked. Based on the last CTA before the operation, the diameter of the target vessel was measured, and the appropriate diameter balloon and the appropriate diameter balloon and the amount of contrast agent were selected. The vascular approach was selected according to the CTA.During the operation, the balloon was filled and fixed well, the distal invasive blood pressure waveform showed advection, and the pressure close to hydrostatic pressure as the complete blocking standard.Results:All 15 cases of balloon endovascular occlusion assisted aortic surgery were successful. After the operation, 14 target vessels normally without damage, and there was no vascular complication. One case after surgical three-branch stent surgery underwent the second thoracoabdominal aortic replacement operation. After the stent was blocked by the balloon, the new tissue in the stent fell off, and the celiac trunk and superior mesenteric artery were embolized for reoperation.Conclusion:Balloon endovascular occlusion technology expands the indications of aortic surgery and simplifies the operation, that is a safe and effective occlusion method. Whether the target vessel is suitable for balloon occlusion should be judged before the operation to avoid related complications.
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A fifty-seven-year-old male farmer with a history of cerebral infarctions twice in the past without any functional disability stopped prescribed antithrombotics and regular medical follow-up. He had sudden left hemiplegia after the work, and was taken to our hospital. A contrast-enhanced computed tomography (CT) scan showed infarction at the right basal ganglia, occlusion of the internal carotid artery and the left vertebral artery, and mural thrombus in the ascending aorta. Mural thrombus in the ascending aorta was suspected to be the causative thrombus of other infarctions. He was started on continuous heparin infusion on the day of presentation, and had ascending aortic replacement surgery on day 24. No perioperative complication was confirmed. He was extubated on postoperative day (POD) 1, and was transferred to another rehabilitation hospital with almost no functional disability. No thrombotic event was confirmed as of POD 180.
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@#Objective To summarize the surgical treatment plan and experience of patients with Marfan syndrome complicated with Stanford type B aortic dissection, and to explore the treatment strategy selection. Methods A retrospective analysis was conducted on 27 patients with Marfan syndrome complicated with thoracoabdominal aortic diseases who were treated in the department of cardiovascular surgery of our hospital from January 2013 to June 2019, including 13 males and 14 females, with an average age of 32.2±8.6 years. According to the patients' conditions, 19 of them received single pump-assisted blood transfusion combined with total thoracoabdominal aortic replacement (TAAAR), and 8 received thoracic endovascular aortic repair (TEVAR) in critically ill and pregnant patients. The patients were followed up in the outpatient clinic, and the thoracoabdominal aortic CT angiography was reexamined at 3 months, 6 months, 12 months and annually. The outcome of surgery, the incidence of intermediate cardiovascular adverse events, defined as the reoperation due to aortic or cardiac diseases, and intermediate survival rate were studied. Results All 27 patients successfully completed the operation, the operation time was 60-852 (395.10±222.60) min, the spinal cord ischemia time was 14-26 (19.33±3.44) min, and the abdominal viscera ischemia time was 16-23 (19.83±1.94) min. Eight patients of TEVAR were all operated in acute phase and 19 patients of TAAAR in chronic phase. Two early postoperative deaths occurred in TEVAR patients. One died of puerperal infection and multiple organ dysfunction after cesarean section at the same time. After TEVAR, type A dissection re-ocurred in one patient. The family member gave up the treatment, and the patient died of the dissection ruptured after cesarean section. During the average follow-up of 47.6±36.7 months, 1 patient died of cerebrovascular accident and 9 patients were reoperated for adverse cardiovascular events, including 4 in TEVAR and 5 in TAAAR. Conclusion TAAAR is the first choice for the treatment of Marfan syndrome combined with thoracoabdominal aortic diseases. TEVAR is easy to operate, with a low incidence of early mortality and complications, but has the risk of internal leakage and avulsion, and a high reoperation rate in the middle stage, so it can be used for high-risk elderly patients not suitable for open surgery, or as a bridge therapy for emergency patients before open surgery.
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Objective To explore the mid-term results of the staged total aortic replacement in Stanford type A aortic dissection.Methods During March 2009 to September 2016,a total of 49 patients with Stanford type A aortic dissection in Beijing Anzhen Hospital cardiovascular center underwent total aortic replacement with a median age of 36 (27,41 years),male 36 (73.5％) cases.30 (61.2％) cases of them combined with Marfan syndrome.Results The interval between two stage operation was 23 (10,57) months.In the first stage operation,45 (91.8％) cases underwent Sun's procedure,2 (4.1％) underwent total aortic arch replacement,2 (4.1％) cases underwent classic elephant trunk and total aortic arch replacement.All patients underwent thoracoabdominal aortic repair(TAAAR).Deep hypothermic circulatory arrest surgery was 12(24.5％)cases in the second stage.7 (14.3％)cases dead postoperative.Spinal cord related complications happened in 3 (6.1％) cases with stroke in 2(4.1％) cases,acute renal insufficiency in 7(14.3 ％) cases,respiratory insufficiency in 7 cases (14.3％),re-operation for hemostasis in 3 (6.1％) cases and gastrointestinal bleeding in 3 cases(6.1％).Univariate analysis showed that the interval between two stage operation,operation time,deep hypothermic circulatory arrest surgery are risk factors for in-hospital mortality;multivariate analysis showed that deep hypothermic circulatory arrest surgery and the interval between two stage operation were independent risk factors for in-hospital mortality.3 years,5 years survival rate were 94.4％ and 78.7％.Conclusion For Stanford type A dissection especially the thoracoabdominal aortic expands,staged total aortic replacement shows good mid-term results.Block stentgraft can reduce the use of deep hypothermic circulatory arrests to decrease the mortality.
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An 83-year-old man who had undergone aortic arch repair using the elephant trunk technique in addition to abdominal aorta repair required surgical intervention for a pseudoaneurysm at the distal anastomosis of the aortic arch graft. Due to marked adhesion around the aneurysm, aortic cross-clamping was not feasible. Thus, under femoro-femoral partial bypass, the arch prosthesis was endoclamped using an aortic occlusion balloon inserted through the left femoral artery into the aortic arch graft and through the elephant trunk, guided by fluoroscopy and transesophageal echocardiography. This allowed descending aorta replacement with minimal bleeding. His postoperative course was uneventful. This technique enabled safe and bloodless clamping of the proximal portion of the aortic arch graft.
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A 26-year-old lady with Loeys Dietz syndrome had undergone 5 consecutive operations from 2007 to 2014. Finally, her total aorta was replaced by vascular grafts and stent grafts. The patient was admitted to our hospital with headache and dizziness in 2016. Computed tomography showed a giant pseudoaneurysm at the aortic arch with extravasation from the vascular graft. The proximal flares of thoracic stent grafts caused perforation of thoracic vascular grafts. Cerebral perfusion was not sufficient, because this aneurysm compressed the innominate, left carotid and left subclavian arteries. Decreasing of cerebral perfusion caused headache and dizziness. We performed total arch replacement. We started extracorporeal circulation before median sternotomy but the aneurysm ruptured during median sternotomy. We controlled the bleeding by manual compression and immediately started selective cerebral perfusion and induced cardiac arrest. After opening the distal portion, we cut down the proximal flares of thoracic stent graft and inserted an elephant trunk into the stent graft. We sutured between the new vascular graft and the stent graft and covered the suture line with another short vascular graft. As a result we could protect the vascular graft from the stent graft. Computed tomography demonstrated that the pseudoaneurysm and extravasation disappeared. Cerebral perfusion increased and the patient's symptoms improved. Postoperatively the patient was discharged from our hospital without any major complications at POD 11.
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Bleeding control during aortic surgery is one of the most important issue. The well-known fibrinogen-based hemostat contains the blood product, which means the potential risk of the blood-related infection. Recently, the newly-designed hemostat “Hydrofit”, which is assembled with urethane-based polymer without blood product (Matsudyte : Sanyo-chemical industry, Kyoto, Japan). Hydrofit is applicated for the hemostasis of thoracic aortic surgery. In sealing of the Hydrofit gel to the anastomosis site of aorta, water-contact initiation boosts the chemical change to the forming elastomer and adheres around anastomosis site rapidly. We experienced the extirpation of the Hydrofit which was used over 4 years ago. The patient is 42 year-old female who was operated aortic valve replacement and graft replacement of ascending aorta using a Hydrofit as a hemostat at 4 year 8 months ago due to the aortitis syndrome. Re-sternotomy and re-AVR was performed because of the prosthetic valve dehiscence due to the active aortitis syndrome. Hydrofit left around suture line without infection, and functioned very well as the elastic sealant for the long-term period.
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A 74-year-old woman was referred to our unit with a chief complaint of dysphagia. Enhanced CT showed a Kommerell diverticulum with a maximum diameter of 46 mm, associated with a right-sided aortic arch and aberrant left subclavian artery. We performed two-staged operations : left subclavian-common carotid artery bypass followed by total arch, and descending aortic replacement by an antero-lateral thoracotomy with partial sternotomy (ALPS). The postoperative course was uneventful. Total arch and descending aortic replacement for a Kommerell diverticulum by an ALPS approach is rare. ALPS approach for Kommerell diverticulum achieves safe surgery with good exposure.
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The optimal strategy for shaggy aorta syndrome has not been established, however, several case reports are published with the increase of the aged population. We report two men with shaggy aorta syndrome. The one was 75 years old with acute limb ischemia at the left popliteal artery due to the macroembolism from infrarenal Shaggy Aorta. The other was 76 years old with kidney dialysis, who had suffered from blue toe syndrome due to microembolism from the mobile plaque adhering to the infrarenal aortic wall. We successfully performed graft replacement of the abdominal aorta in order to prevent the recurrence of atheromatous embolization from the Shaggy Aorta. They have been free from any embolic event for the last 1 year. The ultrasonogram was useful for preoperative diagnosis and intraoperative management.
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Objective To review the experience of aortic root internal drainage in the operation of type A aortic dissection.Methods This was a prospective and observational study.Clinical data were available from 20 cases of type A aortic dissection patients (A group) from March 2003 to March 2008,and anothcr 36 cases of type A aortic dissection patients (B group) from March 2008 to May 2013.All of patients received the operation of replacement of ascending aortic aneurysm and aortic arch replacement and descending aortic stented elephant trunk implantation in our hospital.The additional inside drainage were made between the aortic root aneurysm sac and right atrial appendage in B group.Perioperative and postoperative data including the operation time,the amount of bleeding,cardiopulmonary bypass time,the amount of red cell transfusion,number of postoperative cases re-operated for hemostasis,total drainage volume in 24 hours,amount of postoperative red blood cell transfusion,number of cases of postoperative pulmonary complications,and postoperative mortality rate were analyzed retrospectively.The data was analyzed using SPSS version10.0 software.The chi-square test was used for constituent ratios,whilest was applied to analysis of differences in above variables betweens two groups.Results There were significant differences in the amount of bleeding during surgery,cardiopulmonary bypass time,the amount of red cell transfusion,rate of postoperative re-operation,total drainage volume in 24 hours,amount of postoperative red blood cell transfusion,number of cases of postoperative pulmonary complications and postoperative mortality between the two groups (x2/t =2.658,2.381,2.265,3.056,6.862,2.896,2.316,7.215,7.668,P =0.012,0.034,0.007,0.016,0.013,0.032,0.008,0.008,respectively).Conclusions The method of aortic root internal drainage in the operation of type A aortic dissection could reduce the amount of bleeding and improve the success rate of operation.
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Se efectuó un estudio observacional y analítico de casos y controles en el Servicio de Cirugía Cardiovascular del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, del 2001 al 2010, en los 248 pacientes a quienes se les realizó sustitución valvular aórtica, con empleo tanto de prótesis mecánica como biológica, de los cuales se tomaron como muestra los 30 fallecidos durante dicha etapa (grupo de casos) y 60 intervenidos seleccionados de forma aleatoria (grupo de controles). Pudo observarse un predominio de la estenosis aórtica, el sexo masculino y las edades avanzadas. En la serie la mortalidad resultó de 12,1 % y como factores predictores de esta, mediante el análisis por regresión logística, fueron identificados: las cifras de creatinina elevadas en el período preoperatorio, el tiempo prolongado de derivación cardiopulmonar, la protección miocárdica no óptima, la recuperación cardíaca no espontánea y las complicaciones neurológicas.
An observational and analytic case-control study was carried out in the Cardiovascular Surgery Department of "Saturnino Lora Torres" Provincial Teaching Clinical-Surgical Hospital in Santiago de Cuba, from 2001 to 2010, in the 248 patients to whom an aortic valvar replacement was carried out, with the use of both mechanical and biological prosthesis, of which the 30 deaths during this stage (cases group) and 60 surgically treated selected at random (controls group) were taken as samples. A prevalence of aortic stenosis, the male sex and the advanced ages could be observed. In the series mortality was 12.1% and as predictors of it, by means of the logistical regression analysis, there were: the levels of high creatinine in the preoperative period, the long time of cardiopulmonary bypass, non optimal myocardial protection, non spontaneous heart recovery and the neurological complications.
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Objective To summarize our clinical experience and results of Stanford type B dissection,and analyzed the risk factors of reoperation.Methods From February 2009 to December 2011,81 patients (54 male and 27 female) of Stanford type B aortic dissection underwent surgical procedure in Beijing Anzhen Hospital The mean age was 19 -77 years,averaged (41.6±11.7)years.Associated with hypeftension in 48 cases,Marfan syndrome in 15 case,aortic root aneurysm in 7cases,dilation of aortic sinus and ascending aorta each in one,coarctation of the aorta in 1 case.Reoperation was done in 22cases and 4 of 22 needed the third operation.The risk factors of reoperation were analyzed with Logistic regression analysis.Results Sun (s) procedure was operated on 16 cases,concomitant procedures included Bentall in 7 cases,David in 1,replacement of the ascending aorta in 2 cases,CABG in 1 case.The thoracoabdominal aortic replacement in 31 cases,the descending thoracic aortic replacement in 9 cases,the stented elephant trunk procedure in 24 cases.Concomitant procedures included the bypass from the left subclavian artery to the left common carotid artery in 5 cases,aortic valve replacement and ascending aortic plasty in 3 cases,left subclavian artery reconstruction in 2 cases,double valve replacement in 1 cases,and the bypass from ascending aorta to descending aorta each in one,repair of internal leakage in 1 case.2 patients underwent thoracoabdominal aorta replacement died after surgery due to multiple organ failure caused by postoperative bleeding.The hospital mortality was 2.5％(2/81 cases).Complications occurred in 6 patients (6/81 cases,7.4.％ ),including diastinal bleeding requiring reoperation in 3 cases,respiratory insufficiency and hoarseness each in one,postoperative esophageal fistula needed reoperation and jejunal fistulization in I case.No paraplegia or stroke occurred postoperatively.Logistic regression analysis shows Marfan syndrome is the risk factor of reoperation.Conclusion The surgery on Stanford B aortic dissection can achieve satisfactory clinical results and Marfan syndrome is the risk factor of reoperation.The mid- and long-term results need the further follow-up.
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Objective Retrospectively analyze the mid-term clinical results of single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement(T/STAR).This study describes our experience in this operation in single center of aortic disease at Fuwai Hospital.Methods From February 2004 to February 2011,21 patients with hypertension or Marfan syndrome underwent one-stage total or subtotal aortic replacement for aortic dissection or aortic aneurysms.16 male and 5 female,aged (34 ±9) years.Operations wore performed under circulatory arrest with profound hypothermia.Patients were opened with a mid-sternotomy and a thoracoabdominal incision.Extracorporeal circulation was instituted with two arterial cannulae and a single venous cannula in the right atrium.During cooling,the ascending aorta or aortic root was replaced.At the nasopharyngeal temperature of 20 ℃,the aortic arch was replaced with selective antegrade cerebral perfusion.Staged aortic occlusions allowed for replacement of descending thoracic and abdominal aorta.T6 to T12 intercostal arteries and L1,2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8 mm branch for keeping spinal cord blood perfusion.Visceral arteries were joined into a patch and anastomosed to the end of the main graft.Left renal artery was anastomosed to an 8mm branch or joined to the patch.The other 10 mm branches were anastomosed to iliac arteries.Results Early mortality was4.8％ ( 1/21 eases),the only one patient was dead result from renal failure and multiple organ failure.There were no postoperative spinal cord deficits occurred,two patients were stroked at day 5th and 7th respectively.Three patients were operated with tracheotomy because of respiratory insufficiency.Operation was undertaken on one patient with splenenctomy result of spleen rupture during first aortic aneurysms repair.All patients were follow-up,ranging from 18 to 84 months postoperatively,all 20 survivors were alive and had good functional status.One patient was reoperated with aortic valve replacement because of massive valve insufficiency after two years.Neo- intercostal arteries were clogged in 3 patients within follow-up,and two of those patients with Marfan syndrome underwent pseudoaneurysm after intercostal arteries reconstruction.Conclusion Single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement is safely and effectively.It is feasible with acceptable surgical risks and satisfactory results.It can eliminate the risk of remnant aortic aneurysm rupture in staged total aortic replacement and has satisfactory mid-term results.
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Objective The results of Aortic valve replacement (AVR). Combined with ascending aortic replacement(group A) or aortoplasty (group B) in patients with aortic valve disease and ascending aortic dilatation were analysed to assess the clinical outcomes and respective indications. Methods Among the two groups, the age, gender, NYHA class, types of aortic valve lesions and left ventricular ejection fraction were not different statically. The ascending aortic diameters in group A[(50.41 ±3.71) mm] and group B [(48.29±2.18) mm] were not statically different. Ascending aortic replacement was performed in Group A. A Dacron tube(diameter 28 ～ 30mm) was routinely wrapped around the ascending aorta after aortoplasty in group B. Results There was 1 postoperative death in group B, blood transfusion volume and postoperative complications were not stasticaly different in the two groups. Cardiopulmonary bypass time [(110.52 ± 27.51) min] and aortic across clumping time [(71.70 ± 17.13)min] in group A were significantly longer than that of group B [(97.31 ± 19.46) min,P=0. 004; (57.13 ±19.46) min, respectively. P=0.025]. Conclusion Aortic valve disease, especially bicuspid valve disease often combines with ascending aortic dilatation or aneurysm. In younger patients, ascending aorta should be actively treated surgically when the diameter is equal or more than 40mm. Aortoplasty with external reinforcement of a Dacron tube is simpler and safer than aortic replacement in patient without aortic atherosclerosis or ulceration, and large aneurysm.
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Immune heparin-induced thrombocytopenia (HIT) is a crucial side effect of heparin therapy. We report the case of a 52-year-old man who was strongly suspected of having HIT after urgent descending aorta replacement. This case required continuous hemodiafiltration (CHDF) anticoagulated with unfractionated heparin (UFH) for acute renal failure after the operation. The patient developed thrombocytopenia and thrombus emphraxis in the circuit on the seventh day and was suspected of having HIT. UFH was ceased and replaced with argatroban. After then, thrombus emphraxis was not seen in the circuit and the platelet count was recovered promptly. He tested positive in an enzyme-linked immunosorbent assay for anti-platelet factor 4/heparin antibodies (anti-PF4/H Abs). Six months later, we found, an expanding thoracoabdominal aortic aneurysm and performed thoracoabdominal aorta replacement. We selected heparin anticoagulation for cardiopulmonary bypass because anti-PF4/H Abs were negative at that time. Thrombus emphraxis was not found during the operation. The patient developed neither thrombocytopenia nor thrombosis in the perioperative period.
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Objective: To review the experience of one-stage surgical management of thoracic aortic aneurysm associated with coronary artery disease. Methods: From June 1999 to July 2002, fifteen patients (all the male, average age 57.21 year-old, ranged 40-66 year-old) underwent thoracic aortic aneurysm repair and concomitant coronary revascularization. The diagnosis are aortic root aneurysm in 5 cases,ascending aortic aneurysm in 2,arch aortic aneurysm in 3,and aortic dissecting in 5. 14 patients received operation through midsternotomy,including ascending aorta replacement in 2, Bentall technique in 4, David technique in 1 and total arch replacements in 3 patients. Left thoracotomy and off-pump CABG was done in 1 case. Results: 1 patient died in 30 days after operation. Followed up for a mean duration of 17 months,there were no late death and no reoperation and no related events occurred. Conclusion: Thoracic aortic replacement and CABG (coronary artery bypass grafting) could be done at one-stage. Concomitant coronary revascularization may aggressively obviate CAD events.