Surgical outcomes in acute type A aortic dissection based on surgeon experience.

OBJECTIVES: The aim of this study is to evaluate our surgical strategy for acute aortic dissection Stanford A and determine whether it is safe regardless of the experience of the primary surgeon. METHODS: Between April 2015 and September 2020, a total of 160 patients who underwent open surgery for type A aortic dissection at Shonan Kamakura General Hospital were reviewed. Data were collected from reviews of computerized medical records. From this study cohort, we retrospectively reviewed the cases of trainee (group T) and experienced primary surgeons (group E). We evaluated rates of 30 day and in-hospital mortality, stroke, aortic reintervention, and mid-term survival for both groups. RESULTS: The rates of 30 day and in-hospital mortalities in group T were 5.1 and 7.7%, respectively, whereas those in group E were 4.7 and 4.7%, respectively. One and 3 year survival rates in group T were 88.4 and 87.1% and in group E were 95.3 and 95.3%, respectively (log-rank test, p = 0.11). The 1 year and 3 year rates of freedom from reintervention were 90.9 and 72.8% in group T and 96.8 and 92.7% in group E, respectively (log-rank test, p = 0.29). The permanent neurological dysfunction rate was 8.1% overall, 8.5% in group T, and 7.0% in group E, with no significant difference. CONCLUSIONS: Our surgical strategy for acute type A aortic dissection is safe and appropriate regardless of the experience of the primary surgeon.

Acute type A aortic dissection in non-agenarians: to cut or not.

OBJECTIVES: Surgery for acute type A aortic dissection (type AAD) in non-agenarians is usually contraindicated due to advanced age. The aim of this study was to assess and compare outcomes after surgical or conservative treatment for acute type AAD in non-agenarians by evaluating frailty. METHODS: Between October 2012 and September 2018, 273 patients underwent open repair for type AAD at the Shonan Kamakura General Hospital and the Shonan Fujisawa Tokushukai Hospital, and here, we retrospectively reviewed the case reports of 10 surgically treated non-agenarians and 15 conservatively treated non-agenarians. Exclusion criteria for surgery were the patient's refusal of surgery, severe dementia and coma. In patients considered to be at a high risk, our judgements were based on the results of comprehensive evaluation. RESULTS: Both in-hospital mortality and 30-day mortality in the surgical group were zero, while in-hospital mortality in conservatively treated non-agenarians was 73.3%. Importantly, 1-year survival in the surgical group and conservative group was 90% and 25%, respectively. The 5-year survival in the surgical group and conservative group was 49.2% and 25%, respectively (log-rank test, P = 0.0105). Four of 6 patients with preoperative clinical frailty scores not higher than 4 were still alive at 1 year with the same level of preoperative frailty. CONCLUSIONS: Surgery for acute type AAD in non-agenarians can be performed with acceptable outcomes in carefully selected patients, particularly in those with preoperative clinical frailty scores not higher than 4.

Descending aortic banding for re-rupture of retrograde aortic dissection after emergency thoracic endovascular aortic repair.

Conversion to open repair after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection is rare, but inevitable. We present a case of an 86-year-old man with ruptured type B aortic dissection after TEVAR. He received a successful stent-graft implantation of the descending aorta without any type of endoleak. After the patient was transferred to the intensive care unit, he went into a shock state. Contrast-enhanced CT revealed a re-rupture of acute retrograde type B aortic dissection. The false lumen was patent and perforated to the left thorax. Left thoracotomy and descending aortic banding was performed. Descending aorta was encircled with a woven Dacron graft at the distal part of the rupture site to compress the patent false lumen. The bleeding was stopped, and the follow-up CT showed false lumen thrombosis. Descending aortic banding is one of the quick and effective open conversion techniques.

Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance.

OBJECTIVES: Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes. METHODS: Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed. RESULTS: The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively. CONCLUSIONS: The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes.

Operative results of the anterolateral thoracotomy with partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch.

Objectives: There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch. Methods: From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach. Results: Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively. Conclusions: The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed.

Outcomes of Anterolateral Thoracotomy With or Without Partial Sternotomy for Kommerell Diverticulum.

BACKGROUND: Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically. METHODS: From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction. RESULTS: No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months). CONCLUSIONS: Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes.

Outlet strut fracture and leaflet escape of Bjork-Shiley convexo-concave valve.

Prosthetic valve fracture is a serious complication and may arise in patient post-valve replacement. We experienced an outlet strut fracture and leaflet escape of a Bjork-Shiley convexo-concave valve. We performed an emergency redo mitral valve replacement and successfully retrieved the fractured strut and escaped leaflet from superficial femoral artery and the abdominal aorta. The patient showed an uneventful postoperative recovery.

[Closure of Ascending Aortic Entry by Debranching Endovascular Management in an Elderly Patient with Acute Stanford Type A Dissection].

An 85-year-old woman was hospitalized by emergency for an acute Stanford type A aortic dissection. Computed tomography showed a primary entry on the ascending aorta and pericardial effusion. Although her hemodynamics was unstable due to cardiac shock, her family wished no open surgery considering her age and frailty. A couple of days later, her condition became stabilized with antihypertensive therapy. Since the dissection was limited within the ascending aorta, closure of the entry with the stentgraft was considered appropriate and much less invasive as compared with an open surgery. After obtaining informed consent with her family, thoracic endovascular aortic repair was performed with Gore C-TAG with 2-debranch. The procedure was completed without complications and the entry closure was confirmed by aortography. Her postoperative course was uneventful. Her physical activity restored to the preoperative level and she was discharged.

Extended sleeve lobectomy after induction chemoradiotherapy for non-small cell lung cancer.

PURPOSE: Extended sleeve lobectomy is a challenging surgery. While induction chemoradiotherapy (ChRT) followed by surgery is one of the therapeutic strategies used for locally advanced non-small cell lung cancer (NSCLC), ChRT can impair the anastomotic healing potential. We herein present our experience with cases who underwent an extended sleeve lobectomy after induction ChRT. METHODS: The medical records of patients who underwent a surgery for NSCLC after ChRT were reviewed. RESULTS: Between December 2007 and January 2013, nine patients underwent an extended sleeve lobectomy; the left lingular division and lower lobe in four patients, the right upper lobe and trachea in one patient, the carina and trachea in one patient, the right middle and lower lobes in one patient, the right upper and middle lobes and carina in one patient and the right upper lobe and superior segment of the lower lobe in one patient. While no postoperative 90-day deaths occurred, one case developed a bronchopleural fistula on postoperative day (POD) 25 and one case developed a bronchovascular fistula on POD 163. No cases of local recurrence developed. CONCLUSIONS: Our experience suggests that an extended sleeve lobectomy after induction ChRT is feasible, but careful patient selection and perioperative management are mandatory.