The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function.

Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.

Mid-term outcomes of hybrid debranching endovascular aortic arch repair in landing zones 0-2.

OBJECTIVES: The aim of this study is to summarize a single-center experience of hybrid debranching endovascular repair of the aortic arch and proximal descending thoracic aorta (DTA) with regard to the mid-term outcomes with highlighting the difference between the landing zones 0-2. METHODS: A retrospective review of data from a prospectively collected registry (Gangnam Severance Endovascular Aortic Registry) was performed. From among 332 patients whose aortic pathology was managed with TEVAR, 112 patients who underwent hybrid arch repair during the study period between 2012 and 2016 were identified. The patients were grouped into three cohorts according to the proximal landing zones (0, 1, and 2) of Ishimaru. The early outcome (30-days) in terms of mortality, morbidity, supra-aortic vessels patency, and presence of endoleak were analyzed. The survival, freedom from re-intervention, and major complications during follow-up were demonstrated. RESULTS: During the study period. 112 patients (mean age 65±7, 79% males) were included. The patients were distributed in three cohorts: 8 (7%) patients with proximal landing zone 0, 20 (18%) with zone 1, and 80 (75%) with zone 2 hybrid aortic arch repair. Technical success was achieved in 7 (88%), 19 (90%), and 79 (94%) patients for zones 0, 1, and 2, respectively. The mean intensive care unit (ICU) stay was shorter in zone 2 (p = .005). The mean total hospital stay was shorter in zone 2 (p = .03). The overall in-hospital mortality rate was 5% (4/112). There was no spinal cord ischemia or early surgical conversion. Renal function deterioration was seen more but not significantly in zone 0 patients (p = .08). Respiratory failure was seen significantly in zone 0 patients (p = .01). Stroke occurred in 6/44 (14%) patients with degenerative aneurysm versus 1/60 (2%) patients with aortic dissection (p =.06). Early CTA showed 100% patency of the supra-aortic vessels. The early endoleak rate was significant in zone 0 patients (p = .008). The mean follow-up period was (32±19 months). The survival rates and freedom from re-intervention were not statistically significant among the three zones. However, the survival rate and freedom from intervention tend to be higher in zone 2 versus zone 0 (p = .07 and .09), respectively. CONCLUSION: Hybrid debranching endovascular aortic arch repair is feasible and relatively safe with acceptable mid-term outcomes. Zone 0 patients has worse early and late outcomes in comparison to other zones. Careful patient selection and improved endovascular technology may be the key to improve the outcomes.

Note the descending aorta: predictors of postoperative major adverse aortic event in pure acute type A intramural hematoma.

BACKGROUND: Intramural hematomas (IMHs) may originate from small intimal tears. Although most surgeries for acute type A IMH are conventionally performed solely at the proximal aorta, regardless of the primary intimal tear site, the remnant aortic remodeling stays important during the follow-up period after surgery. METHODS: Forty-seven patients with "pure" acute type A IMHs who underwent surgery from January 2008 to December 2019 were retrospectively analyzed. Acute type A IMH in the entire region without penetrating aortic ulcer (PAU) and aortic dissection (AD), which upon initial computed tomography (CT), can be considered as an intimal tear site, was defined as "pure" type. The maximal diameter of the aorta, maximal thickness of the IMH, and hematoma thickness ratio (HTR) of the ascending and descending aortae were measured from the preoperative computed tomographic scan. The hematoma thickness index was defined as the HTR of the descending aorta divided by that of the ascending aorta. Major adverse aortic events (MAAEs) were defined as AD, rupture, or newly developed PAU and aortic death. Predictors for postoperative MAAEs were analyzed using preoperative computed tomographic findings. RESULTS: The measurements of the descending aorta were larger and those of the ascending aorta were smaller in the MAAEs group, than in the corresponding other. The hematoma thickness index was significantly higher in the group with MAAEs, than in the group without; this variable was an independent predictor of MAAEs. During surgery, intimal tears were found in 16/47 (34%) patients. The hematoma thickness index was significantly smaller in the group with intimal tears than in the group without the tears. The aortic measurement appears to reflect the tear site. CONCLUSIONS: Hematoma thickness index was an independent predictor of MAAE after acute type A IMH surgery. Long-term periodical follow-up with early reintervention may, therefore, be necessary to improve outcome in these patients. As the optimal treatment method is still controversial, inferring the location of the primary tear through the hematoma thickness index can be helpful in determining the treatment method.