Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: a technique for a potential future problem.

BACKGROUND: Acute Stanford type- A aortic dissections make up a large part of emergency cardiac surgery. They also carry a significant burden of morbidity. New techniques to aid aortic remodelling include the Ascyrus Medical Dissection Stent (AMDS): Its increasing use, looks to present a potential problem in cases where surgery involving the aortic arch may be required. CASE REPORT: We present the case of a 49-year-old male who underwent urgent redo-surgery for total arch replacement and de-branching following recent replacement of the ascending aorta for acute type-A dissection, where an AMDS stent was deployed. The patient underwent total arch replacement with a stented tri-furcate prosthesis and de-branching of arch vessels with the stent landed inside the previous AMDS, to good effect. CONCLUSION: This case highlights a possible approach to aortic arch surgery in patients who have previous had AMDS insertion.

Extended Stanford Type-A Aortic Dissection with Multivessel Coronary and Peripheral Artery Involvement: An Autopsy Case Report.

We report the case of a 64-year-old male who died suddenly short after his admission to hospital because of strong chest pain and before any clinical diagnosis was established. His medical history included coronary disease with coronary by-pass surgery at the age of 40 years old, uncontrolled hypertension, diabetes mellitus, and elevated levels of cholesterol. The autopsy revealed quite a rare case of Stanford A aortic dissection with extension to the common and internal carotid arteries; the subclavian, axillary, brachial, and radial arteries; three coronary arteries; the superior mesenteric artery; and the iliac arteries. There was no histological evidence of aortitis or connective tissue disease. The death did not result from the rupture of the aortic dissection, but from myocardial ischemia due to coronary occlusion in combination with hemodynamic disturbance from stress caused by the extended aortic dissection.

Ministernotomy approach to aortic arch inclusion and frozen elephant trunk in the treatment of acute Stanford A aortic dissection.

This study aimed to report our results of ministernotomy approach to Liu's aortic root repair technique, Liu's aortic arch inclusion technique with frozen elephant trunk (FET) in the treatment in type A aortic dissection (TAAD). We retrospectively analyzed data on 68 Stanford A aortic dissection patients from October 2017 to March 2020. All patients underwent Liu's aortic root repair technique, Liu's aortic arch inclusion technique with FET and mild-moderate hypothermic circulatory arrest combined with ministernotomy approach. 154 TAAD patients between January 2014 and December 2016 underwent complete sternotomy were selected as control group. Clinical characteristics, data during operation, in-hospital and postoperative outcomes of these patients were observed. The mean hypothermic circulatory arrest time in ministernotomy Patients was 39.3 ± 7.9 min, aortic cross-clamp time was 105.9 ± 12.8 min, cardiopulmonary bypass time was 152.8 ± 24.3 min. Three patients died of multiple organ dysfunction syndrome in ministernotomy Patients. Perioperative temporary neurological dysfunction occurred in three (4.41%) patients, and 53 (77.9%) patients did not require any blood product transfusion during and after operation in ministernotomy Patients. Postoperative CT angiography (CTA) examination at 6-32 months showed excellent outcomes except in three (4.41%) cases where arch false lumen patency persisted. The Liu's aortic root repair technique, Liu's aortic arch inclusion technique with FET and mild-moderate hypothermia circulatory arrest simplify the surgical procedure and reduce bleeding, which can be accomplished through minimally invasive approach.

The role of peripheral blood eosinophil counts in acute Stanford type A aortic dissection patients.

Background: Acute Stanford-A aortic dissection (AAAD) is a devastating cardiovascular condition with high mortality, therefore identifying risk prognosis factors is vital for the risk stratification of patients with AAAD. Here, we investigated peripheral blood eosinophil (EOS) counts in patients with AAAD and their possible biological implications. Methods: We performed a single center retrospective cohort study. From 2011 to 2021, a total of 1,190 patients underwent AAAD surgery. Patients were categorized first by death and then admission EOS counts (0.00 × 109/L or >0.00 × 109/L). Demographics, laboratory data, and outcomes were analyzed using standard statistical analyses. Ascending aorta specimens were used for western blotting and histological assessments. Results: Death group patients had lower EOS counts than the non-death group (P = 0.008). When patients were stratified using mean blood EOS counts: 681 patients had low (0.00 × 109/L) and 499 had high (>0.00 × 109/L) counts. Patients with low EOS counts at admission were more likely to have a higher mortality risk (P = 0.017) and longer treatment in the intensive care unit (ICU) days (P = 0.033) than patients with normal EOS counts. Also, the five blood coagulation items between both groups showed significantly different (P < 0.001). Hematoxylin & eosin-stained cross-sections of the ascending aorta false lumen showed that EOSs were readily observed in thrombi in the false lumen of the aorta. Conclusions: Peripheral blood EOS counts may be involved in thrombosis and could be an effective and efficient indicator for the diagnosis, evaluation, and prognosis monitoring of patients with AAAD.

Surgical outcomes associated with sleep apnea syndrome in Stanford A aortic dissection patients.

BACKGROUND: Patients suffering from aortic dissection (AD) often experience sleep apnea syndrome (SAS), which aggravates their respiratory function and aortic false lumen expansion. METHODS: We analyzed the peri-operative data of Stanford A AD patients, with or without SAS, between January 2017 and June 2019. Subjects were separated into SAS positive (SAS+) and SAS negative (SAS-) cohorts, based on the Apnea-Hypopnea Index (AHI) and the Oxygen Desaturation Index (ODI). We next analyzed variables between the SAS+ and SAS- groups. RESULTS: 155, out of 198 AAD patients, were enlisted for this study. SAS+ patients exhibited higher rates of pneumonia (p < 0.001), heart failure (HF, p = 0.038), acute kidney injury (AKI, p = 0.001), ventilation time (p = 0.009), and hospitalization duration (p < 0.001). According to subsequent follow-ups, the unstented aorta false lumen dilatation (FLD) rate increased markedly, with increasing degree of SAS (p < 0.001, according to AHI and ODI). The SAS+ patients exhibited worse cumulative survival rate (p = 0.025). The significant risk factors (RF) for poor survival were: severe (p = 0.002) or moderate SAS (p = 0.008), prolonged ventilation time (p = 0.018), AKI (p = 0.015), HF New York Heart Association (NYHA) IV (p = 0.005) or III (p = 0.015), pneumonia (p = 0.005), Marfan syndrome (p = 0.010), systolic blood pressure (BP) upon arrival (p = 0.009), and BMI ≥ 30 (p = 0.004). CONCLUSIONS: SAS+ Stanford A AD patients primarily exhibited higher rates of complications and low survival rates in the mid-time follow-up. Hence, the RFs associated with poor survival must be monitored carefully in SAS patients. Moreover, the FLD rate is related to the degree of SAS, thus treating SAS may mitigate FLD.

Development and Validation of a Diagnostic Model to Predict the Risk of Ischemic Liver Injury After Stanford A Aortic Dissection Surgery.

Objective: To define the risk factors of ischemic liver injury (ILI) following Stanford A aortic dissection surgery and to propose a diagnostic model for individual risk prediction. Methods: We reviewed the clinical parameters of ILI patients who underwent cardiac surgery from Beijing Anzhen Hospital, Capital Medical University between January 1, 2015 and October 30, 2020. The data was analyzed by the use of univariable and multivariable logistic regression analysis. A risk prediction model was established and validated, which showed a favorable discriminating ability and might contribute to clinical decision-making for ILI after Stanford A aortic dissection (AAD) surgery. The discriminative ability and calibration of the diagnostic model to predict ILI were tested using C statistics, calibration plots, and clinical usefulness. Results: In total, 1,343 patients who underwent AAD surgery were included in the study. After univariable and multivariable logistic regression analysis, the following variables were incorporated in the prediction of ILI: pre-operative serum creatinine, pre-operative RBC count <3.31 T/L, aortic cross-clamp time >140 min, intraoperative lactic acid level, the transfusion of WRBC, atrial fibrillation within post-operative 24 h. The risk model was validated by internal sets. The model showed a robust discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.718. The calibration plots for the probability of perioperative ischemic liver injury showed coherence between the predictive probability and the actual probability (Hosmer-Lemeshow test, P = 0.637). In the validation cohort, the nomogram still revealed good discrimination (C statistic = 0.727) and good calibration (Hosmer-Lemeshow test, P = 0.872). The 10-fold cross-validation of the nomogram showed that the average misdiagnosis rate was 9.95% and the lowest misdiagnosis rate was 9.81%. Conclusion: Our risk model can be used to predict the probability of ILI after AAD surgery and have the potential to assist clinicians in making treatment recommendations.

Efficacy of interleukin-6 in combination with D-dimer in predicting early poor postoperative prognosis after acute stanford type a aortic dissection.

BACKGROUND: We studied early poor postoperative prognosis in acute Stanford type A aortic dissection (ATAAD) patients and investigated the predictive effect of interleukin-6 (IL-6) combined with D-dimer in the early poor postoperative prognosis after ATAAD. METHODS: Data on 141 ATAAD patients, who underwent emergency surgery between January 2018 and December 2018 at our hospital, were studied. We analyzed early postoperative prognosis using two patient groups. Patients with good prognosis were included in group A and those with poor prognosis were in group B. Univariate logistic and multivariable logistic regression analysis were performed for poor early postoperative prognosis. RESULTS: Preoperative IL-6 level was lower (57.8 ± 39.0 vs 211.0 ± 153.7 pg/mL, p < 0.001) and the D-dimer was also lower (7.3 ± 6.1 vs. 16.7 ± 5.8 µg/mL, p < 0.001) in group A than in B. The cut-off points, determined by the ROC curve, were preoperative IL-6 > 108 pg/mL (area under the curve: AUC = 0.901) and D-dimer > 14.0 µg/mL (AUC = 0.817). Univariate logistic regression analysis showed that IL-6 > 108 pg/mL, D-dimer > 14.0 µg/mL, prothrombin time > 15 s, creatinine > 135 mmol/mL, and operation time > 306 min for ATAAD appeared to be early postoperative risk factors of poor prognosis. Multivariable logistic regression analysis showed that IL-6 > 108 pg/mL and D-dimer > 14.0 µg/mL were early postoperative risk factors for poor prognosis after ATAAD, and the odds ratios (ORs) of IL-6 > 108 pg/mL and D-dimer > 14.0 µg/mL were 24.937 (6.837, 90.931) and 18.757 (5.094, 69.075), respectively. When IL-6 was > 108 pg/mL (AUC = 0.901), the sensitivity and specificity of predicting early postoperative prognosis after ATAAD were 79.4 and 89.7%, respectively (95% confidence interval [CI] 0.839 to 0.963). When D-dimer was > 14.0 g/mL (AUC = 0.817), the sensitivity and specificity were 82.4 and 84.1%, respectively (95% CI 0.731 to 0.903). When combined with D-dimer (AUC = 0.936) (95% CI 0.793 to 0.979), the AUC values were more predictive than those for the individual marker. CONCLUSION: IL-6 > 108 pg/mL and D-dimer > 14.0 µg/mL is of high predictive value for the assessment of early poor postoperative prognosis after ATAAD. And IL-6 > 108 pg/mL in combination with D-dimer > 14.0 µg/mL is of higher predictive value.

Retrospective study of right axillary and femoral artery cannulation in Sun's operation / 中华胸心血管外科杂志

Objective Summarize the anatomical features of the aortic dissection of right axillary and femoral artery cannulation in Sun's surgery.Exploring whether right axillary and femoral artery cannulation can reduce the incidence of organ malperfusion and improve patient prognosis.Methods From January 2015 to December 2017,181 cases with aortic dissection were treated in Beijing Anzhen Hospital affiliated to Capital Medical University,Beijing Great Blood Vessel Research and Treatment Center,122 patients were enrolled in the right axillary and femoral artery cannulation group,and 59 patients in control group were enrolled.Retrospective analysis the data of two groups,intraoperative,and postoperative univariate were compared between the two groups.Results A total of 17 patients died in the postoperative group,with 9 (7.38％) in the combined perfusion group and 8 (13.56％) in the control group,P =0.t81.Among the complications of the two groups,18 patients (14.75％) in combined perfusion group had renal insufficiency and 17 patients (28.81％) in the control group,P =0.025.0 case had stransient spinal cord injury in combined perfusion group,3 cases(5.08％) in control group,P =0.033.Conclusion Right axillary and femoral artery cannulation can reduce the incidence of complications of postoperative organ dysfunction and improve patient prognosis.

Retrospective study of right axillary and femoral artery cannulation in Sun’s operation / 中华胸心血管外科杂志

Objective@#Summarize the anatomical features of the aortic dissection of right axillary and femoral artery cannulation in Sun's surgery. Exploring whether right axillary and femoral artery cannulation can reduce the incidence of organ malperfusion and improve patient prognosis.@*Methods@#From January 2015 to December 2017, 181 cases with aortic dissection were treated in Beijing Anzhen Hospital affiliated to Capital Medical University, Beijing Great Blood Vessel Research and Treatment Center, 122 patients were enrolled in the right axillary and femoral artery cannulation group, and 59 patients in control group were enrolled. Retrospective analysis the data of two groups, intraoperative, and postoperative univariate were compared between the two groups.@*Results@#A total of 17 patients died in the postoperative group, with 9 (7.38%) in the combined perfusion group and 8 (13.56%) in the control group, P=0.181. Among the complications of the two groups, 18 patients(14.75%) in combined perfusion group had renal insufficiency and 17 patients (28.81%) in the control group, P= 0.025. 0 case had stransient spinal cord injury in combined perfusion group , 3 cases(5.08%) in control group , P=0.033.@*Conclusion@#Right axillary and femoral artery cannulation can reduce the incidence of complications of postoperative organ dysfunction and improve patient prognosis.

Diagnosis and treatment of a case of acute severe Stanford type A aortic dissection / 中华危重病急救医学

Patients?with?acute?myocardial?infarction?(AMI)?complicated?with?acute?Stanford?type?A?aortic?dissection?after?percutaneous?coronary?intervention?(PCI)?are?critically?ill,?with?a?very?high?fatality?rate,?and?few?cases?are?successfully?treated?clinically.?A?case?with?AMI?admitted?to?the?First?Affiliated?Hospital?of?Zhengzhou?University?complicated?with?acute?left?cardiac?insufficiency?after?PCI,?Stanford?type?A?aortic?dissection,?pericardial?and?pleural?infection,?recurrent?AMI?was?reviewed.?In?the?condition?of?coexistence?of?many?diseases,?through?timely?adjustment?of?treatment?strategy?and?exploratory?application?of?drugs?to?improve?cardiac?function,?the?patient?successfully?received?operation?and?discharged?from?the?hospital.?By?presenting?the?successful?treatment?experience?of?this?case,?the?author?aims?to?improve?the?overall?treatment?of?AMI?patients?with?acute?Stanford?type?A?aortic?dissection?after?PCI.

Randomized controlled trial of moderate hypothermia versus deep hypothermia anesthesia on brain injury during Stanford A aortic dissection surgery.

This study aimed to compare the effects of moderate versus deep hypothermia anesthesia for Stanford A aortic dissection surgery on brain injury. A total of 82 patients who would undergo Stanford A aortic dissection surgery were randomized into two groups: moderate hypothermia group (MH, n = 40, nasopharyngeal temperature 25 °C, and rectal temperature 28 °C) and deep hypothermia group (DH, n = 42, nasopharyngeal temperature 20 °C, and rectal temperature 25 °C). Different vascular replacement techniques including aortic root replacement, Bentall, and Wheat were used. The intraoperative and postoperative indicators of these patients were recorded. There were no differences in intraoperative and postoperative measures between MH and DH groups. The concentrations of neuron-specific enolase and S-100ß increased with operation time, and were significantly lower in MH group than those in the DH group (P < 0.05). The occurrence rates of complications including chenosis, postoperative agitation, and neurological complications in MH group were significantly lower than in DH group. The recovery time, postoperative tube, and ICU intubation stay were significantly shorter in MH group than those in DH group (P < 0.05). There were no significant differences revealed in hospital stay and death rate. MH exhibited better cerebral protective effects, less complications, and shorter tube time than DH in surgery for Stanford A aortic dissection.

Establishment of perioperative risk assessment system for type A aortic dissection / 中华胸心血管外科杂志

Objective To explore the independent risk factors of the prolonged time of retention ICU after type A aortic dissection operation,to establish a corresponding perioperative risk assessment system.Methods A total of 509 consecutive patients with type A aortic dissection were enrolled in the study from September 2011 to May 2016,among which,418 patients received emergency operation.The prolonged retention time of ICU was considered as endpoint event.A perioperative assessment system was established through the analysis of related risk factors of the most common complications after type A aortic dissection operation.The possible risk factors of prolonged retention time of ICU were introduced into a single factor analysis.The meaningful variables in the single factor analysis were introduced into logistic regression analysis.The independent risk factors which were obtained from logistic regression analysis were used to establish risk prediction modeL,and the ROC curve and Hosmer-Lemeshow goodness of fit test were used to evaluate the model.Results The perioperative mortality rate was 8.64％,the prolonged retention time of ICU was 5.06 days,and 98 cases exceeded 7 days.The results of logistic regression analysis showed that age,the history of stroke,obesity,emergency operation,cardiopulmonary bypass time,deep hypothermic circulatory arrest time,renal inadequacy,massive transfusion,hypoxemia,and pulmonary infection were the independent risk factors for prolonged retention time of ICU.Accordingly,a mathematical model was established.The area under ROC cure for prediction model(AUC) =0.761,Hosmer-Lemeshow goodness of fit test P =0.512.Conclusion The logistic model estabhshed in this study can successfully predict ICU retention time after type A aortic dissection operation,and the efficacy was predicted satisfactorily.

Risk factors for hypoxemia following surgical repair of acute type A aortic dissection.

Objectives: To identify the risk factors for hypoxaemia following surgical repair of acute type A aortic dissection. Methods: This was a retrospective study of patients treated between October 2013 and December 2014 at the Department of Cardiovascular Surgery, Anzhen Hospital, China. Univariable and multivariable analyses were performed on the clinical data of 160 patients with acute type A dissection and who underwent ascending aortic and arch replacement under deep hypothermic circulatory arrest. Results: Hypoxaemia occurred in 30% (48/160) of patients (age: 49 ± 7.9 years; 40 males, 83.3%). The duration of ventilation and the lengths of intensive care unit and hospital stays were significantly longer in patients with hypoxemia (77.9 ± 56.0 vs 16.5 ± 11.5 h, P < 0.0001; 6.0 ± 2.3 vs 2.0 ± 1.2 days, P = 0.001; 18.1 ± 6.3 vs 13.5 ± 4.7 days, P = 0.0012; respectively). The difference in operative mortality was not statistically significant between the hypoxaemia and non-hypoxaemia groups (6.25% vs 3.57%, P = 0.351). The independent risk factors of postoperative hypoxaemia were time from symptom onset to surgery ≤72 h [odds ratio, 3.63; 95% confidence interval, 1.31-10.02; P = 0.013], preoperative PaO2/FiO2 ≤300 (odds ratio, 15.30; 95% CI, 5.52-42.43; P < 0.001), preoperative white blood cell count >15 000/µl (odds ratio, 9.79; 95% CI, 2.47-38.87; P = 0.001); and deep hypothermic circulatory arrest time >25 min (odds ratio, 3.26; 95% CI, 1.18-8.99; P = 0.023). Conclusions: Time from symptom onset to surgery ≤72 h, preoperative PaO2/FiO2 ≤300, white blood cell count >15 000/µl and deep hypothermic circulatory arrest time >25 min were found to be independently associated with hypoxaemia after surgery for acute type A aortic dissection.

Risk factors for postoperative delirium in patients after Stanford A aortic dissection surgery: a prospective cohort study / 中华胸心血管外科杂志

Objective This study aims to analyze the independent risk factors associated with postoperative delirium of patients undergoing Stanford A aortic dissection surgery.Methods Clinical data of the patients who underwent Stanford A aortic dissection surgery from December 2014 to October 2015 were collected.All patients received surgery under deep hypothermic circulatory arrest(DHCA) and the nasal temperature goal was below 23℃.After surgery,patients were transferred to the cardiovascular ICU,where they received standard postoperative care.The delirium was diagnosed according to the criteria of the confusion assessment method for the intensive care unit(CAM-ICU).The possible risk factors of pre-operation,during operation or post-operation were analyzed via univariate analysis and multivariate logistic regression to determine the independent risk factorsof postoperative delirium.Results 148 patients underwent Stanford A aortic dissection surgery which the incidence of postoperative delirium was 31.1％ (46/148).Univariate analysis showed the associated risk factors were age,hypertension,cognitive impairment,emergency operation,operation time,aorta clamping time,DHCA time,fluctuation of blood pressure during operation,blood transfusion,quality of sleep,length of ICU stay and electrolyte disturbance(P ＜ 0.05).Multivariate logistic regression analysis revealed that hypertension,cognitive impairment,fluctuation of mean arterial blood pressure(MAP) ＞ 30 mmHg (1 mmHg =0.133 kPa),DHCA time ＞ 40 min,postoperative poor quality of sleep and electrolyte disturbance were independently associated with postoperative delirium after Stanford A aortic dissection surgery(P ＜ 0.05).Conclusion Delirium is a frequent complication.Factors independently associated with delirium are hypertension,cognitive impairment,DHCA time,postoperative poor quality of sleep and electrolyte disturbance.Prevent,assess and manage delirium should be paid more attention and reinforced.

Risk factors and treatment strategies for postoperative hypoxemia in patients undergoing acute Stanford A aortic dissection surgery / 中华胸心血管外科杂志

Objective To explore the risk factors and optional treatment strategies for postoperative hypoxemia in patients undergoing acute Stanford A aortic dissection surgery.Methods From December 2012 to April 2014,108 patients received acute Stanford A aortic dissection surgery in Henan Provincial People' s Hospital.Of them,74 men vs.34 women,age (43.2 ± 10.1) years old,and weight (71.3 ± 18.4) kg.The operation was performed within 14 days since disease onset.All patients received surgery under deep hypothermic circulatory arrest(DHCA) and the nasal temperature goal was below 20 ℃ .Postoperative hypoxemia was defined as the arterial partial oxygen over inspired oxygen fraction(PaO2/FiO2) more than 200 after admission to ICU.Pulmonary protective ventilation management took place immediately after hypoxemia was diagnosed.Comparison analysis was performed between hypoxemia group and non-hypoxemia group in age,gender,body mass index (BMI),smoking history,duration of cardiopulmonary bypass(CPB),duration of DHCA,blood transfusion,length of mechanical ventilation,length of ICU stay and mortality.Results The incidence of postoperative hypoxemia was 40.7％ (44/108).There were no statistical differences in age,gender,hypertension,diabetes mellitus or COPD history.In the hypoxemia group,11 cases developed pulmonary infection,3 cases underwent tracheotomy and 10 cases died.In the non-hypoxemia group,4 patients died.Postoperative hypoxemia was significantly associated with more mortality,length of ventilation time,length of ICU stay and in hospital(P ＞ 0.05).Univariate analysis showed the associated factors were BMI,smoking history,preoperative hypoxemia,LVEF ＜ 0.45,operation time,aorta clamping time,DHCA time and blood transfusion.Multivariate analysis showed the independent predictive factors were preoperative hypoxemia,DHCA ＞40 min,blood transfusion ＞ 10 U and BMI ＞25 kg/ m2.Conclusion Obesity,massive blood transfusion,long DHCA time and preoperative hypoxemia are independent risk factors of postoperative hypoxemia in patients undergoing acute Stanford A aortic dissection surgery.Perioperative pulmonary protection should be paid more attention and reinforced.