Cheng-Nan Li

One-stage repair for stanford type B aortic dissection concomitant with cardiac diseases: open stented elephant trunk technique combined with cardiac operation.

BACKGROUND We evaluated an open stented elephant trunk (sET) technique combined with cardiac operations for a one-stage treatment of patients with complicated Stanford type B aortic dissection (AoD) and cardiac diseases. METHODS Between April 2007 and March 2010, 16 patients with Stanford B AoD and cardiac diseases (mean age 49.75 ± 13.42 years) underwent sET combined with cardiac operations. Under deep hypothermic cardiac arrest (DHCA), a stented graft was directly delivered via the incision of aortic arch and the proximal graft was sutured on the normal distal aortic arch wall in a continuous circumferential full-thickness fashion. The combined cardiac operations (Bentall procedure, etc.) were performed before sET implantation while cooling. RESULTS Average time of cardiopulmonary bypass, aortic cross clamping durance, and DHCA was 131.62 ± 23.85, 64.69 ± 9.72, and 21.94 ± 3.60 minutes, respectively. There were no early deaths and no neurological complications. During a follow-up of 18.69 ± 9.94 months, computed tomographic angiography was performed in all patients. Neither endoleak nor stent shifting was observed. Retrograde type A AoD was not found during follow-up. Thrombus was formed in the false lumen from the proximal descending aorta to the diaphragmatic section. CONCLUSIONS The open sET technique combined cardiac procedures can reliably treat Stanford type B AoD concomitant with surgical cardiac disease in a single stage.

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Preservation of autologous brachiocephalic vessels

OBJECTIVE Various techniques have been introduced to treat acute type A dissection during aortic arch reconstruction. We retrospectively reviewed our experience of total arch replacement, with implantation of a stented elephant trunk, using preservation of autologous brachiocephalic vessels in patients with acute type A dissection. METHODS Between August 2011 and April 2013, 20 patients (16 men, 4 women; mean age, 45 ± 10 years, range, 24-62 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation, using preservation of autologous brachiocephalic vessels under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. RESULTS No in-hospital deaths occurred. A transient neurologic deficit occurred in 1 patient, who ultimately required tracheotomy. Reoperation was indicated in 1 patient for bleeding. All patients survived and were discharged. During the mean follow-up period of 26 ± 7 months, 1 patient underwent thoracoabdominal aortic replacement, and 1 patient was lost to follow up. The patency of the anastomotic site between the left subclavian artery and the left common carotid artery was confirmed on computed tomography scanning. CONCLUSIONS This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results. This technique is an alternative approach for suitable patients with acute type A dissection. However, outcomes are preliminary, and long-term follow up is required.

Repair of Complicated Chronic Type B Dissection with Distal Aortic Arch Involvement Using Left Subclavian Artery Transposition with Implantation of a Stented Elephant Trunk

Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP). Preoperative renal dysfunction was observed in three patients, left heart failure in one patient, and spinal cord ischemia in one patient. Results There was one (5.0%, 1/20) in‐hospital death. All but one patient required mechanical ventilation for < 24 hours. Mean duration of mechanical ventilation and mean duration of stay in the intensive care unit was 16 ± 4 and 35 ± 16 hours, respectively. No severe complications occurred. There was one death because of unknown cause during follow‐up. One case received thoracoabdominal aortic replacement 9 months after surgery. Conclusion Acceptable surgical outcomes were obtained using LSCA transposition with implantation of a stented elephant trunk. This method is an alternative to TEVAR for complicated chronic type B dissection with involvement of the distal aortic arch.

Risk Factors for Prolonged Mechanical Ventilation After Total Aortic Arch Replacement for Acute DeBakey Type I Aortic Dissection

BACKGROUND EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation. METHODS Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation. RESULTS The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p<0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p<0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 10⁹/L (p<0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75). CONCLUSIONS EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation.

Treatment with Corticosteroid and/or Immunosuppressive Agents before Surgery can Effectively Improve the Surgical Outcome in Patients with Takayasu's Arteritis

ABSTRACT Objective: To analyze the clinical outcome of corticosteroid and/or immunosuppressive treatment preoperatively in patients with Takayasus arteritis. Patients and Methods: Forty-six patients with Takayasus arteritis who received cardiovascular surgery between January 2010 and December 2015 in Beijing Anzhen Hospital were enrolled in this study. Their clinical characteristics, preoperative drug therapy, surgical treatment, and pathological examination results were retrospectively analyzed for the effect of drugs on outcome of the surgery. Results: All 8 patients with active disease prior to surgery had postoperative complications including one death due to stubborn perivalvular regurgitation induced heart failure during the perioperative period. Among 38 patients without active disease prior to surgery, only 4 patients (10.5%) had postoperative complications. Thirty-four patients showed symptomatic relief in the perioperative period, of whom 23 patients treated with corticosteroid and/or immunosuppressive agents preoperatively. Conclusion: The surgery can effectively improve the symptoms of patients with Takayasus arteritis. Active disease of Takayasus arteritis markedly increased risk for postoperative complication and resulted in poor outcome of the surgery. Treatment with corticosteroid and/or immunosuppressive agents before surgery can effectively control the patients condition, improve the rate of remission, and effectively reduce the incidence of postoperative complications.

The repair of a type Ia endoleak following thoracic endovascular aortic repair using a stented elephant trunk procedure

Background: Type Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent‐graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. Methods: From July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. Results: All cases of type Ia endoleak (100%) were repaired successfully. There were no in‐hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow‐up. During follow‐up, there were 3 deaths. Conclusions: Acceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion.

Can EuroSCORE II predict the mortality and length of intensive care unit stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey type I aortic dissection

BACKGROUND EuroSCORE is a widely used objective risk scoring model. OBJECTIVE The aim of this study was to evaluate the validation of EuroSCORE II for predicting in-hospital mortality and length of intensive care unit (ICU) stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey Type I aortic dissection. PATIENTS AND METHODS Between February 2009 and February 2012, data from 384 consecutive patients, who underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation, were collected retrospectively. EuroSCORE II was applied to predict mortality and length of ICU stay. The C-statistic was used to test discrimination of the model. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS The in-hospital mortality was 8.07%. The mean length of ICU stay was 3.06 days. A total of 75 patients remained at ICU for 5 days or more and 42 patients for 7 days or more. EuroSCORE II did not show good discriminatory ability in predicting mortality and length of ICU stay. The C-statistic of predicting mortality, ICU stay for 5 days or more, and ICU stay for 7 days or more were 0.49, 0.56, and 0.52, respectively. The calibration was poor for predicting mortality (p < 0.001), ICU stay for 5 days or more (p < 0.001), and ICU stay for 7 days or more (p < 0.001). CONCLUSION Although EuroSCORE II is the newest risk model for cardiac surgery, it is not accurate when it is applied for thoracic aortic surgery. A new risk evaluating system specially designed for aortic surgery should be developed in the future.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD). Methods From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up. Results In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%. Conclusions Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery

BACKGROUND To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. METHODS Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two patients underwent one-stage repair under cardiopulmonary bypass. RESULTS No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months [interquartile range (IQR) 16.75-64.50 months] and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3). CONCLUSIONS Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition with Stented Elephant Trunk in the Hybrid Repair Era

BACKGROUND Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. METHODS Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51±14 (range 20-69) years. RESULTS There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33±21months, one patient died. CONCLUSIONS Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.