Qian Chang

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Experience with 107 patients

OBJECTIVE In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation. METHODS Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 +/- 11 years; range, 17-78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up. RESULTS Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 +/- 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100). CONCLUSION Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.

Surgery for marfan patients with acute type a dissection using a stented elephant trunk procedure.

BACKGROUND The purpose of the study was to assess the efficacy of total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute Stanford type A aortic dissection involving the aortic arch. METHODS Between January 2004 and April 2006, 13 consecutive Marfan patients (4 female, 9 male) with acute type A aortic dissection involving the aortic arch underwent total arch replacement combined with implantation of a stented elephant trunk. Aortic dissection extending to the iliac artery was seen in 10 patients, and to the abdominal aorta in 3 patients. Ages ranged from 17 to 65 years (mean, 39 +/- 13). Computed tomography was done to evaluate the residual false lumen in the descending aorta. RESULTS All patients survived and were discharged from hospital. One patient with thrombosis of the innominate artery suffered cerebral infarction and recovered during follow-up. One patient had ischemia of the left upper limb postoperatively, but recovered after axillary to axillary artery bypass. There was 1 death during the mean follow-up period of 27 +/- 10 months. Complete thrombus formation was observed in 84.6% of patients (11 of 13) around the stented elephant trunk, and in 69.2% of patients (9 of 13) at the diaphragmatic level. CONCLUSIONS Total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute type A aortic dissection involving the aortic arch results in less late dilatation of the dissected descending aorta. That prolongs the reoperation interval or reduces the number of late thoracoabdominal aortic replacements, unless there is a patent false lumen around the stented elephant trunk.

Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure

BACKGROUND Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure. METHODS Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography. RESULTS Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up. CONCLUSIONS Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.

Is total arch replacement combined with stented elephant trunk implantation justified for patients with chronic Stanford type A aortic dissection

OBJECTIVE Surgical treatment of chronic Stanford type A aortic dissection using total arch replacement combined with stented elephant trunk implantation is controversial owing to the visceral arteries and intercostal arteries originating from the false lumen. METHODS Eighty-nine patients (mean age, 45.67 +/- 10.18 years; range, 21-68 years) with chronic type A dissection underwent total arch replacement combined with stented elephant trunk implantation between April 2003 and March 2007. Careful assessment of the visceral arteries and location of entry and re-entry was done before surgery. Postoperative patency of the visceral arteries and diameter of the aortic artery and the residual false lumen were evaluated by computed tomography. RESULTS One (1.12%) hospital death and 2 (2.25%) late deaths occurred at a mean follow-up of 28.5 months (range, 8-52 months). Visceral malperfusion was not observed. Two patients had spinal cord injury and recovered during follow-up. One patient had a transient neurologic deficit and recovered completely before discharge. One patient underwent thoracoabdominal aortic replacement for aneurysmal dilatation of the residual descending aorta 3 months after the operation. Thrombus obliteration of the false lumen at the distal edge of the stented elephant trunk and at the diaphragmatic level was 94.2% (81/86) and 61.6% (53/86), respectively. CONCLUSIONS Satisfactory results with low morbidity and mortality were obtained. No visceral malperfusion and a low risk of postoperative spinal cord injury favor this technique in patients with chronic type A dissection.

Treatment of complex coarctation and coarctation with cardiac lesions using extra-anatomic aortic bypass

BACKGROUND Coarctation of the aorta with cardiac lesions or complex coarctation is a formidable challenge for cardiac surgeons. Extra-anatomic bypass allows simultaneous intracardiac repair or an alternative approach for patients with complex coarctation. METHODS Between July 1997 and March 2008, 43 patients with coarctation of the aorta underwent extra-anatomic bypass grafting, including 10 ascending-to-descending aorta bypasses and 33 ascending aorta-to-infrarenal abdominal aorta bypasses. Forty patients had additional cardiovascular disorders and concomitant procedures performed including aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, closure of ventricular septal defect and patent ductus arteriosus, ascending aorta repair, and the Bentall procedure. The other three patients had complex coarctation of the aorta, including a long-segment coarctation in two cases, and descending aortic aneurysm in one. RESULTS Two patients died perioperatively: one due to air embolism during the cardiopulmonary bypass; one due to septic shock. There were no late deaths. Complications included laparotomy for mechanical ileus in one and re-exploration for bleeding in one case. There were no strokes or paraplegia and no grafted-related complication during follow-up period. Systolic blood pressure dropped from 160 +/- 27 mm Hg before surgery to 114 +/- 16 mm Hg postoperatively. Only two patients with mild hypertension postoperatively needed oral medicine. CONCLUSIONS Extra-anatomic aortic bypass via median sternotomy or median sternotomy-laparotomy can be performed with low morbidity and mortality. It is a preferable single-stage approach for patients with concomitant complex coarctation and cardiovascular disorders.

Surgery for patients with Marfan syndrome with type A dissection involving the aortic arch using total arch replacement combined with stented elephant trunk implantation: the acute versus the chronic.

OBJECTIVE The optimal surgical repair for patients with Marfan syndrome with type A dissection involving the aortic arch is controversial. We retrospectively reviewed our experience of total arch replacement combined with stented elephant trunk implantation for patients with Marfan syndrome with type A dissection. METHODS Between April 2003 and September 2008, 44 patients with Marfan syndrome (acute = 19, chronic = 25) with type A dissection underwent this procedure. Postoperative computed tomography was used to evaluate thrombosis and absorption of the residual false lumen. RESULTS In-hospital mortality was 4.55% (2/44) (acute = 0%, 0/19; chronic = 8.00%, 2/25) and follow-up death rate was 4.76% (2/42) (acute = 5.26%, 1/19; chronic = 4.35%, 1/23) during a mean follow-up of 38 ± 17 months. One patient (5.26%, 1/19) with chronic dissection underwent thoracoabdominal aortic replacement 7 months after surgery. Injury to the spinal cord and visceral ischemia were not observed during follow-up. Obliteration of the false lumen around the stented elephant trunk was observed in 76.2% of patients (32/42) (acute = 84.2%, 16/19; chronic = 69.6%, 16/23) as demonstrated by postoperative computed tomography. The distal end of the stent-graft entering the false lumen was observed in 4 patients (21.1%, 4/19) with acute dissection. CONCLUSIONS The procedure was a suitable alternative to patients with Marfan syndrome with chronic type A dissection. However, more attention should be paid to patients with Marfan syndrome with acute dissection caused by the fragile dissecting membrane. If this procedure was adopted in patients with Marfan syndrome with acute type A dissection, an entry adjacent to the distal end of the surgical stent-graft, a small true lumen, or an extremely tortuous morphology of the false lumen aorta should be excluded.

Hybrid total arch repair without deep hypothermic circulatory arrest for acute type A aortic dissection (R1).

OBJECTIVE To investigate the surgical outcomes of hybrid total arch repair without deep hypothermic circulatory arrest for patients with acute Stanford type A aortic dissection. METHODS Retrospective review of clinical data of patients with acute Stanford type A aortic dissection who underwent surgical repair at our institution between November 2009 and December 2011 identified 21 patients who underwent hybrid total arch repair without deep hypothermic circulatory arrest. The in-hospital and follow-up data were investigated. Postoperative serial computed tomography angiography was used to evaluate the fate of true and false lumen in arch and descending aorta. RESULTS Mean follow-up was 13.8 months (range, 3 to 21 months). The 1- and 12-month survival rates (by Kaplan-Meier analysis) were 95.2% (95% confidence interval, 86.2%-100%) and 90.5% (95% confidence interval, 78.0%-100%), respectively. No endograft caudal migration occurred. One patient with type I endoleak was successfully resolved during operation. There was no late rupture or paraplegia. CONCLUSIONS Hybrid total arch repair without deep hypothermic circulatory arrest offers a promising alternative to risk reduction of complications during the postoperative period and late adverse events resulting from false lumen enlargement in the arch and descending aorta.

Elevated expression of connective tissue growth factor, osteopontin and increased collagen content in human ascending thoracic aortic aneurysms

Little is known about the molecular mechanisms of ascending thoracic aortic aneurysms (ATAAs). Abnormal extracellular matrix changes and variations of vascular smooth muscle cells (VSMCs) have been implicated in abdominal aortic aneurysm formation. Our objective was to investigate the alterations of collagen, stimulators of collagen synthesis and synthetic VSMCs in patients with ATAA. Surgical samples from ATAA were taken from 20 patients, and 18 control aortas were obtained during coronary artery bypass surgery. All aortic wall specimens were fixed for histology and immunohistochemistry for collagen, connective tissue growth factor (CTGF) and osteopontin. Realtime polymerase chain reaction was used to determine their mRNA expression. Histology and semi-quantitative analysis demonstrated that protein levels of collagen, CTGF and osteopontin significantly increased by 1.9-, 1.4- and 2.2-fold, respectively (P < 0.01 for all) in the ATAA group than in the control group. Similar results were shown in mRNA levels of type Iα1and IIIα1 collagen, CTGF and osteopontin. The protein levels of CTGF and osteopontin were positively correlated with aortic diameter (r = 0.67, r = 0.73; P < 0.01 for both). In conclusion, overexpression of aortic CTGF and synthetic VSMCs marker (osteopontin), which is likely to be responsible for elevated aortic collagen content, may provide a potential mechanism for aneurysmal enlargement.

Repair of Chronic Type B Dissection With Aortic Arch Involvement Using a Stented Elephant Trunk Procedure

BACKGROUND A conventional single-stage procedure, staged procedures, or debranching of the supraaortic vessels, followed by immediate transfemoral stenting of the aortic arch, have been introduced to treat chronic type B dissection with aortic arch involvement. The best method for surgical repair of chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions is not known. METHODS Between October 2003 and December 2008, 19 patients underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion through a median sternotomy. Thirteen patients had proximal aortic lesions. Postoperative computed tomography was used to evaluate thrombosis and absorption of the false lumen. RESULTS Concomitant proximal aortic lesions were repaired in all patients. Thirty-day mortality was 5.26% (1/19). There was one late death at a mean follow-up of 36 +/- 12 months. There was no spinal cord injury or visceral malperfusion. One patient with Marfan syndrome with chronic dissection underwent thoracoabdominal aortic replacement 6 months later. Obliteration of the false lumen around the stented elephant trunk was observed in 16 patients (94.1%, 16/17) during follow-up. CONCLUSIONS This technique is safe, effective, and economical. Replacement of aortic arch dissection and thrombosis of the dissected descending aorta was achieved simultaneously. Concomitant proximal aortic lesions were repaired. Favorable surgical outcomes and postoperative results using this technique were obtained in patients with chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions.

Venoarterial Extracorporeal Membrane Oxygenation in Adult Patients: Predictors of Mortality.

Background: Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. In this study, we reviewed our experience with extracorporeal membrane oxygenation support and tried to identify measurable values which might predict in-hospital mortality. Methods: From January 2004 through December 2008, 50 of 21,298 adult patients received venoarterial extracorporeal membrane oxygenation. We retrospectively analyzed clinical records of these 50 consecutive patients. Details of demographics, preoperative measurements, clinical characteristics at the time of extracorporeal membrane oxygenation implantation, extracorporeal membrane oxygenation-related complications and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A p-value ≤ 0.05 was accepted as significant. Results: Thirty-eight patients were weaned from extracorporeal membrane oxygenation and 33 patients survived to discharge. The overall survival rate was 66%. In a multiple logistic regression analysis, blood lactate level before initiation of extracorporeal membrane oxygenation was a risk factor associated with in-hospital mortality (OR 1.27 95% CI 1.042-1.542). To evaluate the utility of the lactate in predicting mortality, a conventional receiver operating characteristic curve was produced. Sensitivity and specificity were optimal at a cut-off point of 12.6mmol/L, with an area under the curve of 0.752. The positive and negative predictive values were 73.3% and 83.9%, respectively. Conclusions: Extracorporeal membrane oxygenation is a justifiable alternative treatment for postoperative refractory cardiac and pulmonary dysfunction which could rescue more than sixty percent of otherwise fatal patients. Patients with pre-extracorporeal membrane oxygenation lactate levels above 12.6mmol/L are at higher risks for in-hospital death. Evidence-based therapy for this group of high risk patients is needed.BACKGROUND Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. In this study, we reviewed our experience with extracorporeal membrane oxygenation support and tried to identify measurable values which might predict in-hospital mortality. METHODS From January 2004 through December 2008, 50 of 21,298 adult patients received venoarterial extracorporeal membrane oxygenation. We retrospectively analyzed clinical records of these 50 consecutive patients. Details of demographics, preoperative measurements, clinical characteristics at the time of extracorporeal membrane oxygenation implantation, extracorporeal membrane oxygenation-related complications and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A p-value < or = 0.05 was accepted as significant. RESULTS Thirty-eight patients were weaned from extracorporeal membrane oxygenation and 33 patients survived to discharge. The overall survival rate was 66%. In a multiple logistic regression analysis, blood lactate level before initiation of extracorporeal membrane oxygenation was a risk factor associated with in-hospital mortality (OR 1.27 95% CI 1.042-1.542). To evaluate the utility of the lactate in predicting mortality, a conventional receiver operating characteristic curve was produced. Sensitivity and specificity were optimal at a cut-off point of 12.6 mmol/L, with an area under the curve of 0.752. The positive and negative predictive values were 73.3% and 83.9%, respectively. CONCLUSIONS Extracorporeal membrane oxygenation is a justifiable alternative treatment for postoperative refractory cardiac and pulmonary dysfunction which could rescue more than sixty percent of otherwise fatal patients. Patients with pre-extracorporeal membrane oxygenation lactate levels above 12.6 mmol/L are at higher risks for in-hospital death. Evidence-based therapy for this group of high risk patients is needed.