Rui-Dong Qi

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

BACKGROUND Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Suns procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Suns procedure in patients with AAAD. METHODS Clinical data of 398 consecutive AAAD patients undergoing the Suns procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. RESULTS Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). CONCLUSIONS The Suns procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?

OBJECTIVE We seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality. METHODS We performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure. RESULTS The operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P < .001). However, acuity was not identified as a risk factor for operative mortality (odds ratio [OR], 1.67; P = .152). The risk factors were previous cerebrovascular disease (OR, 7.01; P = .001); malperfusion of the brain (OR, 7.10; P = .002), kidneys (OR, 12.67; P = .005), spinal cord (OR, 22.79; P = .008), and viscera (OR 22.98; P = .002); concomitant extra-anatomic bypass (OR, 9.50; P < .001); and cardiopulmonary bypass time >180 minutes (OR, 1.01; P < .001). CONCLUSIONS In this group of patients with type A dissection, acuity was not a risk factor for operative mortality after the Sun procedure. Patients with previous cerebrovascular disease; malperfusion of the brain, kidneys, spinal cord, and/or viscera; concomitant extra-anatomic bypass; and a longer cardiopulmonary bypass time (>180 minutes) were at greater risk of operative mortality.

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 type B dissection with an aberrant right subclavian artery

OBJECTIVES An aberrant right subclavian artery (ARSA) is one of most common congenital anomalies, but the coexistence of type B dissection and an ARSA is extremely rare. Repair of type B dissection poses a technical challenge due to an ARSA. We retrospectively reviewed our experience of surgical treatment of a complicated type B dissection with an ARSA. METHODS From August 2010 to March 2014, 7 patients with chronic type B dissection with an ARSA underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass in our centre. The mean age was 45 ± 7 (range, 32-54) years. Total arch replacement was performed in 2 patients. Revascularization of the ARSA was done in 5 of 7 patients. RESULTS There were no in-hospital deaths. The mean time of mechanical ventilation and stay in the intensive care unit was 22 ± 11 and 53 ± 11 h, respectively. Neurological deficit, visceral ischaemia or injury to the spinal cord was not observed. Right upper-limb ischaemia was not observed in patients without ARRA revascularization during follow-up. CONCLUSIONS In patients not undergoing descending aortic replacement, the stented elephant trunk method is our preferred procedure for this anomaly via a median sternotomy. Repair of type B dissection and revascularization of the ARSA were achieved in a single stage using this technique. Satisfactory surgical results and follow-up outcomes were obtained. There was no right upper-limb ischaemia or neurological deficit in patients without ARSA revascularization, but revascularization of the ARSA is recommended for this vessel anomaly.

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.

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.

Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique

OBJECTIVES The presence of an isolated left vertebral artery (ILVA) remains a challenging issue for thoracic endovascular aortic repair (TEVAR) of type B dissection if the proximal landing zones are inadequate. We retrospectively reviewed our experience of the surgical management of complicated type B dissection with an ILVA using the stented elephant trunk technique. METHODS Between February 2009 and May 2013, 7 patients with complicated type B dissection (acute = 2 and chronic = 5) underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All the patients were males with a median age of 53 ± 6 (range 42-59) years. Preoperative lower limb ischaemia was observed in 1 patient, renal dysfunction in 1 patient and visceral ischaemia in 1 patient. RESULTS There were no in-hospital deaths. The median ventilator support time was 16 ± 3 (range 11-20) h. Ischaemia of the lower limb and viscera was ameliorated after surgical stent-graft implantation. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurological deficits were observed in any patients prior to hospital discharge. One patient underwent TEVAR due to distal aortic dilatation within the mean follow-up period, which was 44 ± 19 months. CONCLUSION Repair of complicated type B dissection with an ILVA using the stented elephant trunk technique was associated with satisfactory surgical results in patients with inadequate proximal fixation zones. This technique is an alternative to TEVAR for complicated type B dissection with inadequate proximal landing zones.

Repair of Type A Dissection with Mitral Regurgitation Using Total Arch Replacement with Mitral Valve Surgery

Mitral regurgitation (MR) is very rare in patients with type A dissection. We retrospectively reviewed our experience of total arch replacement (TAR) with mitral valve surgery for type A dissection with MR.

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.

Repair of Distal Aortic Arch Aneurysms by Left Subclavian Artery Transposition with Stented Elephant Trunk Implantation

BACKGROUND Repair of distal aortic arch aneurysms remains technically challenging using conventional open surgery due to its location. Several techniques, including a conventional prosthetic graft replacement and a hybrid technique, were introduced to manipulate this lesion. We retrospectively reviewed our experience with left subclavian artery (LSCA) transposition with stented elephant trunk implantation for repair of distal aortic arch aneurysms. METHODS From May 2009 to December 2014, 9 men (mean age 55 ± 16 years) with distal aortic arch aneurysms underwent LSCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with antegrade selective cerebral perfusion via a median sternotomy. One case had a history of endovascular abdominal aortic repair. RESULTS There was no in-hospital death. The mean time of mechanical ventilation and intensive care unit stay was 22 ± 9 and 53 ± 17 hr, respectively. No severe complications occurred in this group. All patients survived and were discharged. No patient died during the follow-up period. Postoperative computed tomography revealed good patency of the anastomotic site between the LSCA and the left common carotid artery. CONCLUSIONS Satisfactory surgical results and follow-up outcomes were achieved by simultaneous repair of proximal aortic lesions and complete seal of the lesion involving the distal aortic arch and proximal descending aorta using LSCA transposition with implantation of a stented elephant trunk. Encouraging outcomes favor this technique for distal aortic arch aneurysm.