ObjectiveTo analyze the causes and preventions of stent graft induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection, particularly from the standpoint of biomechanical behavior of stent graft. MethodsSINE was defined as the new tear caused by the stent graft itself, excluding those arising from natural disease progression or any iatrogenic injury from the endovascular manipulation. Twentytwo patients with SINE were retrospectively collected and analyzed out of 650 cases undergoing TEVAR for type B dissection from August 2000 to June 2008 in our center. An additional case included was referred to our center in 14 months after TEVAR performed in another hospital. ResultsTotally, there were 24 SINEs found in 23 cases, including SINE at the proximal end in 15 cases, at the distal end in 7, and at both in 1, and 6 patients died. The incidence was 3.4% ( 22/650) in our hospital, and the mortality was 26.1% (6/23). All 16 proximal SINEs was located at the greater curve of the arch and caused retrograde type A dissection. All 8 distal SINEs occurred at the dissected flap, and 5 of them caused enlarging aneurysm while 3 remained stable. All 23 cases had the endograft placed across the distal aortic arch during the primary TEVAR. ConclusionsSINE is not rare following TEVAR for type B dissection, and associates with a high substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is of significance to take the stressinduced injury into account during both design and placement of the endograft.
目的:探讨主动脉夹层患者误诊的原因,提高主动脉夹层患者的早期诊断率,为及时、正确救治患者生命提供有力的科学依据。方法:回顾性分析3例主动脉夹层患者实际诊断与误诊的情况,查明误诊原因。结果:3例主动脉夹层患者经检查后证实,1例误诊为急性食道撕裂伤或消化性溃疡,占33.33%;1例误诊为急腹症,占33.33%;1例误诊为急性颅内病变,占33.33%。结论积极评估其病情的危险程度,监测生命体征,快速建立静脉通道,同时仔细询问相关病史,认真查体,积极采取相应辅助检查,可降低误诊率。
ObjectiveTo investigate the prognosis and impact of postoperative acute kidney injury (AKI) on patients with acute Stanford type A aortic dissection (ATAAD), and to analyze the predictors for short- and medium-term survival. MethodsClinical data of patients who underwent ATAAD surgery in Qingdao Municipal Hospital from May 2014 to May 2019 were retrospectively analyzed. All discharged patients underwent telephone or outpatient follow-up, and were divided into an AKI group and a non-AKI group based on whether AKI occurred after surgery. The impact of postoperative AKI on the short- and medium-term prognosis was analyzed, and multivariate Cox analysis was used to screen the risk factors for short- and medium-term mortality. ResultsA total of 192 patients were collected, including 139 males and 53 females, with an average age of 53.3±11.4 years. Postoperative AKI was identified in 43 (22.4%) patients. The average follow-up time of discharged patients was 23.4±2.4 months, and the lost rate was 5.1%. The two-year survival rate after discharge of the AKI group was 88.2%, and that of the non-AKI group was 97.2%. Kaplan-Meier survival analysis and log-rank test showed that there was a statistical difference between the two groups (χ2=5.355, log-rank P=0.021). Multivariate Cox analysis results showed that age (HR=1.070, 95%CI 1.026 to 1.116, P=0.002), cardiopulmonary bypass time (HR=1.026, 95%CI 1.003 to 1.050, P=0.026), postoperative AKI (HR=3.681, 95%CI 1.579 to 8.582, P=0.003), transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively (HR=1.548, 95%CI 1.183 to 2.026, P=0.001) were independent risk factors for the short- and medium-term mortality of ATAAD patients. ConclusionThe incidence of postoperative AKI is high in ATAAD patients, and the mortality of patients with AKI increases significantly within two years. Age, cardiopulmonary bypass time and transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively are also independent risk factors for short- and medium-term prognosis.
With the development of radiologic intervention, the treatments of aortic dissection are getting more and more diversified. In recent years, Debakey Ⅲ and DebakeyⅠaortic dissection has been usually treated with endovascular graft exclusion, or combined surgical and endovascular treatment. It is therefore more important to evaluate the aorta and its complications after interventional treatments. Because multidetector-row computed tomography (MDCT) has advantages, such as short examination time, high spatial resolution, and simple operation, this modality has become a first choice of non-invasive methods for the follow-up of aortic diseases after the intervention. Now the MDCT presentations and their anatomic-pathologic features of aortic dissection after endovascular graft exclusion or combined surgical and endovascular treatment are reviewed in this article.
ObjectiveTo investigate the clinical effect of in situ fenestration combined with chimney technique in the treatment of aortic dissection involving left common carotid artery.MethodsFrom January 2012 to June 2019, 53 patients with aortic dissection involving left common carotid artery were selected. There were 21 patients in the test group, including 14 males and 7 females, with an average age of 57.2±11.2 years; there were 32 patients in the control group, including 20 males and 12 females, with an average age of 56.7±12.1 years. In the test group, the left subclavian branch was reconstructed by in situ fenestration and the left common carotid artery was reconstructed by chimney technique. In the control group, the left common carotid artery was reconstructed by hybrid operation. The clinical data of the patients were compared.ResultsThe operation time of the test group was significantly longer than that of the control group (151.8±35.2 min vs. 101.3±29.6 min, P=0.00). The patients in the two groups were followed up for 6-20 months. There was no significant difference in the incidence of pulmonary infection, stroke, steal blood syndrome, false lumen thrombosis or internal leakage between the two groups (P>0.05). The diameters of the distal and proximal ends of the true cavity in the test group increased significantly compared with those in the control group (P<0.05).ConclusionIn situ fenestration combined with chimney technique is an effective method for the treatment of aortic dissection involving left common carotid artery, which is worthy of further clinical promotion.
ObjectiveTo summarize the surgical strategy of reoperative aortic root replacement after prior aortic valve replacement (AVR), and analyze the early and mid-term outcomes.MethodsFrom April 2013 to January 2020, 75 patients with prior AVR underwent reoperative aortic root replacement in Fuwai Hospital. There were 54 males and 21 females with a mean age of 56.4±12.7 years. An emergent operation was performed in 14 patients and an elective operation in 61 patients. The indications were aortic root aneurysm in 38 patients, aortic dissection involving aortic root in 30 patients, root false aneurysm in 2 patients, prosthesis valve endocarditis with root abscess in 2 patients, and Behçet's disease with root destruction in 3 patients. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.ResultsThe operative procedures included prosthesis-sparing root replacement in 45 patients, Bentall procedure in 26 patients, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/75). A composite of adverse events occurred in 5 patients, including operative death (n=1), stroke (n=1), and acute renal injury necessitating hemodialysis (n=3). The follow-up was available for all 74 survivors, with the mean follow-up time of 0.5-92.0 (30.3±25.0) months. Four late deaths occurred during the follow-up. The survival rate at 1 year, 3 years and 6 years was 97.2%, 91.4% and 84.4%, respectively. Aortic events developed in 2 patients. The rate of freedom from aortic events at 1 year, 3 years, and 6 years was 98.7%, 95.0% and 87.7%, respectively. There was no difference in rate of survival or freedom from aortic events between the elective patients and the emergent patients.ConclusionReoperative aortic root replacement after prior AVR can be performed to treat the root pathologies after AVR, with acceptable early and mid-term outcomes.
ObjectiveTo compare the clinical efficacy of typeⅡhybrid surgery versus Sun’s surgery in treating acute Stanford A aortic dissection. MethodsA retrospective analysis was conducted on the clinical data of patients with acute Stanford A aortic dissection who were treated at the Central Hospital of Wuhan affiliated to Tongji Medical College, Huazhong University of Science and Technology from 2016 to 2022. According to the surgical method, patients were divided into a typeⅡhybrid group and a Sun’s surgery group, and the clinical efficacy of the two groups was compared. ResultsA total of 52 patients were included, with 22 in the typeⅡhybrid surgery group and 30 in the Sun’s surgery group. The typeⅡhybrid group consisted of 18 males and 4 females, with an average age of (58.18±6.00) years, while the Sun’s surgery group consisted of 22 males and 8 females, with an average age of (53.03±11.89) years. All surgeries were successfully completed. There were 4 (13.3%) perioperative deaths in the Sun’s surgery group, including 2 patients of multiple organ failure, 1 patient of paraplegia, and 1 patient of uncontrollable postoperative bleeding. There was 1 (4.5%) perioperative death in the typeⅡhybrid surgery group, who was suspected of acute coronary syndrome and took a loading dose of dual antiplatelet drugs preoperatively. The patient underwent secondary thoracotomy for hemostasis, was re-cannulated during the operation, and finally died of circulatory failure after implantation of intra-aortic balloon pumping. There was no statistical difference in perioperative mortality between the two groups (P=0.381). Compared with the Sun’s surgery group, the typeⅡhybrid surgery group had shorter cardiopulmonary bypass time [153.00 (135.00, 185.25) min vs. 182.50 (166.50, 196.75) min, P=0.013], aortic cross-clamping time [77.00 (70.50, 92.00) min vs. 102.50 (93.50, 109.75) min, P<0.001], postoperative ICU stay [4.00 (2.83, 6.00) days vs. 8.00 (6.38, 11.78) days, P<0.001], postoperative ventilator support time [72.00 (29.50, 93.25) h vs. 87.65 (39.13, 139.13) h, P=0.138], less intraoperative blood loss [(1586.82±209.41) mL vs. (1 806.00±292.62) mL, P=0.004], postoperative 24 h drainage volume [612.50 (507.50, 762.50) mL vs. 687.50 (518.75, 993.75) mL, P=0.409], and shorter postoperative hospital stay [18.00 (13.00, 20.25) days vs. 22.00 (17.00, 29.25) days, P=0.013]. There was no statistically significant difference in the incidence of other early postoperative complications such as secondary thoracotomy for hemostasis, tracheotomy, renal dysfunction requiring dialysis, stroke, and paraplegia between the two groups (P>0.05). ConclusionFor patients with acute Stanford A aortic dissection, typeⅡhybrid surgery is safe and effective; compared with traditional Sun’s surgery, typeⅡhybrid surgery has relatively less trauma, lower incidence of complications, satisfactory short-term results, and further research is needed on long-term prognosis.