Objective To introduce the experience of treating 85 cases of stanford type B aortic dissection by endovascular implantment of stent-grafts，to provide more clinical evidence for endovascular repairment for stanford B type aortic dissections.Methods Imaging examination by computed tomography angiography （CTA） were done to obtain anatomical detail of dissection. Stent-grafts were implanted under the guide of DSA in all cases. The patients were followed-up for 3 months，6 months，12 months，and then annually by CTA examination to observe the complications and morphological changes of the aneurysm.Results The technical success rate was 95.3%（81/85），and the clinical success rate was 91.8%（78/85）. Eight patients died after operation in hospital，who were all in acute phase，and no patients of chronic phase died，there had statistic differences （P＜0.05）. The perioperative complications’ incidence of endovascular repair which happened in patients of acute phase was higher than that patients of chronic phase （38.2% vs.13.3%，P＜0.05）. Left subclavian artery were covered completely for 13 cases，and partially covered for 22 cases，there was no obvious cerebralvascular insufficiency. There were 41 patients of whom other tears which were not covered during operation exsited at abdominal aortic and one year following-up showed that at those section thromblization of false cavity was not clear. The rest of patients whose abdominal aortic didn’t exist tears hadn’t new tears appeared.Conclusions Regardless in the acute or chronic stage，endovascular therapy is an effective mathod of treating stanford type B dissection. However，implanting stent-grafts have a higher security in chronic period than doing that in acute period. If the right carotid artery，vertebra and Willis ring are smoothly，there is little need to set up a by-pass to left subclavian artery before endovascular repairment. For those patients that other uncovered tears exited，following-up should be a must，and further strategy should be studied and prepared in advance.
Objective To investigate the impact of different modes of cardiopulmonary bypass （CPB） and cerebral perfusion on cerebral protection in patients with Stanford type A aortic dissection （AD）. Methods Clinical data of 117 patients with Stanford type A AD who underwent surgical therapy from April 2007 to March 2012 in the First Affiliated Hospital of Harbin Medical University were retrospectively analyzed. All the patients were divided into 3 groups according to different modes of CPB and cerebral perfusion they received. In group 1，45 patients received CPB perfusion through the femoral artery and unilateral or bilateral antegrade selective cerebral perfusion （ASCP） after circulatory arrest. In group 2，38 patients received CPB perfusion through the subclavian artery or innominate artery and unilateral or bilateral ASCP after circulatory arrest. In group 3，34 patients received antegrade and retrograde CPB perfusion through both subclavian artery or innominate artery and femoral artery，and unilateral or bilateral ASCP after circulatory arrest. Postoperative occurrence of transient neurological dysfunction （TND），permanent neurological dysfunction （PND） and influential factors were compared between the 3 groups. Results Incidence of postoperative cerebral complications of group 1 was significantly higher than those of group 2 and 3 （37.77% vs. 13.16% vs. 14.71%，P ＜0.05）. During CPB，cooling time of group 3 was significantly shorter than those of group 1 and 2 （35.56±4.35 vs. 40.00±5.63 and 39.58±6.03，P ＜0.05）. There was no statisticaldifference in other influential factors among the 3 groups （P ＞0.05）. Conclusion Antegrade and retrograde CPB perfusionin combination with ASCP has a smooth and quicker cooling rate，may provide better protection for the spinal cord，kidney and intraperitoneal organs and especially decrease the incidence of postoperative cerebral complications，therefore is proved current best method for organ protection.
Objective To compare surgical outcomes of Stanford type A acute aortic dissection between operations at midnight and daytime. Methods From January 2004 to March 2013，195 patients with Stanford type A acute aortic dissection received surgical treatment in Nanjing Hospital Affiliated to Nanjing Medical University （Nanjing Cardiovascular Disease Hospital）. Patients with identical or similar propensity scores were matched from 127 patients who underwent emergency operation at daytime and 68 patients who underwent emergency operation at midnight. A total of 58 pairs of matched patients which had the same or similar propensity score were selected in daytime surgery group （n=58，43 males and 15 females，47.7±14.6 years） and midnight surgery group （n=58，45 males and 13 females，48.3±14.6 years）. Operation time，postoperative chest drainage，mechanical ventilation time，postoperative incidence of dialysis and tracheostomy，length of ICU stay and in-hospital mortality were compared between the daytime group and midnight group. Results A total of 58 pair of patients were matched in this study. There was no statistical difference in postoperative incidence of tracheostomy ［19.0% （11/58） vs. 6.9% （4/58），P=0.053］ or in-hospital mortality ［8.6% （5/58） vs. 6.9%（4/58），P=0.729］ between the midnight group and daytime group. Operation time （485.7±93.5 minutes vs. 428.5±123.3 minutes，P=0.048），postoperative chest drainage （979.5±235.7 ml vs. 756.6±185.9 ml，P=0.031），mechanical ventilation time （67.9±13.8 hours vs. 55.7±11.9 hours，P=0.025），postoperative incidence of dialysis ［17.2% （10/58） vs. 5.2%（3/58），P=0.039］ and length of ICU stay （89.4±16.2 hours vs. 74.8±12.5 hours，P=0.023） of the midnight group weresignificantly longer or higher than those of the daytime group. A total of 107 patients were followed up for 4-6 months after discharge. During follow-up，there was no late death. Among the 13 patients who required postoperative dialysis，12 patientsno longer needed regular dialysis. Conclusion Emergency operation at midnight does not increase in-hospital mortalitybut increase some postoperative morbidity in patients with Stanford type A acute aortic dissection. Whether at midnight or daytime，better preoperative preparation and surgeons’ vigor are needed for timely surgical treatment for patients with Stanford type A acute aortic dissection.
Objective To summarize treatment experience and evaluate clinical outcomes of surgical therapy for Stanford type A aortic dissection （AD）. Methods Clinical data of 48 patients with Stanford type A AD who underwent surgical treatment in General Hospital of Lanzhou Military Region from October 2006 to March 2013 were retrospectively analyzed. There were 41 males and 7 females with their age of 26-72 （47.6±9.2） years. There were 43 patients with acute Stanford type A AD （interval between symptom onset and diagnosis＜14 days） and 5 patients with chronic AD. There were 19 patients with moderate to severe aortic insufficiency and 6 patients with Marfan symdrome but good aortic valve function，who all received Bentall procedure，total arch replacement and stented elephant trunk implantation. There were 8 patients with AD involving the aortic root but good aortic valve function who underwent modified David procedure，total arch replacement and stented elephant trunk implantation. There were 10 patients with AD involving the ascending aorta who received ascending aorta replacement，total arch replacement and stented elephant trunk implantation. There were 5 patients with AD involving partial aortic arch who underwent ascending aorta and hemiarch replacement. Patients were followed up in the 3rd，6th and 12th month after discharge then once every year. Follow-up evaluation included general patient conditions，blood pressure control，chest pain recurrence，mobility and computerized tomography arteriography （CTA）. ResultsCardiopulmonary bypass time was 121-500 （191.4±50.6） minutes，aortic cross-clamp time was 58-212 （112.3±31.7） minutes，and circulatory arrest and selective cerebral perfusion time was 26-56 （34.8±8.7） minutes. Postoperative mechanicalventilation time was 32-250 （76.2±35.6） hours，and ICU stay was 3-20 （7.1±3.4） days. Thoracic drainage within 24 hours postoperatively was 680-1 600 （1 092.5±236.3） ml. Seven patients （14.5%） died perioperatively including 2 patients with multiple organ dysfunction syndrome，2 patients with low cardiac output syndrome，1 patient with renal failure，1patient with delayed refractory hemorrhage，and 1 patient with coma. Twenty patients had other postoperative complicationsand were cured or improved after treatment. A total of 38 patients ［92.7% （38/41）］ were followed up for 3-48 （13.0±8.9） months，and 3 patients were lost during follow-up. During follow-up，there were 36 patients alive and 2 patients who died of other chronic diseases. There was no AD-related death during follow-up. None of the patients required reoperation for AD or false-lumen expansion. CTA at 6th month after discharge showed no anastomotic leakage，graft distortion or obstruction.Conclusion According to aortic intimal tear locations，ascending aorta diameter and AD involving scopes，appropriate surgical strategies，timing and organ protection are the key strategies to achieve optimal surgical results for Stanford type A AD. Combined axillary and femoral artery perfusion and increased lowest intraoperative temperature are good methods for satisfactory surgical outcomes of Stanford type A AD.
Abstract： Objective To summarize and evaluate the clinical effect of “modified” ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique, a new surgical approach for patients with Stanford type A aortic dissection. Methods Between December 2009 and January 2011, the “modified” ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique was performed to a total of 47 patients suffering from Stanford type A aortic dissection in the First Affiliated Hospital of China Medical University. There were 35 male patients and 12 female patients. Their mean age was（57.9±16.0）years （ranging from 29 to 86 years）. Preoperative computedtomography angiography（CTA） imaging was analyzed using three-dimensional （3D） reconstruction to clarify their diagnosis.All these patients underwent their procedures under cardiopulmonary bypass（CPB）, hypothermic circulatory arrestand right axilary artery cannulation for selected cerebral perfusion. The treatment of proximal end to heart included： ascending aorta replacement in 29 patients, Bentall procedure in 11 patients, Wheat procedure in 4 patients, and David procedure in 3 patients. Five patients underwent concomitant coronary artery bypass grafting. Results Their average CPB time was （136±32） min, average aortic cross-clamp time was （97±28） min, and average selected cerebral perfusion andlower body arrest time was （27±11） min. The in-hospital mortality was （4.25% , 2/47）. Postoperatively, two patients had transient neurological disorder, 1 patient had irreversible paraplegia, and 4 patients underwent reoperations for bleeding. All the 45 surviving patients underwent 3D CTA before discharge and 6 months after operation. The stented elephanttrunk-elastic metal stent were all well exhibited in the true lumen of the descending aorta, and the true lumens distal to the stent graft were also significantly enlarged compared with their preoperative diameters（P ＜ 0.05）. All the patients were followed up from 1 to 13 months. There was no aneurysm rupture and no reoperation related to residual dissected aorta wascarried out during follow-up. Conclusions “Modified” ascending aorta and hemiarch replacement combined with stentgraftelephant trunk technique is a safe and effective approach to treat patients with Stanford type A aortic dissection without involvement of 3 vessels of the arch. The main advantage of this approach is to simplify the surgical procedure, shorten the procedure time and CPB time, and reduce morbidity with a satisfying short-term result.
Abstract： Objective To evaluate the clinical safety and neurological outcomes of right axillary artery cannulation with a side graft compared with a direct approachin aortic arch replacement for patients with acute Stanford type A aortic dissection. Methods Between July 2008 and July 2010， 280 consecutive patients with acute Stanford type A aortic dissection underwent right axillary artery cannulation for cardiopulmonary bypass （CPB） in total arch replacement and stented “elephant trunk” implantation in our hospital.These 280 patients were divided into two groups according to the method of axillary artery cannulation in operation:direct arterial cannulation was used in 215 patients（direct arterial cannulationgroup， DG group， mean age of 43.1±9.5 years）， while cannulation with a side graft was used in 65 patients（ indirect cannulation group， IG group， mean age of 44.7±8.3 years）. Clinical characteristics of both groups were similar except their axillary artery cannulation method. Patient outcomes were compared as to the prevalence of clinical complications， especially neurological deficits and postoperative morbidity. Results The overall hospital mortality was 3.6% （10/280）， 3.3% （7/215） in DG group and 4.6% （3/65） in IG group respectively.Right axillary artery cannulation was successfully performed in all cases without any occurrence of malperfusion. Postoperatively， 25 patients（8.9%）developed temporaryneurological deficits， 19 cases in DG group（8.8%）， and 6 cases in IG group （9.2%）， and all these patients were cured after treatment. The incidence of postoperative complications directly related to axillary artery cannulation was significantly lower in IG group than that in DG group（1 case vs. 19 cases， P=0.045）. There were no statistical differences in arterial perfusion peak flow， peak pressure，antegrade cerebral perfusion time， deep hypothermic circulatory arrest time， and CPB time between the two groups（P ＞ 0.05）. Conclusion Right axillary artery cannulation with a side graftcan significantly reduce the postoperative complications of axillary artery cannulation. It is a safe and effective method for patients undergoing surgery for acute Stanford type A aortic dissection.
Abstract： Objective To summarize the clinical characteristics of young patients with Stanford type A aortic dissection. Methods We retrospectively analyzed 54 patients with Stanford type A aortic dissection who received surgical treatment in General Hospital of PLA between March 2004 and June 2011. All the patients were divided into two groups: a young patient group with patients’ age less than 40 years and a control group with patients’ age more than or equal to 40 years. There were 23 patients including 17 males and 6 females with an average age of 34.2±6.3 years in the young patient group and 31 patients including 27 males and 4 females with an average age of 51.5±6.8 years in the control group. The clinical characteristics and surgical treatment outcomes of the two groups were compared. Results There was no statistical difference in cardiopulmonary bypass（CBP）time（224.4±83.1 min vs. 215.0±88.0 min, t=0.39, P=0.69） and aortic cross-clamping time（152.3±60.8 min vs. 130.9±51.2 min, t=1.34, P=0.18）between the two groups. Compared with the patients in the control group, young patients were more likely to have congenital malformations with rate at 34.7%（8/23） vs. 6.4%（2/31） with χ2=5.27, P=0.02, such as Marfan syndrome and bicuspid aortic valve. The mortality of the young patients was similar to patients in the control group at rate of 13.0%（3/23）vs.12.9%（4/31） with χ2=0.15 and P=0.69, but postoperative mental and neurological complications rate in the young patient group were less frequent than those in the control group at 4.3%（1/23）vs. 32.2%（10/31） with χ2=5.32 and P=0.02. Conclusion Young patients with Stanford type A aortic dissection have fewer cardiovascular risk factors for aortic dissection but are more likely to have congenital malformations. The surgical methods are more active for young patients with less frequency of postoperative mental and neurological complications.
Abstract: Objective To evaluate surgical strategies for the treatment of acute Stanford type A aortic dissection with involvement of the aortic root. Methods From January 2005 to December 2010, 62 consecutive patients underwent emergency surgical intervention for acute Stanford type A aortic dissection with involvement of the aortic root in Renji Hospital Affiliated to Medical School of Shanghai Jiaotong University. According to different methods for the management of proximal aortic dissection, these patients were divided into 3 groups: group A, aortic valve commissural suspension＋supracommissural replacement of the ascending aorta （SCR）,including 28 patients （20 males and 8 females，mean age 45.2±15.6 years）; group B, partial sinus remodeling+ascending aortic replacement, including 10 patients （7 males and 3 females，mean age 44.6±14.9 years）；group C, Bentall procedure,including 24 patients （17 males and 7 females，mean age 46.2±15.6 years）. Clinical outcomes were compared among the three groups. Results Six patients died peri-operatively and in-hospital mortality was 9.67% （6/62）. Fifty-four patients were followed up, and the mean follow-up time was 27.3±15.7 months. During follow up, 2 patients died, one for lung cancer and the other for unknown reason. One patient in group A underwent CT scan 6 months after surgery which showed aortic root pseudo-aneurysm. Cardiopulmonary bypass time and aortic cross-clamping time of group C were significantly longer than those of group A and group B （274±97 min vs. 194±65 min, 210±77 min, t=22.482, 30.419, P=0.002， 0.122；150±56 min vs. 97±33 min, 105±46 min, t=12.630, 17.089, P=0.000，0.034）. There was no statistical difference in mortality （t=1.352，P=0.516）, incidence of postoperative reexploration for bleeding, acute renal failure and neurological complication （t=0.855, 0.342, 2.281; P=0.652, 0.863, 0.320） among the three groups. Conclusion For patients with acute aortic dissection involving the aortic root, aortic valve commissural suspension+SCR，partial sinus remodeling＋ascending aortic replacement and Bentall procedure may be considered the surgical treatment of choice with respective advantages and disadvantages. Satisfactory clinical outcomes can be achieveed if surgical indications and procedures are properly employed.
Abstract: Objective To explore the surgical procedures and cerebral protection and improve surgical results by summarizing the experiences of surgical treatment of 68 patients of De Bakey Ⅰ aortic dissection. Methods We retrospectively analyzed the clinical data of 68 patients (including 45 males and 23 females aged 29 to 72 years with an age of 44.5±17.2 years) with De Bakey Ⅰ aortic dissection who were treated in the General Hospital of Shenyang Command between May 2004 and April 2010. Acute aortic dissection (occurring within 2 weeks) was present in 57 patients and chronic aortic dissection in 11. The intimal tear was located in the ascending aorta in 45 patients, in the aortic arch in 12 and in the descending part of the aortic arch in 11. Thirtyfive patients underwent emergency operation and 33 underwent selected or limited operation. The operations were performed under hypothermic circulation arrest plus selective antegrade cerebral perfusion or right vena cave retrograde cerebral perfusion to protect the brain. Total arch replacement and stented elephant trunk were performed in 25 patients, Bentall operation with concomitant total arch replacement and stented elephant trunk in 16 patients, pure right semi aortic arch replacement and stented elephant trunk in 15 patients, total aortic arch replacement in 7 patients, right semi aortic arch replacement and stented elephant trunk in 3 patients, and Cabrol operation with concomitant aortic conduit with valve and total arch replacement and stented elephant trunk in 2 patients. Results Five patients (4 with acute aortic dissection and 1 with chronic aortic dissection) died with an operative mortality of 7.4%(5/68). The causes of death were anastomotic bleeding during surgery in 1 patient, postoperative low cardiac output syndrome and malignant arrhythmia in 2, acute renal failure in 1 and cerebral complications in 1. During perioperative period, psychotic symptoms occurred in 5 patients, pericardial effusion in 2 patients, hoarseness in 6 patients and poor wound healing in 1 patient. All of them were cured before dehospitalization. Sixty patients (95.2%, 60/63) were followed up for 2 months to 6 years with the other 3 patients lost. During the ollow-up, sudden death occurred to 1 patient with unknown reasons, and 1 patient had pericardial effusion and symptoms improved with relevant treatment. All the other patients followed up had a good quality of life with significant improvement of heart function. Fiftyfour patients had a heart function of New York Heart Association class Ⅰ and 5 had a function of class Ⅱ. Conclusion The surgical treatment for De Bakey Ⅰ aortic dissection should be active. The beneficial results can be obtained with best choice of operative procedures, methods of cerebral protection, and adequate treatment of complications of operation.
Objective To evaluate the applicability of Transcranial Doppler (TCD) monitoring in brain protection in the process of aortic dissection surgical procedure. Methods From Feburary 2007 to November 2007, six patients with type I aortic dissection underwent surgical procedure in Xuanwu Hospital of Capital Medical University. All patients are male with their age ranged from 48 to 60 years. During the operation, right subclavian arterial cannulation technique was used to protect the brain, and TCD monitoring was adopted to guide cerebral perfusion. The function of nervous system after operation was observed, and the minimental state examination (MMSE) was used to assess the cognitive function of the patients. A twoyear followup was done to monitor patients’ aorta condition. Results The time of cardiopulmonary bypass (CPB) was 136 to 350 minutes. The time of selected cerebral perfusion was 20 to 65 minutes. The lowest cerebral blood flow was 31% of basic level according to TCD monitoring. All patients were successfully treated without neurological complication and cognitive dysfunction when discharged from hospital. MMSE score was 28 to 30 points. During the twoyear followup after operation, all aortic false lumen were closed and there was no dissection recurrence. Conclusion Monitoring blood change with TCD monitoring technique is safe and effective in evaluating brain protection by selective cerebral perfusion in aortic dissection surgical procedure.