Search

There is no treatment for acute aortic dissection (AAD) targeting inflammatory cells. We aimed to identify the new therapeutic targets associated with inflammatory cells. We characterized the specific distribution of myeloid cells of both human type A AAD samples and a murine AAD model generated using angiotensin II (ANGII) and β-aminopropionitrile (BAPN) by single-cell RNA sequencing (scRNA-seq). We also examined the effect of an anti-interleukin-1β (IL-1β) antibody in the murine AAD model. IL1B + inflammatory macrophages and classical monocytes were increased in human AAD samples. Trajectory analysis demonstrated that IL1B + inflammatory macrophages differentiated from S100A8/9/12 + classical monocytes uniquely observed in the aorta of AAD. We found increased infiltration of neutrophils and monocytes with the expression of inflammatory cytokines in the aorta and accumulation of inflammatory macrophages before the onset of macroscopic AAD in the murine AAD model. In blocking experiments using an anti-IL-1β antibody, it improved survival of murine AAD model by preventing elastin degradation. We observed the accumulation of inflammatory macrophages expressing IL-1β in both human AAD samples and in a murine AAD model. Anti-IL-1β antibody could improve the mortality rate in mice, suggesting that it may be a treatment option for AAD., (© 2024. The Author(s).)

Malperfusion syndrome of the visceral branches associated with acute aortic dissection brings an extremely poor outcomes leading to perioperative and long-term mortality in both Stanford type A and type B acute aortic dissection. The conventional surgical strategy for these cases has been to prioritize aortic repair and to improve blood flow of true lumen in aorta and visceral branches. Today, various techniques for early reperfusion have been reported. For bowel ischemia, it is necessary to evaluate substantial ischemia of the intestinal tract and hypoperfusion of the superior mesenteric artery( SMA) using contrast-enhanced computed tomography( CT) and intraoperative transesophageal echocardiography in addition to clinical presentation. The most important factor of the surgical intervention is the improvement of true luminal blood flow by reconstruction of the central aorta. However, an intervention to SMA prior to central aortic repair might be an important process for patients with Stanford type A acute aortic dissection to avoid irreversible bowel necrosis. In type B aortic dissection, thoracic endovascular aortic repair (TEVAR) with or without provisional extension to induce complete attachment (PETTICOAT) technique and additional SMA intervention based on intraoperative contrast findings are necessary. Renal malperfusion is also a risk factor of postoperative accute kidney injury( AKI) and perioperative mortality. The revascularizations of renal arteries might improve outcomes when renal blood flow was not recovered with central aortic repair.

Objectives: The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement., Methods: Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years., Results: The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P < 0.001). Positive aortic remodelling was observed in the proximal descending (P < 0.001) to mid-descending (P < 0.001) aorta exclusively in patients with acute aortic dissection., Conclusions: The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Surgical outcomes for acute type A aortic dissection (ATAAD) have been improving, but mortality rate remains about 10% in the last decade. Based on the current literatures including American Association for Thoracic Surgery (AATS) expert consensus, we presented the latest treatments and our surgical strategies for ATAAD. This section states about cannulation strategies for cardio-pulmonary bypass, aortic root managements, aggressive arch strategies, distal anastomosis strategies and the managements of malperfusion syndrome. We recommended the ascending aorta using the Seldinger technique as the cannulation site. As the aortic root management, valve resuspension is effective, but valve-sparing aortic root repair may be an option for young patients with annulo-aortic ectasia, intimal tear located in Valsalva sinus or Valsalva sinus rupture. The tear-oriented surgery is the standard for the range of the graft replacement, however, aggressive arch repair is also good indication for young patients. Distal anastomoses are felt sandwich technique for hemi-arch replacement or partial arch replacement and frozen elephant trunk is useful to total arch replacement. Early reperfusion strategies were important to the malperfusion syndrome of coronary arteries, supra-aortic vessels and superior mesenteric artery. To the dissected common carotid arteries (CCAs), early reperfusion and direct reconstruction of CCAs were effective.

Objective: Aortic root reoperation after aortic dissection repair sometimes requires aortic root replacement. A valve-preserving technique should be applied when the aortic cusp is normal. Valve-sparing aortic root reconstruction using the reimplantation technique resolves aortic valve regurgitation, root dilatation, and pseudoaneurysm in the proximal anastomosis. Our experience in aortic root reoperation is presented., Methods: From January 2000 to March 2019, 26 patients underwent reoperative valve-sparing aortic root reconstruction using the reimplantation technique. The time from the initial operation to reoperation was 69.3 ± 51.6 months. Aortic root reoperation was required for a fragile wall at the previous proximal anastomosis or aortic root dilatation. We aimed to stabilize the aortic root without valve regurgitation. The native aortic cusp was aggressively preserved when nearly normal. Indications included root dilatation ( n  = 13), pseudoaneurysm of the previous proximal anastomosis ( n  = 11), and aortic valve regurgitation ( n  = 4)., Results: There was no early postoperative mortality. Follow-up was 49 ± 47 months (range 4-161 months). The 3, 5, and 10-year survival was 88.9% ± 7.4%, 88.9% ± 7.4%, and 77.8% ± 12.2%, respectively. Freedom from recurrence of a greater than moderate degree of aortic valve regurgitation at 3, 5, and 10 years was 86.5% ± 8.9%, 86.5% ± 8.9%, and 86.5% ± 8.9%, respectively. One patient underwent aortic valve replacement for recurrent aortic valve regurgitation 15 months after the valve-sparing reoperation., Conclusions: Midterm outcomes of reoperative valve-sparing aortic root reconstruction using the reimplantation technique and postoperative aortic valve performance were satisfactory.

Objective: Presenting our experience of treating patients with organ malperfusion secondary to acute aortic dissection., Patients: Among 383 patients who underwent aortic repair for acute type A aortic dissection from 1999 to 2017, 107 patients were operated on because of vascular complications. Fourteen patients had coronary, 50 had brain, 3 had paraplegia, 13 had superior mesenteric artery, 21 had lower limb, and 16 had combined organ malperfusion. Age was 65.8 years., Results: In coronary malperfusion, three had a preoperative percutaneous coronary intervention, and two had mechanical support. All underwent repair of the aorta. Hospital mortality was 28.5%. Fifty patients had brain malperfusion. Hemiplegia was found in 28 patients, transient ischemic attack in 10, and coma in 12. The level of consciousness was severe in 12, moderate in 18, and mild in 20. Twenty-eight percent died of a stroke. Nine had direct perfusion from the right common carotid artery, and the consciousness level was improved in 5 patients. Eight patients had mesenteric malperfusion. Four patients had a central aorta repair first, and four patients had peripheral intervention first. Three patients had a bypass grafting to the superior mesenteric artery, and one had a catheter intervention. Postoperative mortality was found in four patients due to bowel necrosis and six required resections of the bowel., Conclusion: Acute organ malperfusion caused by the aortic dissection requires accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta for preventing irreversible organ damage., (© 2020 Wiley Periodicals LLC.)

Objectives: We aimed to identify predictors of postoperative permanent neurological deficits (PNDs) and evaluate the early management of cerebral perfusion in patients undergoing surgical repair of acute type A aortic dissection with cerebral malperfusion., Methods: Between October 2009 and September 2018, a total of 197 patients with acute type A aortic dissection underwent aortic replacement. Of these, 42 (21.3%) patients had an imaging cerebral malperfusion (ICM). ICM was assessed preoperatively, which also revealed whether dissected supra-aortic branch vessels were occluded or narrowed by a thrombosed false lumen. After September 2017, early reperfusion and extra-anatomic revascularization were performed in cases with ICM., Results: Hospital mortality rates for cases with ICM were 4.8% (2/42). Before September 2017, PND were observed in 6 patients (54.5%) with preoperative neurological symptoms (n = 11), and 7 patients (33.3%) without neurological symptoms (n = 21) in patients with ICM. Occlusion or severe stenosis of supra-aortic branch vessels (odds ratio, 7.66; P < 0.001), regardless of preoperative clinical neurological symptoms, was a risk factor for PND. After September 2017, 7 of 10 patients with ICM underwent early reperfusion and extra-anatomic revascularization. PND did not occur in any of these 7 patients., Conclusions: Occlusion or severe stenosis of supra-aortic branch vessels is a predictor of PND risk in patients undergoing surgery for acute type A aortic dissection. Early reperfusion and extra-anatomic revascularization may reduce the risk of neurological complications in patients with ICM, with or without neurological symptoms., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aim of this study was to evaluate the fate of the preserved aortic root after supracoronary aortic replacement for acute type A aortic dissection., Methods: Between October 1999 and March 2018, 339 patients underwent supracoronary aortic replacement for acute type A aortic dissection at our institution. Late outcomes were evaluated, including overall survival, aortic-related death, and aortic root-related reoperation. The median follow-up was 3.7 years (1.4-8.4 years)., Results: Operative mortality was 46 patients (13.6%). The cumulative incidences at 5 years for aortic root-related reoperation, aortic-related death, and non-aortic related death were 2.5%, 14.5% and 12.4%, respectively. Multivariable Cox hazard regression analysis demonstrated greater sinus of Valsalva diameter and number of commissural detachments to be significant risk factors for a composite outcome consisting of aortic-related death or aortic root-related reoperation. Mixed-effects regression demonstrated that sinus of Valsalva diameter significantly increased with time (P < .001), and aortic regurgitation significantly worsened (P < .001)., Conclusions: Sinus of Valsalva diameter and commissural detachment were independent predictors of unfavorable outcomes after supracoronary aortic replacement. Close follow-up is particularly necessary for these patients, and aortic root replacement at the time of initial operation may lead to more favorable late outcomes., (Copyright © 2019. Published by Elsevier Inc.)

Background: The aim of this study was to evaluate the impact of diffuse aortic atherosclerosis-related thrombosis, or "shaggy aorta" on the outcomes of open thoracoabdominal aortic aneurysm repair (TAAA)., Methods: From October 1999 to March 2018, 251 patients underwent open TAAA repair using segmental-staged aortic clamping. Twenty-eight patients (11.2%) received emergent or urgent operations. Patients were classified into 3 groups: dissection aneurysm (139 patients, 55.4%), degenerative aneurysm without shaggy aorta (76 patients, 30.3%), and degenerative aneurysm with shaggy aorta (36 patients, 14.3%). Shaggy aorta was assessed using enhanced computed tomography and defined as patients with atheroma thickness ≥5 mm with irregular atheroma surface. Mean follow-up was 4.3 ± 4.1 years., Results: Operative mortality was 8% (20 patients) and spinal cord injury occurred in 25 patients (10.0%), 16 of whom (6.4%) had permanent neurologic dysfunction. Operative mortality was significantly worse in patients with shaggy aorta (dissection: 2.2%, non-shaggy: 6.6%, and shaggy: 33.3%, P < .001) and shaggy aorta was a significant risk factor for spinal cord injury (dissection: 7.2%, non-shaggy: 6.6%, and shaggy: 27.8%, P < .003). Multivariable analysis demonstrated that shaggy aorta was a significant risk factor for composite outcome consisted of operative mortality, spinal cord injury, and acute renal failure (odds ratio, 4.78; 95% confidence interval, 1.91-12.3, P < .001)., Conclusions: Preoperative enhanced computed tomography assessment of shaggy aorta could predict high-risk patients for open TAAA repair., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Although skeletal muscle quantity is linked to surgical outcomes, quality remains unexamined. In this study, we evaluated whether skeletal muscle quality and quantity could predict surgical outcomes in acute type A aortic dissection (ATAAD)., Methods: Skeletal muscle quality and quantity were evaluated using computed tomography (CT) values and the psoas muscle mass index, respectively. From May 2004 to December 2017, 324 ATAAD patients underwent aortic replacement after CT scans and psoas muscle mass index measurements. Patients were grouped into intramuscular fat (IMF; n = 55) and non-IMF (n = 269) deposition groups., Results: The mean ages of the patients were 72.3 ± 9.7 and 66.8 ± 12.1 years (P = 0.002), and hospital mortality rates were 3.6% (2/55) and 7.4% (20/269; P = 0.393) for IMF and non-IMF deposition groups, respectively. IMF deposition was a risk factor for a deterioration in activities of daily living at discharge by multivariable analysis [odds ratio 0.33, 95% confidence interval (CI) 0.16-0.69; P = 0.003]. The mean follow-up was 43.9 ± 36.8 months. The 5-year survival was significantly worse for the IMF deposition group (IMF 73.8% vs non-IMF 88.2%; P = 0.010). The multivariable Cox proportional hazard analysis showed that IMF deposition significantly predicted poor survival (hazard ratio 3.26, 95% CI 1.47-7.24; P = 0.004), unlike psoas muscle mass index and age., Conclusions: Skeletal muscle quality, defined by IMF deposition, was an independent predictor of overall survival and postoperative activities of daily living dependence risk in patients undergoing surgery for ATAAD. Thus, IMF deposition may be an additional risk factor for estimating late outcomes of ATAAD surgery., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Although frailty is used to predict morbidity and mortality, its effect on the outcomes of acute type A aortic dissection has not been examined. Therefore, the objective of this study was to evaluate the role of frailty in predicting postoperative morbidity and mortality of patients with acute type A aortic dissection., Methods: A retrospective analysis of a prospectively maintained database was undertaken for all patients (n = 310) undergoing aortic surgery between May 2004 and March 2017. Frailty was evaluated using an index consisting of age more than 70 years, body mass index less than 18.5 kg/m 2 , serum creatinine greater than 1.2 mg/dL, anemia, history of stroke, hypoalbuminemia, and the psoas muscle area index. One point was given for each criterion met, for a frailty score between 0 and 7. Frailty was defined as a score of 3 or more., Results: Of all patients, 106 (34.2%) were defined as frail. Inhospital mortality rates of frail versus nonfrail patients were not significantly different (10.4% versus 8.3%, respectively; p = 0.54). Incidences of postoperative major morbidities without reexploration for bleeding were also not statistically different. Five-year survival rates were significantly worse for frail patients than for nonfrail patients (57.7% versus 85.1%, respectively; p = 0.0001). A frailty score of 3 or greater was associated with late mortality, and long-term outcomes were clearly stratified by frailty score., Conclusions: Frailty, as defined using a seven-component frailty index, can serve as an independent predictor of the risk of late mortality for patients undergoing surgery for acute type A aortic dissection. Such frailty markers, all of which are easily assessed preoperatively, may provide valuable information for patient counseling and risk stratification before aortic surgery., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Vascular Ehlers-Danlos syndrome (vEDS), a genetic disorder caused by mutations in procollagen type III gene (COL3A1), may lead to fatal vascular complication during peripartum period because of the arterial fragility. We experienced a case of vEDS with peripartum life-threatening arterial rapture diagnosed by next-generation sequencing (NGS) and successfully treated the vascular complications. A 25-year-old female in pregnancy at 34 weeks had sudden and acute pain in the left lower abdomen. After successful delivery, her computed tomography scan showed a dissecting aneurysm of the left common iliac artery (CIA). Four days after delivery, she presented in hemorrhagic shock induced by arterial rupture in the CIA. Since her clinical presentations inferred vEDS even in the absence of familial history, we performed NGS-based genetic screening for inherited connective tissue disorders including vEDS with informed consent. Even though we started intensive medication, her iliac aneurysm was progressively enlarging within 3 weeks. After an urgent molecular diagnosis for vEDS (a splice-site mutation), cautious endovascular therapy for her CIA aneurysm was successfully performed. This is the first report for pretreatment molecular diagnosis of vEDS using NGS in an emergent situation of severe vascular complications.

Objective: The present study aimed to determine the impact of the extent of graft replacement on early and late outcomes in acute DeBakey type I aortic dissection., Methods: Between October 1999 and July 2014, 197 consecutive patients were surgically treated for acute DeBakey type I aortic dissection. The extent of graft replacement (hemiarch, partial, or total arch replacement) was mainly determined by the location of the primary entry. Early and late results were compared in patients after total arch replacement (n = 88) and combined hemiarch and partial arch replacement: non-total arch replacement (n = 109)., Results: The in-hospital mortality rates of the total arch replacement and non-total arch replacement groups were 10.2% and 14.7%, respectively (P = .47). Multivariate analysis revealed preoperative cardiopulmonary resuscitation and visceral organ malperfusion as significant risk factors for in-hospital mortality, but not total arch replacement. During a mean follow-up period of 60 ± 48 months, the 5-year survivals in the total arch replacement and non-total arch replacement groups were 88.6% ± 4.2% and 83.8% ± 4.4%, respectively (P = .54). Rates of distal aortic events (defined as freedom from surgery for distal aorta dilation or distal arch diameter expanding to 50 mm) at 5 years were significantly better in the total arch replacement group than in the non-total arch replacement group (94.9% ± 3.5% vs 83.6% ± 4.9%, P = .01)., Conclusions: The operative mortality of patients with acute DeBakey type I aortic dissection treated by total arch replacement was acceptable with good long-term survival after both total arch replacement and non-total arch replacement. The frequency of distal aortic events might be reduced in patients after total arch replacement compared with non-total arch replacement., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: When treating dissecting aneurysm of the thoracoabdominal aorta surgically in patients with Marfan syndrome, we have usually performed graft replacement- including the entire thoracoabdominal aorta and reconstruction of all visceral branches, even if dilatation is mild in some segments-to avoid further aortic operations in the follow-up period., Methods: From October 1999 through July 2011, 20 consecutive patients with Marfan syndrome underwent repair of dissecting aneurysm of the thoracoabdominal aorta (median age, 45 years; range, 19-65 years). All patients underwent surgical intervention with cerebrospinal fluid (CSF) drainage and distal aortic and selective organ perfusion. Deep hypothermia was used in 13 patients for spinal cord protection., Results: No in-hospital mortality was observed. One patient had temporary spinal cord ischemia but was fully recovered by discharge. Other complications included exploration for bleeding (n=1), prolonged ventilation (n=1), and graft infection (n=1). At a mean follow-up of 54 months (range, 9-129 months), 1 patient had died of interstitial pneumonia at 38 months postoperatively. Survival at 8% years was 91.2±9.0%. Two patients required additional aortic procedures (total arch replacement and aortic valve-sparing surgery). Actuarial rate of freedom from aortic operations at 8 years was 83.9%±10.5%, but no patient needed required repeated thoracotomy for an aortic procedure. Neither false nor patch aneurysms were observed using computed tomography (CT) during follow-up surveillance., Conclusions: Graft replacement for dissecting aneurysm of the thoracoabdominal aorta in Marfan syndrome offers good early and long-term results. We believe total aortic replacement including the entire thoracoabdominal aorta and reconstruction of all visceral arteries should be recommended for selected patients with Marfan syndrome., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Recent advancements in total aortic arch replacement achieved by our approach were presented., Methods: From January 2002 to December 2010, 321 consecutive patients (mean age 69.8 ± 13.3 years) underwent total arch replacement through a median sternotomy at our institute. Aortic dissection was present in 94 (28.3%) patients and shaggy aorta in 36 (11.2%), with emergency/urgent surgery required in 106 (33.0%). Our current approach included the following: (1) meticulous selection of arterial cannulation site and type of arterial cannula; (2) antegrade selective cerebral perfusion; (3) maintenance of minimal tympanic temperature between 20 °C and 23 °C; (4) early rewarming just after distal anastomosis; (5) after 2004, bolus injection of 100 mg of sivelestat sodium hydrate into the pump circuit at the initiation of cardiopulmonary bypass; (6) after 2006, maintaining fluid balance below 1000 mL during cardiopulmonary bypass., Results: Overall hospital mortality was 4.4% (14/321) and was 1.9% (4/215) in elective cases. Permanent neurologic deficit occurred in 4.4% (14/321) of patients and in 2.8% (6/215) of elective cases. Prolonged ventilation was necessary in 53 (16.5%), with a significant reduction after 2006 (22.8% vs 12.6%; P = .02). Multivariate analysis demonstrated that risk factors for hospital mortality were octogenarian (odds ratio, 4.32; P = .03), brain malperfusion (odds ratio, 21.2; P = .001) and cardiopulmonary bypass time (odds ratio, 1.01; P = .04). Survival at 3 and 5 years after surgery was 82.4% ± 2.5% and 78.5% ± 3.1%, respectively., Conclusions: Our current approach for total aortic arch replacement was associated with low hospital mortality and morbidities and with favorable long-term outcome., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Surgical treatment of acute type A aortic dissection complicated by cerebral malperfusion remains challenging. This study evaluated predictors of lack of neurologic improvement after aortic repair for acute type A dissection complicated by cerebral malperfusion and assessed relationship with survival., Methods: We retrospectively reviewed 41 consecutive patients operated on between 1999 and 2008 for acute type A dissection complicated by cerebral malperfusion. Lack of postoperative neurologic improvement was defined as a difference between baseline and postoperative National Institutes of Health Stroke Scale scores of 3 points or less., Results: Lack of neurologic improvement was seen in 15 patients (37%). Logistic regression analysis, baseline National Institutes of Health Stroke Scale score (odds ratio, 6.7; 95% confidence interval, 1.4-32.4; P = .02), and time to surgery (odds ratio, 14.6; 95% confidence interval, 2.7-8.5; P = .002) were significantly associated with lack of neurologic improvement. In receiver operating characteristic analysis, National Institutes of Health Stroke Scale score greater than 11 and time to surgery longer than 9.1 hours were best cutoffs for predicting lack of neurologic improvement. Thirty-day mortality was 14.6%. All early deaths were caused by large hemispheric infarction. Postoperative computed tomography or magnetic resonance imaging revealed cerebral infarction in 21 patients (51%). Five-year survival was significantly lower in patients without neurologic improvement (33% ± 12% vs 84% ± 7%, log-rank P <.001)., Conclusions: Time to surgery and baseline National Institutes of Health Stroke Scale score were predictors of lack of improvement, which was associated with poor survival., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

'Anastomotic leak' after ascending aortic replacement for acute aortic dissection, which is determined as direct forward blood flow into the false lumen at the distal anastomosis, prevents the false lumen from being thrombosed. The aim of this study is to determine whether the leak influences on residual aortic growth. Between October 1999 and May 2006, 100 patients presenting for acute type A aortic dissection underwent surgery at our institution. Among the population, 34 patients who underwent ascending aortic replacement and have been followed by computed tomography (CT) for over 6 months were reviewed. On the follow-up CT, maximum diameter of aortic arch and descending aorta were measured and the presence of anastomotic leak was determined. The growth rates of aortic arch and descending aorta in patients diagnosed as having anastomotic leak were greater than patients not having leak (P=0.003, P<0.001, respectively). Initial maximum diameter just after ascending aortic replacement was greater in patients with anastomotic leak than without anastomotic leak in aortic arch and descending aorta (P=0.013, P=0.06). Anastomotic leak after ascending aortic replacement for acute type A aortic dissection contributed to remnant aortic growth. More sophisticated method for reapproximation of dissected aorta should be dictated.

Brain malperfusion caused by acute type A aortic dissection is a life threatening situation that should be relieved as early as possible with minimal reperfusion injury prior to aortic repair. The patient was 72-year-old woman with acute type A aortic dissection. She was referred to us 2.5 hours after onset of chest pain, and she was unconscious with a complete left paralysis. The true lumen of internal carotid artery was severely stenosed. A simple bypass circuit was installed from the femoral artery to the true lumen of the right common carotid artery, which consisted with a roller pump and cold bath for blood cooling. Regional oxygen saturation of the right frontal brain was immediately raised after initiation of the bypass, and she underwent emergency ascending hemi-arch replacement. The postoperative course was complicated with a right brain stroke; however, brain computed tomography and magnetic resonance imaging disclosed minimum brain edema. She was discharged on foot on the 35th postoperative day, and she was walking with a stick after 7 months.

Objective: To present our experience of total aortic arch replacement through a left posterolateral thoracotomy., Methods: Sixteen patients (13 males; mean age 62.1+/-11.3 years) with extended thoracic aortic aneurysms, including those in the thoracoabdominal aorta, underwent replacement through a left posterolateral thoracotomy. The pathology of the diseased aorta was non-dissecting aneurysm due to aortitis in 1 patient and aortic dissection in 15 patients (acute type A: 1, chronic type A: 12, chronic type B: 2). In a prior operation, the patient with aortitis had undergone the Bentall procedure with endovascular stenting of the brachiocephalic artery, and among the other 15 patients, one previously had endovascular stenting for the aortic arch and 12 had hemi-arch replacement for acute type A dissection. Extension of arch replacement was the aortic arch and descending aorta in eight patients, the ascending arch and descending aorta in five patients and the descending arch, and thoracoabdominal aorta in three patients. Additional retroperitoneal dissection was required for the repair of a thoracoabdominal aortic aneurysm., Results: One patient died of traumatic cerebral hemorrhage on day 145 (hospital mortality 6.3%). Average duration of ventilation support was 19.4+/-17.0h and length of ICU stay was 3.6+/-1.6 days. Actuarial survival at 2 years after the operations was 67.7%. However, no aortic-related mortality was observed during follow-up., Conclusions: Early results of extended aortic arch replacement through a left posterolateral thoracotomy were satisfactory in selected patients.

A 61-year-old man developed a ruptured innominate artery associated with localized acute dissection. The innominate artery was reconstructed with a bifurcated prosthetic graft without brain complication.

Postoperative paraplegia after repairing type A acute aortic dissection has been rarely reported and the causes have not been clearly elucidated. We had three cases of newly developed paraplegia after repair of type A acute aortic dissection. In these cases, we speculated that some intercostal arteries were occluded by completely thrombosed false lumen with late onset of systemic hypotension, which might have reduced spinal cord perfusion followed by paraplegia.

Objectives: Femoral arterial perfusion can be associated with complications, and axillary arterial perfusion is not free from risk. The purpose of this study was to describe the incidence and complications of femoral versus axillary artery cannulation for surgical repair of aortic dissection and to devise a strategy for early detection and monitoring of complications using transesophageal echocardiography, near-infrared spectroscopy, and orbital Doppler., Design: Retrospective and observational., Setting: University hospital., Participants: Seventy-five consecutive patients with aortic dissection who underwent aortic repair between 1995 and 2004., Interventions: Aortic surgery., Measurements and Main Results: Among the 44 cases with femoral arterial perfusion, sudden onset of hypotension occurred in 3 cases but was immediately treated based on the TEE diagnosis (collapse of true lumen in the descending aorta). In another case, myocardial ischemia occurred because of occlusion of the coronary artery. These four cases comprised 57.1% of 7 patients with type III dissection with retrograde extension in whom femoral arterial perfusion was used. However, malperfusion was not encountered in 3 cases of the same type of dissection but with axillary arterial perfusion. Axillary artery perfusion (29 cases) led to malperfusion of the right frontal lobe and coronary artery in 1 case each., Conclusions: Flexible management guided by real-time information is essential. Upon initiating femoral arterial perfusion, malperfusion should first be checked for in the descending aorta and then in the coronary and visceral arteries, especially in cases of type III dissection with retrograde extension. Attention should be paid to cerebral and coronary malperfusion when initiating axillary arterial perfusion.

Objective: Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia., Methods: The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5 MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data., Results: The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia., Conclusions: The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion.

A 75-year-old woman presented with superior mesenteric artery and celiac artery occlusion associated with acute type B dissection. Emergent bypass grafting by using the right gastroepiploic artery and the left radial artery for the superior mesenteric artery and the celiac artery was performed without bowel resection.

Background: In patients with acute type A aortic dissection complicated by cerebral malperfusion, the surgical treatment remains challenging. This retrospective study reports the results of surgical interventions and the clinical features of these patients., Methods: From 1999 to 2004, 63 patients underwent surgical treatment for acute type A aortic dissection. Sixteen patients (25.3%) showed preoperative newly developed neurologic deficits (cerebral malperfusion). In patients with cerebral malperfusion, the characteristics, neurologic symptoms, computed tomography findings, interval from onset to operation, and operative details (procedure, arterial cannulation site, method of brain protection) were reviewed., Results: The hospital mortality rate was 43.7% (7 of 16 patients) for the cerebral malperfusion group and 17.0% (8 of 47 patients) for the noncerebral malperfusion group (all patients, 23.8%). Multivariate analysis showed preoperative cerebral malperfusion as the sole risk factor for hospital mortality. Six patients, including all patients in a preoperative coma, died of severe brain damage within 1 month after surgery. Most patients were diagnosed with right hemispheric cerebral infarction by postoperative brain computed tomography. The operative details and the time interval from onset to operation were not significant predictors of death. The cumulative survival rate at 4 years was 75.5% in patients without cerebral malperfusion and 50.1% with cerebral malperfusion (p = 0.091)., Conclusions: The results of surgical treatment for acute type A dissection complicated with cerebral malperfusion demonstrated high hospital mortality, but the long-term survival was similar to patients without cerebral malperfusion, with an acceptable neurologic outcome, excluding preoperative coma patients. Appropriate protection of ischemic brain tissue should be implemented to improve the surgical results in these patients.

Background: Aortic dissection after femoral arterial perfusion has been reported as a dreadful complication. Apart from such a drastic event, using intraoperative transesophageal echocardiography we detected aortic dissection confined to the abdominal aorta that was associated with visceral malperfusion., Methods: We examined 11 consecutive patients with aortic dissection in whom the abdominal aorta was intact, and surgeries were performed with femoral perfusion. The abdominal aorta and visceral branches were examined for new development of dissection or malperfusion by means of transesophageal echocardiography before, during, and after cardiopulmonary bypass. These echocardiographic findings were then related to the postoperative assessment and midterm results., Results: Aortic dissection was found in 3 of 11 cases (27.2%). Unusual progression of metabolic acidosis (base excess < or =10 mEq/L) occurred, possibly as a result of malperfusion of visceral arteries, in 2 of these 3 cases, whereas none of the 8 cases presented with such findings. The presence of dissection was later confirmed by postoperative computed tomography in all but 1 case. In the midterm follow-up period, aneurysm formation was found in the infrarenal aorta and iliac arteries in 2 of the 3 cases with new aortic dissection but not in any of the remaining 8 cases., Conclusions: New development of aortic dissection after femoral arterial perfusion was found in 27% of the cases in this series. Although these occurred without dramatic symptoms, this event may be related to unusual metabolic acidosis during cardiopulmonary bypass or to subsequent aneurysmal formation of the infrarenal aorta or iliac arteries, or both.

A 65-year-old male with four-channel aortic dissection successfully underwent replacement of the thoracoabdominal aorta, reconstruction of the celiac, superior mesenteric artery, renal arteries, and 5 pairs of intercostals or lumbar arteries using deep hypothermic technique.

A 75-year-old woman who had suffered type B dissection had coronary artery bypass grafting surgery using a mechanical aortic connector. Four days after the operation, she had a sudden syncope. CT demonstrated type A dissection, and an emergency operation was done, and postoperative course was uneventful. This case demonstrates that this connector should be used carefully in patients with a history of type B dissection.

We present a new technique, which is the distal perfusion first technique, for chronic dissection with dilatation of the aorta. Using a "side-ways-tau shaped" incision, this technique allows single-staged repair, full-time antegrade perfusion, less possibility of mesenteric malperfusion and cerebral embolism.

Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high hospital mortality rate. Open aortic surgery for ATAAD is always required to save the patient, particularly elderly patients. Tear-oriented surgery is recommended as the frontline treatment for ATAAD, and hemiarch replacement (HAR) is sufficient because the primary entry is often observed in the ascending aorta (60%–70%). However, HAR has some drawbacks, such as new creation of an anastomotic entry and unfavorable distal aortic remodeling during long-term follow-up. Although total arch replacement (TAR) is a demanding procedure, it is another useful option for ATAAD. Proper patient selection for TAR is controversial. Standardized procedure for TAR, including the optimal brain protection methods and the use of excellent sealed vascular prosthetic grafts, has been established over the past decades. Therefore, TAR is increasingly being selected for HAR in patients who are young or have enlarged aortic arch, severely dissected supra-aortic arch vessels, or hereditary thoracic aortic disorders. The emerging technology of commercially available frozen elephant trunk accelerated the application of TAR, facilitates distal anastomosis, and improves distal aortic remodeling. Although further evidence is required, TAR could be the best choice for HAR for selected patients. Currently, appropriate selection of the surgical technique is important to maximize the benefits of open surgery for ATAAD. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement. METHODS Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years. RESULTS The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P  < 0.001). Positive aortic remodelling was observed in the proximal descending (P  < 0.001) to mid-descending (P  < 0.001) aorta exclusively in patients with acute aortic dissection. CONCLUSIONS The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events. [ABSTRACT FROM AUTHOR]

Minimization of end-organ ischemia is a key tenet in successful thoracoabdominal aortic aneurysm (TAAA) surgery. During these reattachments, antegrade pulsatile blood flow to the spinal cord was guaranteed not only via the Adamkiewicz artery but also the collateral network, which ultimately minimizes spinal cord ischemia. Therefore, the question remains whether the incidence of spinal cord ischemia in patients with atherothrombotic aorta could be reduced by the current technique. [Extracted from the article]

OBJECTIVES We present our experience of total aortic arch replacement. METHODS Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years. CONCLUSIONS Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients. [ABSTRACT FROM AUTHOR]

Background: Acute occlusion of the carotid artery caused by acute type A aortic dissection (AAD) induces on-going warm brain ischemia. The purpose of this study was to elucidate the hypothesis that low-flow reperfusion could mitigate reperfusion injury after warm ischemic damage to the brain. Methods: Experiments were performed using a canine global brain ischemia model, with 15 minutes of ischemia followed by 3 hours reperfusion, which was established by a simple brain reperfusion circuit with a roller pump. The right common carotid artery (RCCA) flow ratio was determined as the mean RCCA flow during reperfusion divided by the mean RCCA flow during pre-ischemia. Animals were divided into two groups according to the RCCA flow ratio; low RCCA flow ratio of 0.3 to 0.6 (Group L, n=5) and control RCCA flow ratio of 1.0 to 1.4 (Group C, n=5). At the 3-hour reperfusion time point, physiological and histopathological assessments were performed in both groups. Results: Electroencephalographic activity recovered in four of five animals (80%) animals in Group L, whereas no recovery (0%) in activity was observed in Group C. Brain water content in Group L animals was significantly less than that in Group C. Apoptosis, number of perivascular edematous regions and NFκB expression were apparently suppressed in Group L compared with Group C. There were significant positive correlations of RCCA flow with brain water content, apoptosis and number of perivascular edematous regions. Conclusions: Controlled low-flow reperfusion mitigated reperfusion-induced brain edema and apoptosis, leading to rescue of brain function in the canine model. [ABSTRACT FROM AUTHOR]

This study evaluates our 18-year experience of total arch replacement in the octogenarian and nonagenarian population. Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement at our institution. A total of 139 patients were aged 80 years or more (83.1 ± 2.8 years), and 601 patients were aged less than 80 years (66.9 ± 11.3 years). Early and late outcomes were compared between the groups. In the group aged 80 years or more, operative mortality occurred in 12 patients (8.6%) and significantly improved over time (P =.010). Operative mortality was significantly higher in the group aged 80 years or more (P =.033) when compared with the group aged less than 80 years (4.0%). Regarding postoperative complications, deep sternal wound infection, pneumonia, and tracheostomy occurred in significantly more patients in the group aged 80 years or more. In the group aged 80 years or more, there were 52 late deaths, with 4 aortic-related deaths. Overall survival was 55.4% ± 5.0% at 5 years and 32.2% ± 6.1% at 8 years. Multivariable Cox-hazard regression analysis demonstrated that chronic kidney disease, nonelective surgery, and concurrent procedures were significant risk factors for overall survival in the group aged 80 years or more. Cumulative incidence for reoperation was significantly lower in the group aged 80 years or more (8.7% at 5 years) compared with the group aged less than 80 years (14.2% at 5 years). Total arch replacement was performed with an acceptable overall survival in octogenarians and nonagenarians, although operative mortality was higher than in younger patients. However, older patients had a lesser burden of reoperation compared with younger patients. [ABSTRACT FROM AUTHOR]

The elephant trunk technique is used as a standard method in the approach to staged repair of extensive thoracic aneurysms. Here, we present a rare case of a graft infection, in which vegetation was attached to the distal end of the elephant trunk. A 36-year old male who had undergone total arch replacement with elephant trunk installation for type A aortic dissection was readmitted for high-grade fever. At the time of admission, Osler's nodules were present and brain magnetic resonance imaging showed multiple small emboli and haemorrhages. Transoesophageal echocardiography could not locate any sign of infection within the cardiac chambers, but disclosed vegetation attached to the elephant trunk. He underwent successful emergent graft replacement of the lesion, and no recurrence of the infection has been observed. [ABSTRACT FROM AUTHOR]

Objective: The technical details of total arch replacement using antegrade cerebral perfusion are presented. Methods: From January 2002 to May 2012, 423 consecutive patients (mean age, 69.2 ± 13.1 years) underwent total arch replacement using antegrade selective cerebral perfusion through a median sternotomy. Acute aortic dissection was present in 81 patients (19.1%; 75 type A, 6 type B), and a shaggy aorta was present in 37 patients (8.7%). Emergency/urgent surgery was required in 135 patients (31.9%). Our current approach included meticulous selection of the arterial cannulation site and type of arterial cannula, antegrade selective cerebral perfusion, maintenance of the minimal tympanic temperature between 20°C and 23°C, early rewarming immediately after distal anastomosis, and maintenance of the fluid balance at less than 1000 mL during cardiopulmonary bypass. A woven Dacron 4-branch graft was used in all patients. Results: The overall hospital mortality was 4.5% (19/423): 9.6% (13/135) in urgent/emergency surgery cases and 2.1% (6/288) in elective cases. Permanent neurologic deficits occurred in 3.3% patients (14/423). Prolonged ventilation was necessary in 57 patients (13.4%). A multivariate analysis demonstrated the risk factors for hospital mortality to be age (octogenarian; odds ratio, 4.45; P = .02), brain malperfusion (odds ratio, 22.5; P = .002), and cardiopulmonary bypass time (odds ratio, 1.06; P = .04). The follow-up was completed in 97.2% of patients (mean, 29 ± 27; 1-126) and included 2.3 patients per year. Survival at 5 and 10 years after surgery was 79.6% ± 3.3% and 71.2% ± 5.0%, respectively. In the acute A dissection group, the 10-year survival was 96.6% ± 2.4%. In the elective nondissection group, the 5- and 10-year survivals were 80.3% ± 4.2% and 76.1% ± 5.7%, respectively. Conclusions: Our current approach for total aortic arch replacement is associated with low hospital mortality and morbidity, thus leading to a favorable long-term outcome. [Copyright &y& Elsevier]