Aortic arch disease is one of the research hotspots and treatment difficulties in the field of aorta, including aortic arch aneurysms, pseudoaneurysm, ulcer, dissection and intramural hematoma. By summarizing the clinical data of the vascular surgery center of Fuwai Hospital of Chinese Academy of Medical Sciences in the past five years and combining with the latest theories of the cutting-edge development of aortic surgery, the authors proposed the "HENDO" concept, including using hybrid technique (H), endovascular repair (Endo) and open surgery (O), properly to treat aortic arch pathologies individually. The authors advocated the establishment of HENDO team and cooperation mechanism in large aortic centers, to eliminate technical shortcomings of a single surgeon by fully mastering the three main technology clusters by teamwork. Accordingly, the best treatment for each patient can be administrated and the survival rate and quality of life can be improved eventually.
Objective To compare the outcome of patients with the strategy of conventional and steady cooling ＆ rewarming and cold reperfusion , who suffered from DeBakey type Ⅰ aortic dissection or aortic arch aneurysm and underwent the total aortic arch replacement. Methods Thirty-two patients who underwent total arch replacement were randomly allocated to one of two strategies of temperature management in cardiopulmonary bypass （CPB）, conventional group （group C, 16 cases） and steady cooling ＆. rewarming and cold reperfusion group （group S, 16 cases）. The jugular bulb venous oxygenation saturation （SjvO2）, jugular bulb venous oxygen tension （PivO2） and jugular bulb venous blood temperature （JVBT） were tested or monitored during the operation. Preoperative and postoperative neurological examinations and brain computerized tomography scan were performed. Results All patients survived the operations and were discharged from hospital. No new brain infarction occurred. Transient neurologic dysfunction occurred in 2 patients of the group S and 3 patients of the groupC. The “cooling ＆ rewarming blanket-impress puple” occurred in 4 cases of the group C. The SjvO2, PjvO2, lowest nasopharyngeal temperature and the post operative nasopharyngeal temperature of the patients in group S were significantly higher than those of the patients in group C （SjvO2 0.85±0. 11 vs. 0. 74±0.23, PjvO2 36. 9± 15.6mmHg vs. 24.5±7.7mmHg, P（ 0.01 ）. While the highest brain temperature, wake time and ICU stay in group S were remarkably lower than those in group C （P 〈0. 01,0. 05）. Conclusion With less postbypass afterdrop and satisfactory clinical outcome, the strategy of steady cooling ＆ rewarming and cold reperfusion can effectively avoid brain hyperthermia and mismatch of cerebral blood flow metabolism in the surgery of total aortic arch replacement.
Objective To investigate the efficacy and safety of the application of selective cerebral perfusion (SCP) technique in pediatric aortic arch reconstruction, so as to alleviate brain injury during operation. Methods From April 2007 to May 2008, 32 children aged from 8 days to 103 months (14.4±25.4 months) and weighed from 27 kg to 22.0 kg (6.7±4.4 kg) underwent aortic arch reconstruction with selective cerebral perfusion in Shanghai Children’s Medical Center. Twentytwo suffered from aortic coarctationwith intracardiac anomaly, and 10 suffered from interrupted aortic arch with intracardiac anomaly. The arterial cannulation was achieved by placing a flexible wire wound cannula in ascending aorta close to the root part of innominate artery. The rectal temperature was about 1820℃. Then the cannula was moved upward into innominate artery to perform SCP. Results The time of SCP was 17-121 mins（39.6±19.4 mins）, perfusion blood flow maintained in 15-40 ml/(kg·min)［29.7±6.1 ml/(kg·min）］. Four cases died of low cardiac output syndrome or arrhythmia, and no evidence of brain injury was observed. No obvious neurologic complication was observed in 28 survivls. No abnormal electroencephalogram was observed in 25 cases. The results of head Bsonography and brain magnetic resonance image (MRI) were normal in 5 neonates. Conclusion Selective cerebral perfusion is a simple, feasible, safe and effective technique in pediatric aortic arch reconstruction.
The conventional total arch replacement (cTAR) with frozen elephant trunk implantation is commonly regarded as the gold standard for aortic pathologies involving ascending aorta and proximal aortic arch. By combining open supra-aortic vessels debranching and emerging endovascular technologies, hybrid arch repair (HAR) has been increasingly performed as a promising alternative in risky patients with comorbidities and frailties. Nevertheless, the advantages or disadvantages of hybrid arch procedures and cTAR in terms of survival and related outcomes remain controversial. This study is aimed to briefly review the role and results of HAR in the management of aortic arch pathology in comparison of contemporary cTAR.
Objective To monitor the distribution of blood perfusion during aortic arch aneurysm surgery under double arterial lines with single pump. Methods We retrospectively analyzed the clinical data of 37 patients underwent aortic arch repair or reconstruction between September 2012 and April 2014. There were 9 females and 28 males at mean age of 48.1±10.8 years ranging from 19.0-72.0 years.We took double arterial lines with single pump for cardiopulmonary bypass (CPB) during the operation and we monitored the perfusion tube flow of both the upper and lower body by blood flow detector. Cerebral blood perfusion was measured by transcranial cerebral Doppler and near-infrared spectroscopy cerebral oxygen saturation (rSO2). Results The mean CPB time of all 37 patients was 195.8±40.5 minutes ranging from 136.0-277.0 minutes and the mean duration time of selective antegrade cerebral perfusion (SCAP) was 21.6±5.6 minutes ranging from 5.0-35.0 minutes. During cooling and rewarming phases, the part of blood flow through axillary artery cannulation ranged from 31.5% to 40.8% of the whole body perfusion. The blood flow of SACP was increased to 15.0 ml / (kg·min) in 2 patients with significantly lower rSO2 and middle cerebral artery blood flow during SACP, and they had an uneventful recovery process after surgery. There were another 2 patients recorded abnormal situation of rSO2 without interventions. One patient died and the other one recovered with compications of spinal cord. Conclusions The technique of double arterial lines with single pump is reasonable and effective. The cerebral perfusion monitoring is helpful to detect abnormal perfusion during aortic arch aneurysm surgery.
ObjectiveTo evaluate the short-and long-term results of hybrid procedures in the treatment for aortic arch lesions. MethodsFrom October 2002 to March 2011, 28 patients with thoracic aortic aneurysms or dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Twenty-two males and 6 females were in the series. The mean age of the patients was 68 years old. Of 28 patients, 15 were atherosclerotic thoracic aortic aneurysms and 13 were thoracic aortic dissection. Follow-up protocol consisted of computed tomography (CT) angiograms or ultrasound was performed in 3, 6, and 12 months, and annually thereafter. The main goal was to evaluate the operative mortality, morbidity, and the longterm survival of these patients. ResultsHybrid procedures included 12 totalarch transpositions, 3 left common carotid artery (LCCA)left subclavian artery (LSA) bypass, 11 right common carotid artery (RCCA)LCCA-LSA bypass, 2 RCCA-LCCA bypass. The technical success rate was 92.9% (26/28). The complications occurred in 10 patients (35.7%). Operative mortality was 7.1% (2/28). The apoplexia rate was 7.1% (2/28). The time of followup was (36±3) months. The patency rates of 1-year, 3-year, and 5-year were 100%, 92.9% (26/28), and 85.7% (24/28), respectively. The survival rates of 1-year, 3-year, and 5-year were 89.3% (25/28), 71.4% (20/28), and 60.7% (17/28), respectively. ConclusionsThe short-and long-term results with hybrid procedures in the treatment for aortic arch diseases are satisfactory. Further reducing the complications is the key to increase the survival rate.
ObjectiveTo establish a mouse model of pressure overload-induced heart failure via suprasternal notch approach. MethodsMale mice were separated into a sham group and an experiment group. Through suprasternal notch approach, the aortic arch port between the origin of the right innominate and left common carotid arteries was partially clipped with tantalum clip, which had a remaining opening of 0.35 mm or 0.25 mm in diameter to cause progres-sively increased afterload. Echocardiography was performed 10 weeks after aortic arch clipped or sham surgery to deter-mine left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular posterior wall end-diastolic thickness (LVPWD), ejection fraction (EF) and fractional shortening (FS). After hemodynamic recordings were completed, mouse body weight (BW) and heart weight (HW) were measured for obtaining HW/BW ratio (mg/g). After heart function examination, mice blood sample was collected for evaluation of serum N-terminal pro-brain natriuretic peptide (NT-proBNP). At the end, part of left ventricular free wall was excised, and hematoxylin and eosin stain was made for histopathological examination. ResultsThe HW/BW, LVEDD and serum NT-proBNP significantly increased in the experiment group compared with those in the sham group (P < 0.01, respectively). The LVPWD, EF and FS significantly decreased compared with the sham group (P < 0.01, respectively). Histopathological examination showed malalignment and rupture of cardiac muscle fibers, hypertrophy and degeneration of myocardial cells, part of which had local or patchy necrosis in left ventricule postoperatively 10 weeks. ConclusionThe model of pressure overload-induced heart failure in mice established through suprasternal approach is simple, minimally invasive and reliable.
Abstract： Objective To determine the risk factors for acute kidney injury (AKI) after thoracic aortic arch replacement surgery under deep hypothermic circulatory arrest (DHCA). Methods We retrospectively analyzed the clinical data of 139 patients who underwent thoracic aortic arch replacement surgery under DHCA between January 2004 and December 2008 in Beijing Anzhen Hospital Affiliated to Capital University of Medical Sciences. The patients were divided into two gro-ups according to whether AKI occurred after thoracic aortic arch replacement surgery. In the AKI gro-up (n=48), there were 39 males and 9 females with an age of 57.67±9.56 years. In the normal renal function gro-up (n=91), there were 69 males and 22 females with an age of 41.30±13.37 years. We observed the clinical data of the patients in both gro-ups, including left ventricular ejecting fraction (LVEF) before operation, diameter of the left ventricle, diameter of the ascending aorta, renal function, cardiopulmonary bypass time, aortic crossclamp time, and DHCA time. The risk factors for AKI and death after operation were evaluated by univariate analysis and stepwise logistic regression analysis. Results Among all the patients, AKI occurred in 48 (34.53%), 17 (12.23%) of whom underwent continuous renal replacement therapy (CRRT). Respiratory failure occurred in 27 patients (19.42%). Twentynine patients (20.86%) had cerebral complications, including temporary cerebral dysfunction in 26 patients and permanent cerebral dysfunction in 3 patients. In all the patients, 14 (10.07%) died, including 4 patients of heart failure, 9 patients of multiple organ failure, and 1 patient of cerebral infarction. There were 3 (3.30%)deaths in the normal renal function gro-up and 11 (22.92%) deaths in the AKI gro-up with a significant difference of mortality rate between the two gro-ups (P=0.011). A total of 118 patients were followed -up and 7 were lost. The follow-up time was from 5 to 56 months with an average time of 42 months. During the follow-up period, 7 patients died, including 3 patients of heart failure, 2 patients of cerebral apoplexy, and 2 patients of unknown reasons. The logistic regression analysis revealed that creatinine level was greater than 13260 μmol/L before operation (OR=1.042, P=0.021) and respiratory failure (OR=2.057, P=0.002) were independent determinants for AKI after the operation. Conclusion AKI is the most common complication of thoracic aortic arch replacement surgery under DHCA, and is the risk factor of mortality after the surgery. It is important to enhance perioperative protection of the renal function.
Increasing evidences show that a gradual trend away from deep hypothermia toward moderate hypothermic circulatory arrest, which has been proved to be safe and effective in clinic. By summarizing and analyzing the research progress and applying status of the moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion, the article aims at promoting the application of this tenique as a cerebral protection strategy in aortic arch surgery for adults in China.
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.