ObjectiveTo investigate the independent risk factors associated with postoperative acute respiratory distress syndrome in patients undergoing type A aortic dissection surgery.MethodsThe clinical data of 147 patients who underwent acute type A aortic dissection surgery in the First Affiliated Hospital of Anhui Medical University from 2015 to 2019 were retrospectively analyzed. There were 110 males at age of 51.9±10.1 years and 37 females at age of 54.3±11.1 years. According to whether the patients developed ARDS after surgery, all of the patients were divided into a ARDS group or a non-ARDS group. Logistic regress analysis was utilized to establish the predictive mode to identify the independent risk factors related to ARDS.ResultsOf the patients, 25 developed postoperative ARDS. Among them, 5 patients were mild ARDS, 13 patients were moderate, and 7 patients were severe ARDS. Multivariate logistic regression analysis showed that deep hypothermic circulatory arrest time [odds ratio (OR)=1.067, 95% confidence interval (CI) 1.014-1.124, P=0.013], cardiopulmonary bypass time (OR=1.012, 95%CI 1.001-1.022, P=0.027) and perioperative plasma input (OR=1.001, 95%CI 1.000-1.002, P=0.011) were independently associated with ARDS in patients undergoing acute A aortic dissection surgery. Receiver operating characteristic (ROC) curve analysis demonstrated a good discrimination ability of the logistic regression model, with an area under the curve of 0.835 (95%CI 0.740-0.929, P=0.000).ConclusionDuration of deep hypothermic circulatory arrest, cardiopulmonary bypass time and perioperative plasma are independent risk factors for postoperative ARDS in patients undergoing type A aortic dissection surgery.
ObjectiveTo evaluate the involvement of renal artery in acute Stanford type A aortic dissection (TAAD) using CT angiography (CTA) and to analyze the difference of renal function among different types of renal artery involvement.MethodsFrom January 2016 to November 2017, 151 patients of acute TAAD with renal artery involvement were included in the study. There were 118 males and 33 females, with an average age of 47.93±10.53 years. All patients underwent aortic CTA to confirm the TAAD. According to CTA, involvement of one side of renal artery can be divided into four types: type A, large tear near renal artery orifice, difficult to distinguish true or false lumen; type B, the orifice of the renal artery originates entirely from the false lumen; type C, the orifice of the renal artery originates entirely from the true lumen; type D, renal artery dissection is observed, renal artery intima can be seen. The levels of serum creatinine (sCr) and creatinine clearance (CC) in all groups were analyzed and compared. ResultsThe results of one-way ANOVA analysis showed that there was no significant difference in sCr or CC among the groups (P>0.05). There was no significant difference in age, sex, proportion of hypertension history and onset time among the above groups (P>0.05).ConclusionThe three most common types of renal artery involvement were BC type, CC type, and AC type. The types of renal artery involvement do not affect renal function.
ObjectiveTo evaluate the preoperative risk factors for acute Stanford type A aortic dissection (ASTAAD) patients in our country by collecting multi-center data.MethodsWe consecutively enrolled 700 patients who underwent surgery for ASTAAD in the multi-center hospital database from January 2018 to January 2020. According to the ascending aorta size (AAS), the patients were divided into two groups: a group AAS≥55 mm and a group AAS<55 mm. Univariate and multivariate logistic regression analyses were used to investigate the related preoperative risk factors for the onset of ASTAAD.ResultsAccording to the exclusion criteria, a total of 621 patients were finally enrolled, including 453 males and 168 females with an average age of 48.24±11.51 years, and 509 (81.94%) patients had AAS<55 mm. Univariate and multivariate statistical analyses showed that smoking, hypertension, preoperative cardiac troponin I, and left ventricular ejection fraction were related to the occurrence of ASTAAD. The mortality rate of the patient during hospitalization was 13.04% (81 patients).ConclusionIn clinical practice, various preoperative risk factors affect ASTAAD patients, which should be paid attention to. Comprehensive evaluation and an individualized analysis of patients and timely prevention and intervention improve patients' survival rate.
ObjectiveTo analyze the risk factors for neurological complications after emergency surgery of acute type A aortic dissection.MethodsThe clinical data of 51 patients with acute Stanford type A aortic dissection who were admitted to Shanghai Delta Hospital from October 2018 to May 2019 were retrospectively analyzed. There were 37 males (72.5%) and 14 females (27.5%), aged 29-85 (55.1±12.3) years. The patients were divided into two groups, including a N1 group (n=12, patients with postoperative neurological insufficiency) and a N0 group (n=39, patients without postoperative neurological insufficiency). The clinical data of the two groups were compared and analyzed.ResultsThere were statistical differences in age (62.6±11.2 years vs. 51.7±11.4 years, P=0.003), preoperative D-dimer (21.7±9.2 μg/L vs.10.8±10.7 μg/L, P=0.001), tracheal intubation time (78.7±104.0 min vs. 19.6±31.8 min, P=0.003), ICU stay time (204.1±154.8 min vs. 110.8±139.9 min, P=0.037) and preoperative coagulation factor activity R (4.0±1.5 vs. 5.1±1.6, P=0.022). Preoperative coagulation factor activity R was the independent risk factor for neurological insufficiency after emergency (OR=2.013, 95%CI 1.008-4.021, P=0.047).ConclusionFor patients with pre-emergent acute aortic dissection who are older (over 62.6-64.5 years), with reduced coagulation factor R (less than 4.0), it is recommended to take more active brain protection measures to reduce the occurrence of postoperative neurological complications in patients with acute aortic dissection, and further improve the quality of life.
Objective To explore the therapeutic effect of mild hypothermia on the inflammatory response, organ function and outcome in perioperative patients with acute Stanford type A aortic dissection (AAAD). Methods From February 2017 to February 2018, 56 patients with AAAD admitted in our department were enrolled and randomly allocated into two groups including a control group and an experimental group. After deep hypothermia circulatory arrest during operation, in the control group (n=28), the patients were rewarmed to normal body temperatures (36 to 37 centigrade degree), and which would be maintained for 24 hours after operation. While in the experimental group (n=28), the patients were rewarmed to mild hypothermia (34 to 35 centigrade degree), and the rest steps were the same to the control group. The thoracic drainage volume and the incidence of shivering at the first 24 hours after operation, inflammatory indicators and organ function during perioperation, and outcomes were compared between the two groups. There were 20 males and 8 females at age of 51.5±8.7 years in the control group, 24 males and 4 females at age of 53.3±11.2 years in the experimental group.Results There was no obvious difference in the basic information and operation information in patients between the two groups. Compared to the control group, at the 24th hour after operation, the level of peripheral blood matrix metalloproteinases (MMPs) was lower than that in the experimental group (P=0.008). In the experimental group, after operation, the awakening time was much shorter (P=0.008), the incidence of bloodstream infection was much lower (P=0.019). While the incidence of delirium, acute kidney injury (AKI), hepatic insufficiency, mechanical ventilation duration, intensive care unit (ICU) stays, or hospital mortality rate showed no statistical difference. And at the first 24 hours after operation, there was no difference in the thoracic drainage volume between the two groups, and no patient suffered from shivering. Conclusion The mild hypothermia therapy is able to shorten the awakening time and reduce the incidence of bloodstream infection after operation in the patients with AAAD, and does not cause the increase of thoracic drainage volume or shivering.
ObjectiveTo observe the efficacy of restrictive bare stent released on the distal end of the trunk of Stanford type A aortic dissection. Methods The clinical data of 22 patients with Stanford type A aortic dissection requiring aortic arch replacement and trunk surgery and selected for restrictive bare stent placement from November 2016 to February 2018 in our hospital were retrospectively analyzed. Among them, there were 19 males and 3 females, aged 34-68 (49.72±8.05) years. The bare stent was released in the descending thoracic aorta, and the stented elephant trunk was placed in the bare stent. The aortic computerized tomography angiography was reviewed before discharge and the stent position and complications were observed. ResultsOne patient failed to be implanted with bare stents due to a greater resistance and prolapse during implantation. Bare stents were successfully implanted in the remaining 21 patients. One patient died of large-area cerebral infarction after surgery and one patient suffered paraplegia. Twenty patients who survived and successfully implanted bare stents were followed up at regular intervals for 4-21 (13.00±6.14) months. No stroke or death occurred during the follow-up. The computerized tomography angiography showed good stent morphology and position, and no displacement or type Ⅲ endoleak. No stent graft-induced new entry was found. ConclusionAs an adjunct to stented elephant trunk, the use of restrictive bare stents can reduce the possibility of recurrence of a distal stent fracture, significantly expand the narrowest segment and true lumen caliber near the endoluminal graft. Aortic remodeling works well.
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.
ObjectiveTo explore the single-center experience of hybrid therapy in treatment of Stanford type A aortic dissection, and to make a comparison of the clinical results of this hybrid therapy with total arch replacement surgery in the same period.MethodsFrom March 2017 to April 2020, 272 patients with Stanford type A aortic dissection underwent surgical treatment in our center, including 147 patients (126 males and 21 females) who received the aortic arch surgery. Among them, 106 patients underwent replacement of ascending aorta+aortic arch+stent trunk (total arch replacement group), while 41 patients underwent one-stop compound total arch type Ⅱ hybrid surgery (compound total arch replacement group). We tried to identify whether hybrid surgery really simplified total arch replacement surgery of the aortic dissection by comparing the operative mortality, postoperative complication rate, operative time, extracorporeal circulation time, etc.ResultsThere was no statistical difference in preoperative clinical data or death rate between the two groups. However, blood transfusion (6.74±7.35 U vs. 4.65±6.87 U, P<0.05), postoperative respiratory insufficiency [16 (15.09%) vs. 2 (4.88%), P<0.05], and apoplexy [3 (2.83%) vs. 0, P<0.05], paraplegia [2 (1.89%) vs. 0, P<0.05], in the compound total arch replacement group was significantly better than those of the total arch replacement group. The compound total arch replacement group did not shorten the total operation time, but it was significantly better in terms of extracorporeal circulation time (175.50±55.70 min vs. 129.70±48.80 min, P<0.05), aortic block time (103.10±23.70 min vs. 49.70±30.10 min, P<0.05), and the time of stopping the circulation or avoiding stopping the circulation (32.10±7.20 min vs. 0 min, P<0.05). The postoperative mechanical ventilation time was shorter in the compound total arch group (62.60±31.70 h vs. 41.30±32.60 h, P<0.05), and the time of staying in ICU (124.50±61.50 h vs. 63.40±71.20 h, P<0.05) and the postoperative hospital stay (13.50±11.20 d vs. 9.20±7.20 d, P<0.05) were significantly shorter than those in the total replacement group. A total of 138 patients were followed up for 6-38 (15.8±6.4) months. There was no statistical difference in one-year mortality or three-year mortality (P>0.05).ConclusionHybrid surgery shortens extracorporeal circulation time, while reduces or avoids the time of deep hypothermia circulatory arrest, the incidence of complications and the time of hospital stay. In conclusions, hybrid surgery simplifies the arch management of acute Stanford type A aortic dissection.