Objective To summarize the characteristics and management of pregnancy complicated with aortic dissection, and to explore the reasonable diagnosis and treatment plan. Methods The clinical data of 10 patients of pregnancy complicated with aortic dissection in Wuhan Tongji Hospital from January 2011 to June 2017 were collected. Their age was 25.2 (21-29) years. Results In the 10 patients, the majority (8 patients) were primipara, and most of them were in the late stages of pregnancy (5 patients) and puerperal (4 patients). Among them, 1 patient had gestational hypertension, and the blood pressure of the left and right upper extremities was significantly abnormal (initial blood pressure: left upper limb blood pressure: 90/60 mm Hg, right upper limb blood pressure: 150/90 mm Hg). The major clinical manifestations were severe chest and back pain which happened suddenly, with D-dimmer and C-creative protein increased which may be associated with inflammatory reaction. All patients were diagnosed by thoracoabdominal aortic CTA, including 5 patients of Stanford type A dissection and 5 patients of Stanford type B dissection. In the 10 patients, 1 patient refused surgery and eventually died of aortic rupture with the death of fetus before birth. And the remaining 9 patients underwent surgical treatment, 3 patients of endovascular graft exclusion for thoracic aortic stent graft, 2 patients underwent Bentall operation, 1 patient with Bentall + total aortic arch replacement + vascular thoracic aortic stent graft, 1 patient with Bentall operation combined with endovascular graft exclusion for thoracic aortic stent graft, 1 patient with Bentall + coronary artery bypass grafting, 1 patient of thoracoabdominal aortic vascular replacement. Among them, 1 patient underwent endovascular graft exclusion for thoracic aortic stent graft died of severe postoperative infection, and the remaining 8 patients were discharged from hospital. Nine patients were single birth, among them 5 newborn patients had severe asphyxia, 4 patients had mild asphyxia. Finally, 3 neonates died of severe complications, and the remaining 6 survived. Conclusion The ratio of pregnancy with Stanford type A aortic dissection is far higher than in the general population, the possibility of fetal intrauterine asphyxia is larger, but through active and effective surgical and perioperative treatment, we can effectively save the life of mother and fetus.
Objective To explore the effectiveness and predictive value of computer simulated thoracic endovascular aortic repair (TEVAR). Methods The clinical data of the patients with Stanford type B aortic dissection who underwent TEVAR from February 2019 to February 2022 in our hospital was collected. According to whether there was residual false cavity around the stent about 1 week after TEVAR, the patients were divided into a false cavity closure group and a false cavity residual group. Based on computer simulation, personalized design and three-dimensional construction of the stent framework and covering were carried out. After the stent framework and membrane were assembled, they were pressed and placed into the reconstructed aortic dissection model. TEVAR computer simulation was performed, and the simulation results were analyzed for hemodynamics to obtain the maximum blood flow velocity and maximum wall shear stress at the false lumen outlet level at the peak systolic velocity of the ventricle, which were compared with the real hemodynamic data of the patient after TEVAR surgery. The impact of hemodynamics on the residual false lumen around the stent in the near future based on computer simulation of hemodynamic data after TEVAR surgery was further explored. Results Finally a total of 28 patients were collected, including 24 males and 4 females aged 53.390±11.020 years. There were 18 patients in the false cavity closure group, and 10 patients in the false cavity residual group. The error rate of shear stress of the distal decompression port of the false cavity after computer simulation TEVAR was 6%-25%, and the error rate of blood flow velocity was 3%-31%. There was no statistical difference in age, proportion of male, history of hypertension, history of diabetes, smoking history, prothrombin time or activated partial thromboplatin time at admission between the two groups (all P>0.05). The blood flow velocity and shear stress after TEVAR were statistically significant (all P<0.05). The maximum shear stress (OR=1.823, P=0.010) of the false cavity at the level of the distal decompression port after simulated TEVAR was an independent risk factor for the residual false cavity around the stent. Receiver operating characteristic curve analysis showed that the area under the curve corresponding to the maximum shear stress of false cavity at the level of distal decompression port after simulated TEVAR was 0.872, the best cross-sectional value was 8.469 Pa, and the sensitivity and specificity were 90.0% and 83.3%, respectively. Conclusion Computers can effectively simulate TEVAR and perform hemodynamic analysis before and after TEVAR surgery through simulation. Maximum shear stress at the decompression port of the distal end of the false cavity is an independent risk factor for the residual false cavity around the stent. When it is greater than 8.469 Pa, the probability of residual false cavity around the stent increases greatly.
Objective To assess the independent risk factors of in-hospital mortality and morbidity after surgical procedure for Stanford type A aortic dissection (TAAD). Methods Between May 2013 and May 2015, 341 TAAD patients were treated with surgical procedure in Fu Wai Hospital. There were 246 males and 95 females with a mean age of 47.42±11.54 years (range 29-73 years). Among them, 87 patients suffered severe complications or death after the procedure (complication group) and the other 254 patients recovered well without any severe complications (no complication group). Perioperative clinical data were compared between the two groups. Results Mean age of patients in the complication group was significantly higher than that of the no complication group (49.91±11.22 yearsvs. 46.57±11.54 years,P=0.019). The incidence of preoperative ischemic organ injury in the complication group was significantly higher than that in the no complication group: cerebral ischemia (18.4%vs. 5.9%,P=0.001), spinal cord injury (16.1%vs. 4.7%,P=0.001), acute kidney injury (31.0%vs. 10.6%,P=0.000). The incidence of branch vessels involvement in the complication group was significantly higher than that in the no complication group: coronary artery involvement (52.9%vs. 17.1%,P=0.000), supra-aortic vessels involvement (73.6%vs. 53.9%,P=0.001), celiac artery involvement (37.9%vs. 22.0%,P=0.003), mesenteric artery involvement (18.4%vs. 9.8%,P=0.030), and unilateral or bilateral renal artery involvement (27.6%vs. 9.8%,P=0.000). Surgical time of patients in the complication group was significantly longer than that of the no complication group, including cardiopulmonary bypass time (205.05±63.65 minvs. 167.67±50.24 min,P<0.05) and cross-clamp time (108.11±34.79 minvs. 90.75±27.33 min,P<0.05). Multiple regression analysis found that age, preoperative concomitant cerebral ischemic injury, preoperative concomitant acute renal injury, preoperative limb sensory and/or motor dysfunction, coronary artery involvement, cardiopulmonary bypass time were independent risk factors of postoperative death and severe complications in TAAD patients. However, risk of postoperative mortality and morbidity significantly decreased after the concomitant coronary artery bypass graft [OR=0.167 (0.060, 0.467),P=0.001]. Conclusion The high risk factors of postoperative complication in TAAD patients are explored to provide an important clinical basis for preoperative identification of patients at high risk and we need pay more attention to the prevention of these postoperative complications.
Objective To analyze the clinical effect of hybrid surgery on complex type B aortic dissection in 5 years. Methods A retrospective analysis of 47 patients with complex type B aortic dissection in the Central Hospital of Wuhan affiliated to Tongji Medical College of Huazhong University of Science and Technology from 2014 to 2017 was conducted, including 42 males and 5 females with an average age of 54.9±11.2 years. Twenty-one patients underwent the left common carotid artery to the left subclavian artery bypass (a bypass group), and 26 patients underwent the left common carotid artery to the left subclavian artery transposition (a transposition group). Results All patients accepted hybrid surgery successfully. There was no statistical difference in arterial occlusion time or intraoperative blood loss between the two groups (P＞0.05). The 5-year follow-up rate was 100.0% (47/47). During the follow-up period, 12 (25.5%) patients developed complications, including 5 (10.6%) patients of endoleak, 5 (10.6%) patients of hoarseness, 2 (4.3%) patients of stroke/dizziness. There was no patient of left upper limb weakness, paraplegia or retrograde aotic dissection. The reconstructed left subclavian artery remained patent in 46 (97.9%) patients. The overall 5-year survival rate was 100.0%. Conclusion The long-term therapeutic outcome of hybrid surgery for the treatment of complex type B aortic dissection is satisfying. In 5 years, the rebuilt left subclavian artery has a remarkable patency rate. Endoleak and hoarseness are the most common surgical complications.
ObjectiveTo investigate the effect of early postoperative systemic inflammatory response syndrome (SIRS) on the short-term outcome of patients with acute Stanford type A aortic dissection (ATAAD).MethodsThe clinical data of 88 patients with ATAAD who were treated in our hospital from January 2018 to January 2020 were retrospectively analyzed. Patients were divided into a SIRS group (n=37) and a non-SIRS group (n=51) according to whether SIRS occurred within 24 hours after surgery. The perioperative data of the two groups were compared.ResultsThere was no significant difference between the two groups in general clinical data, preoperative left ventricular ejection fraction, white blood cell (WBC) and body temperature (P>0.05). Compared with the non-SIRS group, the cardiopulmonary bypass time in the SIRS group was significantly longer (P<0.05), and the WBC and body temperature within 1 day after surgery in the SIRS group were higher (P<0.01). A significant difference was revealed in the mechanical ventilation time, ICU stay, total hospitalization time and hospitalization costs between two groups (P<0.01). Patients in the SIRS group had higher postoperative acute physiology and chronic health evaluationⅡscores, sequential organ failure assessment score as well as a greater risk of developing postoperative acute lung injury, acute kidney injury, continuous renal replacement therapy, delirium, liver dysfunction and morbidity (P<0.05).ConclusionEarly postoperative SIRS significantly increases the incidence of major adverse complications and the mortality rate of patients with ATAAD.
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.
ObjectiveTo summarize clinical experience of total aortic arch reconstruction with triple-branched stent graft placement in elderly patients with Stanford type A aortic dissection (SAAD). MethodsFrom December 2008 to December 2012, 46 elderly SAAD patients underwent total aortic arch reconstruction with triple-branched stent graft placement under deep hypothermic circulatory arrest and selective cerebral perfusion (SCP)in Department of Cardiova-scular Surgery, Henan Provincial Chest Hospital. There were 37 male and 9 female patients with their age of 65-75 (68.2±5.0)years. There were 6 patients undergoing modified David procedure, 1 patient undergoing Bentall procedure, 2 patients undergoing Wheat procedure, and 37 patients undergoing ascending aortic replacement. ResultsThere was no in-hos-pital death. Cardiopulmonary bypass time was 135-183 (131.1±10.5)minutes, aortic cross-clamping time was 81-100 (61.5±18.3)minutes, and SCP time was 19-28 (24.4±5.6)minutes. Postoperative complications included low cardiac output syndrome in 3 patients, acute renal failure in 2 patients, pleural effusion in 5 patients, lung infection in 2 patients, and sternal dehiscence in 1 patient, who were all cured after treatment. All the patients were followed up for 3 to 12 months without complication related to the stent graft. ConclusionTotal aortic arch reconstruction with triple-branched stent graft placement is an easy surgical procedure for SAAD with a high successful rate and low morbidity, and especially suitable for elderly patients who can't bear traditional operation.
ObjectiveTo investigate the prognosis and impact of postoperative acute kidney injury (AKI) on patients with acute Stanford type A aortic dissection (ATAAD), and to analyze the predictors for short- and medium-term survival. MethodsClinical data of patients who underwent ATAAD surgery in Qingdao Municipal Hospital from May 2014 to May 2019 were retrospectively analyzed. All discharged patients underwent telephone or outpatient follow-up, and were divided into an AKI group and a non-AKI group based on whether AKI occurred after surgery. The impact of postoperative AKI on the short- and medium-term prognosis was analyzed, and multivariate Cox analysis was used to screen the risk factors for short- and medium-term mortality. ResultsA total of 192 patients were collected, including 139 males and 53 females, with an average age of 53.3±11.4 years. Postoperative AKI was identified in 43 (22.4%) patients. The average follow-up time of discharged patients was 23.4±2.4 months, and the lost rate was 5.1%. The two-year survival rate after discharge of the AKI group was 88.2%, and that of the non-AKI group was 97.2%. Kaplan-Meier survival analysis and log-rank test showed that there was a statistical difference between the two groups (χ2=5.355, log-rank P=0.021). Multivariate Cox analysis results showed that age (HR=1.070, 95%CI 1.026 to 1.116, P=0.002), cardiopulmonary bypass time (HR=1.026, 95%CI 1.003 to 1.050, P=0.026), postoperative AKI (HR=3.681, 95%CI 1.579 to 8.582, P=0.003), transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively (HR=1.548, 95%CI 1.183 to 2.026, P=0.001) were independent risk factors for the short- and medium-term mortality of ATAAD patients. ConclusionThe incidence of postoperative AKI is high in ATAAD patients, and the mortality of patients with AKI increases significantly within two years. Age, cardiopulmonary bypass time and transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively are also independent risk factors for short- and medium-term prognosis.
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 summarize clinical experience of different surgical strategies for the treatment of acute Stanford type A aortic dissection (AD). MethodsClinical data of 197 patients with acute Stanford type A AD who underwent surgical treatment in the First Affiliated Hospital of China Medical University from January 2008 to November 2012 were retrospectively reviewed. There were 131 males and 66 females with their age of 24-77 (51.2±13.9) years. All the patients received magentic resonance imaging (MRI) or aortic CT angiography (CTA) for the establishment of diagnosis. According to different aortic root conditions,ascending aorta replacement,Bentall,Wheat,Cabrol or David procedures were performed. Total arch replacement, hemiarch replacement or simplified total arch replacement was also performed for aortic arch dissection combined with stented elephant trunk implantation. ResultsA total of 113 patients (57.4%) underwent isolated ascending aorta replacement,67 patients (34.0%) received Bentall procedure,13 patients (6.6%) received Wheat procedure,1 patient(0.5%) received Cabrol procedure,and 3 patients (1.5%) received David procedure. Eighty-two patients (41.6%) underwent total arch replacement combined with stented elephant trunk implantation,77 patients (39.1%) received hemiarch replacement, and the other 41 patients (20.8%) received simplified total arch replacement combined with stented elephant trunk implantation. One patient (0.5%) underwent reexploration for postoperative bleeding. No permanent neurological complication occurred. Thirty-day mortality after surgery was 4.1% (8/197). Follow-up duration was 3-52 (15.9±11.4) months with the follow-up rate of 65.0%. One patient with Marfan syndrome died of abdominal aortic aneurysm rupture 8 months after surgery. ConclusionAccording to different AD conditions, appropriate surgical strategies can be chosen to achieve satisfactory clinical outcomes for patients with acute Stanford type A AD.