Objective To summarize our experience and the early and midterm outcomes of stented elephant trunk procedure for right-sided aortic arch (RAA) with Kommerell's diverticulum (KD). Methods From April 2013 to July 2020, patients with RAA and KD who underwent stented elephant trunk procedure at our center were collected. Surgery was performed under moderate hypothermic circulatory arrest combined with selective antegrade cerebral perfusion via median sternotomy. Results A total of 8 patients were included, including 7 males and 1 female with a mean age of 51.88±9.61 years. All patients had an aneurysmal KD and aberrant left subclavian artery. Preoperative comorbidities included acute Stanford type B aortic dissection in 1 patient, aortic arch pseudoaneurysm in 1 patient, acute type B intramural hematoma in 2 patients, and coronary artery disease in 1 patient. Concomitant procedures included reconstruction of the left subclavian artery in all patients and coronary artery bypass grafting in 1 patient. The mean time of operation, cardiopulmonary bypass, aortic cross-clamping, and selective cerebral perfusion was 6.25±1.16 h, 157.75±40.07 min, 77.75±33.10 min, and 28.50±5.55 min, respectively. No intraoperative death occurred. There was 1 in-hospital death. Follow-up was completed in all patients with a mean period of 3.58±2.08 years. No late death occurred. A persistent anastomotic leak of the proximal arch was detected in 1 patient, but reintervention was not performed because neither aortic dilatation nor symptoms of tracheal and esophageal compression were observed during the follow-up. The remaining 6 patients showed positive aortic remodeling with complete thrombosis of the aneurysmal KD, and neither aortic event nor tracheal and esophageal compression occurred. Conclusion Stented elephant trunk procedure is a safe and feasible technique for selected patients with RAA and KD, which can achieve favorable early and midterm outcomes.
Objective To analyze the efficacy of and recurrence mode after adjuvant radiotherapy for lower thoracic esophageal squamous cell carcinoma (TESCC) patients after radical operation with anastomosis above aortic arch. Methods Sixty-three patients with lower TESCC who received adjuvant radiotherapy after R0 radical operation with anastomosis above aortic arch between February 2011 and February 2019 were retrospectively enrolled. The clinical tumor volume (CTV) included anastomotic stoma, and lymph node drainage area in mediastinum and upper abdomen. The survival status, recurrence and metastasis of tumors, and the influencing factors were analyzed. Results The 1-, 2-, and 3-year overall survival rates were 98.3%, 83.3%, and 63.7%, respectively. The median disease-free survival (DFS) was 33 months [95% confidence interval (23.2, 42.8) months], and the 1-, 2-, and 3-year DFS rates were 76.3%, 58.5%, and 41.7%, respectively. Patients with N0-1 had longer DFS than those with N2-3 (median: not reached vs. 15 months, P=0.045). The recurrence rate of anastomotic site was 7.9%. The recurrence rates of lymph nodes in supraclavicular region, upper middle mediastinum, and upper abdomen were 4.8%, 15.9%, and 1.6%, respectively. The distant metastasis rate was 17.5%. The incidence of grade 2-3 radiation pneumonitis, grade 3 anastomotic stenosis, and grade 3 tracheal fistula were 4.8%, 3.2%, and 1.6%, respectively. Conclusions N2-3 is a poor prognostic factor for such patients. Regional lymph node recurrence is mainly revealed in the middle and upper mediastinum. Whether the CTV should include anastomotic stoma and lymph node drainage area in lower mediastinum and upper abdomen is questionable.
Objective To analyze the curative effect of nitric oxide (NO) and bosentan on treatment of the interruption of aortic arch (IAA) with ventricular septal defect (VSD) and serious pulmonary hypertension (SPH). Methods Thirty-two children with IAA and VSD combined SPH from January 2015 to May 2017 confirmed by cardiac CT and ultrasound in Children’s Hospital of Hebei Province were enrolled including 17 males and 15 females, aged 1.10-4.30 months (mean, 2.71±0.98 months) and weighing 3.33-6.10 kg (mean, 4.57±0.88 kg). The 32 children were randomly divided into two groups (n=16 in each), a NO group and a bosentan group. All the patients underwent interruption of aortic arch and ventricular septal defect repair. When patients returned to cardiosurgery intensive care unit (CSICU) half an hour later, patients in the NO group inhaled NO 20 ppm for 36 h and those in the bosentan group were given bosentan by nasogastric feeding 15 mg, twice a day. The cardic index, pulmonary/systemic pressure ratio, oxygenation index at 3 h, 6 h, 12 h, 24 h, 36 h after surgery were evaluated, and the differences between the two groups were compared. Results The pulmonary/systemic pressure ratio in the two groups increased at first and then decreased, while oxygenation index in the two groups decreased at first and then increased, and the differences in the same groups at the adjacent time points were statistically significant (P<0.05). The cardiac index in the two groups decreased at first and then increased, the differences in the same groups at the adjacent time points were statistically significant, except for 6 h and 12 h after surgery in the bosentan group (P>0.05). At postoperative 6 h, 12 h, the oxygenation index in the NO group was significantly higher than that in the bosentan group, and the pulmonary/systemic pressure ratio in the NO group was less than that in the bosentan group (P<0.01). The cardiac index in the NO group was higher than that of the bosentan group after 6 h, 12 h, 24 h of operation, which were statistically significant (P<0.05), and the cardic index of children in the NO group was greatly higher than that in the bosentan group after 12 h of surgery (P<0.01); at the same time point, the corresponding indexes were not statistically significant between the two groups (P>0.05). Conclusion NO inhalation in the treatment of IAA with VSD and SPH in children with early postoperative SPH is better than the bosentan, but in the late postoperative period, the effect is similar.
Objective To summarize the surgical treatment experience in neonates with coarctation of the aorta (CoA) and aortic arch hypoplasia (AAH). Methods The neonates with CoA and AAH who underwent surgical treatment in the Department of Pediatric Cardiac Surgery of Guangdong Provincial People's Hospital from 2013 to 2020 were retrospectively enrolled. The postoperative complications, long-term survival rate, and freedom from aortic reobstruction were analyzed. Patients undergoing extended end-to-end anastomosis were allocated into an extended end-to-end group, those undergoing extended end-to-side anastomosis into an extended end-to-side group, and those undergoing pulmonary autograft patch aortoplasty into a patch aortoplasty group.Results Finally 44 patients were enrolled, including 37 males and 7 females, aged 5.00-30.00 (19.34±7.61) days and weighted 2.00-4.50 (3.30±0.60) kg. There were 19 patients of extended end-to-end anastomosis, 19 patients of extended end-to-side anastomosis, and 6 patients of pulmonary autograft patch aortoplasty. The mean values of the Z scores of the proximal, distal, and isthmus of the aortic arch were –2.91±1.52, –3.40±1.30, and –4.04±1.98, respectively. The mean follow-up time was 45.6±3.7 months. There were 2 early deaths and no late deaths. Aortic reobstruction occurred in 8 patients, and 3 patients underwent reoperation intervention. The 5-year rate of freedom from reobstruction was 78.8%. The Cox multivariable regression analysis showed that the related factors for postoperative reobstruction were the Z score of the preoperative proximal aortic arch (HR=0.152, 95%CI 0.038-0.601, P=0.007) and the postoperative left main bronchus compression (HR=15.261, 95%CI 1.104-210.978, P=0.042). Conclusion Three surgical procedures for neonates with CoA and AAH are safe and effective, but the aortic reobstruction rate in long term is not low. The smaller Z score of the preoperative proximal aortic arch and the postoperative left main bronchus compression are risk factors for long-term aortic reobstruction.
Objective To assess the efficacy and safety of ascending aorta banding technique combined with typeⅠhybrid aortic arch repair for the aortic arch diseases. Methods The clinical data of patients undergoing ascending aorta banding technique combined with type Ⅰ hybrid arch repair for aortic arch diseases from March 2019 to March 2022 in Beijing Anzhen Hospital were retrospectively analyzed. The technical success, perioperative complications and follow-up results were evaluated. Results A total of 44 patients were collected, including 35 males and 9 females, with a median age of 63.0 (57.5, 64.6) years. The average EuroSCORE Ⅱ score was 8.4%±0.7%. The technical success rate was 100.0%. All patients did not have retrograde type A aortic dissection and endoleaks. One patient died of multiple organ failure 5 days after operation, the in-hospital mortality rate was 2.3%, and the remaining 43 patients survived and were discharged from hospital. The median follow-up period was 14.5 (6-42) months with a follow-up rate of 100.0%. One patient with spinal cord injury died 2 years after hospital discharge. One patient underwent thoracic endovascular aortic repair at postoperative 3 months due to new entry tears near to the distal end of the stent. Conclusion Ascending aorta banding combined with typeⅠhybrid arch repair for the aortic arch diseases does not need cardio-pulmonary bypass. Ascending aorta banding technique strengthens the proximal anchoring area of the stent to avoid risks such as retrograde type A dissection, endoleak and migration. The operation owns small trauma, rapid recovery, low mortality and a low rate of reintervention, which may be considered as a safe and effective choice in the treatment of the elderly, high-risk patients with complex complications.
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.
Objective To evaluate the short- and middle-term outcomes of surgical treatment for distal aortic arch lesions using stented elephant trunk implantation combined with transposition of left subclavian artery to left common carotid artery. Methods The clinical data of 14 patients with distal aortic arch lesions undergoing stented elephant trunk procedure with left subclavain artery transposition under hypothermic cardiopulmonary bypass (CPB) with antegrade selective cerebral perfusion from May 2009 to November 2015 in our hospital were retrospectively reviewed. All of them were males with a mean age of 52±14 years ranging from 20 to 69 years. Hypertension was observed in nine patients, coronary artery disease in five and prior cerebral infarction in one. History of percutaneous coronary intervention was noted in one patient, history of Bentall operation in one, ligation of patent ductus arteriosus in one and endovascular aneurysm repair in one. Results There was no hospital death. Concomitant procedures included coronary artery bypass grafting in two patients and plasty of the ascending aorta replacement in one. Mean duration of mechanical ventilation and ICU stay was 21±7 h and 43±19 h, respectively. All patients survived and were discharged. One patient was lost to follow-up and no patient died during the follow-up. Postoperative computed tomography revealed good patency of the anastomotic site between the left subclavian artery and the left common carotid artery. Conclusion Stented elephant trunk procedure with left subclavain artery transposition obtains satisfactory surgical results in patients with distal aortic arch lesions.
Myocardial and cerebral protection are always the major concerns in neonatal aortic arch surgery. From the application of deep hypothermic circulatory arrest technology to continuous cardio-cerebral perfusion strategy adopted in many cardiac centers recently, each perfusion method has its own pros and cons, so there is no consensus on which one is the most suitable. This review aims to summarize the development and research progress of various perfusion methods, so that to provide a foundation for further development.
Objective To analyze the risk factors for death in children with interruption of aortic arch (IAA) and ventricular septal defect (VSD) after one-stage radical surgery. Methods A retrospective analysis was performed on patients with IAA and VSD who underwent one-stage radical treatment in the First Hospital of Hebei Medical University from January 2006 to January 2017. Cox proportional hazards regression model was used to analyze the risk factors for death after the surgery. Results A total of 152 children were enrolled, including 70 males and 82 females. Twenty-two patients died with a mean age of 30.73±9.21 d, and the other 130 patients survived with a mean age of 37.62±11.06 d. The Cox analysis showed that younger age (OR=0.551, 95%CI 0.320-0.984, P=0.004), low body weight (OR=0.632, 95%CI 0.313-0.966, P=0.003), large ratio of VSD diameter/aortic root diameter (VSD/AO, OR=2.547, 95%CI 1.095-7.517, P=0.044), long cardiopulmonary bypass time (OR=1.374, 95%CI 1.000-3.227, P=0.038), left ventricular outflow tract obstruction (LVOTO, OR=3.959, 95%CI 1.123-9.268, P=0.015) were independent risk factors for postoperative death. Conclusion For children with IAA and VSD, younger age, low body weight, large ratio of VSD/AO, long cardiopulmonary bypass time and LVOTO are risk factors for death after one-stage radical surgery.
Objective To investigate the surgical approach and efficacy of reconstruction of the isolated left vertebral artery (ILVA) in single upper hemisternotomy for total aortic arch replacement. Methods From March 2017 to October 2023, patients who underwent total aortic arch replacement under single upper hemisternotomy in General Hospital of Northern Theater Command were selected. According to the presence of ILVA, they were divided into a conventional group and an ILVA group. All the ILVA group underwent intraoperative ILVA reconstruction. The perioperative clinical data between two groups were compared. Results A total of 504 patients were collected, including 471 males and 31 females, with an average age of 50.4±11.4 years. There was no increase in the duration of cardiopulmonary bypass or postoperative hospitalization in the ILVA group (n=31) compared to the conventional group (n=473), and the rates of perioperative complications and in-hospital mortality were not significantly different between the two groups. There were 2 (6.45%) patients of acute cerebral infarction and 2 (6.45%) patients of perioperative death in the ILVA group, with no spinal cord injuries. Conclusion ILVA reconstruction during total aortic arch replacement in single upper hemisternotomy is feasible, safe, and effective, and prioritizing off pump ILVA-left common carotid artery transposition.