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ABSTRACT: Stent grafting is a very important treatment for type B dissection. Some patients are unsuitable for endograft repair because of inadequate proximal and/or distal fixation zones. We reviewed our experience of proximal descending thoracic replacement combined with short-stented elephant trunk implantation for type B dissection for patients without adequate fixation zones for endografts.
Twenty-one patients with type B dissection (10 acute, 11 chronic) underwent this procedure between August 2003 and December 2007. After replacement of the proximal descending thoracic aorta, a short-stented elephant trunk was implanted into the residual descending thoracic aorta. The residual false lumen was evaluated post-operatively using computed tomography (CT) scans.
There were no in-hospital deaths. One death was observed during a mean follow-up of 69 ± 15 months. One patient with preoperative shock suffered paraparesis but recovered postoperatively. One patient had paraplegia and was lost to follow-up. Cerebral hemorrhage was observed in 1 patient, but he recovered. Thrombus obliteration of the false lumen around the stented elephant trunk was observed in 19 patients (95%) and at the diaphragmatic level in 17 patients (85%) during follow-up.
Replacement of the proximal descending thoracic aorta combined with short-stented elephant trunk implantation was a suitable alternative for type B dissection for patients without adequate fixation zones for endografts (particularly for young subjects). This procedure allowed enlargement of the true lumen, re-establishment of the true lumen, induction of thrombosis of the false lumen, and shrinkage of the aorta. Injury to the spinal cord, however, was an intractable problem.
Heart Surgery Forum 04/2012; 15(2):E79-83. · 0.63 Impact Factor
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ABSTRACT: In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation.
Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 +/- 11 years; range, 17-78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up.
Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 +/- 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100).
Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.
The Journal of thoracic and cardiovascular surgery 06/2009; 138(6):1358-62. · 3.41 Impact Factor
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ABSTRACT: Surgical treatment of chronic Stanford type A aortic dissection using total arch replacement combined with stented elephant trunk implantation is controversial owing to the visceral arteries and intercostal arteries originating from the false lumen.
Eighty-nine patients (mean age, 45.67 +/- 10.18 years; range, 21-68 years) with chronic type A dissection underwent total arch replacement combined with stented elephant trunk implantation between April 2003 and March 2007. Careful assessment of the visceral arteries and location of entry and re-entry was done before surgery. Postoperative patency of the visceral arteries and diameter of the aortic artery and the residual false lumen were evaluated by computed tomography.
One (1.12%) hospital death and 2 (2.25%) late deaths occurred at a mean follow-up of 28.5 months (range, 8-52 months). Visceral malperfusion was not observed. Two patients had spinal cord injury and recovered during follow-up. One patient had a transient neurologic deficit and recovered completely before discharge. One patient underwent thoracoabdominal aortic replacement for aneurysmal dilatation of the residual descending aorta 3 months after the operation. Thrombus obliteration of the false lumen at the distal edge of the stented elephant trunk and at the diaphragmatic level was 94.2% (81/86) and 61.6% (53/86), respectively.
Satisfactory results with low morbidity and mortality were obtained. No visceral malperfusion and a low risk of postoperative spinal cord injury favor this technique in patients with chronic type A dissection.
The Journal of thoracic and cardiovascular surgery 05/2009; 138(4):892-6. · 3.41 Impact Factor
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LiZhong Sun,
RuiDong Qi,
Qian Chang,
JunMing Zhu,
YongMin Liu,
ChunTao Yu,
HaiTao Zhang,
Bin Lv,
Jun Zheng, LiangXin Tian,
JinGuo Lu
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ABSTRACT: Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure.
Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography.
Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up.
Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.
The Annals of thoracic surgery 05/2009; 87(4):1177-80. · 3.74 Impact Factor
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Lizhong Sun,
Ruidong Qi,
Qian Chang,
Junming Zhu,
Yongmin Liu,
Chuntao Yu,
Haitao Zhang,
Bin Lv,
Jun Zheng, Liangxin Tian,
Jinguo Lu
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ABSTRACT: The purpose of the study was to assess the efficacy of total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute Stanford type A aortic dissection involving the aortic arch.
Between January 2004 and April 2006, 13 consecutive Marfan patients (4 female, 9 male) with acute type A aortic dissection involving the aortic arch underwent total arch replacement combined with implantation of a stented elephant trunk. Aortic dissection extending to the iliac artery was seen in 10 patients, and to the abdominal aorta in 3 patients. Ages ranged from 17 to 65 years (mean, 39 +/- 13). Computed tomography was done to evaluate the residual false lumen in the descending aorta.
All patients survived and were discharged from hospital. One patient with thrombosis of the innominate artery suffered cerebral infarction and recovered during follow-up. One patient had ischemia of the left upper limb postoperatively, but recovered after axillary to axillary artery bypass. There was 1 death during the mean follow-up period of 27 +/- 10 months. Complete thrombus formation was observed in 84.6% of patients (11 of 13) around the stented elephant trunk, and in 69.2% of patients (9 of 13) at the diaphragmatic level.
Total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute type A aortic dissection involving the aortic arch results in less late dilatation of the dissected descending aorta. That prolongs the reoperation interval or reduces the number of late thoracoabdominal aortic replacements, unless there is a patent false lumen around the stented elephant trunk.
The Annals of thoracic surgery 01/2009; 86(6):1821-5. · 3.74 Impact Factor
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ABSTRACT: Although deep hypothermic circulatory arrest has been known to induce neuronal injury, the molecular mechanism of this damage has not been identified. We studied the key molecular mediators through cellular energy failure, excitotoxicity, and overactivation of poly(adenosine diphosphate-ribose) polymerase 1 in brain tissues of a rabbit model of deep hypothermic circulatory arrest similar to clinical settings.
We established 2 models of cardiopulmonary bypass (n = 15) and deep hypothermic circulatory arrest (n = 15) associated with cerebral microdialysis in rabbits. Deep hypothermic circulatory arrest lasted for 60 minutes. The measurements of glucose, lactate, pyruvate, and glutamate collected by means of microdialysis were quantified by using a microdialysis analyzer and high-performance liquid chromatography. The overactivation of poly(adenosine diphosphate-ribose) polymerase 1 was assessed by detecting immunostaining of poly(adenosine diphosphate-ribose). Histologic studies were used to identify neuronal morphologic changes and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling staining and poly(adenosine diphosphate-ribose) polymerase 1 Western blotting were used to identify apoptotic cells and early apoptotic signals.
Deep hypothermic circulatory arrest significantly increased the lactate/pyruvate and lactate/glucose ratios and the glutamate value, whereas cardiopulmonary bypass did not (P < .05). Deep hypothermic circulatory arrest significantly increased the numbers of poly(adenosine diphosphate-ribose)-positive and apoptotic neurons compared with cardiopulmonary bypass (P < .05). The cleavage of poly(adenosine diphosphate-ribose) polymerase 1 was only found in the deep hypothermic circulatory arrest group. More injured neurons were found in the deep hypothermic circulatory arrest group (histologic scores, P < .05).
This study demonstrated that deep hypothermic circulatory arrest results in an overactivation of poly(adenosine diphosphate-ribose) polymerase 1, and that there were molecular events consisting of cellular energy failure, excitotoxicity, overactivation of poly(adenosine diphosphate-ribose) polymerase 1, and necrosis and/or apoptosis in neuronal injury.
The Journal of thoracic and cardiovascular surgery 11/2007; 134(5):1227-33. · 3.41 Impact Factor
