Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience

Background Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. Methods Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. Results A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 – 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 – 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 – 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 – 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. Conclusions Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.

Surgical treatment of type A acute aortic dissection with cerebral malperfusion: a systematic review

Purpose: Type A acute aortic dissection (TAAAD) complicated with cerebral malperfusion (CM) is a life-threatening condition associated with high mortality, poor outcomes, and the optimal surgical management remains controversial. The aim of this review was to report the current results of surgical interventions of these patients. Methods: A systematic review was performed using PubMed and MEDLINE search for cases underwent surgical repair for TAAAD with CM. Demographics, neurological symptom, the time from onset of symptoms to operation, operation data, mortality, neurological outcome, and follow-up were reviewed. Results: A total of 363 patients with mean age of 65.7±13 years underwent surgical repair for TAAAD with CM were identified in 12 retrospective studies. In-hospital mortality was 20.1%. Mean duration of follow-up was 40.1 ± 37.6 months. The involved supra-aortic branch vessels were RCCA (n=99), LCCA (n=25) , B-CCA (n=52), CCA (n=131), IA (n=19), and LSA (n=8). Time from onset of neurological symptoms to surgery was 13.3 hours. Antegrade and/or retrograde cerebral perfusion was applied. Postoperatively, improved, unchanged and worsened neurological status was occurred in 54.3%, 27.1%, and 8.5%, respectively in 199 patients. Conclusion: The outcomes of surgical treatment of TAAAD complicated with CM indicate acceptable early mortality and morbidity. It is reasonable to perform lifesaving surgery on these patients. Early central surgical repair and reperfusion of brain may improve the outcomes.

Retrograde Carotid Stenting Using Newly Released Venous Stent for Cerebral Malperfusion in Type A Aortic Dissection

Stanford Type A aortic dissections (TAAD) should be considered for repair, given the involvement of branch vessels which can result in malperfusion, specifically cerebral malperfusion secondary to dissection of the innominate and carotid arteries. This is a case report with a focus on four patients presenting with both acute and chronic symptomatic TAAD, with extension into the innominate and common carotid arteries. In all four cases, the decision to intervene utilizing a hybrid endovascular approach was made to increase perfusion to the brain and alleviate symptoms. Through the use of retrograde carotid stenting utilizing both the VICI venous stent (Boston Scientific, Marlborough, MA) and Abre self-expanding Nitinol stent (Medtronic, Minneapolis, MN) we obtained good results, specifically absence of symptoms and return to normal function of the patients.

Aggressive strategy to save the brain in a case of acute aortic dissection

The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis’ circle is incomplete is difficult to judge during emergency surgery, and the authors’ judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.

Post-operative Uric Acid: A Predictor for 30-days Mortality of Acute Type A Aortic Dissection Repair

Background: Hyperuricemia is associated with aortic dissection and cardiovascular diseases. The implication of high serum uric acid (UA) level after acute aortic dissection repair remains unknown. The aim of this study is to explore the role of peri-operative serum UA level in predicting 30-days mortality with acute type A aortic dissection (AAAD) patients, who underwent surgery. Methods and Results: 209 consecutive AAAD patients were included, 14.3% (n=30) were dead within 30 days after surgery. By univariate analysis, we found AAAD repair patients with 30-days mortality had a higher prevalence of cerebral malperfusion, lower pre-operative fibrinogen, longer cardiopulmonary bypass and aortic crossclamp time, and higher post-operative day 1 (POD1) creatinine and urea levels. Both pre-operative (433.80±152.59 vs. 373.46±108.31mmol/L, P=0.038) and POD1 (559.78±162.23 vs. 391.29±145.19 mmol/L, P=0.000) UA level were higher in mortality group than in survival group. In regression model, only cerebral malperfusion (OR, 7.937, 95% CI, 1.252-50.323; P=0.028) and POD1 UA level (OR, 1.006; 95% CI, 1.003-1.009; P=0.000) were independent predictors of 30-days mortality in AAAD repair patients. According to the ROC curve, the POD1 UA level provided positive value for 30-days mortality in AAAD repair patients with 0.799 areas under the curve. The optimum cutoff value selected by ROC curve was 500.15 mmol/L, with a sensitivity of 69.2% and a specificity of 81.7%. Conclusion: Pre- and post-operative hyperuricemia are potentially associated with worsened outcomes in AAAD surgery patients. The POD1 UA level has a predictive role in 30-days mortality in AAAD repair patients.

Type A aortic dissection: involvement of carotid artery and impact on cerebral malperfusion

Acute type A aortic dissection is a surgical emergency and management of such pathology can be complex with poor outcomes when there is organ malperfusion. Carotid artery involvement is present in 30% of patients diagnosed with acute type A aortic dissection, and given its emergency and complex nature, there is much controversy regarding the approach, extent of treatment, and timing of the intervention. It is clear that the occurrence of cerebral malperfusion adds an extra layer of complexity to the decision-making framework for treatment. Standardization and validation of the optimal management approach is required, and this should ideally be addressed with large-scale studies. Nonetheless, current literature supports the need for rapid recognition and diagnosis of acute type A aortic dissection with cerebral malperfusion, immediate and extensive surgical repair, and the appropriate use of cerebral perfusion techniques. This paper aims to discuss the current evidence regarding the impact of carotid artery involvement in both the management and outcomes of acute type A aortic dissection.

Hybrid Stepwise External Wrapping for Type A Acute Aortic Dissection with Cerebral Malperfusion

Background: Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion. Case presentation: The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications. Conclusions: Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.