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Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience.

ABSTRACT: OBJECTIVES:Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD. METHODS:All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation. RESULTS:A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups. CONCLUSIONS:DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons' armamentarium.

SUBMITTER: El Beyrouti H

PROVIDER: S-EPMC7549816 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience.

El Beyrouti Hazem H Dohle Daniel-Sebastian DS Izzat Mohammad Bashar MB Brendel Lena L Pfeiffer Philipp P Vahl Christian-Friedrich CF

PloS one 20201012 10

<h4>Objectives</h4>Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD.<h4>Methods</h4>All patients who underwent surgery for A-AAD between January ...[more]

PMID: 33045000

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Project description:BackgroundCannulation strategy in surgery for acute type A aortic dissection (ATAAD) remains controversial. We aimed to retrospectively analyze the safety and efficacy of double arterial cannulation (DAC) compared with right axillary cannulation (RAC) for ATAAD.MethodsFrom January 2016 to December 2018, 431 ATAAD patients were enrolled in the study. Patients were divided into DAC group (n = 341) and RAC group (n = 90). Propensity score matching analysis was performed to compare the early and mid-term outcomes between these two groups. To confirm the organ protection effect by DAC, intraoperative blood gas results and cardiopulmonary bypass parameters were compared between the two groups.ResultsDemographics and preoperative comorbidities were comparable between two groups, while patients in DAC group were younger than RAC group (51.55 ± 13.21 vs. 56.07 ± 12.16 years, P < 0.001). DAC had a higher incidence of limb malperfusion (18.2% vs. 10.0%, P = 0.063) and lower incidence of coronary malperfusion (5.3% vs. 12.2%, P = 0.019). No significant difference in cardiopulmonary bypass and cross-clamp time was found between the two groups. The in-hospital mortality was 13.5% (58/431), while there was no difference between the two groups (13.5% vs. 13.3%; P = 0.969). Patients who underwent DAC had higher incidence of postoperative stroke (5.9% vs. 0%, P = 0.019) and lower incidence of postoperative acute kidney injury (AKI) (24.7% vs. 40.3%; P = 0.015). During a mean follow-up period of 31.8 (interquartile range, 25-45) months, the overall survival was 81.5% for DAC group and 78.0% for RAC group (P = 0.560). Intraoperative blood gas results and cardiopulmonary bypass parameters showed that DAC group had more intraoperative urine output volume than RAC group (P = 0.05), and the time of cooling (P = 0.04) and rewarming (P = 0.04) were shorter in DAC group.ConclusionsDAC will not increase the surgical risks compared to RAC, but could reduce the incidence of postoperative AKI which may be benefit for renal protection.

Project description:Acute aortic dissection (AAD) is among the most challenging cases for surgical treatment and requires procedural expertise for its safe conduct. Aortic surgery has undergone several changes over the last years, especially concerning cerebral protection. The brilliant results obtained with the aid of selective anterograde cerebral perfusion led to a progressive increase of circulatory arrest temperature, with the rise of safe time along with a reduction of the extracorporeal circulation time and hypothermia-related side effects. However, there is still no definitive consensus concerning the optimal range of temperature to be used during circulatory arrest. Objectives. This is a retrospective observational study, and we examined 16-year trends in the presentation, diagnosis, hospital outcome and treatment of A AAD type. In our Cardiac Surgery Unit in Policlinico Umberto I of Rome, our analysis focused on patients, who received ACP during aortic surgery and we analyzed the differences between two distinct groups based on the lowest temperature reached during CPB conduction: Lower Temperature Group (LT) (T < 24°C) versus Higher Temperature Group (HT) (T ≥ 24°C) arrest circulation temperature. Methods. Data from 241 patients enrolled between August 2002 and March 2018 were analyzed. Patients were divided according to the lowest temperature reached into 2 groups: Lower Temperature group (LT) (94 patients) and Higher Temperature Group (HT) (147 patients). Results. Our results showed a significant reduction of in-hospital mortality and in-hospital results in patients with higher CPB temperature. The global incidence of complications was statistically reduced in HT group: we found a statistical significant reduction of intestinal ischemia, and a similar trend also for other complications analyzed, such as infections. Since the two groups were similar for type of surgical procedures, we considered these differences depending on the lower temperature value reached, according to the current literature. Conclusions. We found a significantly higher mortality in patients with lower temperature during CPB and a global reduction of complications and in particular a significant reduction of intestinal ischemia in patients with higher temperature during CPB. We found a similar trend in other fields of investigations, so we can conclude that circulatory arrest performed at temperature ≥24°C nasopharyngeal temperature associated with ACP is a safe strategy for aortic surgery for AAD.

Project description:OBJECTIVE:To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS). METHODS:Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n = 419) served as controls. RESULTS:In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008-2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P = .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P = .016), and serum lactate ≥6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P = .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P = .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome. CONCLUSIONS:In patients with acute type A aortic dissection with mesMPS, endovascular fenestration/stenting, and delayed open aortic repair achieved favorable short- and long-term outcomes. Surgeons should consider correcting mesenteric malperfusion before undertaking open aortic repair in patients with mesMPS, especially those with acute stroke, gross bowel necrosis at laparotomy, or serum lactate ≥6 mmol/L.

Project description:BackgroundChronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax).MethodsCMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either 'stable' (< 3 mm/year) or 'enlarging' (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL.ResultsFLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = - 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter.ConclusionComparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

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Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience.

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Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience.

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