Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review

BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation(ECMO)for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.AIM To review the available literature to determine if there was any evidence.METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.RESULTS The search resulted in 29 publications relevant to the subject:1 brief communication,1 surgical technique report,1 invited commentary,1 retrospective case review,1 observational study,4 retrospective reviews,13 case reports and 7 conference abstracts.A total of 194 patients were included in these publications of whom 77 survived.CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection,it is enough to justify its use in this patient population despite current adverse attitude.

Risk Factors for Intraoperative Pressure Injury in Aortic Surgery:A Nested Case-Control Study

Aims and Objectives:The aim of this study was to identify risk factors associated with an increased risk of intraoperative pressure injury in patients undergoing aortic surgery.Background:Intraoperative pressure injuries are some of the most signifi cant health problems in clinical practice.According to previous studies,patients undergoing aortic surgery are at high risk of developing an intraoperative pressure injury,with an incidence much higher than that associated with other types of cardiac surgery.Design:This was a nested case-control study.Methods:Following the STROBE checklist,a nested case-control approach was adopted in this study.A patient cohort was selected on the basis of inclusion and exclusion criteria from patients undergoing aortic surgery.Data were collected from these patients by means of a tailored questionnaire designed in-house.Patients with intraoperative pressure injury at the end of surgery were identifi ed as the case group,while the control group consisted of patients without intraoperative pressure injury.Patients in the groups underwent 1:1 matching based on age and sex.Initially,a single-factor analysis was conducted between the two groups.Subsequently,risk factors for intraoperative pressure injury were identifi ed through conditional logistic regression analysis with use of the variables that exhibited statistically signifi cant differences in the single-factor analysis.Results:A total of 400 patients were selected.Among these,167 patients experienced intraoperative pressure injury at an incidence rate of 41.8%.Strict preoperative bed confi nement,deep hypothermic circulatory arrest during surgery,application of norepinephrine or dopamine during surgery,and intraoperative skin wetting were associated with the occurrence of intraoperative pressure injury in patients undergoing aortic surgery.Conclusions:Nurses should thoroughly assess the risk of intraoperative pressure injury and implement appropriate preventative interventions,particularly in high-risk patients undergoing aortic surgery.

Mechanisms of spinal cord injury in aortic surgery

In aortic surgery, interruption of spinal cord blood flow might cause irreversible spinal cord injury which is rare and devastating. However, the mechanisms of spinal cord injury remain elusive. Methods A PubMed/Medline-literature search for spinal cord injury in aortic surgery over the past decade （aortic surgery 2000-2012） was conducted. Results Spinal cord injury generally results from interruption of the blood supply to the spinal cord due to aortic occlusion. Multiple factors are involved in the development of spinal cord injury and the mechanism includes two phases. The immediate spinal cord injury is related to acute ischemia of the spinal cord. And the delayed spinal cord injury involves both ischemic cellular death and reperfusion injury which is a biochemically mediated event and manifests complex lesion. Conclusions Acute ischemia injury and delayed reperfusion injury are involved in spinal cord injury and multiple factors contribute to its outcome.

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection(AAD)is an infrequently documented condition,comprising of only a small proportion of all AADs.The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD,have led to an ongoing controversy around the topic.It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections,frequently leading to serious complications and thus mandating early intervention.Currently,the available treatment methods in the surgical armamentarium are conventional open,endovascular techniques and combined hybrid methods.The optimum approach is tailored in every individual case and may be determined by the dissection’s location,extent,the aortic diameter,the associated complications and the patient’s status.The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached.In an attempt to provide further insight into this perplexing entity,we performed a minireview of the literature,aiming to elucidate the epidemiology,clinical course and the optimal treatment modality.

Clinical application of retrograde cerebral perfusion for brain protection during the surgery of ascending aortic aneurysm:50 cases report

Objective To assess retrospectively the effects of different protective methods on brain in ascending aortic aneurysm surgery. Methods In 65 patients, aneurysm was dissected to the aortic arch or right arch. To protect brain, deep hypotermic circulatory arrest ( DHCA.) combined with retrograde cerebral perfusion ( RCP) June 2003 Vol11 No2 through the superior vena cava ( n = 50) and simple DHCA ( n = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups at different plase, and perfusion blood distribution and oxygen content difference between the perfused and returned blood were measured in some RCP patients. Results The DHCA time was 35.9 ± 8 min (10. 0 - 63. 0 min) and DHCA+ RCP time was 45.5 ± 17. 2 min (16. 0 - 81. 0 min)The resuscitationtime was 7.1 ± 1.6 h (4.4 - 9.4H)in DHCA patients and 5.4±2.2h(2.0-9.0 h)in RCP patients. Operation death was 3/15 in the DHCA group and 1/50 in the RCP patients. Central nervous complication

Combined Surgical Treatment of Atherosclerotic Coronary Artery Disease and Moderate Aortic Valve Stenosis in Patient with Concomitant Lipton’s R-III Type of Single Coronary Artery Anomaly

A single coronary artery is a very rare condition,commonly associated with other congenital anomalies.It could be generally considered as neither benign nor malignant form of congenital coronary artery anomalies since its pathophysiological and clinical implications grossly depend on different anatomical patterns defined by the site of origin and distribution of the branches.By presenting the patient who underwent successful coronary artery bypass grafting and aortic valve replacement surgery in a presence of isolated single coronary artery,we intend to emphasize natural and procedural risks and distinguish casual from causal in this extremely rare clinical and surgical scenario.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.

A Cardiac Surgical Perspective on Hypothermia for Protection of Neural Tissues

Background: In clinical and basic science medicine, we often isolate ourselves in silos, unaware of developments in other related disciplines. Our team has had substantial experience, both in the operating room and in the laboratory, with protecting the brain and the spinal cord via hypothermia. Herein, we briefly share this experience with our colleagues in Neurology, eager for comments and advice from the neurologic perspective. Methods: 1) Clinical brain protection via deep hypothermic circulatory arrest (DHCA) for surgery of the aortic arch. For aortic arch replacement (performed for aortic arch aneurysm or aortic dissection), the aortic arch must be opened and native perfusion stopped. We have decades of experience in many hundreds of patients with this technique. This experience is reviewed. 2) Experimental protection of the spinal cord via cooling. We review our laboratory experience with a novel, recirculating cooling catheter for the vulnerable spinal cord. 3) Experimental protection of the brain via an intraventricular cooling catheter. We review our laboratory experience cooling the brain with a balloon-tipped catheter residing the lateral ventricles. Results: 1) Deep hypothermic circulatory arrest for aortic arch surgery provides superb brain protection for periods up to 45 minutes or longer. Clinical neurologic function, and quantitative neurologic tests, show excellent brain preservation. 2) The novel spinal cooling catheter provides excellent cooling of the spinal cord in a large animal model, without apparent injury of any type. 3) The intraventricular brain cooling catheter provides excellent cooling of the brain, documented by both direct temperature probe and high-tech brain imaging. Conclusions: We wish herein (in this article) to share this experience across our disciplines (Cardiac Surgery and Neurology). We welcome advice from the Neurology community on these surgically-directed methods for cooling and protection of neurological tissue in both the brain and the spinal cord.

Successful Surgical Treatment of a Giant Mediastinal False Aneurysm 30 Years after Bentall Operation

False aneurysm occurring after replacement of ascending aorta by a vascular prosthesis is a rare, but life-threatening complication. In spite of advances in endovascular techniques, surgery remains the treatment of choice in the majority of cases. We report the case of a huge pseudoaneurysm caused by late dehiscence of the right coronary ostium-aortic tubular graft anastomosis, occurred 30 years after replacement of aortic valve and ascending aorta by classical Bentall operation. A fistula originating from the aneurysmal sac extended across the sternum into the thoracic subcutaneous soft tissues and gave rise to a pulsatile mass well appreciable on the anterior chest wall. The surgical treatment, consisting of partial resection of the aortic tubular graft and sternal reconstruction was effective and uneventful.