Video-Assisted Thoracic Surgery for Residual Aneurysm after Total Arch Replacement

Background: Residual aneurysms after graft replacement are rare, but they can be detrimental if they are saccular and large. The etiology of residual aneurysms remains unknown, and their management is controversial. One treatment option is late open surgical conversion;however, postoperative respiratory complications resulting from the dissection of pleural adhesions, which is frequently necessary with this approach, are often unavoidable. Case presentation: Herein, we report a case of open surgical repair of a residual distal aortic arch aneurysm that occurred after total arch replacement and thoracic endovascular aortic repair. Contrast-enhanced magnetic resonance imaging was not possible in this case due to the patient’s severe renal dysfunction;however, contrast-enhanced computed tomography using minimal contrast did not detect remarkable leakage through the graft or stent graft into the aneurysm. Late open surgical conversion using video-assisted thoracic surgery was performed by thoracic surgeons, and the adhesion between the aortic wall and the lung was safely and effectively dissected. Because there was no significant pulsation or evidence of feeding arteries in the aortic wall, the aortic wall was opened carefully. No bleeding or backflow from any branch arteries into the aneurysm was noted, so the aortic wall was ligated with continuous sutures. The patient recovered without experiencing any major complications. Conclusions: This case report demonstrates that video-assisted thoracic surgery is safe and effective for late open conversion in cases of residual aneurysm;furthermore, this case suggests that video-assisted thoracic surgery may be particularly beneficial for the dissection of adhesions between the aortic wall and lung in these cases.

Strategy of dealing with left subclavian artery in total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection

Objective To summarize the experiences of ligating left subclavian artery ( LSA ) in total arch peplacement and stented elephant trunk implantation for Stanford type A aortic dissection patients with difficulty in exposing the LSA. Methods Total arch replacement and stented elephant trunk implantation were performed on 79 consecutive

Comparison of Partial Upper Sternotomy Versus Median Sternotomy for Total Arch Replacement in Patients With Type A Aortic Dissection

Objective:Comparative studies of median sternotomy and partial upper sternotomy in total arch replacement for type A aortic dissection are rare,and the safety and benefits of partial upper sternotomy need further evaluation.This study aimed to explore the effectiveness and prognosis of partial upper sternotomy in total arch replacement among patients with type A aortic dissection.Methods:This is a retrospective study of patients who underwent total arch replacement for type A aortic dissection at the First Medical Center of Chinese People’s Liberation Army General Hospital between January 2016 and December 2019.They were grouped into the median sternotomy and partial upper sternotomy groups according to the different treatment methodologies.The intra-operative and prognostic indicators were compared between both groups.Results:Forty-nine patients were included:31 in the median sternotomy group and 18 in the partial upper sternotomy group.The partial upper sternotomy group had a shorter incision((9.0±0.8)cm vs.(25.5±1.3)cm,P=0.02)and smaller postoperative total drainage volume(885mL vs.1,820mL,P=0.03)than the median sternotomy group.The differences between the 2 groups with respect to other intra-operative indicators such as operation duration,cardiopulmonary bypass duration,aortic occlusion duration,hypothermic circulatory arrest duration,and intra-operative blood loss,and prognostic indicators such as red blood cell infusion,ventilator aid duration,cardiac intensive care unit stay,postoperative hospital stay,and postoperative complications were not significantly different(all P>0.05).Conclusions:The utilization of partial upper sternotomy in patients with type A aortic dissection resulted in a smaller incision and more aesthetically pleasing scar,along with reduced drainage volume compared to median sternotomy.

Effect of total arch replacement combined with stent trunk on treating De Bakey typeⅠaortic dissection

Background Aortic dissection（AD） is a life-threatening surgical emergency. Total arch replacement combined with stent trunk has gradually become the standard procedure for De Bakey type Ⅰ AD in China, but the complication and mortality rates are still relatively high due to surgical technical difficulties and complexity. In principle, AD should be treated with emergency surgery once the diagnosis is confirmed, but the operation time varies greatly in China due to the restriction of medical conditions. Therefore, analyzing and comparing the surgical mortality and complications rate between acute and chronic phase may facilitate the clinicians to comprehensively evaluate the patient＇s condition, and thus select an appropriate operation timing. Methods A total of330 De Bakey type Ⅰ AD patients admitted and treated with total arch replacement combined with stent trunk procedure in Guangdong Cardiovascular Institute from Jan 2010 to Jan 2014 were retrospectively analyzed. According to whether the onset was longer than 2 w, patients were divided into acute phase group and chronic phase group. There were 231 cases in acute phase group（≤ 2 w）, and the average length from onset to operation was 5.6± 3.8 d; while 99 cases in chronic phase group（〉 2 w）, and the average length from onset to operation was 20.6 ±14.7 d. Results The total mortality rate was 13%. Acute renal failure, neurological dysfunction, and wound healing were the major complications after operation. The in-hospital morality rate was 16.0%（37/231） in the acute group, while 6.1 %（6/99） in the chronic group. The surgical data of the ratio of CABG, cardiopulmonary bypass（CPB） time, aortic cross clamp time, intra-operative RBC infusion were significant higher in the acute phase group（P 〈 0.05）. The postoperative data of ICU stay, mechanical ventilation time, the incidences of neurological dysfunction, CRRT-dependent acute renal failure, hepatic insufficiency, and poor wound healing were significant higher in the acute phase group（P 〈 0.05）. Conclusions The total arch replacement combined with stent trunk for De Bakey type Ⅰ aortic dissection is safe and effective. Patients in the acute phase show higher postoperative mortality and complications. The acute phase is associated with relatively higher risk of surgical treatment.

The clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010,101 cases of DeBakeyⅠaortic dissection were treated by modified total arch replacement and stent elephant trunk technique,in which emergencey surgery were performed on 73 cases. There were 76 male and 25

Acute Type A Aortic Dissection—Replacement of Ascending Aorta, Aortic Arch and Antegrade Stenting of the Descending Thoracic Aorta Using the Thoraflex™Hybrid Plexus Device (Terumo Aortic)—“Frozen Elephant Trunk”: The Plymouth Way!

Objectives: To describe our technique for the implantation of the Thoraflex Hybrid prosthesis for replacement of the aortic arch in a safe and reproducible way. Materials: Thoraflex™ Hybrid Plexus Device (Terumo Aortic). Design: Drawing on our own experience over the past 4 years in the management of acute type A aortic dissection, we have distilled the essentials of our “Frozen Elephant Trunk” technique which have led us through our own learning curve to the improved management of this taxing condition. Method/ Results: Small extension of the median sternotomy incision along the medial border of sternocleidomastoid muscle. End to side graft anastomosis near the origin of the left subclavian artery during cooling on bypass towards 20 degrees. Attention to cardiac protection and maintenance of cerebral perfusion during the shortened corporeal arrest period. Excellent results in 24 consecutive AAAD patients with just one hospital mortality. Conclusions: We believe we are entering a new phase in the treatment of AAAD, facilitated by the availability of a hybrid prosthesis which combines expanding stent technology with familiar surgical graft material. Our particular management of the left subclavian artery and of the cerebral circulation during implantation has contributed to an expeditious and reproducible method of treating dissection within the arch of the aorta and beyond.

Effect on surgery outcomes owing to the interval between onset of symptoms and surgery of patients with acute type A aortic dissection

Background:This study aimed to identify whether the interval from onset of symptoms to surgery affects the outcomes of surgery in patients with acute type A aortic dissection(AAAD).Methods:This study retrospectively examined 249 patients with AAAD who underwent Sun’s procedure.All patients were divided into 2 groups,hyperacute and acute,according to the interval from onset of symptoms to surgery.The primary endpoint was all-cause early mortality,and the secondary endpoint was early reoperation.Results:The surgery time,cardiopulmonary bypass time,clamp time,and selective cerebral perfusion time were not significantly different between the 2 groups.The intensive care unit length of stay and duration of mechanical ventilation of the 2 groups were 185.50hours versus 185.00hours(P=0.970)and 41.50hours versus 44.00hours(P=0.678),respectively.There were 52 early deaths:29 in the hyperacute group and 23 in the acute group(21.6%vs.20.0%,P=0.751).The incidence of reoperation was 0.7% and 0.9%(P>0.999),respectively.The incidence rates of postoperative acute heart failure(AHF),acute respiratory failure(ARF),nervous dysfunction,and acutekidney injury were37.3% versus 25.2%(P=0.041),51.5%versus51.3%(P=0.976),13.4% versus 7.0%(P=0.096),and 37.3% versus 37.4%(P=0.990),respectively.Multivariable analysis indicated that surgery in the hyperacute phase might be an independent risk factor for AHF(OR:1.765;95%CI:1.021–3.052;P=0.042).Conclusion:Surgery in the hyperacute phase of AAAD was associated with postoperative AHF.Therefore,early medical management or interventional therapy for complications before surgery performed by experienced surgeons is recommended,especially in the hyperacute phase.