Optimized arterial perfusion strategy in total arch replacement for acute type A aortic dissection with malperfusion syndrome_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIN Xi , YU Hao , WANG Xianyue , ZHANG Ben , YAN Tao , WANG Xiaowu , MA Tao ,  ZHANG Weida

Department of Cardiothoracic Surgery, General Hospital of Southern Theatre Command, PLA, Guangzhou, 510010, P. R. China;

Corresponding author：

ZHANG Weida, Email: xzwkzx@163.com

Keywords：

Aortic dissection; malperfusion syndrome; total arch replacement; extracorporeal circulation; bilateral selective anterograde cerebral perfusion

DOI：

10.7507/1007-4848.202010018

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Objective To investigate the effect of optimized arterial perfusion strategy on total arch replacement for acute type A aortic dissection (AAAD) with malperfusion syndrome (MPS).Methods From 2017 to 2019, 51 patients with AAAD and MPS who had received total arch replacement with optimized arterial perfusion strategy in our hospital were included in the optimized perfusion group, including 40 males and 11 females, with an average age of 47.43±13.39 years. A total of 40 patients with AAAD and MPS who had been treated with traditional Sun's surgery were taken as the traditional control group, including 31 males and 9 females, with an average age of 50.66±12.05 years. The perioperative clinical data of the two groups were compared.Results The preoperative baseline data of the two groups were basically consistent (P>0.05). The comparison of operative data between the optimized perfusion group and the traditional control group showed that in the optimized perfusion group, the extracorporeal circulation time, aortic occlusion time, and circulation-out cerebral perfusion time were significantly less than those in the traditional control group (223.64±65.13 min vs. 266.77±87.04 min, 114.48±27.28 min vs. 138.20±39.89 min, 8.28±3.81 min vs. 50.53±23.60 min, all P≤0.05). The lowest intraoperative nasopharyngeal temperature in the optimized perfusion group was significantly higher than that in the traditional control group (27.10±1.18℃ vs. 23.6±3.30℃, P=0.000). Postoperative wakefulness time of the optimized perfusion group was earlier than that of the traditional control group (4.50±1.35 h vs. 5.27±1.15 h, P=0.019). The volume of blood transfusions in the optimized perfusion group was significantly less than that in the traditional control group (13.25±9.06 U vs. 16.95±7.53 U, P=0.046). There was no significant difference in ICU time and invasive ventilation time between the two groups (P>0.05). Postoperative complications of the two groups showed that the incidence of postoperative continuous renal replacement therapy in the optimized perfusion group was significantly lower than that in the traditional control group, with a statistically significant difference (21.6% vs. 42.5% P=0.003). The incidence of postoperative delirium, coma, low cardiac row syndrome and limb ischemia in the optimized perfusion group was lower than that in the traditional control group, but the difference was not statistically significant (P>0.05). The incidence of postoperative hemiplegia, sepsis, and secondary thoracotomy in the optimized perfusion group was higher than that in the traditional control group, and the difference was not statistically significant (P>0.05). Postoperative mortality in the optimized perfusion group was significantly lower than that in the traditional control group (13.7% vs. 27.5%), but the difference was not statistically significant (P=0.102).Conclusion Optimized arterial perfusion strategy and its related comprehensive surgical technique reduce surgical trauma, shorten the operation time, reduce perioperative consumption of blood products. Postoperative wakefulness is rapid and the incidence of complications of nervous system, kidney and limb ischemia is low. Optimized arterial perfusion strategy is suitable for operation of AAAD with MPS by inhibiting the related potential death risk factors to reduce operation mortality.

Citation： LIN Xi, YU Hao, WANG Xianyue, ZHANG Ben, YAN Tao, WANG Xiaowu, MA Tao, ZHANG Weida. Optimized arterial perfusion strategy in total arch replacement for acute type A aortic dissection with malperfusion syndrome. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(4): 467-472. doi: 10.7507/1007-4848.202010018 Copy

1.	Hideo Kanamitsu, Kenji Minatoya. The mesenteric malperfusion with aortic dissection and perioperative management of mesenteric malperfusion. Kyobu Geka, 2020, 73(10): 783-788.
2.	林曦, 王晓武, 马涛, 等. 299 例急性 A 型主动脉夹层术后死亡危险因素分析. 实用医学杂志, 2019, 35(8): 1255-1259.
3.	Lawton JS, Moon MR, Liu JX, et al. The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg, 2018, 155(3): 897-904.
4.	Kawahito K, Kimura N, Yamaguchi A, et al. Malperfusion in type A aortic dissection: Results of emergency central aortic repair. Gen Thorac Cardiovasc Surg, 2019, 67(7): 594-601.
5.	Czerny M, Schoenhoff F, Etz C, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: Results from the GERAADA Registry. J Am Coll Cardiol, 2015, 65(24): 2628-2635.
6.	孙立忠. 急性 A 型主动脉夹层的外科治疗. 心血管外科杂志(电子版), 2014, 3(3): 105-108.
7.	Pacini D, Leone A, Belotti LM, et al. Acute type A aortic dissection: Significance of multiorgan malperfusion. Eur J Cardiothorac Surg, 2013, 43(4): 820-826.
8.	Ma WG, Zhu JM, Zheng J, et al. Sun’s precedure for complex aortic arch repair: Total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg, 2013, 2(5): 642-648.
9.	王显悦, 董文鹏, 童光, 等. A 型主动脉夹层伴灌注不良手术效果分析. 临床心血管病杂志, 2016, 32(10): 1039-1042.
10.	Berretta P, Trimarchi S, Patel HJ, et al. Malperfusion syndromes in type A aortic dissection: What we have learned from IRAD. J Vis Surg, 2018, 10(4): 65-72.
11.	Thurau J, Habazettl H, El Al Md AA, et al. Left ventricular systolic dysfunction in patients with type A aortic dissection is associated with 30-day mortality. J Cardiothorac Vasc Anesth, 2018, 14(2): 123-127.
12.	Julia D, Markus K, Lukas S, et al. Stroke after emergent surgery for acute type A aortic dissection: Predictors, outcome and neurological recovery. Eur J Cardiothorac Surg, 2018, 53(5): 1013-1020.
13.	Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients with acute aortic dissection type A: Analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac, 2016, 49(2): 44-52.
14.	Frist WH, Baldwin JC, Starnes VA, et al. A reconsideration of cerebral perfusion in aortic arch replacement. Anna of Thorac Surg, 1986, 42(3): 273-281.
15.	Peterson MD, Mazine A, El-Hamamsy I, et al. Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection. J Thorac Cardiovasc Surg, 2015, 150(4): 824-831.
16.	Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to 338 postoperative complications following aortic arch surgery for acute aortic dissection type A. J Card Surg, 2008, 23(5): 480-487.
17.	Angeloni E, Benedetto U, Takkenberg JJM, et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: A meta-analysis of 5100 patients. J Thorac Cardiovasc Surg, 2014, 147(1): 60-67.
18.	Emiliano A, Giovanni M, Simone KR, et al. Unilateral versus bilateral antegrade cerebral protection during aortic surgery: An updated meta analysis. Ann Thorac Surg, 2015, 99(6): 2024-2031.
19.	王显悦. A型主动脉夹层围术期脑保护研究. 第二军医大学, 2017.
20.	于浩, 童光, 颜涛, 等. 优化选择性动脉灌注策略在 Stanford A 型主动脉夹层全弓置换术中的应用. 第二军医大学学报, 2018, 39(04): 404-410.
21.	Qi RD, Zhu JM, Chen L, et al. Experience of Sun’s procedure for chronic type B dissection with aortic arch involvement. Zhonghua Yi Xue Za Zhi, 2017, 97(24): 1867-1870.
22.	Di EM, Pantaleo A, Petridis FD, et al. Impact of different cannulation strategies on in-hospital outcomes of aortic arch surgery: A propensity-score analysis. Ann Thorac Surg, 2013, 96(5): 1656-1663.
23.	胡知朋, 张敏, 王志维, 等. 急性 A 型主动脉夹层合并腹腔脏器灌注不良的治疗. 实用医学杂志, 2017, 33(23): 4011-4012.
24.	Yassin MM, Harkin DW, Barros D’sa AA, et al. Lower limb ischemia-reperfusion injury triggers a systemic inflammatory response and multiple organ dysfunction. World J Surg, 2002, 26(1): 115-121.
25.	戎天华, 潘旭东, 刘宁宁, 等. Stanford A 型主动脉夹层合并急性下肢缺血的临床研究现状与展望. 心肺血管病杂志, 2015, 34(11): 867-870.
26.	Qiu JT, Zhang L, Luo XJ, et al. Higher mortality in patients undergoing nighttime surgical procedures for acute type A aortic dissection. Ann Thorac Surg, 2018, 106(4): 1164-1170.
27.	Zhang Y, Chen T, Chen Q, et al. Development and evaluation of an early death risk prediction model after acute type A aortic dissection. Ann Transl Med, 2021, 9(18): 1442.
28.	吴路加, 童光, 罗林, 等. 全弓置换术后行肾脏替代治疗的危险因素分析及预测. 第三军医大学学报, 2018, 40(3): 237-241.
29.	Matalanis G, Perera NK, Galvin SD. Aortic arch replacement without circulatory arrest or deep hypothermia: The "branch-first" technique. J Thorac Cardiovasc Surg, 2015, 149(2): 76-82.
30.	Zhang Q, Ma X, Zhang W, et al. Surgical repair and reconstruction of aortic arch in debakey type Ⅰ aortic dissection: Recent advances and single-center experience in the application of branched stent graft. J Cardiothorac Surg, 2017, 12(1): 86.

1. Hideo Kanamitsu, Kenji Minatoya. The mesenteric malperfusion with aortic dissection and perioperative management of mesenteric malperfusion. Kyobu Geka, 2020, 73(10): 783-788.
2. 林曦, 王晓武, 马涛, 等. 299 例急性 A 型主动脉夹层术后死亡危险因素分析. 实用医学杂志, 2019, 35(8): 1255-1259.
3. Lawton JS, Moon MR, Liu JX, et al. The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg, 2018, 155(3): 897-904.
4. Kawahito K, Kimura N, Yamaguchi A, et al. Malperfusion in type A aortic dissection: Results of emergency central aortic repair. Gen Thorac Cardiovasc Surg, 2019, 67(7): 594-601.
5. Czerny M, Schoenhoff F, Etz C, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: Results from the GERAADA Registry. J Am Coll Cardiol, 2015, 65(24): 2628-2635.
6. 孙立忠. 急性 A 型主动脉夹层的外科治疗. 心血管外科杂志(电子版), 2014, 3(3): 105-108.
7. Pacini D, Leone A, Belotti LM, et al. Acute type A aortic dissection: Significance of multiorgan malperfusion. Eur J Cardiothorac Surg, 2013, 43(4): 820-826.
8. Ma WG, Zhu JM, Zheng J, et al. Sun’s precedure for complex aortic arch repair: Total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg, 2013, 2(5): 642-648.
9. 王显悦, 董文鹏, 童光, 等. A 型主动脉夹层伴灌注不良手术效果分析. 临床心血管病杂志, 2016, 32(10): 1039-1042.
10. Berretta P, Trimarchi S, Patel HJ, et al. Malperfusion syndromes in type A aortic dissection: What we have learned from IRAD. J Vis Surg, 2018, 10(4): 65-72.
11. Thurau J, Habazettl H, El Al Md AA, et al. Left ventricular systolic dysfunction in patients with type A aortic dissection is associated with 30-day mortality. J Cardiothorac Vasc Anesth, 2018, 14(2): 123-127.
12. Julia D, Markus K, Lukas S, et al. Stroke after emergent surgery for acute type A aortic dissection: Predictors, outcome and neurological recovery. Eur J Cardiothorac Surg, 2018, 53(5): 1013-1020.
13. Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients with acute aortic dissection type A: Analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac, 2016, 49(2): 44-52.
14. Frist WH, Baldwin JC, Starnes VA, et al. A reconsideration of cerebral perfusion in aortic arch replacement. Anna of Thorac Surg, 1986, 42(3): 273-281.
15. Peterson MD, Mazine A, El-Hamamsy I, et al. Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection. J Thorac Cardiovasc Surg, 2015, 150(4): 824-831.
16. Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to 338 postoperative complications following aortic arch surgery for acute aortic dissection type A. J Card Surg, 2008, 23(5): 480-487.
17. Angeloni E, Benedetto U, Takkenberg JJM, et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: A meta-analysis of 5100 patients. J Thorac Cardiovasc Surg, 2014, 147(1): 60-67.
18. Emiliano A, Giovanni M, Simone KR, et al. Unilateral versus bilateral antegrade cerebral protection during aortic surgery: An updated meta analysis. Ann Thorac Surg, 2015, 99(6): 2024-2031.
19. 王显悦. A型主动脉夹层围术期脑保护研究. 第二军医大学, 2017.
20. 于浩, 童光, 颜涛, 等. 优化选择性动脉灌注策略在 Stanford A 型主动脉夹层全弓置换术中的应用. 第二军医大学学报, 2018, 39(04): 404-410.
21. Qi RD, Zhu JM, Chen L, et al. Experience of Sun’s procedure for chronic type B dissection with aortic arch involvement. Zhonghua Yi Xue Za Zhi, 2017, 97(24): 1867-1870.
22. Di EM, Pantaleo A, Petridis FD, et al. Impact of different cannulation strategies on in-hospital outcomes of aortic arch surgery: A propensity-score analysis. Ann Thorac Surg, 2013, 96(5): 1656-1663.
23. 胡知朋, 张敏, 王志维, 等. 急性 A 型主动脉夹层合并腹腔脏器灌注不良的治疗. 实用医学杂志, 2017, 33(23): 4011-4012.
24. Yassin MM, Harkin DW, Barros D’sa AA, et al. Lower limb ischemia-reperfusion injury triggers a systemic inflammatory response and multiple organ dysfunction. World J Surg, 2002, 26(1): 115-121.
25. 戎天华, 潘旭东, 刘宁宁, 等. Stanford A 型主动脉夹层合并急性下肢缺血的临床研究现状与展望. 心肺血管病杂志, 2015, 34(11): 867-870.
26. Qiu JT, Zhang L, Luo XJ, et al. Higher mortality in patients undergoing nighttime surgical procedures for acute type A aortic dissection. Ann Thorac Surg, 2018, 106(4): 1164-1170.
27. Zhang Y, Chen T, Chen Q, et al. Development and evaluation of an early death risk prediction model after acute type A aortic dissection. Ann Transl Med, 2021, 9(18): 1442.
28. 吴路加, 童光, 罗林, 等. 全弓置换术后行肾脏替代治疗的危险因素分析及预测. 第三军医大学学报, 2018, 40(3): 237-241.
29. Matalanis G, Perera NK, Galvin SD. Aortic arch replacement without circulatory arrest or deep hypothermia: The "branch-first" technique. J Thorac Cardiovasc Surg, 2015, 149(2): 76-82.
30. Zhang Q, Ma X, Zhang W, et al. Surgical repair and reconstruction of aortic arch in debakey type Ⅰ aortic dissection: Recent advances and single-center experience in the application of branched stent graft. J Cardiothorac Surg, 2017, 12(1): 86.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Optimized arterial perfusion strategy in total arch replacement for acute type A aortic dissection with malperfusion syndrome

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