Objective To analyze the risk factors and prognosis of acute gastrointestinal injury (AGI) early after acute type A aortic dissection (ATAAD) repair, and develop the Nomogram prediction model of AGI. Methods The patients who underwent ATAAD cardiopulmonary bypass surgery in our hospital from 2016 to 2021 were collected and divided into an AGI group and a non-AGI group. The clinical data of the two groups were compared. A Nomogram prediction model was established by using R language. Results A total of 188 patients were enrolled, including 166 males and 22 females, aged 22-70 (49.70±9.96) years. Through multivariate logistic regression analysis, the aortic dissection (AD) risk score, poor perfusion of superior mesenteric artery (SMA), duration of aortic occlusion and intraoperative infusion of red blood cells were the predictors for AGI (P<0.05). There were statistical differences in the ventilator-assisted duration, ICU stay time, liver dysfunction, renal insufficiency, parenteral nutrition, nosocomial infection and death within 30 days after the operation between the two groups (P<0.05). The Nomogram prediction model was established by using the prediction factors, and the C index was 0.888. Through internal verification, the C index was 0.848. The receiver operating characteristic curve was used to evaluate the discrimination of the model, and the area under the curve was 0.888. Conclusion The AD risk score after ATAAD, poor perfusion of SMA, duration of aortic occlusion and intraoperative infusion of red blood cells are independent predictors for AGI. The Nomogram model has good prediction ability.
ObjectiveTo summarize our experience and clinical effect of surgical treatment of Stanford type A aortic dissection (TAAD) involving an aberrant right subclavian artery (ARSA). MethodsFrom March 2009 to January 2016, 14 patients with TAAD involving an ARSA (acute TAAD, n=10; chronic TAAD, n=4) underwent operation under hypothermic cardiopulmonary bypass combined with selective antegrade cerebral perfusion in our center. There were 11 male and 3 female patients with a mean age of 46.07±8.45 years. A total of 13 patients (13/14, 92.86%) underwent stented elephant trunk procedure combined with total arch replacement (Sun's procedure). The remaining patient (1/14, 7.14%) underwent partial aortic arch replacement combined with Bentall procedure without ARSA revascularization. ResultsThe average operation time, cardiopulmonary bypass time, aortic cross-clamping time and selective cerebral perfusion time was 7.89±1.80 h, 208.43±28.84 min, 117.64±23.30 min, and 30.50±10.15 min, respectively. No operation-related deaths occurred. However, two (14.29%) patients died on postoperative 5 d, 7 d, respectively in hospital. One patient required repeat thoracotomy for bleeding, one suffered temporary renal dysfunction and one renal failure (this patient had renal failure before surgery). The mean follow-up was 28.42±22.52 months with a follow-up rate of 100.00% (12/12). One patient died of heart failure and renal failure at 64 months after operation. The others were free from any aortic complications during follow-up. ConclusionsTAAD involving an ARSA should be clearly diagnosed before surgery, and treated by the optimal arterial cannulation and cerebral perfusion during operation. Repair of aortic dissection with Sun's procedure and revascularization of the ARSA can obtain satisfactory clinical outcomes in patients with TAAD involving an ARSA.
ObjectiveTo summarize clinical outcomes of different end-to-end anastomotic methods for surgical treatment of acute Stanford type A aortic dissection (AD). MethodsBetween January 2012 and May 2013, 95 patients with acute Stanford type A AD received surgical treatment in Nanjing Hospital Affiliated to Nanjing Medical University. According to different end-to-end anastomotic methods, 72 patients were divided into 3 groups (23 patients undergoing Bentall procedure were excluded from this study). In group A, there were 23 patients including 18 males and 5 females with their age of 48.67±9.23 years, who received 'sandwich' anastomotic technique strengthening both the inner and outer layers of the aortic wall. In group B, there were 11 patients including 8 males and 3 females with their age of 48.00±9.17 years, who received pericardium strengthening only inner layer of the aortic wall. In group C, there were 38 patients including 29 males and 9 females with their age of 49.20±8.57 years, who received artificial graft that was anastomosed directly to the aortic wall without any reinforcement. Postoperative outcomes were compared among the 3 groups. ResultsEight patients (11.11%)died postoperatively including 1 patient in group A (1/23, 4.35%)and 7 patients in group C (7/38, 18.42%). One patient in group A died of persistent wound errhysis and later disseminated intravascular coagulation. Three patients in group C died of persistent anastomotic incision errhysis and circulatory failure. Four patients in group C died of postopera-tive severe tricuspid regurgitation, secondary severe low cardiac output syndrome and multiple organ dysfunction syndrome. Severe postoperative complications included renal failure in 5 patients, respiratory failure in 7 patients, severe cerebral infarction and paralysis in 1 patient, paresis in 3 patients, delayed recovery of consciousness in 2 patients, and ischemic necrosis of the lower limb in 1 patient. Postoperative thoracic drainage amount in group C was significantly larger than that of the other 2 groups, and there was no statistical difference in thoracic drainage amount between group A and group B. Sixty-four patients were followed up for 1 to 6 months, and there was no late death during follow-up. Among the 5 patients with postoperative renal failure, only 1 patient needed regular hemodialysis, and renal function of the other 4 patients returned to normal. One patient with cerebral infarction recovered partial limb function and was able to walk with crutches. All the 3 patients with paresis recovered their limb function. ConclusionsAnastomotic quality of end-to-end anastomosis is of crucial importance for surgical treatment of acute Stanford type A AD. Appropriate reinforcement methods can be chosen according to individual intraoperative findings. 'sandwich' anastomotic technique can significantly reduce incision errhysis, prevent acute myocardial infarction caused by aortic anastomotic tear, and decrease postoperative mortality. If coronary ostia are involved in AD, concomitant coronary artery bypass grafting is needed.
ObjectiveTo investigate the prognosis and impact of postoperative acute kidney injury (AKI) on patients with acute Stanford type A aortic dissection (ATAAD), and to analyze the predictors for short- and medium-term survival. MethodsClinical data of patients who underwent ATAAD surgery in Qingdao Municipal Hospital from May 2014 to May 2019 were retrospectively analyzed. All discharged patients underwent telephone or outpatient follow-up, and were divided into an AKI group and a non-AKI group based on whether AKI occurred after surgery. The impact of postoperative AKI on the short- and medium-term prognosis was analyzed, and multivariate Cox analysis was used to screen the risk factors for short- and medium-term mortality. ResultsA total of 192 patients were collected, including 139 males and 53 females, with an average age of 53.3±11.4 years. Postoperative AKI was identified in 43 (22.4%) patients. The average follow-up time of discharged patients was 23.4±2.4 months, and the lost rate was 5.1%. The two-year survival rate after discharge of the AKI group was 88.2%, and that of the non-AKI group was 97.2%. Kaplan-Meier survival analysis and log-rank test showed that there was a statistical difference between the two groups (χ2=5.355, log-rank P=0.021). Multivariate Cox analysis results showed that age (HR=1.070, 95%CI 1.026 to 1.116, P=0.002), cardiopulmonary bypass time (HR=1.026, 95%CI 1.003 to 1.050, P=0.026), postoperative AKI (HR=3.681, 95%CI 1.579 to 8.582, P=0.003), transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively (HR=1.548, 95%CI 1.183 to 2.026, P=0.001) were independent risk factors for the short- and medium-term mortality of ATAAD patients. ConclusionThe incidence of postoperative AKI is high in ATAAD patients, and the mortality of patients with AKI increases significantly within two years. Age, cardiopulmonary bypass time and transfusion volume of red blood cell intraoperatively and within 24 hours postoperatively are also independent risk factors for short- and medium-term prognosis.
目的探讨急性Stanford A型主动脉夹层的临床特点、基层医院救治策略及围术期常见并发症的处理措施。 方法回顾性分析遂宁市中心医院2010年2月至2013年9月16例采用三分支主动脉支撑型覆膜支架重建弓部手术治疗的Stanford A型主动脉夹层患者的临床资料，其中男12例、女4例，马凡综合征1例，原发性高血压病15例。分析其临床特点、影像学表现及治疗效果。 结果16例患者手术均成功。本组体外循环时间（202.2±50.4）min，升主动脉阻断时间（94.6±16.9）min，深低温停循环时间（11.5±7.4）min，选择性脑灌注时间（40.6±6.8）min，术后胸腔及心包积液引流量（700.6±368.6）ml，重症监护室停留时间3～26 d。住院期间死亡1例，于术后28 d突发远端夹层破裂死亡。术后发生慢性心脏压塞导致胸骨哆开1例，10例出现一过性精神障碍，5例并发急性肾功能不全，4例出现急性呼吸功能不全，3例出现急性肝功能不全。术后随访15例，门诊及电话随访6～49个月；2例于术后1年随访中因其他慢性疾病死亡；其余13例均存活。 结论基层医院采用三分支主动脉支撑型覆膜支架重建弓部手术治疗急性Stanford A型主动脉夹层，简化了手术方式，针对围术期并发症采取有效的治疗措施可显著提高患者生存率。
Objective To analysis correlation factors for preoperative sudden death of patients with type A aortic dissection in order to determine clinical management strategy.?Methods?We retrospectively analyzed clinical data of 52 patients with type A aortic dissection who were admitted in Department of Cardiothoracic Surgery of the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2003 to January 2010. According to the presence of preoperative death, all the patients were divided into two groups, 9 patients in the preoperative sudden death （PSD）group including 7 males and 2 females with their mean age of 52.0±12.1 years；43 patients in the control group including 31 males and 12 females with their mean age of 51.5±10.9 years. Univariate and multivariate logistic regression analysis were used for analysis of preoperative factors related to sudden death.?Results?Univariate analysis result showed 7 candidate variables：body mass index （BMI, Wald χ2=2.150, P=0.143）, time of onset （Wald χ2=2.711, P= 0.100）, total cholesterol （TC, Wald χ2=1.444, P=0.230）, low density lipoprotein cholesterol （L-C, Wald χ2=1.341, P=0.247）, aortic insufficiency （AI, Wald χ2=2.093, P=0.148）, aortic sinus involvement （Wald χ2=3.386, P=0.066）and false lumen thrombosis （Wald χ2=7.743, P=0.005）. Multivariate logistic regression analysis showed that BMI （Wald χ2=4.215, P=0.040, OR=1.558）and aortic sinus involvement （Wald χ2=4.592, P=0.032, OR=171.166 ）were preoperative risk factors for sudden death, and thrombosed false lumen （Wald χ2=5.097, P=0.024, OR=0.011）was preoperative protective factor for sudden death.?Conclusion?Type A aortic dissection patients with large BMI and/or aortic sinus involvement should receive operation more urgently than others and patients with thrombosed false lumen may have relatively low risk of preoperative sudden death.
ObjectiveTo summarize clinical experience of total aortic arch reconstruction with triple-branched stent graft placement in elderly patients with Stanford type A aortic dissection (SAAD). MethodsFrom December 2008 to December 2012, 46 elderly SAAD patients underwent total aortic arch reconstruction with triple-branched stent graft placement under deep hypothermic circulatory arrest and selective cerebral perfusion (SCP)in Department of Cardiova-scular Surgery, Henan Provincial Chest Hospital. There were 37 male and 9 female patients with their age of 65-75 (68.2±5.0)years. There were 6 patients undergoing modified David procedure, 1 patient undergoing Bentall procedure, 2 patients undergoing Wheat procedure, and 37 patients undergoing ascending aortic replacement. ResultsThere was no in-hos-pital death. Cardiopulmonary bypass time was 135-183 (131.1±10.5)minutes, aortic cross-clamping time was 81-100 (61.5±18.3)minutes, and SCP time was 19-28 (24.4±5.6)minutes. Postoperative complications included low cardiac output syndrome in 3 patients, acute renal failure in 2 patients, pleural effusion in 5 patients, lung infection in 2 patients, and sternal dehiscence in 1 patient, who were all cured after treatment. All the patients were followed up for 3 to 12 months without complication related to the stent graft. ConclusionTotal aortic arch reconstruction with triple-branched stent graft placement is an easy surgical procedure for SAAD with a high successful rate and low morbidity, and especially suitable for elderly patients who can't bear traditional operation.
ObjectiveTo summarize our clinical experience of surgical treatment for 51 patients with Stanford type A aortic dissection (AD). MethodsClinical data of 51 patients with Stanford type A AD who received surgical treatment in Shanghai Yuanda Heart Hospital between February 2009 and January 2013 were retrospectively analyzed. There were 29 males and 22 females with their age of 35-63 (47.2±11.1)years. The diagnosis of all the patients was confirmed by enhanced CT scan and Doppler echocardiography. Surgical procedures included Bentall procedure and Sun's procedure in 29 patients, Bentall procedure, mitral valve replacement and Sun's procedure in 2 patients, ascending aorta replacement and Sun's procedure in 17 patients, valsalva sinus plasty, ascending aorta replacement and Sun's procedure in 2 patients, ascending aorta replacement (stage 1), Sun's procedure (stage 2)and endovascular exclusion of the thoracic aorta (stage 3)in 1 patient. ResultsMean operation time was 320.6±77.3 minutes, cardiopulmonary bypass time was 190.4±63.4 minutes, aortic cross-clamp time was 123.2±45.1 minutes, duration of circulatory arrest with hypothermia was 28.2±11.1 minutes, and mean length of hospital stay was 13.4±4.2 days. Two patients (3.9%)died perioperatively including 1 patient with intraoperative bleeding and another patient with delayed bleeding after operation. Postoperative complications included bleeding, paraplegia, perivalvular leak and sternal dehiscence in 1 patient respectively, and endoleak in 2 patients. Forty-nine patients were followed up for 3-48 (25.3±10.5)months and no late death occurred. ConclusionSurgical treatment is effective for patients with Stanford type A AD.