The treatment of acute Stanford type A aortic dissection has always been extremely challenging. Organ malperfusion syndrome is a common severe complication of acute aortic dissection, which can cause organ ischemia and internal environment disorder. Malperfusion increases early mortality, and impacts the long-term prognosis. In recent years, many scholars have done some studies on aortic dissection complicated with malperfusion. They explored the pathogenesis, proposed new classification, and innovated new treatment strategies. However, at present, the treatment strategies of acute Stanford type A aortic dissection complicated with organ malperfusion are different at different centers and consensus on its treatment is still lacking. Therefore, this review summarized the pathogenesis, classification, treatment strategy, and prognosis of acute Stanford type A aortic dissection complicated with malperfusion.
ObjectiveTo explore the single-center experience of hybrid therapy in treatment of Stanford type A aortic dissection, and to make a comparison of the clinical results of this hybrid therapy with total arch replacement surgery in the same period.MethodsFrom March 2017 to April 2020, 272 patients with Stanford type A aortic dissection underwent surgical treatment in our center, including 147 patients (126 males and 21 females) who received the aortic arch surgery. Among them, 106 patients underwent replacement of ascending aorta+aortic arch+stent trunk (total arch replacement group), while 41 patients underwent one-stop compound total arch type Ⅱ hybrid surgery (compound total arch replacement group). We tried to identify whether hybrid surgery really simplified total arch replacement surgery of the aortic dissection by comparing the operative mortality, postoperative complication rate, operative time, extracorporeal circulation time, etc.ResultsThere was no statistical difference in preoperative clinical data or death rate between the two groups. However, blood transfusion (6.74±7.35 U vs. 4.65±6.87 U, P<0.05), postoperative respiratory insufficiency [16 (15.09%) vs. 2 (4.88%), P<0.05], and apoplexy [3 (2.83%) vs. 0, P<0.05], paraplegia [2 (1.89%) vs. 0, P<0.05], in the compound total arch replacement group was significantly better than those of the total arch replacement group. The compound total arch replacement group did not shorten the total operation time, but it was significantly better in terms of extracorporeal circulation time (175.50±55.70 min vs. 129.70±48.80 min, P<0.05), aortic block time (103.10±23.70 min vs. 49.70±30.10 min, P<0.05), and the time of stopping the circulation or avoiding stopping the circulation (32.10±7.20 min vs. 0 min, P<0.05). The postoperative mechanical ventilation time was shorter in the compound total arch group (62.60±31.70 h vs. 41.30±32.60 h, P<0.05), and the time of staying in ICU (124.50±61.50 h vs. 63.40±71.20 h, P<0.05) and the postoperative hospital stay (13.50±11.20 d vs. 9.20±7.20 d, P<0.05) were significantly shorter than those in the total replacement group. A total of 138 patients were followed up for 6-38 (15.8±6.4) months. There was no statistical difference in one-year mortality or three-year mortality (P>0.05).ConclusionHybrid surgery shortens extracorporeal circulation time, while reduces or avoids the time of deep hypothermia circulatory arrest, the incidence of complications and the time of hospital stay. In conclusions, hybrid surgery simplifies the arch management of acute Stanford type A aortic dissection.
Objective To explore the efficacy of prone positioning ventilation in patients with acute respiratory distress syndrome (ARDS) after acute Stanford type A aortic dissection (STAAD) surgery. Methods From November 2019 to September 2021, patients with ARDS who was placed prone position after STAAD surgery in the Xiamen Cardiovascular Hospital of Xiamen University were collected. Data such as the changes of blood gas, respiratory mechanics and hemodynamic indexes before and after prone positioning, complications and prognosis were collected for statistical analysis. ResultsA total of 264 STAAD patients had surgical treatment, of whom 40 patients with postoperative ARDS were placed prone position. There were 37 males and 3 females with an average age of 49.88±11.46 years. The oxygen partial pressure, oxygenation index and peripheral blood oxygen saturation 4 hours and 12 hours after the prone positioning, and 2 hours and 6 hours after the end of the prone positioning were significantly improved compared with those before prone positioning ventilation (P<0.05). The oxygenation index 2 hours after the end of prone positioning which was less than 131.42 mm Hg, indicated that the patient might need ventilation two or more times of prone position. Conclusion Prone position ventilation for patients with moderate to severe ARDS after STAAD surgery is a safe and effective way to improve the oxygenation.
ObjectiveTo evaluate the involvement of renal artery in acute Stanford type A aortic dissection (TAAD) using CT angiography (CTA) and to analyze the difference of renal function among different types of renal artery involvement.MethodsFrom January 2016 to November 2017, 151 patients of acute TAAD with renal artery involvement were included in the study. There were 118 males and 33 females, with an average age of 47.93±10.53 years. All patients underwent aortic CTA to confirm the TAAD. According to CTA, involvement of one side of renal artery can be divided into four types: type A, large tear near renal artery orifice, difficult to distinguish true or false lumen; type B, the orifice of the renal artery originates entirely from the false lumen; type C, the orifice of the renal artery originates entirely from the true lumen; type D, renal artery dissection is observed, renal artery intima can be seen. The levels of serum creatinine (sCr) and creatinine clearance (CC) in all groups were analyzed and compared. ResultsThe results of one-way ANOVA analysis showed that there was no significant difference in sCr or CC among the groups (P>0.05). There was no significant difference in age, sex, proportion of hypertension history and onset time among the above groups (P>0.05).ConclusionThe three most common types of renal artery involvement were BC type, CC type, and AC type. The types of renal artery involvement do not affect renal function.
ObjectiveTo investigate the effect of early postoperative systemic inflammatory response syndrome (SIRS) on the short-term outcome of patients with acute Stanford type A aortic dissection (ATAAD).MethodsThe clinical data of 88 patients with ATAAD who were treated in our hospital from January 2018 to January 2020 were retrospectively analyzed. Patients were divided into a SIRS group (n=37) and a non-SIRS group (n=51) according to whether SIRS occurred within 24 hours after surgery. The perioperative data of the two groups were compared.ResultsThere was no significant difference between the two groups in general clinical data, preoperative left ventricular ejection fraction, white blood cell (WBC) and body temperature (P>0.05). Compared with the non-SIRS group, the cardiopulmonary bypass time in the SIRS group was significantly longer (P<0.05), and the WBC and body temperature within 1 day after surgery in the SIRS group were higher (P<0.01). A significant difference was revealed in the mechanical ventilation time, ICU stay, total hospitalization time and hospitalization costs between two groups (P<0.01). Patients in the SIRS group had higher postoperative acute physiology and chronic health evaluationⅡscores, sequential organ failure assessment score as well as a greater risk of developing postoperative acute lung injury, acute kidney injury, continuous renal replacement therapy, delirium, liver dysfunction and morbidity (P<0.05).ConclusionEarly postoperative SIRS significantly increases the incidence of major adverse complications and the mortality rate of patients with ATAAD.
Objective To investigate activated toll-like receptor-4 (TLR4) signaling pathway involved in pathophysiological mechanisms of type A aortic dissection (TAAD). Methods Specimens of full-thickness ascending aorta wall from the TAAD patients (n=12) and the controlled donors (n=12) were collected. Western blotting was used to examine the associated proteins' expression of TLR4 signaling pathway. Blood samples from TAAD (n=43) and controlled patients (n=50) were examined by enzyme-linked immunosorbent assay (ELISA) to detect the circulating plasma cytokines levels of interleukin-1β (L-1β). Results In the aortic wall of TAAD, expression levels of TLR4 and protein expression of major molecule significantly elevated, and activated macrophages increased. Furthermore, elevated IL-1β levels were observed in the TAAD patients’ plasma compared with the control plasma. Multiple logistic regression analysis and receiver operating characteristic (ROC) curve showed that elevated IL-1β could be a novel and promising biomarker with important diagnostic and predictive value in the identification of TAAD. Conclusion Activated TLR4/NF-κB signaling pathway regulates inflammatory response to involve in pathophysiological mechanisms of type A aortic dissection and its regulated inflammatory products have important predictive value for patients with TAAD.
ObjectiveTo investigate the situation of off-label drug use in dose (OLDUD) of ambroxol hydrochloride injection (AHI) in perioperative period among patients for stanford type A aortic dissection in Guangdong General Hospital, so as to provide references for the rational application of AHI in clinical practice. MethodsAll medical orders of AHI for patients had aortic arch replacement for Stanford type A aortic dissection in Guangdong General Hospital between January 2005 and December 2014 were included. The patients were divided into a mild OLDUD ( < 450 mg) group, a moderate OLDUD (450 mg≤OLDUD < 900 mg) group, and a high OLDUD (≥900 mg)group. The preoperative and postoperative features, incidence of PPCs, mortality, incidence of reintubation, time of mechanical ventilation, time stay in ICU, time stay in hospital and the overall costs among three groups were compared by SPSS 22.0 software. Resultsa) A total of 549 patients were included. The incidence of OLDUD was 99.82%. The most common PMDDs were 450 mg (n=358) and 900 mg (n=88). b) The three groups were well matched for perioperative and operative variables. c) The incidence of preoperative drug use was 8.6%. The incidences (5.5% vs. 7.7% vs. 15.7%, P=0.022) and maximum doses (180 mg vs. 300 mg vs. 450 mg, P=0.014) of preoperative drug use were statistically different in mild OLDUD, moderate OLDUD and high OLDUD groups. The days of preoperative drug use were not different (3 d vs. 2.5 d vs. 2 d, P=0.307). The days of postoperative drug use (9.5 d vs. 13 d vs. 19 d, P < 0.001) and postoperative drug use in maximum doses (7 d vs. 8 d vs. 7 d, P=0.005) were different. d) The incidence of PPCs was 100%, and the mortality (8.2% vs. 6.6% vs. 9.0%, P=0.696) was not statistically different among mild OLDUD, moderate OLDUD and high OLDUD groups. However the incidence of reintubation (14.3% vs. 13.8% vs. 27%, P=0.009), time of mechanical ventilation (37 h vs. 50 h vs. 114 h, P < 0.001), time stay in ICU (138 h vs. 178.5 h vs. 316 h, P < 0.001), time stay in hospital (25 d vs. 27 d vs. 34 d, P=0.001) and the overall costs (¥ 0.17 million vs. ¥ 0.19 million vs. ¥ 0.25 million, P < 0.001) were different among three groups. Moreover, they were all increasing along with the dose of AHI. ConclusionAHI cannot improve the prognosis of patients having aortic arch replacement for Stanford Type A Aortic Dissection in a dose-dependent manner. Further well-designed prospective studies should be conducted to verification or falsification.
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 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.
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.