ObjectiveTo explore the short- and mid-term efficacy of Castor single branch aortic stent combined with subclavian artery bypass grafting for the aortic arch lesions. MethodsA retrospective analysis of the clinical data of patients with proximal anchor zone insufficiency aortic arch lesions treated with Castor stent combined with carotid-subclavian bypass at the Department of Cardiac Surgery, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from August 2020 to November 2023 was performed. ResultsA total of 22 patients were included, including 19 males and 3 females, with an average age of 56±16 years. There were 18 patients of aortic dissection and 4 patients of aortic arch tumors. The success rate of surgical technique was 100.0%, and the average postoperative hospital stay for patients was 10±4 days. The median follow-up time was 20 months. During the follow-up period, there were no major complications such as endoleak, paraplegia, cerebral infarction, renal insufficiency, etc., and all patients had no readmissions. ConclusionFor proximal anchor zone insufficiency aortic arch lesions, the treatment method of using a Castor stent branch placed in the left common carotid artery can effectively extend the anchor zone, avoid the huge trauma of open chest surgery, and achieve good short- and mid-term efficacy.
ObjectiveTo investigate the impact of anatomical variations of the isolated left vertebral artery (ILVA) on clinical outcomes and imaging outcomes in patients with Stanford type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair. MethodsThe clinical data of patients with TBAD in West China Hospital, Sichuan University from January 2016 to December 2023 were collected, and the differences of clinical outcomes and imaging outcomes between patients with and without ILVA were compared. ResultsBased on the inclusion criteria and the result of propensity score-based matching, 82 patients with TBAD were included, including 17 patients with ILVA (ILVA group) and 65 patients without ILVA (control group). There was no significant difference between the two groups in terms of the radiological and surgical information (P>0.05). The median time of the follow-up for these 82 patients were 37 months, during which there were no significant differences in aortic-related death, aortic event, stroke, adverse aortic remodeling, type Ⅰ A endoleak, and retrograde progression between the two groups (P>0.05). Compared with the control group, the re-intervention rate [HR=2.56, 95%CI (1.55, 8.11), P=0.03] and the incidence of type Ⅱ internal leakage [OR=1.36, 95%CI (1.08, 2.11), P=0.04] in the ILVA group were higher. ConclusionsNo significant differences were observed for ILVA patients in terms of serious adverse events such as aortic-related death and retrograde progression, comparing with the patients with normal aortic arch. However, the patients with ILVA were more susceptible to complications such as reintervention and type Ⅱ endoleak, which warranted the necessity of intensive postoperative follow-up for these patients.
ObjectiveTo analyze the risk factors relevant retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection and provide a reference for its prevention and management. MethodsA retrospective analysis was conducted on patients with Stanford type B aortic dissection who underwent TEVAR at the First Affiliated Hospital of Chongqing Medical University from January 2017 to June 2023. The patients met the inclusion and exclusion criteria were included in the study. The multivariate logistic regression was used to analyze the risk factors for RTAD, with a test level of α=0.05. ResultsA total of 176 patients were included, among whom 7 developed RTAD, with an occurrence rate of 3.98%. The multivariate logistic regression analysis revealed that the larger τ angle between the centerline of the aorta [OR (95%CI)=1.195 (1.032, 1.384)] and the degree of curvature of the aortic arch (the curve distance from the proximal brachiocephalic trunk to the distal left subclavian artery) [OR (95%CI)=0.756 (0.572, 0.999)], the higher probability of RTAD after TEVAR (P＜0.05). ConclusionsFrom the results of this study, it can be seen that for patients with Stanford B-type aortic dissection underwent TEVAR treatment, careful preoperative evaluation of morphological characteristics of the aortic arch (particularly the τ angle of the aorta centerline and the degree of curvature of the aortic arch (the curve distance from the proximal brachiocephalic trunk to the distal left subclavian artery) is crucial for reducing the occurrence of RTAD after TEVAR in patients with Stanford type B aortic dissection.
Objective To analyze the etiologies, surgical treatment and outcomes of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. Methods The clinical data of patients with RTAD after TEVAR for Stanford type B aortic dissection receiving operations in Changhai Hospital from March 2014 to August 2018 were analyzed. All patients were followed-up by clinic interview or telephone. Results A total of 16 patients were enrolled, including 13 males and 3 females with a mean age of 49.1±12.2 years. The main symptoms of RTAD were chest pain in 12 patients, headache in 1 patient, conscious disturbance in 1 patient, and asymptomatic in 2 patients. All the 16 patients received total arch replacement with the frozen elephant trunk technique. Bentall procedure was used in 2 patients, aortic root plasticity in 10 patients and aortic valve replacement in 1 patient. The primary tear in 10 patients was located in the area which were anchored by bare mental stent, and in the other 6 patients it was located in the anterior part of ascending aorta. The mean cardiopulmonary bypass time was 152.2±29.4 min, aortic cross-clamping time was 93.6±27.8 min and selective cerebral perfusion time was 29.8±8.3 min. There was no death in hospital or within postoperative 30 days. The follow-up period was 32-85 (57.4±18.3) months. No death occurred during the follow-up period. One patient underwent TEVAR again 3 years after this operation and had an uneventful survival. Conclusion Total arch replacement with the frozen elephant trunk technique is a suitable strategy for the management of RTAD after TEVAR for Stanford type B aortic dissection.
In recent years, the diagnosis and management technology of type B aortic dissection (TBAD) has developed rapidly worldwide along with evidence-based medicine practice and clinical research data. But the standard clinical criteria are still limited. Based on this, the Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) established an expert group dominated by aortic surgeons to collate and analyze the comprehensive literature data of acute and chronic, complicated and uncomplicated TBAD. And then, the group formulated and officially released the clinical practice guidelines for TBAD in 2022. In this paper, we interpreted and analyzed the main contents of the guideline in combination with domestic research, in order to provide reference and help for the clinical diagnosis and treatment of TBAD at the present stage in China.
Objective To summarize the advantages and key points of external fenestration in the treatment of aortic dissection involved visceral branch arteries after endovascular aortic repair (EVAR), and to explore the application effect of external fenestration in aortic dissection involved visceral branch arteries. Methods A patient with abdominal aortic aneurysm resulting in abdominal aortic dissection and involving multiple visceral arteries after EVAR was treated in Center of Vascular and Interventional Surgery, Department of General Surgery, The Third People’s Hospital of Chengdu. The surgical procedure of this patient was summarized, and the current status of total lumen technique in the treatment of such diseases was discussed and analyzed. Results The operation was successful, and it took only five hours, the intraoperative blood loss was about 100 mL, the patient was kept in ICU for one day and discharged one week after surgery and no serious postoperative complications occurred (such as spinal cord ischemia, liver and kidney insufficiency, infection, lower limb ischemia, puncture pseudoaneurysm, etc.). Aortic CT angiography was reexamined in three months after surgery, and the three-dimensional reconstruction showed that the aortic stent was stable, the blood flow of visceral branch arteries was smooth, and the aortic dissection was well isolated. Conclusion Endovascular repair of aortic dissection involving branch arteries of important organs can be achieved by external fenestration technique, it is a new treatment for aortic lesions involved visceral branch arteries.
Objective To analyze the clinical effect of hybrid surgery on complex type B aortic dissection in 5 years. Methods A retrospective analysis of 47 patients with complex type B aortic dissection in the Central Hospital of Wuhan affiliated to Tongji Medical College of Huazhong University of Science and Technology from 2014 to 2017 was conducted, including 42 males and 5 females with an average age of 54.9±11.2 years. Twenty-one patients underwent the left common carotid artery to the left subclavian artery bypass (a bypass group), and 26 patients underwent the left common carotid artery to the left subclavian artery transposition (a transposition group). Results All patients accepted hybrid surgery successfully. There was no statistical difference in arterial occlusion time or intraoperative blood loss between the two groups (P＞0.05). The 5-year follow-up rate was 100.0% (47/47). During the follow-up period, 12 (25.5%) patients developed complications, including 5 (10.6%) patients of endoleak, 5 (10.6%) patients of hoarseness, 2 (4.3%) patients of stroke/dizziness. There was no patient of left upper limb weakness, paraplegia or retrograde aotic dissection. The reconstructed left subclavian artery remained patent in 46 (97.9%) patients. The overall 5-year survival rate was 100.0%. Conclusion The long-term therapeutic outcome of hybrid surgery for the treatment of complex type B aortic dissection is satisfying. In 5 years, the rebuilt left subclavian artery has a remarkable patency rate. Endoleak and hoarseness are the most common surgical complications.
ObjectiveTo summarize the surgical treatment plan and experience of patients with Marfan syndrome complicated with Stanford type B aortic dissection, and to explore the treatment strategy selection.MethodsA retrospective analysis was conducted on 27 patients with Marfan syndrome complicated with thoracoabdominal aortic diseases who were treated in the department of cardiovascular surgery of our hospital from January 2013 to June 2019, including 13 males and 14 females, with an average age of 32.2±8.6 years. According to the patients' conditions, 19 of them received single pump-assisted blood transfusion combined with total thoracoabdominal aortic replacement (TAAAR), and 8 received thoracic endovascular aortic repair (TEVAR) in critically ill and pregnant patients. The patients were followed up in the outpatient clinic, and the thoracoabdominal aortic CT angiography was reexamined at 3 months, 6 months, 12 months and annually. The outcome of surgery, the incidence of intermediate cardiovascular adverse events, defined as the reoperation due to aortic or cardiac diseases, and intermediate survival rate were studied.ResultsAll 27 patients successfully completed the operation, the operation time was 60-852 (395.10±222.60) min, the spinal cord ischemia time was 14-26 (19.33±3.44) min, and the abdominal viscera ischemia time was 16-23 (19.83±1.94) min. Eight patients of TEVAR were all operated in acute phase and 19 patients of TAAAR in chronic phase. Two early postoperative deaths occurred in TEVAR patients. One died of puerperal infection and multiple organ dysfunction after cesarean section at the same time. After TEVAR, type A dissection re-ocurred in one patient. The family member gave up the treatment, and the patient died of the dissection ruptured after cesarean section. During the average follow-up of 47.6±36.7 months, 1 patient died of cerebrovascular accident and 9 patients were reoperated for adverse cardiovascular events, including 4 in TEVAR and 5 in TAAAR.ConclusionTAAAR is the first choice for the treatment of Marfan syndrome combined with thoracoabdominal aortic diseases. TEVAR is easy to operate, with a low incidence of early mortality and complications, but has the risk of internal leakage and avulsion, and a high reoperation rate in the middle stage, so it can be used for high-risk elderly patients not suitable for open surgery, or as a bridge therapy for emergency patients before open surgery.
Objective To analyze the clinical characteristics and risk factors of noninfectious fever after endovascular repair of aortic dilatation diseases, and explore the management strategy. Methods We reviewed 468 patients who received endovascular aortic repair from January 2021 to October 2023. The patients who were selected were classified into a febrile group and an afebrile group according the fever after operation. The fever data were analyzed, and the demographics, operative data were researched to sieve out the correlation factors. Logistic regression analysis was conducted for the risk factors of postoperative fever if the P value≤0.05 in the univariate analysis, and receiver operating characteristic curve (ROC) was used to analyze the predictive indexes of postoperative noninfectious fever. Results75.08% (229/305) patients had noninfectious fever after aortic repair and 98.25% of them had fever within 2 days. There were 229 patients in the febrile group, mean age 65 (53.0,73.0) years (83.4% males , and 76 patients in the afebrile group, mean age 71(65.0,76.7) years(84.2% males). Univariate analysis showed that the number of patients with coronary heart disease, using statins before operation and aortic aneurysm in the febrile group were significantly lower than those in the afebrile group, and patients were younger in the febrile group. The logistic regression showed that age, surgical site, type of disease, preoperative hyperthermia, type of stent were positively correlated with noninfectious fever, while statin use was negatively associated with noninfectious fever. And age, surgical site, preoperative hyperthermia and stent type were analyzed by means of ROC curve (P<0.01). Conclusion Noninfectious fever is very common after aortic repair. The relationship between fever and infection should be comprehensively judged according to the risk factors of noninfectious fever and the disease status to promote rational use of antibiotics.
Objective To explore the effectiveness and predictive value of computer simulated thoracic endovascular aortic repair (TEVAR). Methods The clinical data of the patients with Stanford type B aortic dissection who underwent TEVAR from February 2019 to February 2022 in our hospital was collected. According to whether there was residual false cavity around the stent about 1 week after TEVAR, the patients were divided into a false cavity closure group and a false cavity residual group. Based on computer simulation, personalized design and three-dimensional construction of the stent framework and covering were carried out. After the stent framework and membrane were assembled, they were pressed and placed into the reconstructed aortic dissection model. TEVAR computer simulation was performed, and the simulation results were analyzed for hemodynamics to obtain the maximum blood flow velocity and maximum wall shear stress at the false lumen outlet level at the peak systolic velocity of the ventricle, which were compared with the real hemodynamic data of the patient after TEVAR surgery. The impact of hemodynamics on the residual false lumen around the stent in the near future based on computer simulation of hemodynamic data after TEVAR surgery was further explored. Results Finally a total of 28 patients were collected, including 24 males and 4 females aged 53.390±11.020 years. There were 18 patients in the false cavity closure group, and 10 patients in the false cavity residual group. The error rate of shear stress of the distal decompression port of the false cavity after computer simulation TEVAR was 6%-25%, and the error rate of blood flow velocity was 3%-31%. There was no statistical difference in age, proportion of male, history of hypertension, history of diabetes, smoking history, prothrombin time or activated partial thromboplatin time at admission between the two groups (all P>0.05). The blood flow velocity and shear stress after TEVAR were statistically significant (all P<0.05). The maximum shear stress (OR=1.823, P=0.010) of the false cavity at the level of the distal decompression port after simulated TEVAR was an independent risk factor for the residual false cavity around the stent. Receiver operating characteristic curve analysis showed that the area under the curve corresponding to the maximum shear stress of false cavity at the level of distal decompression port after simulated TEVAR was 0.872, the best cross-sectional value was 8.469 Pa, and the sensitivity and specificity were 90.0% and 83.3%, respectively. Conclusion Computers can effectively simulate TEVAR and perform hemodynamic analysis before and after TEVAR surgery through simulation. Maximum shear stress at the decompression port of the distal end of the false cavity is an independent risk factor for the residual false cavity around the stent. When it is greater than 8.469 Pa, the probability of residual false cavity around the stent increases greatly.
