Surgical Treatment of Stanford Type A Aortic Dissection_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

DONG Yifei , LU Andong , MING Kai , YIN Qing , DONG Shuqiang , CAO Wenfeng , MENG Yi .

Department of Cardiovascular Surgery，General Hospital of Lanzhou MilitaryRegion，Lanzhou 730050，P. R. China;

Corresponding author：

Keywords：

Aortic dissection; 　Cardiovascular surgery; 　Selected cerebral perfusion; 　Aortic arch replacement; 　Stented elephant trunk

DOI：

10.7507/1007-4848.20130204

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Objective To summarize treatment experience and evaluate clinical outcomes of surgical therapy for Stanford type A aortic dissection （AD）. Methods Clinical data of 48 patients with Stanford type A AD who underwent surgical treatment in General Hospital of Lanzhou Military Region from October 2006 to March 2013 were retrospectively analyzed. There were 41 males and 7 females with their age of 26-72 （47.6±9.2） years. There were 43 patients with acute Stanford type A AD （interval between symptom onset and diagnosis＜14 days） and 5 patients with chronic AD. There were 19 patients with moderate to severe aortic insufficiency and 6 patients with Marfan symdrome but good aortic valve function，who all received Bentall procedure，total arch replacement and stented elephant trunk implantation. There were 8 patients with AD involving the aortic root but good aortic valve function who underwent modified David procedure，total arch replacement and stented elephant trunk implantation. There were 10 patients with AD involving the ascending aorta who received ascending aorta replacement，total arch replacement and stented elephant trunk implantation. There were 5 patients with AD involving partial aortic arch who underwent ascending aorta and hemiarch replacement. Patients were followed up in the 3rd，6th and 12th month after discharge then once every year. Follow-up evaluation included general patient conditions，blood pressure control，chest pain recurrence，mobility and computerized tomography arteriography （CTA）. ResultsCardiopulmonary bypass time was 121-500 （191.4±50.6） minutes，aortic cross-clamp time was 58-212 （112.3±31.7） minutes，and circulatory arrest and selective cerebral perfusion time was 26-56 （34.8±8.7） minutes. Postoperative mechanicalventilation time was 32-250 （76.2±35.6） hours，and ICU stay was 3-20 （7.1±3.4） days. Thoracic drainage within 24 hours postoperatively was 680-1 600 （1 092.5±236.3） ml. Seven patients （14.5%） died perioperatively including 2 patients with multiple organ dysfunction syndrome，2 patients with low cardiac output syndrome，1 patient with renal failure，1patient with delayed refractory hemorrhage，and 1 patient with coma. Twenty patients had other postoperative complicationsand were cured or improved after treatment. A total of 38 patients ［92.7% （38/41）］ were followed up for 3-48 （13.0±8.9） months，and 3 patients were lost during follow-up. During follow-up，there were 36 patients alive and 2 patients who died of other chronic diseases. There was no AD-related death during follow-up. None of the patients required reoperation for AD or false-lumen expansion. CTA at 6th month after discharge showed no anastomotic leakage，graft distortion or obstruction.Conclusion According to aortic intimal tear locations，ascending aorta diameter and AD involving scopes，appropriate surgical strategies，timing and organ protection are the key strategies to achieve optimal surgical results for Stanford type A AD. Combined axillary and femoral artery perfusion and increased lowest intraoperative temperature are good methods for satisfactory surgical outcomes of Stanford type A AD.

Citation： DONG Yifei,LU Andong,MING Kai,YIN Qing,DONG Shuqiang,CAO Wenfeng,MENG Yi .. Surgical Treatment of Stanford Type A Aortic Dissection. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2013, 20(6): 647-652. doi: 10.7507/1007-4848.20130204 Copy

1.	Mehta RH， Suzuki T， Hagan PG， et al. Predicting death in patients with acute type a aortic dissection. Circulation， 2002， 105 （2）：200-206.
2.	Atkins MD， Blark JH， Cambria RP. Aortic dissection：perspectives in the era of stent-graft repair. J Vasc Surg， 2006， 43 （2）：30-43.
3.	范阜东，张杰，武忠，等. A型主动脉夹层患者术前猝死相关因素分析. 中国胸心血管外科临床杂志， 2012， 19 （5）：502-506.
4.	Trimarchi S， Eagle KA， Nienaber CA， et al. Role of age in acute type A aortic dissection outcome：report from the International Registry of Acute Aortic Dissection （IRAD）. J Thorac Cardiovasc Surg， 2010， 140 （4）：784-789.
5.	Mészáros I， Mórocz J， Szlávi J， et al. Epidemiology and clinicopathology of aortic dissection. Chest， 2000， 117 （5）：1271-1278.
6.	Weigang E， Nienaber CA， Rehders TC， et al. Management of patients with aortic dissection. Dtsch Arztebl Int， 2008， 105 （38）：639-645.
7.	Hoefer D， Ruttmann E， Riha M， et al. Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A. Ann Thorac Surg， 2002， 73 （3）：714-718.
8.	Issa M， Avezum Á， Dantas DC， et al. Risk factors for pre， intra， and postoperative hospital mortality in patients undergoing aortic sur-gery. Rev Bras Cir Cardiovasc， 2013， 28 （1）：10-21.
9.	Sun L， Qi R， Zhu J， et al. Total arch replacement combined with stented elephant trunk implantation：a new “standard” therapy for type a dissection involving repair of the aortic arch ? Circulation， 2011， 123 （9）：971-978.
10.	Halstead JC， Meier M， Etz C， et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg， 2007， 133 （1）：127-135.
11.	Crawford ES， Kirklin JW， Naftel DC， et al. Surgery for acute dissec-tion of ascending aorta. Should the arch h included ? J ThoracCardiovasc Surg， 1992， 104 （1）：46-59.
12.	Chua M， Ibrahim I， Neo X， et al. Acute aortic dissection in the ED：risk factors and predictors for missed diagnosis. Am J Emerg Med， 2012， 30 （8）：1622-1626.
13.	Paparella D， Rotunno C， Guida P， et al. Hemostasis alterations in patients with acute aortic dissection. Ann Thorac Surg， 2011， 91 （5）：1364-1369.
14.	Sun L， Qi R， Zhu J， et al. Repair of acute type A dissection：our experiences and results. Ann Thorac Surg， 2011， 91 （4）：1147-1152.
15.	刘心甜，吴明祥，刘成伟，等. 马方综合征并发A型主动脉夹层的手术疗效. 中国胸心血管外科临床杂志， 2013， 20 （1）：49-53.
16.	Shi E， Gu T， Yu L， et al. Repair of Stanford type A aortic dissectionwith ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique by using innominate cannulation. J Thorac Cardiovasc Surg， 2011， 142 （6）：1458-1463.
17.	Chen X， Huang F， Xu M， et al. The stented elephant trunk procedure combined total arch replacement for Debakey I aortic dissection：operative result and follow-up. Interact Cardiovasc Thorac Surg， 2010， 11 （5）：594-598.
18.	Uchida N， Ishihara H， Shibamura H， et al. Midterm result s of exte-nsive primary repair of the thoracic aorta by means of total arch repl-acement with open stent graft placement for an acute type A aortic dissection. J Thorac Cardiovasc Surg， 2006， 131 （4）：862-867.
19.	Schmoker JD， Terrien C， McPartland KJ， et al. Cerebrovascular response to continuous cold perfusion and hypothermic circulatory arrest. J Thorac Cardiovasc Surg， 2009， 137 （2）：459-464.
20.	Bachet J， Guilmet D. Brain protection during surgery of the aortic arch. J Card Surg， 2002， 17 （2）：115-124.
21.	Zierer A， El-Sayed Ahmad A， Papadopoulos N， et al. Selectiveantegrade cerebral perfusion and mild （28 ℃ -30 ℃） systemic hypothermic circulatory arrest for aortic arch replacement：results from 1002 patients. J Thorac Cardiovasc Surg， 2012， 144 （5）：1042-1049.
22.	Christensen MC， Krapf S， Kempel A， et al. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg， 2009， 138 （3）：687-693.
23.	Nakanishi K， Takeda S， Sakamoto A， et al. Effects of ulinastatin treatment on the cardiopulmonary bypass-induced hemodynamic instability and pulmonary dysfunction. Crit Care Med， 2006， 34 （5）：1351-1357.
24.	Ide M， Bolliger D， Taketomi T， et al. Lessons from the aprotinin saga：current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth， 2010， 24 （1）：96-106.
25.	Emmert MY， Salzberg SP， Theusinger OM， et al. How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery. Interact Cardiovasc Thorac Surg， 2011， 12 （2）：183-188.

1. 　Mehta RH， Suzuki T， Hagan PG， et al. Predicting death in patients with acute type a aortic dissection. Circulation， 2002， 105 （2）：200-206.
2. 　Atkins MD， Blark JH， Cambria RP. Aortic dissection：perspectives in the era of stent-graft repair. J Vasc Surg， 2006， 43 （2）：30-43.
3. 　范阜东，张杰，武忠，等. A型主动脉夹层患者术前猝死相关因素分析. 中国胸心血管外科临床杂志， 2012， 19 （5）：502-506.
4. 　Trimarchi S， Eagle KA， Nienaber CA， et al. Role of age in acute type A aortic dissection outcome：report from the International Registry of Acute Aortic Dissection （IRAD）. J Thorac Cardiovasc Surg， 2010， 140 （4）：784-789.
5. 　Mészáros I， Mórocz J， Szlávi J， et al. Epidemiology and clinicopathology of aortic dissection. Chest， 2000， 117 （5）：1271-1278.
6. 　Weigang E， Nienaber CA， Rehders TC， et al. Management of patients with aortic dissection. Dtsch Arztebl Int， 2008， 105 （38）：639-645.
7. 　Hoefer D， Ruttmann E， Riha M， et al. Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A. Ann Thorac Surg， 2002， 73 （3）：714-718.
8. 　Issa M， Avezum Á， Dantas DC， et al. Risk factors for pre， intra， and postoperative hospital mortality in patients undergoing aortic sur-gery. Rev Bras Cir Cardiovasc， 2013， 28 （1）：10-21.
9. 　Sun L， Qi R， Zhu J， et al. Total arch replacement combined with stented elephant trunk implantation：a new “standard” therapy for type a dissection involving repair of the aortic arch ? Circulation， 2011， 123 （9）：971-978.
10. 　Halstead JC， Meier M， Etz C， et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg， 2007， 133 （1）：127-135.
11. 　Crawford ES， Kirklin JW， Naftel DC， et al. Surgery for acute dissec-tion of ascending aorta. Should the arch h included ? J ThoracCardiovasc Surg， 1992， 104 （1）：46-59.
12. 　Chua M， Ibrahim I， Neo X， et al. Acute aortic dissection in the ED：risk factors and predictors for missed diagnosis. Am J Emerg Med， 2012， 30 （8）：1622-1626.
13. 　Paparella D， Rotunno C， Guida P， et al. Hemostasis alterations in patients with acute aortic dissection. Ann Thorac Surg， 2011， 91 （5）：1364-1369.
14. 　Sun L， Qi R， Zhu J， et al. Repair of acute type A dissection：our experiences and results. Ann Thorac Surg， 2011， 91 （4）：1147-1152.
15. 　刘心甜，吴明祥，刘成伟，等. 马方综合征并发A型主动脉夹层的手术疗效. 中国胸心血管外科临床杂志， 2013， 20 （1）：49-53.
16. 　Shi E， Gu T， Yu L， et al. Repair of Stanford type A aortic dissectionwith ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique by using innominate cannulation. J Thorac Cardiovasc Surg， 2011， 142 （6）：1458-1463.
17. 　Chen X， Huang F， Xu M， et al. The stented elephant trunk procedure combined total arch replacement for Debakey I aortic dissection：operative result and follow-up. Interact Cardiovasc Thorac Surg， 2010， 11 （5）：594-598.
18. 　Uchida N， Ishihara H， Shibamura H， et al. Midterm result s of exte-nsive primary repair of the thoracic aorta by means of total arch repl-acement with open stent graft placement for an acute type A aortic dissection. J Thorac Cardiovasc Surg， 2006， 131 （4）：862-867.
19. 　Schmoker JD， Terrien C， McPartland KJ， et al. Cerebrovascular response to continuous cold perfusion and hypothermic circulatory arrest. J Thorac Cardiovasc Surg， 2009， 137 （2）：459-464.
20. 　Bachet J， Guilmet D. Brain protection during surgery of the aortic arch. J Card Surg， 2002， 17 （2）：115-124.
21. 　Zierer A， El-Sayed Ahmad A， Papadopoulos N， et al. Selectiveantegrade cerebral perfusion and mild （28 ℃ -30 ℃） systemic hypothermic circulatory arrest for aortic arch replacement：results from 1002 patients. J Thorac Cardiovasc Surg， 2012， 144 （5）：1042-1049.
22. 　Christensen MC， Krapf S， Kempel A， et al. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg， 2009， 138 （3）：687-693.
23. 　Nakanishi K， Takeda S， Sakamoto A， et al. Effects of ulinastatin treatment on the cardiopulmonary bypass-induced hemodynamic instability and pulmonary dysfunction. Crit Care Med， 2006， 34 （5）：1351-1357.
24. 　Ide M， Bolliger D， Taketomi T， et al. Lessons from the aprotinin saga：current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth， 2010， 24 （1）：96-106.
25. 　Emmert MY， Salzberg SP， Theusinger OM， et al. How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery. Interact Cardiovasc Thorac Surg， 2011， 12 （2）：183-188.

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Surgical Treatment of Stanford Type A Aortic Dissection

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