Objective To compare surgical outcomes of Stanford type A acute aortic dissection between operations at midnight and daytime. Methods From January 2004 to March 2013，195 patients with Stanford type A acute aortic dissection received surgical treatment in Nanjing Hospital Affiliated to Nanjing Medical University （Nanjing Cardiovascular Disease Hospital）. Patients with identical or similar propensity scores were matched from 127 patients who underwent emergency operation at daytime and 68 patients who underwent emergency operation at midnight. A total of 58 pairs of matched patients which had the same or similar propensity score were selected in daytime surgery group （n=58，43 males and 15 females，47.7±14.6 years） and midnight surgery group （n=58，45 males and 13 females，48.3±14.6 years）. Operation time，postoperative chest drainage，mechanical ventilation time，postoperative incidence of dialysis and tracheostomy，length of ICU stay and in-hospital mortality were compared between the daytime group and midnight group. Results A total of 58 pair of patients were matched in this study. There was no statistical difference in postoperative incidence of tracheostomy ［19.0% （11/58） vs. 6.9% （4/58），P=0.053］ or in-hospital mortality ［8.6% （5/58） vs. 6.9%（4/58），P=0.729］ between the midnight group and daytime group. Operation time （485.7±93.5 minutes vs. 428.5±123.3 minutes，P=0.048），postoperative chest drainage （979.5±235.7 ml vs. 756.6±185.9 ml，P=0.031），mechanical ventilation time （67.9±13.8 hours vs. 55.7±11.9 hours，P=0.025），postoperative incidence of dialysis ［17.2% （10/58） vs. 5.2%（3/58），P=0.039］ and length of ICU stay （89.4±16.2 hours vs. 74.8±12.5 hours，P=0.023） of the midnight group weresignificantly longer or higher than those of the daytime group. A total of 107 patients were followed up for 4-6 months after discharge. During follow-up，there was no late death. Among the 13 patients who required postoperative dialysis，12 patientsno longer needed regular dialysis. Conclusion Emergency operation at midnight does not increase in-hospital mortalitybut increase some postoperative morbidity in patients with Stanford type A acute aortic dissection. Whether at midnight or daytime，better preoperative preparation and surgeons’ vigor are needed for timely surgical treatment for patients with Stanford type A acute aortic dissection.
Objective To summarize our diagnostic and treatment experience for patients with acute Stanford type A aortic dissection （AAAD） during pregnancy. Methods Clinical data of 3 AAAD gravida （age of 30，32，35） who received surgical treatment in Beijing Anzhen Hospital of Capital Medical University from May 2008 to July 2010 were retros-pectively analyzed. One gravida received Sun’s procedure （total arch replacement combined with stented elephant trunk implantation） 3 days after cesarean section，but the fetus died in the uterus. Another gravida successfully underwent Bentall procedure and Sun’s procedure immediately after cesarean section and hysterectomy. The third gravida received cesarean section with the uterus in situ followed by ascending aorta replacement and Sun’s procedure. Results All the 3 puerperasrecovered uneventfully，and the 2 newborns of the second and third puerperas also lived well. The 3 puerperas were followedup for 6 months after discharge. CT scan showed organized thrombus in the aortic false lumen. During follow-up，the 3 puerperas recovered well，and the 2 infants had normal growth and development. Conclusions Management principles of AAAD during pregnancy firstly include timely and accurate diagnosis，which is of prime importance. Secondly，gravidas’hemodynamics should maintain stable. Thirdly，intraoperative hemorrhage should be satisfactorily controlled. Lastly，multi-modality treatment is very important to improve the prognosis of both gravidas and fetuses.
Objective To systematic evaluate the efficacy and safety of the endovascular aortic repair （endovascular stent placement） and open operation in treatment of acute Stanford type B aortic dissection. Methods The literatures about clinical controlled trials of endovascular aortic repair and open operation in treatment of acute Stanford type B aortic dissection that were included in CNKI， Wanfang data， VIP， Cochrane Central Register of Controlled Trials of the Cochrane Library， OVID， Pubmed Medline， EBSCO， EMBASE， Springer Link，Science Direct， and other databases from January 1991 to January 2013 were retrieved by computer. RevMan 5.1 software were used to analyze the clinical trial data. Results Eight trials （5 618 patients with acute Stanford type B aortic dissection） were included in the analysis.There was statistically significant difference of the 30 d mortality after operation between the endovascular repair group and the open operation group， which endovascular repair group was significantly better than the open operation group〔OR=0.55，95% CI （0.46-0.65）， P＜0.000 01〕. In addition， there were significant difference between the incidence of stroke 〔OR=0.57， 95% CI （0.39-0.84）， P=0.005〕， respiratory failure 〔OR=0.64， 95% CI （0.53-0.78）， P＜0.000 01〕， and cardiac complications 〔OR=0.49，95% CI （0.38-0.64），P＜0.000 01〕，which endovascular repair group was better than the open operation group. However，endovascular repair could not improve the postoperative outcomes of paraplegia〔OR=1.30，95% CI （0.82-2.05），P=0.26〕 and acute renal failure 〔OR=0.86，95% CI （0.41-1.80），P=0.69〕. Conclusion Endovascular repair for treatment acute Stanford type B aortic dissection is preferred method.
ObjectiveTo investigate the therapeutic strategies of endovascular repair for complicated Stanford type B aortic dissection. MethodThe clinical data of 36 patients with complicated Stanford type B aortic dissection treated by endovascular repair were analyzed retrospectively. ResultsThirty-six patients with complicated Stanford type B aortic dissection were treated successfully by endovascular repair. Twenty-two cases were treated by endovascular repair combined with covering left subclavian artery (LSA). Ten cases were treated by endovascular repair combined with chimney technique. Two cases were treated by endovascular repair combined with vascular prosthesis bypass from left common carotid artery to LSA. Two cases were treated by endovascular repair combined with vascular prosthesis bypass from right common carotid artery to left common carotid artery, whose proximal part were ligated. The viscera artery and lower extremity artery supply were restored gradually. No complication such as endoleak occurred. ConclusionFor endovascular repair of complicated Stanford type B aortic dissection, strategies combined with covering LSA, chimney technique, and hybrid operation of small incision could extend anchor zone, expand the range of endovascular repair of aortic dissection, improve curative effect, reduce complications.
ObjectiveTo summarize clinical experience of different surgical strategies for the treatment of acute Stanford type A aortic dissection (AD). MethodsClinical data of 197 patients with acute Stanford type A AD who underwent surgical treatment in the First Affiliated Hospital of China Medical University from January 2008 to November 2012 were retrospectively reviewed. There were 131 males and 66 females with their age of 24-77 (51.2±13.9) years. All the patients received magentic resonance imaging (MRI) or aortic CT angiography (CTA) for the establishment of diagnosis. According to different aortic root conditions,ascending aorta replacement,Bentall,Wheat,Cabrol or David procedures were performed. Total arch replacement, hemiarch replacement or simplified total arch replacement was also performed for aortic arch dissection combined with stented elephant trunk implantation. ResultsA total of 113 patients (57.4%) underwent isolated ascending aorta replacement,67 patients (34.0%) received Bentall procedure,13 patients (6.6%) received Wheat procedure,1 patient(0.5%) received Cabrol procedure,and 3 patients (1.5%) received David procedure. Eighty-two patients (41.6%) underwent total arch replacement combined with stented elephant trunk implantation,77 patients (39.1%) received hemiarch replacement, and the other 41 patients (20.8%) received simplified total arch replacement combined with stented elephant trunk implantation. One patient (0.5%) underwent reexploration for postoperative bleeding. No permanent neurological complication occurred. Thirty-day mortality after surgery was 4.1% (8/197). Follow-up duration was 3-52 (15.9±11.4) months with the follow-up rate of 65.0%. One patient with Marfan syndrome died of abdominal aortic aneurysm rupture 8 months after surgery. ConclusionAccording to different AD conditions, appropriate surgical strategies can be chosen to achieve satisfactory clinical outcomes for patients with acute Stanford type A AD.
ObjectiveTo evaluate clinical outcomes of thoracic endovascular aortic repair (TEVAR)for the treatment of Stanford type B aortic dissection (AD)and descending aortic aneurysm. MethodsClinical data of 20 patients with Stanford type B AD or descending aortic aneurysm who underwent TEVAR in West China Hospital from March to June 2013 were retrospectively analyzed. There were 19 male and 1 female patients with their age of 41-76 (58.3±10.2)years. Clinical outcomes were analyzed. ResultsAmong the 20 patients, 18 patients were successfully discharged, 1 patient refused further postoperative treatment and was discharged, and 1 patient died postoperatively. Sixteen patients (88.9%)were followed up for over 3 months. In all the patients during follow-up, true lumen diameter recovered within the scope of intravascular stents, and there was thrombosis in false lumen or aneurysm lumen. ConclusionTEVAR provides a new choice with significant advantages for the treatment of Stanford type B AD, especially for the elderly and patients with concomitant serious diseases, so it is worthy of clinical application.
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.
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 clinical experience and surgical indications of open stented elephant trunk (sET) procedure for the treatment of complex acute Stanford type B aortic dissection (AD). MethodsFrom February 2009 to April 2013, 25 patients with complex acute Stanford type B AD underwent open sET procedure in Beijing Anzhen Hospital. There were 22 male and 3 female patients with their age of 46.92±9.12 years (range, 30 to 66 years). There were 16 patients with hypertension and 3 patients with preoperative acute renal failure. All the patients received sET implantation via an aortic arch incision under deep hypothermic circulatory arrest. Concomitant procedures included extra-anatomic bypass grafting in 11 patients, Bentall procedure in 1 patient, aortic valve replacement in 3 patients, and ascending aorta plasty in 3 patients. Computed tomography angiography (CTA) was performed before discharge and during follow-up for all the patients. ResultsOperation time was 4-7 (5.5±0.7) hours, cardiopulmonary bypass time was 93-206 (137.64±30.02) minutes, aortic cross-clamping time was 28-109 (57.96±21.05) minutes, and selective cerebral perfusion time was 15-76 (26.76±11.88) minutes. There was no in-hospital death. Postoperatively, there were 2 patients with pulmonary complications, 2 patients with type I endoleak, 1 patient with acute renal failure, 1 patient with temporary neurological disorder, 1 patient with sudden ventricular fibrillation, and 1 patient with delayed wound healing. Mean follow-up time was 6-54 (25.76±16.15) months, and 2 patients were lost during follow-up. The follow-up rate was 92%.There was no late death during follow-up. ConclusionsOpen sET procedure is a reliable and efficacious therapeutic strategy for patients with complex acute Stanford type B AD. Surgical indications include complex Stanford type B AD without enough landing zone, type B AD with ascending aortic disease, aortic root disease, valvular heart disease, coronary artery disease and congenital heart defects, and type B AD caused by genetic connective tissue disorder.
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.