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 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 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.
Objective To compare the short and mid-term outcomes of open surgery and hybrid technique for the treatment of complex type B aortic dissection (AD). Methods A total of 45 patients (37 acute AD and 8 chronic AD) with complex type B AD were admitted to Nanjing First Hospital from January 2012 to June 2016, including 37 males and 8 females. All patients were confirmed by computed tomography angiography (CTA), and ultrasonic cardiogram (UCG) to rule out valvular diseases, aortic root and ascending aorta lesion, and pericardial effusion. According to different treatments, patients were divided into two groups: the open surgery group (OS group) with a total of 25 patients (20 males, 5 females, a mean age of 50.16±10.87 years); the hybrid technique group (HT group) with a total 20 patients (18 males, 2 females, mean age of 51.31±8.11 years). The short and mid-term outcomes of open surgery and hybrid technique for the treatment of complex type B AD were compared. Results All the patients were discharged successfully. There was no death, cognitive impairment, cerebral infarction, hemiplegia, paraplegia, coma and other neurological complications in both groups. In the OS group, one patient suffered acute kidney injury and received renal replacement therapy (RRT), whose renal function was returned to normal prior to discharge; one patient was transferred to ICU again owing to pericardial effusion, respiratory failure and lung infection; one patient underwent debridement surgery because of postoprative sternal dehiscence. In the HT group, one patient with recurrent chest pain five days after endovascular aortic repair, whose CTA showed hematoma of aortic arch and ascending aorta caused by reverse tear, underwent Sun’s procedure immediately. All patients received CTA examination three months after operation in outpatient room. In the OS Group, the tear of AD was closed well by stent-graft and no leakage or shunt was detected in CTA. The rate of thrombosis formation in thoracic aortic false lumen was 100.0%. Meanwhile, in the HT Group, there was one patient with type Ⅱ leakage and the rate of thrombosis formation in thoracic aortic false lumen was 94.7%. Conclusion For complex type B AD without optimal "landing zone" in descending aorta, open surgery is recommended as the first choice for experienced team because of its less costs and perfect results; hybrid technique which can achieve quicker recovery with less surgical trauma still has serious complications such as leakage, reverse tear, and so on.
Acute aortic dissection is featured as sudden onset and high mortality. Regardless early optimal surgical intervention and strict medical therapy, incidence of late complications is still high. Thus, specific imaging techniques and precise measurement of biomarkers to predict complications are needed. In the present study, we reviewed related papers to compare traditional imaging techniques (computed tomography, echocardiography) and magnetic resonance imaging (MRI) in the diagnosis of chronic aortic dissection. In addition, we discussed how to further evaluate aortic dissection by MRI.
ObjectiveTo investigate the effect of distal tears on postoperative aortic remodeling after Thoracic Endovascular Aortic Repair (TEVAR) for the patients with subacute stage of Stanford type B aortic dissection.MethodsForty three cases with Stanford type B aortic dissection, admitted in Anhui Provincial Hospital from July 2011 to April 2015, who underwent TEVAR to repair the proximal aortic entrance tear, after which the blood reflex from distal tears were still observed were analyzed retrospectively. According to the number of heart volume required to fill the two groups, group A (≤2 heart rate) group B （>2 heart rate）, We then assessed the changes of the true and false lumen area and analyzed the effects of direction of blood flow and the number of heart rate to fill the false lumen on formation of false lumen thrombosis in the period of 3–24 months.ResultsAll the stents were successful implanted. There was a statistically significant difference in lumen area between the two groups before and after surgery, and univariate analysis showed that the direction of distal rupture of blood flow into the false lumen had no effect on postoperative aortic remodeling (P<0.05), but postoperative hypertension (≥140/90 mmHg) slows down the formation of false lumen thrombosis.ConclusionPatients had entrance tear in the distal of aortic, still broken and faster flow after TEVAR stent-graft implantation in the proximal closed entrance tear. Blood pressure should be strictly controlled and close follow-up also needed, meanwhile, the distal entrances can be closed the same period if there is a faster flow from them.
ObjectiveTo analyze the effectiveness of in vitro fenestration versus bypass surgery techniques in the treatment of type B aortic dissection involving the left subclavian artery by thoracic endovascular aortic repair (TEVAR).MethodsAmong the 53 patients with type B aortic dissection involving the left subclavian artery admitted to our center from January 2017 to October 2020, 23 underwent in vitro fenestration + TEVAR (a fenestration group with 18 males and 5 females aged 53.6±5.3 years), and 30 patients underwent left common carotid artery-left subclavian artery bypass + TEVAR (a bypass group with 24 males and 6 females aged 51.8±3.8 years). The effectiveness and safety between the two groups were compared.ResultsThe surgical success rate was 100.0% in both groups. And there was no death within postoperative 30 days and during the follow-up. There was no endoleak immediately postoperatively and during 1-year follow-up in the two groups. The operation time and hospitalization expenses in the fenestration group was less or shorter than those in the bypass group (P<0.05). The reduction in blood pressure of the left upper limb in the fenestration group was greater than that in the bypass group (P<0.05). There was no symptom of left upper limb ischemia, dizziness or hoarseness in both groups.ConclusionThe two methods of reconstruction of the left subclavian artery are safe and effective. In vitro fenestration can reduce surgical trauma and costs, and bypass surgery can provide better forward blood flow for the left subclavian artery.
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.
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.