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Der Anaesthesist Dec 2021Aortic arch repair for aortic dissection is still associated with a high mortality rate. Providing adequate means of neuromonitoring to guide cerebral hemodynamics is...
BACKGROUND
Aortic arch repair for aortic dissection is still associated with a high mortality rate. Providing adequate means of neuromonitoring to guide cerebral hemodynamics is advantageous, especially during selective anterior cerebral perfusion (SACP).
OBJECTIVE
We aimed to investigate an easy multimodal neuromonitoring set-up consisting of processed electroencephalography (EEG), near infrared spectroscopy (NIRS), and transcranial doppler sonography (TCD).
MATERIAL AND METHODS
We collected intraoperative data from six patients undergoing surgery for aortic dissection. In addition to standard hemodynamic monitoring, patients underwent continuous bilateral NIRS, processed EEG with bispectral index (BIS), and intermittent transcranial doppler sonography of the medial cerebral artery (MCA) with a standard B‑mode ultrasound device. Doppler measurements were taken bilaterally before cardiopulmonary bypass (CPB), during CPB, and during SACP at regular intervals.
RESULTS
Of the patients four survived without neurological deficits while two suffered fatal outcomes. Of the survivors two suffered from transient postoperative delirium. Multimodal monitoring led to a change in CPB flow or cannula repositioning in three patients. Left-sided mean flow velocities of the MCA decreased during SACP, as did BIS values.
CONCLUSION
Monitoring consisting of BIS, NIRS, and TCD may have an impact on hemodynamic management in aortic arch operations.
Topics: Aortic Dissection; Aorta, Thoracic; Cardiopulmonary Bypass; Cerebrovascular Circulation; Humans; Monitoring, Intraoperative; Ultrasonography, Doppler, Transcranial
PubMed: 34097082
DOI: 10.1007/s00101-021-00983-y -
Surgery Today Mar 2017Traumatic aortic injury (TAI) is a rare but life-threatening type of injury. We investigate whether the anatomy of the aortic arch influences the severity of aortic...
PURPOSE
Traumatic aortic injury (TAI) is a rare but life-threatening type of injury. We investigate whether the anatomy of the aortic arch influences the severity of aortic injury.
METHODS
This is a retrospective study of twenty-two cases treated with TEVAR for TAI in our department from 2009 to 2014. Aortic injury was assessed in accordance with the recommendations of the Society of Vascular Surgery. We measured the aortic arch angle and the aortic arch index, based on the initial angio-CT scan, in each of the analyzed cases.
RESULTS
The mean aortic arch index and mean aortic arch angle were 6.8 cm and 58.3°, respectively, in the type I injury group; 4.4 cm and 45.9° in the type III group; 3.3 cm and 37° in the type IV group. There were substantial differences in both the aortic arch index and the aortic arch angle of the type III and IV groups. A multivariate analysis confirmed that the aortic arch angle was significantly associated with the occurrence of type III damage (OR 1.5; 95% CI 1.03-2.2).
CONCLUSIONS
The severity of TAI is influenced by the sharpness of the aortic arch. There is an inverse relationship between the severity of aortic injury and the aortic arch index.
Topics: Adult; Aorta; Aorta, Thoracic; Endovascular Procedures; Female; Humans; Male; Middle Aged; Multivariate Analysis; Retrospective Studies; Stents; Thoracic Injuries; Tomography, X-Ray Computed; Trauma Severity Indices; Treatment Outcome; Young Adult
PubMed: 27858166
DOI: 10.1007/s00595-016-1443-0 -
Journal of Endovascular Therapy : An... Aug 2023The RelayBranch stent-graft (Terumo Aortic, Sunrise, FL, USA) offers a custom-made endovascular solution for complex aortic arch pathologies. In this technical note, a...
The RelayBranch stent-graft (Terumo Aortic, Sunrise, FL, USA) offers a custom-made endovascular solution for complex aortic arch pathologies. In this technical note, a modified electrocardiography (ECG)-gated computed tomography (CT)-based algorithm was applied to quantify cardiac-pulsatility-induced changes of the aortic arch geometry and motion before and after double-branched endovascular repair (bTEVAR) of an aortic arch aneurysm. This software algorithm has the potential to provide novel and clinically relevant insights in the influence of bTEVAR on aortic anatomy, arterial compliance, and stent-graft dynamics.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Stents; Treatment Outcome; Endovascular Procedures; Prosthesis Design; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Retrospective Studies
PubMed: 35352980
DOI: 10.1177/15266028221086474 -
Pediatric Cardiology Dec 2021Left ventricular outflow tract obstruction is an important complication after interrupted aortic arch repair and subsequent interventions may adversely affect survival.... (Review)
Review
Left ventricular outflow tract obstruction is an important complication after interrupted aortic arch repair and subsequent interventions may adversely affect survival. Identification of patients at risk for obstruction is important to facilitate clinical decision-making and monitoring during follow-up. The aim of this review is to summarize reported risk factors for left ventricular outflow tract obstruction after corrective surgery for interrupted aortic arch. A systematic search of the literature was performed across the PubMed and EMBASE databases. Studies that reported echocardiographic and/or clinical predictors for left ventricular outflow tract obstruction in infants that underwent biventricular repair of interrupted aortic arch were included. From the 44 potentially relevant studies, eight studies met the inclusion criteria. Postoperative left ventricular outflow tract obstruction requiring an intervention was common, with an incidence ranging between 14 and 38%. Manifestation of postoperative left ventricular outflow tract obstruction was associated with a smaller pre-operative size of the aortic root (sinus of Valsalva), sinotubular junction, and aortic annulus. Anatomic and surgical risk factors for left ventricular outflow tract obstruction were the presence of an aberrant right subclavian artery, use of a pulmonary homograft or polytetrafluoroethylene interposition graft for aortic arch repair, and the presence of a small- or medium-sized ventricular septal defect. In patients with a borderline left ventricular outflow tract that undergo a primary repair, these (pre-) operative predictors can provide guidance for optimal surgical decision-making and for close monitoring during follow-up of patients at increased risk for developing left ventricular outflow tract obstruction after corrective surgery.
Topics: Aorta, Thoracic; Aortic Coarctation; Follow-Up Studies; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Humans; Infant; Ventricular Outflow Obstruction
PubMed: 34338828
DOI: 10.1007/s00246-021-02689-9 -
Interactive Cardiovascular and Thoracic... Jul 2022The best treatment for a right-sided aortic arch (RAA) and Kommerell diverticulum (KD) has not been determined due to the rarity of these conditions. The current trend...
The best treatment for a right-sided aortic arch (RAA) and Kommerell diverticulum (KD) has not been determined due to the rarity of these conditions. The current trend in the treatment of this disease is to increase the endovascular approach without a sternotomy. We describe a rare condition with an association of an RAA with a KD of an aberrant left subclavian artery and an anomalous right vertebral artery originating from the aortic arch (AVA). The left vertebral artery was missing. Also, there was an incomplete circle of Willis due to the absence of the left and right posterior communication arteries. Therefore, the AVA was the only artery to supply the vertebral-basilar system. In our case, a simple thoracic endovascular aortic repair was not suitable because of the sharply curved arch and short landing zone. Also, a debranching thoracic endovascular aortic repair was not appropriate because that approach would not permit reconstruction of the AVA. The patient successfully underwent a total arch replacement with the frozen elephant trunk technique. This procedure could be an effective option for patients with RAAs with KDs associated with another arch vessel anomaly.
Topics: Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Cardiovascular Abnormalities; Diverticulum; Endovascular Procedures; Heart Defects, Congenital; Humans; Subclavian Artery; Vertebral Artery
PubMed: 35333342
DOI: 10.1093/icvts/ivac075 -
PloS One 2013Transformation from the bilaterally symmetric embryonic aortic arches to the mature great vessels is a complex morphogenetic process, requiring both vasculogenic and...
Transformation from the bilaterally symmetric embryonic aortic arches to the mature great vessels is a complex morphogenetic process, requiring both vasculogenic and angiogenic mechanisms. Early aortic arch development occurs simultaneously with rapid changes in pulsatile blood flow, ventricular function, and downstream impedance in both invertebrate and vertebrate species. These dynamic biomechanical environmental landscapes provide critical epigenetic cues for vascular growth and remodeling. In our previous work, we examined hemodynamic loading and aortic arch growth in the chick embryo at Hamburger-Hamilton stages 18 and 24. We provided the first quantitative correlation between wall shear stress (WSS) and aortic arch diameter in the developing embryo, and observed that these two stages contained different aortic arch patterns with no inter-embryo variation. In the present study, we investigate these biomechanical events in the intermediate stage 21 to determine insights into this critical transition. We performed fluorescent dye microinjections to identify aortic arch patterns and measured diameters using both injection recordings and high-resolution optical coherence tomography. Flow and WSS were quantified with 3D computational fluid dynamics (CFD). Dye injections revealed that the transition in aortic arch pattern is not a uniform process and multiple configurations were documented at stage 21. CFD analysis showed that WSS is substantially elevated compared to both the previous (stage 18) and subsequent (stage 24) developmental time-points. These results demonstrate that acute increases in WSS are followed by a period of vascular remodeling to restore normative hemodynamic loading. Fluctuations in blood flow are one possible mechanism that impacts the timing of events such as aortic arch regression and generation, leading to the variable configurations at stage 21. Aortic arch variations noted during normal rapid vascular remodeling at stage 21 identify a temporal window of increased vulnerability to aberrant aortic arch morphogenesis with the potential for profound effects on subsequent cardiovascular morphogenesis.
Topics: Animals; Aorta, Thoracic; Chick Embryo; Hemodynamics
PubMed: 23555940
DOI: 10.1371/journal.pone.0060271 -
Interactive Cardiovascular and Thoracic... May 2021The critical step in total endovascular aortic arch repair is to ensure alignment of fenestrations with, and thus maintenance of flow to, supra-aortic trunks. This...
OBJECTIVES
The critical step in total endovascular aortic arch repair is to ensure alignment of fenestrations with, and thus maintenance of flow to, supra-aortic trunks. This experimental study evaluates the feasibility and accuracy of a double-fenestrated physician-modified endovascular graft [single common large fenestration for the brachiocephalic trunk and left common carotid artery and a distal small fenestration for left subclavian artery (LSA) with a preloaded guidewire for the LSA] for total endovascular aortic arch repair.
METHODS
Eight fresh human cadaveric thoracic aortas were harvested. Thoracic endografts with a physician-modified double fenestration were deployed for total endovascular aortic arch repair in a bench test model. A guidewire was preloaded through the distal fenestration for the LSA. All experiments were undertaken in a hybrid room under fluoroscopic guidance with subsequent angioscopy and open evaluation for assessment.
RESULTS
Mean aortic diameter in zone 0 was 31.3 ± 3.33 mm. Mean duration for stent graft modification was 20.1 ± 5.8 min. Mean duration of the procedure was 24 ± 8.6 min. The Medtronic Valiant Captivia stent graft was used in 6 and the Cook Alpha Zenith thoracic stent graft in 2 cases. LSA catheterization was technically successful with supra-aortic trunk patency in 100% of cases.
CONCLUSIONS
The use of a double-fenestrated stent graft with a preloaded guidewire appears to be a useful technical addition to facilitate easy and correct alignment of stent graft fenestrations with supra-aortic trunk origins.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Physicians; Prosthesis Design; Stents; Treatment Outcome
PubMed: 34047348
DOI: 10.1093/icvts/ivab023 -
The Journal of Thoracic and... Sep 2021
Topics: Aortic Dissection; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Humans
PubMed: 32217022
DOI: 10.1016/j.jtcvs.2020.02.060 -
Medicina (Kaunas, Lithuania) Oct 2021The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic...
The frozen elephant trunk technique (FET) requires the use of a pre-assembled hybrid prosthesis consisting of a standard Dacron vascular portion to replace the aortic arch and a stent graft component, which is placed into the proximal descending thoracic aorta (DTA) anterogradely in the proximal descending thoracic aorta. In Europe, two hybrid prostheses are available: the E-evita Open Plus hybrid stent graft system provided by JOTEC (Hechingen, Germany) and the ThoraflexTM Hybrid (Vascutek, Inchinnan Scotland). Recommendations for use are extensive pathologies of the arch in case of acute and chronic aortic dissection, degenerative aneurysm and intramural hematoma. The FET approach allows the replacement of the whole arch in one stage with the option of direct treatment of the proximal descending thoracic aorta based on the stent component, creating a safe landing zone for further endovascular treatment more distally. The remarkable feature of this technique is the possibility to perform more proximally (from zone 3 to zone 0) the distal anastomosis in to the arch. This allows for an easier distal anastomosis, reduced hypothermic circulatory arrest time and decreased risk of paraplegia (<5%). Early results are promising and according to the most recent series the rate of developing post-operative renal insufficiency ranges from 3 to 10%, the risk of stroke from 3% to 8% and mortality from 8-15%. The aim of the article will be to provide some knowledge about the use and application of FET procedures in different aortic situations.
Topics: Aortic Dissection; Aorta, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Humans; Stents; Treatment Outcome
PubMed: 34684127
DOI: 10.3390/medicina57101090 -
Journal of Cardiothoracic Surgery Sep 2021Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We...
BACKGROUND
Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study.
METHODS
This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded.
RESULTS
The 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge.
CONCLUSIONS
The ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Balloon Occlusion; Blood Vessel Prosthesis Implantation; Factor Analysis, Statistical; Humans; Retrospective Studies; Treatment Outcome
PubMed: 34496891
DOI: 10.1186/s13019-021-01643-3