Objective To monitor the distribution of blood perfusion during aortic arch aneurysm surgery under double arterial lines with single pump. Methods We retrospectively analyzed the clinical data of 37 patients underwent aortic arch repair or reconstruction between September 2012 and April 2014. There were 9 females and 28 males at mean age of 48.1±10.8 years ranging from 19.0-72.0 years.We took double arterial lines with single pump for cardiopulmonary bypass (CPB) during the operation and we monitored the perfusion tube flow of both the upper and lower body by blood flow detector. Cerebral blood perfusion was measured by transcranial cerebral Doppler and near-infrared spectroscopy cerebral oxygen saturation (rSO2). Results The mean CPB time of all 37 patients was 195.8±40.5 minutes ranging from 136.0-277.0 minutes and the mean duration time of selective antegrade cerebral perfusion (SCAP) was 21.6±5.6 minutes ranging from 5.0-35.0 minutes. During cooling and rewarming phases, the part of blood flow through axillary artery cannulation ranged from 31.5% to 40.8% of the whole body perfusion. The blood flow of SACP was increased to 15.0 ml / (kg·min) in 2 patients with significantly lower rSO2 and middle cerebral artery blood flow during SACP, and they had an uneventful recovery process after surgery. There were another 2 patients recorded abnormal situation of rSO2 without interventions. One patient died and the other one recovered with compications of spinal cord. Conclusions The technique of double arterial lines with single pump is reasonable and effective. The cerebral perfusion monitoring is helpful to detect abnormal perfusion during aortic arch aneurysm surgery.
Objective To investigate the efficacy and safety of the application of selective cerebral perfusion (SCP) technique in pediatric aortic arch reconstruction, so as to alleviate brain injury during operation. Methods From April 2007 to May 2008, 32 children aged from 8 days to 103 months (14.4±25.4 months) and weighed from 27 kg to 22.0 kg (6.7±4.4 kg) underwent aortic arch reconstruction with selective cerebral perfusion in Shanghai Children’s Medical Center. Twentytwo suffered from aortic coarctationwith intracardiac anomaly, and 10 suffered from interrupted aortic arch with intracardiac anomaly. The arterial cannulation was achieved by placing a flexible wire wound cannula in ascending aorta close to the root part of innominate artery. The rectal temperature was about 1820℃. Then the cannula was moved upward into innominate artery to perform SCP. Results The time of SCP was 17-121 mins（39.6±19.4 mins）, perfusion blood flow maintained in 15-40 ml/(kg·min)［29.7±6.1 ml/(kg·min）］. Four cases died of low cardiac output syndrome or arrhythmia, and no evidence of brain injury was observed. No obvious neurologic complication was observed in 28 survivls. No abnormal electroencephalogram was observed in 25 cases. The results of head Bsonography and brain magnetic resonance image (MRI) were normal in 5 neonates. Conclusion Selective cerebral perfusion is a simple, feasible, safe and effective technique in pediatric aortic arch reconstruction.
ObjectiveTo evaluate the short-and long-term results of hybrid procedures in the treatment for aortic arch lesions. MethodsFrom October 2002 to March 2011, 28 patients with thoracic aortic aneurysms or dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Twenty-two males and 6 females were in the series. The mean age of the patients was 68 years old. Of 28 patients, 15 were atherosclerotic thoracic aortic aneurysms and 13 were thoracic aortic dissection. Follow-up protocol consisted of computed tomography (CT) angiograms or ultrasound was performed in 3, 6, and 12 months, and annually thereafter. The main goal was to evaluate the operative mortality, morbidity, and the longterm survival of these patients. ResultsHybrid procedures included 12 totalarch transpositions, 3 left common carotid artery (LCCA)left subclavian artery (LSA) bypass, 11 right common carotid artery (RCCA)LCCA-LSA bypass, 2 RCCA-LCCA bypass. The technical success rate was 92.9% (26/28). The complications occurred in 10 patients (35.7%). Operative mortality was 7.1% (2/28). The apoplexia rate was 7.1% (2/28). The time of followup was (36±3) months. The patency rates of 1-year, 3-year, and 5-year were 100%, 92.9% (26/28), and 85.7% (24/28), respectively. The survival rates of 1-year, 3-year, and 5-year were 89.3% (25/28), 71.4% (20/28), and 60.7% (17/28), respectively. ConclusionsThe short-and long-term results with hybrid procedures in the treatment for aortic arch diseases are satisfactory. Further reducing the complications is the key to increase the survival rate.
Aortic arch disease is one of the research hotspots and treatment difficulties in the field of aorta, including aortic arch aneurysms, pseudoaneurysm, ulcer, dissection and intramural hematoma. By summarizing the clinical data of the vascular surgery center of Fuwai Hospital of Chinese Academy of Medical Sciences in the past five years and combining with the latest theories of the cutting-edge development of aortic surgery, the authors proposed the "HENDO" concept, including using hybrid technique (H), endovascular repair (Endo) and open surgery (O), properly to treat aortic arch pathologies individually. The authors advocated the establishment of HENDO team and cooperation mechanism in large aortic centers, to eliminate technical shortcomings of a single surgeon by fully mastering the three main technology clusters by teamwork. Accordingly, the best treatment for each patient can be administrated and the survival rate and quality of life can be improved eventually.
Increasing evidences show that a gradual trend away from deep hypothermia toward moderate hypothermic circulatory arrest, which has been proved to be safe and effective in clinic. By summarizing and analyzing the research progress and applying status of the moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion, the article aims at promoting the application of this tenique as a cerebral protection strategy in aortic arch surgery for adults in China.
ObjectiveTo investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP).MethodsWe retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg.ResultsCPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time >72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group.ConclusionEmergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.
Objective To determine risk factors of delayed recovery of consciousness after aortic arch surgery underdeep hypothermic circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods We retrospectively analyzed clinical data of 113 patients who underwent aortic arch surgery under DHCA＋ASCP in the Affiliated Drum Tower Hospital， Medical School of Nanjing University from October 2004 to April 2012. According to whether they regained consciousness within 24 hours after surgery， all the 113 patients were divided into normal group （73 patients including 55 males and 18 females with their average age of 48.1±10.9 years） and delayed recovery group （40 patients including 29 males and 11 females with their average age of 52.2±11.4 years）. Risk factors of delayed recovery of consciousness after surgery were evaluated by univariate analysis and multivariate logistic regression analysis. Results Nine patients （8.0%） died postoperatively， including 5 patients with multi-organ failure， 2 patients with heart failure， 1 patient with mediastinal infection， and 1 patient with pulmonary hemorrhage. There were 7 deaths （17.5%） in the delayed recovery group and 2 deaths （2.7%） in the normal group， and the in-hospital mortality of the delayed recovery group was significantly higher than that of the normal group （P=0.016）. A total of 94 patients （including 65 patients in the normal group and 29 patients in the delayed recovery group） were followed up for 4-95 months. Eight patients （including 5 patients in the normal group and 3 patients in the delayed recovery group） died during follow-up， including 2 patients with stroke， 3 patients with heart failure， 2 patients with pulmonary hemorrhage and 1 patient with unknown cause. Ten patients were lost during follow-up. Univariate analysis showed that age （P=0.042）， hypertension （P=0.017）， emergency surgery （P=0.001）， cardiopu- lmonary bypass （CPB） time （P=0.007）， aortic cross-clamp time （P=0.021）， and blood transfusion（P=0.012）were risk factors of delayed recovery of consciousness after aortic arch surgery. Multivariate logistic regression showed that emergency surgery （P=0.005） and CPB time＞240 minutes （P=0.000） were independent risk factors of delayed recovery of consciousness after aortic arch surgery. Conclusion Delayed recovery of consciousness after aortic arch surgery is attributed to a combination of many risk factors. Correct patient diagnosis， lesion site and involved scope should be made clear preoperatively in order to choose appropriate surgical strategies. During the surgery， strengthened brain protection， shortened operation time， improved surgical techniques， and perioperative stable circulation maintenance are all important measures to prevent delayed recovery of consciousness after aortic arch surgery.
ObjectiveTo evaluate the initial results of hybrid procedure without sternotomy for aortic arch dissection, and also report our initial experience in performing this procedure. MethodsFrom January 2011 to September 2014, 17 patients diagnosed with aortic arch dissection by CT angiography undergoing the hybrid procedure (thoracic endovascular aortic repair combined with supra-arch branch vessel bypass) in the department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command. There were 12 males and 5 females aged from 46 to 71 years. Their clinical data, including the imaging findings, treatment, and prognosis were retrospectively analyzed. ResultsLeft common carotid artery (LCCA) to left subclavian artery (LSA) bypass (n=4), right common carotid artery (RCCA) to LCCA to LSA bypass (n=3), RCCA to LCCA bypass merger covered LSA (n=3) were performed. All operations were successful. Laryngeal recurrent nerve injury occurred in one patient. All patients were followed up on the postoperative day 7, 30 and one year. All patients were followed up for 12 to 53 months till September 2015. There was no death, and no complications such as endoleak after the hybrid procedure, stenosis or blockage of the bypass graft during the follow-up period. ConclusionInitial results suggest that the hybrid procedure without sternotomy is a suitable therapeutic option for high risk aortic arch dissection patients in poor general condition with little tolerance to aortic arch replacement．
Objective To summarize the methods and experiences of surgical treatment of aortic arch diseases with four branches aortic graft under deep hypothermia circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods In 2004 from September to December, surgical treatment of 12 patients with 7 aortic aneurysm（4 cases with ascending aorta and aortic arch aneurysm, 3 cases with aneurysm of aortic isthmus） and 5 aortic dissection（DeBakey Ⅰ 1 case, DeBakey Ⅱ 3 cases, DeBakey Ⅲ 1 case） were collected in Gunma Prefectural Cardiovascular Center. All operations were carried out under DHCA and ASCP, and four branches aortic graft were used to replace the aortic arch. The Bentall procedure, total and partial arch replacement and elephant trunk technique were undertaken in different patients. Results Total 12 patients recovered from the great vessel diseases smoothly without severe cerebral and other systematic complications, the time of operation was 5.5±1.7 h, the period of DHCA was 42.2±12.9min, 4 cases with no blood transfusion, the time of hospitalization was 22.3±7.2d. Conclusion ASCP is a safe. and effective method of cerebral protection during circulation arrest, and four branches aortic graft may shorten the time of DHCA and simplify the procedure of aortic arch replacement.
Objectives To investigate the effect of the combined treatment with probiotics and lactulose of gastrointestinal function and postoperative infection after open cardiac surgery. Methods We retrospectively analyzed the clinical data of 264 patients underwent cardiopulmonary bypass in our hospital between August 2013 and June 2014. There were 129 males and 135 females at the mean age of 53.06±10.97 years. We divided those patients into a treatment group and a control group. In the treatment group, there were 58 males and 63 females at the mean age of 52.29±14.31 years. They took probiotics and lactulose from the first day to the seventh day after operation. In the control group, there were 71 males and 72 females at the mean age of 52.29±14.31 years. They didn’t take probiotics or lactulose after the surgery. Procalcitonin (PCT) and lipopolysaccharides (LPS) concentrations were measured before operation, at 24 hours postoperatively, at 72 hours and on the seventh day. We recorded the condition of postoperative infection, gastrointestinal disorders and relative informations. Results The PCT and LPS concentrations in the treatment group after 72 hours postoperatively were statistically lower than those of the control group (1.04±5.39 ng/ml vs. 3.51±4.28 ng/ml, P=0.04; 11.28±4.34 EU/ml vs. 21.59±7.34 EU/ml, P=0.03). The PCT and LPS concentrations in the treatment group were also statistically lower than those of the control group on the 7th day postoperatively (0.17±2.79 ng/ml vs. 1.98±4.62 ng/ml，P=0.04; 6.74±6.38 EU/ml vs. 15.96±4.61 EU/ml, P=0.01). The ICU stay time (43.25±14.36 h vs. 63.47±24.46 h, P=0.01) and postoperative hospital stay time (15.07±4.52 d vs. 21.08±6.49 d, P=0.02) were significantly less in the treatment group than those in the control group. The morbidity of infection and the morbidity of gastrointestinal disorders of the treatment group were statistically less than those of the control group (1.65% vs. 5.59%, P=0.00; 2.48% vs. 6.99%, P<0.001), and there was no statistical difference in mortality between the two groups (1.65% vs. 2.10%, P=0.12). Conclusions The combined treatment with probiotics and lactulose can improve the postoperative inflammatory reaction, gastrointestinal function, and reduce the morbidity of infection.