Between January 2012 and June 2015, 31 TBAD patients without an optimal landing zone were underwent open surgery in our cardiovascular institution. Twenty-seven patients had uncontrolled chest pain and the other four patients were in their chronic stage with increased false lumen. All of the patients were diagnosed by computed tomography (CT) angiography and evaluated by echocardiography preoperatively. Information pertaining to medical history (co-morbidities including: hypertension, chronic obstructive pulmonary disease, diabetes mellitus, uremia need dialysis, and stroke) was collected. The demographics and clinical characgteristics of the patients are shown in Table 1. All of the patients gave their consent for this clinical information and data analysis. The procedure was approved by the ethical committee of Nanjing First Hospital and Nanjing Medical University before January 2012. The exclusion criteria were as follows: 1) TBAD due to connective tissue disorders or genetic reasons; 2) TBAD combined valvular disease or ascending aortopathy; 3) TBAD patients in a coma or stage of organ ischemia preoperatively.
Variable Value Gender (n) Male 24 Female 7 Age (year) 52.16±11.05 Stage (n) Acute 27 Chronic 4 Hypertension [n (%)] 31 (100) COPD* [n (%)] 1 (3.23) Diabetes mellitus [n (%)] 3 (9.68) Uremia need dialysis [n (%)] 2 (6.45) Stroke [n(%)] 1 (3.23) *COPD: chronic obstructive pulmonary disease.
Table 1. Demographics and clinical characteristics (n=31)
Patients were examined by CT angiography and echocardiography preoperatively to assess the true/false lumen, branch involvement, proximal entry tear, abdominal aorta diameter, and measurement of the heart function. Transesophageal echocardiography (TEE) was performed in all of the patients during the operation. After general anesthesia, the arterial blood pressures of both the upper and lower limbs were monitored. The the right axillary artery was exposed for perfusion cannula and a median sternotomy was performed. An arterial cannulation was inserted into the right axillary artery, and a dual-stage atriocaval cannula was placed at the right atrium. Right axillary artery cannulation was routinely used for cardiopulmonary bypass (CPB) was routinely established with selected cerebral perfusion (SCP). Patients were cooled to a nasopharyngeal temperature of approximately 24 °C to 26 °C by CPB. During the cooling process, the brachiocephalic arteries were dissociated and exposed for as long as possible. The ascending aorta was clamped and cardioplegia was given. CPB was discontinued when the nasopharyngeal temperature was less than 26 °C, while the time of circulatory arrest, the brain continued to be perfused at a rate of approximately 5 to 10 mL/(kg·minute) through the right axillary artery cannulation. A curved incision in the aortic arch was performed. A catheter sheath containing the surgical stent-graft (diameter 26–30 mm, length 100–150 mm, CRONUS, Shanghai MicroPort Lifesciences Co., Ltd.) was inserted into the descending aorta, then deployed. The proximal entry tear, including left subclavian artery (LSA), was covered by the stent-graft. The proximal end of stent-graft was sutured to the aortic wall carefully without creating a new tear. The aortic arch incision was closed as quickly as possible and systemic perfusion was restored. LSA was transplanted to the left carotid artery (LCA) following this procedure. If the left vertebral artery (LVA) was present to be dominant, both the LSA and dominant LVA were transplanted to the LCA. If the lusorian artery was present, the femoral artery was chosen for perfusion, and bilateral carotid arteries were used for cerebral perfusion during circulatory arrest. In this situation, apart from reconstruction of the LSA, the right subclavian artery (RSA) also needed to be transplanted. All of the operations were done by the authors of this paper in Nanjing First Hospital.
Follow-up CT angiography studies were performed at three months and one year regularly postoperatively. Graft patency, true and false lumen, endoleak, and aortic morphology were assessed.
Values are expressed as mean±SD. For continuous variables where the one-way ANOVA analysis was used for the comparison in more than two groups. The survival analyses were performed using the Kaplan-Meier method. A P value of less than 0.05 (P<0.05) was considered statistically significant.
Surgical stent-graft implantation by open procedure for type B aortic dissection without optimal landing zone
- Received Date: 2017-08-12
- Accepted Date: 2018-10-10
- Available Online: 2019-09-01
Abstract: Thoracic endovascular aortic repair (TEVAR) has been considered as a first-choice treatment for type B aortic dissection (TBAD). However, some patients that is lack of optimal landing zones (<15 mm in dissected Z2, Z3 or the presence of a lusorian artery) still pose significant challenges for TEVAR. We utilized a surgical stent-graft implantation in the descending aorta combined with supra-aortic vessels transposition through median sternotomy for these special TBAD patients. The short- and mid-term results showed that our procedure is a good and alternative therapy for such kind patients.