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ABSTRACT Introduction: We evaluated the outcomes of the selective intercostal artery reconstruction for preventing spinal cord injury during thoracoabdominal aortic aneurysm repair. Methods: We retrospectively assessed 84 consecutive patients who underwent thoracoabdominal aortic aneurysm repairs between 2004 and 2016. The mean age of the patients was 57.3 years. We performed preoperative multidetector computed tomography in 74 patients (88.0%) to identify the Adamkiewicz artery. Spinal cord injury preventive measures included motor evoked potential monitoring, hypothermia induction, Adamkiewicz artery or other intercostal artery reconstruction, and cerebrospinal fluid drainage. Results: The hospital death rate was 5.9%, and paraplegia occurred in four patients (4.7%). The Adamkiewicz artery or other intercostal arteries were reconstructed selectively in 46 patients (54.7%). Of these patients, 41 underwent postoperative multidetector computed tomography, which revealed occlusion of the reconstructed grafts in 23 patients (56.0%). There was no paraplegia in the patients who underwent reconstruction of the Adamkiewicz artery, which was patent on postoperative multidetector computed tomography. Univariate analysis showed no significant effect of various risk factors on the development of spinal cord injury. Conclusion: Outcome of open surgery for thoracoabdominal aortic aneurysm in our institution regarding spinal cord injury was satisfactory. The benefits of Adamkiewicz artery reconstruction remain inconclusive, and further larger studies are required to identify its validation for spinal cord protection in thoracoabdominal aortic aneurysm repair.
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INTRODUCTION: We evaluated the outcomes of the selective intercostal artery reconstruction for preventing spinal cord injury during thoracoabdominal aortic aneurysm repair. METHODS: We retrospectively assessed 84 consecutive patients who underwent thoracoabdominal aortic aneurysm repairs between 2004 and 2016. The mean age of the patients was 57.3 years. We performed preoperative multidetector computed tomography in 74 patients (88.0%) to identify the Adamkiewicz artery. Spinal cord injury preventive measures included motor evoked potential monitoring, hypothermia induction, Adamkiewicz artery or other intercostal artery reconstruction, and cerebrospinal fluid drainage. RESULTS: The hospital death rate was 5.9%, and paraplegia occurred in four patients (4.7%). The Adamkiewicz artery or other intercostal arteries were reconstructed selectively in 46 patients (54.7%). Of these patients, 41 underwent postoperative multidetector computed tomography, which revealed occlusion of the reconstructed grafts in 23 patients (56.0%). There was no paraplegia in the patients who underwent reconstruction of the Adamkiewicz artery, which was patent on postoperative multidetector computed tomography. Univariate analysis showed no significant effect of various risk factors on the development of spinal cord injury. CONCLUSION: Outcome of open surgery for thoracoabdominal aortic aneurysm in our institution regarding spinal cord injury was satisfactory. The benefits of Adamkiewicz artery reconstruction remain inconclusive, and further larger studies are required to identify its validation for spinal cord protection in thoracoabdominal aortic aneurysm repair.
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Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Aneurisma da Aorta Toracoabdominal , Traumatismos da Medula Espinal , Isquemia do Cordão Espinal , Humanos , Pessoa de Meia-Idade , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Estudos Retrospectivos , Isquemia do Cordão Espinal/prevenção & controle , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/prevenção & controle , Paraplegia/etiologia , Paraplegia/prevenção & controleRESUMO
BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) is an infrequent disease and demands a highly specialized and experienced management. Open repair (OR) is the gold standard but it is associated with significant morbidity and mortality. Paraplegia and renal failure are the most important complications. AIM: To report our results with OR treatment of TAAA. MATERIAL AND METHODS: Descriptive study including all patients with TAAA operated electively and consecutively by OR between 1983 and 2019. Main outcomes are operative mortality, renal and neurological morbidity, and long-term survival. RESULTS: We report 45 operated patients aged 33 to 84 years, 74% males. Aneurysm extension according to Crawford classification was I in 18%, II in 18 %, III in 36% and IV in 29%. Operative mortality was 4%. The frequency of paraplegia or paraparesis at discharge was 9%. No patient was discharged on hemodialysis. Survival at 5 and 10 years were 60% and 40% respectively. CONCLUSIONS: OR of TAAA is a complex procedure. Our results show perioperative mortality rates comparable to highly experienced centers. Although being a major procedure, OR remains an alternative to treat this serious condition.
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Humanos , Masculino , Feminino , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/complicações , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Paraplegia/cirurgia , Paraplegia/complicações , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Abstract Introduction: Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort. Methods: Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports. Results: The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3±8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital. Conclusion: Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.
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Humanos , Masculino , Cocaína/efeitos adversos , Transtornos Relacionados ao Uso de Cocaína/complicações , Dissecção Aórtica/induzido quimicamente , Estudos Retrospectivos , Resultado do Tratamento , Mortalidade HospitalarRESUMO
OBJECTIVE: To systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery. METHODS: A comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms. RESULTS: In total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies. CONCLUSION: Although there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Stents , Resultado do TratamentoRESUMO
Abstract Objective: To systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery. Methods: A comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms. Results: In total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies. Conclusion: Although there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.
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Humanos , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Aorta Torácica/cirurgia , Prótese Vascular , Stents , Resultado do TratamentoRESUMO
Abstract Chylous ascites is the pathologic accumulation of chylous fluid in the peritoneal cavity, caused by lymphomas, metastatic malignancies, and abdominal surgeries, rarely due to surgical trauma of the cisterna chyli or its major branches. A 24-year-old man with history of Marfan syndrome presented to our hospital with abdominal distention, abdominal pain, fluid in the incision region, and weakness. He had underwent an elective open aneurysm repair surgery nine days before for thoracoabdominal aortic aneurysm. Computed tomography revealed massive fluid collection in the abdominal cavity, which was drained surgically. He was diagnosed with chylous ascites and was discharged after conservative treatment.
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Humanos , Masculino , Adulto Jovem , Ascite Quilosa/etiologia , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Síndrome de Marfan/cirurgia , Síndrome de Marfan/complicações , Drenagem , Procedimentos Cirúrgicos EletivosAssuntos
Humanos , Arterite de Células Gigantes/complicações , Aneurisma da Aorta Torácica , Aorta , Síndrome , CoraçãoRESUMO
Chylous ascites is the pathologic accumulation of chylous fluid in the peritoneal cavity, caused by lymphomas, metastatic malignancies, and abdominal surgeries, rarely due to surgical trauma of the cisterna chyli or its major branches. A 24-year-old man with history of Marfan syndrome presented to our hospital with abdominal distention, abdominal pain, fluid in the incision region, and weakness. He had underwent an elective open aneurysm repair surgery nine days before for thoracoabdominal aortic aneurysm. Computed tomography revealed massive fluid collection in the abdominal cavity, which was drained surgically. He was diagnosed with chylous ascites and was discharged after conservative treatment.
Assuntos
Aneurisma da Aorta Torácica , Ascite Quilosa , Síndrome de Marfan , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/cirurgia , Ascite Quilosa/etiologia , Drenagem , Procedimentos Cirúrgicos Eletivos , Humanos , Masculino , Síndrome de Marfan/complicações , Síndrome de Marfan/cirurgia , Adulto JovemRESUMO
OBJECTIVE: To evaluate the aortic wall elasticity using the maximal rate of systolic distension (MRSD) and maximal rate of diastolic recoil (MRDR) and their correlation with the aortic size index (ASI). METHODS: Forty-eight patients with thoracic aortic aneurysm were enrolled in this study. A standard magnetic resonance imaging (MRI) protocol was used to calculate MRSD and MRDR. Both MRSD and MRDR were expressed as percentile of maximal area/10-3 sec. ASI (maximal aortic diameter/body surface area) was calculated. A correlation between MRSD, MRDR, ASI, and the patient's age was performed using regression plot. RESULTS: A significant correlation between MRSD (t=-4,36; r2=0.29; P≤0.0001), MRDR (t=3.92; r2=0.25; P=0.0003), and ASI (25±4.33 mm/m2; range 15,48-35,14 mm/m2) is observed. As ASI increases, aortic MRSD and MRDR decrease. Such inverse correlation between MRSD, MRDR, and ASI indicates increased stiffness of the ascending aorta. A significant correlation between the patient's age and the decrease in MRSD and MRDR is observed. CONCLUSION: MRSD and MRDR are significantly correlated with ASI and the patient's age. They seem to describe properly the increasing stiffness of aortas. These two new indexes provide a promising, accessible, and reproducible approach to evaluate the biomechanical property of the aorta.
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Aorta/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Dissecção Aórtica/diagnóstico por imagem , Imageamento por Ressonância Magnética , Adulto , Idoso , Diástole/fisiologia , Dilatação Patológica , Elasticidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sístole/fisiologiaRESUMO
Abstract Objective: To evaluate the aortic wall elasticity using the maximal rate of systolic distension (MRSD) and maximal rate of diastolic recoil (MRDR) and their correlation with the aortic size index (ASI). Methods: Forty-eight patients with thoracic aortic aneurysm were enrolled in this study. A standard magnetic resonance imaging (MRI) protocol was used to calculate MRSD and MRDR. Both MRSD and MRDR were expressed as percentile of maximal area/10-3 sec. ASI (maximal aortic diameter/body surface area) was calculated. A correlation between MRSD, MRDR, ASI, and the patient's age was performed using regression plot. Results: A significant correlation between MRSD (t=-4,36; r2=0.29; P≤0.0001), MRDR (t=3.92; r2=0.25; P=0.0003), and ASI (25±4.33 mm/m2; range 15,48-35,14 mm/m2) is observed. As ASI increases, aortic MRSD and MRDR decrease. Such inverse correlation between MRSD, MRDR, and ASI indicates increased stiffness of the ascending aorta. A significant correlation between the patient's age and the decrease in MRSD and MRDR is observed. Conclusion: MRSD and MRDR are significantly correlated with ASI and the patient's age. They seem to describe properly the increasing stiffness of aortas. These two new indexes provide a promising, accessible, and reproducible approach to evaluate the biomechanical property of the aorta.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Aorta/fisiopatologia , Imageamento por Ressonância Magnética , Aneurisma da Aorta Torácica/diagnóstico por imagem , Dissecção Aórtica/diagnóstico por imagem , Sístole/fisiologia , Diástole/fisiologia , Dilatação Patológica , ElasticidadeRESUMO
Abstract Introduction: Non-familial ascending thoracic aorta dilation and aneurysms (TAAs) are silent diseases in elderly patients. Histopathology revealed that functionally polarized infiltrating CD4+ T-cells play a key role in aortic wall weakening. Objective: To evaluate the possible associations between phenotype and cytokine production of circulating CD4+ T-lymphocytes and the presence of TAA in patients with aortic valve disease (AVD). Methods: We studied blood samples from 10 patients with TAA and 10 patients with AVD. Flow cytometry was used to quantify: a) CD4+ T-lymphocytes surface expression of CD25, CD28, and chemokine receptors (CCR5, CXCR3, CX3CR1); b) fractions of in vitro stimulated CD4+ T-cells producing cytokines (interferon gamma [IFN-γ], interleukin [IL]-17A, IL-21, IL-10); c) CD4+CD25highFoxP3+ regulatory T-cells (Treg) fraction. Enzyme-linked immunosorbent assays (ELISA) were performed for cytokines (IFN-γ, IL-6, IL-10, IL-17A, IL-23, transforming growth factor beta [TGF-β]) and chemokines (RANTES, CX3CL1). Results: The total CD4+CD28±CD4+/CX3CR1+ T-cells fraction was higher (P=0.0323) in AVD (20.452±4.673) than in TAA patients (8.633±2.030). The frequency ratio of CD4+ T-lymphocytes producing IFN-γ vs. IL-17A+IL-21 cytokine-producing CD4+ T-cells was higher (P=0.0239) in AVD (2.102±0.272) than in TAA (1.365±0.123) patients. The sum of CD4+CD28±CD4+/CX3CR1+ T-cells correlated positively with values of the previous cytokine ratio (P=0.0002, R=0.732). The ratio of CD4+CD28±CD4+/CX3CR1+ T-cells vs. Treg was higher (P=0.0008) in AVD (20.859±3.393) than in TAA (6.367±1.277) patients. Conclusion: Our results show that the presence of TAA in subjects with AVD is associated with imbalance between phenotypic and cytokine-producing subsets of circulating CD4+ T-lymphocytes, prevalently oriented towards a pro-fibrotic and IFN-γ counteracting effect to functional polarization.
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Humanos , Masculino , Feminino , Idoso , Valva Aórtica , Fenótipo , Linfócitos T CD4-Positivos/fisiologia , Citocinas/sangue , Aneurisma da Aorta Torácica/sangue , Doenças das Valvas Cardíacas/sangue , Valores de Referência , Ensaio de Imunoadsorção Enzimática , Análise de Variância , Citometria de Fluxo/métodosRESUMO
Abstract Introduction: The aim of this study is to investigate the change in the dimension of sinus of Valsalva in patients who underwent supracoronary ascending aorta replacement with aortic valve replacement. Methods: A total of 81 patients who underwent supracoronary ascending aorta replacement with aortic valve replacement were included. Ten of 81 patients died during the follow-up. The patients were divided into three groups according to the aortic valve diseases. Group I (n=17) included patients with bicuspid valves, group II (n=30) included patients with stenotic degenerative valves, and patients with aortic regurgitation constituted group III (n=24). In preoperative and follow-up periods, the sinus of Valsalva diameter of the patients was evaluated by echocardiographic examination. The mean age was 54.1±15.1 years. Twenty-eight (34.6%) patients were female and 12 (14.8%) patients were in New York Heart Association functional class III. Results: There was no early mortality. Late mortality was developed in 10 (12.4%) patients, 8 (9.9%) due to non-cardiac reasons. Late follow-up was obtained in 71 patients with a mean of 60±30.1 months postoperatively. During follow-up, the increase in the diameter of the sinus of Valsalva was significant in Group I (P<0.01), while in Group II and III it was insignificant (P>0.05). Conclusion: To avoid the risks associated with sinus of Valsalva dilatation, it is reasonable to replace the sinus of Valsalva in the setting of aortic valve replacement and ascending aorta replacement for bicuspid aortic valve with a dilated ascending aorta and relatively normal sinuses of Valsalva in young patients.
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Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Valva Aórtica/anormalidades , Valva Aórtica/cirurgia , Seio Aórtico/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Valva Mitral/cirurgia , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Seio Aórtico/diagnóstico por imagem , Ecocardiografia , Estudos Retrospectivos , Fatores Etários , Implante de Prótese de Valva Cardíaca/mortalidade , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/diagnóstico por imagem , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/diagnóstico por imagem , Valva Mitral/diagnóstico por imagemRESUMO
AbstractObjective:To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.Methods:From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.Results:In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.Conclusion:The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.
ResumoObjetivo:Analisar comparativamente os resultados da operação de preservação da valva aórtica e do tubo valvulado nas reconstruções da raiz da aorta.Métodos:No período de janeiro de 2002 a outubro de 2013, 324 pacientes foram submetidos à reconstrução da raiz da aorta. Foram 263 tubos valvulados e 61 preservações da valva aórtica (43 reimplantes e 18 remodelamentos). 26% dos pacientes estavam em classe funcional III e IV; 9,6% com síndrome de Marfan e 12% apresentavam valva aórtica bivalvulada. Houve predomínio dos aneurismas sobre as dissecções (81% contra 19%), sendo 7% de dissecções agudas. O seguimento completo de 100% dos pacientes foi realizado com tempo mediano de seguimento de 902 dias para pacientes submetidos à tubo valvulado e de 1492 para aqueles submetidos à preservação da valva aórtica.Resultados:A mortalidade hospitalar foi de 6,7% contra 4,9% respectivamente para tubo valvulado e preservação da valva aórtica (ns). No seguimento tardio, a insuficiência aórtica importante foi de 0% e 5,8%, e a insuficiência cardíaca crônica, classe funcional I e II de 89,4% e 94%, respectivamente, para tubo valvulado e preservação da valva aórtica (ns). A reconstrução da raiz da aorta com a preservação da valva aórtica apresentou menor mortalidade tardia (P=0,001) e menos complicações hemorrágicas (P=0,006). Não houve diferença para tromboembolismo, endocardite ou necessidade de reoperação.Conclusão:A reconstrução da raiz da aorta com a preservação valvar deve ser a operação a ser realizada por apresentar menor mortalidade e sobrevida livre de eventos hemorrágicos.
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Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aorta/cirurgia , Doenças da Aorta/cirurgia , Valva Aórtica/cirurgia , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Tratamentos com Preservação do Órgão/métodos , Doenças da Aorta/mortalidade , Métodos Epidemiológicos , Cardiopatias Congênitas/mortalidade , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Síndrome de Marfan/cirurgia , Tratamentos com Preservação do Órgão/mortalidade , Complicações Pós-Operatórias , Reoperação , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do TratamentoRESUMO
We report a 61 years old male presenting with a right cerebral infarction, along with a type I persistent left proatlantal artery (PA), which is a form of primitive carotid-basilar anastomosis. The patient had an absence of the ipsilateral vertebral artery (VA) and hypoplasia of the contralateral VA, while the basilar artery was supplied by the PA. Other vascular anomalies present were a fusiform aneurysm of the right subclavian artery, and an A1 segment aplasia of the hypoplastic anterior right cerebral artery, which originated from the anterior communicating artery. To our knowledge these anomalies were not described previously.
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Humanos , Masculino , Pessoa de Meia-Idade , Aneurisma Intracraniano/diagnóstico , Artéria Subclávia/anormalidades , Artéria Vertebral/anormalidades , Isquemia Encefálica/complicações , Infarto Cerebral/diagnóstico , Endarterectomia das Carótidas , Evolução Fatal , Acidente Vascular Cerebral/complicaçõesRESUMO
Abstract Objective: Report initial experience with the Frozen Elephant Trunk technique. Methods: From July 2009 to October 2013, Frozen Elephant Trunk technique was performed in 21 patients (66% male, mean age 56 ±11 years). They had type A aortic dissection (acute 9.6%, chronic 57.3%), type B (14.3%, all chronic) and complex aneurysms (19%). It was 9.5% of reoperations and 38% of associated procedures (25.3% miocardial revascularization, 25.3% replacement of aortic valve and 49.4% aortic valved graft). Aortic remodeling was evaluated comparing preoperative and most recent computed tomography scans. One hundred per cent of complete follow-up, mean time of 28 months. Results: In-hospital mortality of 14.2%, being 50% in acute type A aortic dissection, 8.3% in chronic type A aortic dissection, 33.3% in chronic type B aortic dissection and 0% in complex aneurysms. Mean times of cardiopulmonary bypass (152±24min), myocardial ischemia (115±31min) and selective cerebral perfusion (60±15min). Main complications were bleeding (14.2%), spinal cord injury (9.5%), stroke (4.7%), prolonged mechanical ventilation (4.7%) and acute renal failure (4.7%). The need for second-stage operation was 19%. False-lumen thrombosis was obtained in 80%. Conclusion: Frozen Elephant Trunk is a feasible technique and should be considered. The severity of the underlying disease justifies high mortality rates. The learning curve is a reality. This approach allows treatment of more than two segments at once. Nonetheless, if a second stage is made necessary, it is facilitated. .
Resumo Objetivo: Relatar experiência inicial com a técnica "Frozen Elephant Trunk". Métodos: Entre julho de 2009 e outubro de 2013, 21 pacientes, 66% homens, média de idade de 56±11 anos, 66,7% portadores de dissecção da aorta tipo A de Stanford (9,6% agudas e 57,1% crônicas), tipo B (14,3%, todas crônicas) e aneurismas complexos (19%), foram operados pela técnica Frozen Elephant Trunk. Foram 9,5% de reoperações e 38% com procedimentos associados (25,3% revascularizações do miocárdio, 25,3% troca da valva aórtica e 49,4% tubos valvulados). Remodelamento da aorta foi avaliado com a comparação de angiotomografia pré-operatória e pós-operatória mais recente. Seguimento 100% dos pacientes, tempo médio de 28 meses. Resultados: Mortalidade hospitalar de 14,2%, sendo 50% nas dissecções do tipo A agudas, 8,3% nas tipo A crônicas, 33,3% nas tipo B crônicas e 0% nos aneurismas complexos. Tempos médios de CEC (152±24min), isquemia miocárdica (115±31min) e perfusão cerebral seletiva (60±15min). Principais complicações pós-operatórias foram sangramento (14,2%), acidente vascular encefálico (4,7%), paraplegia (9,5%), intubação>72h (4,7%) e insuficiência renal aguda (4,7%). Houve necessidade de complementação do tratamento (distal ao stent) em 19%. Houve trombose da falsa luz em 80%. Conclusão: Frozen Elephant Trunk é opção técnica a ser utilizada. A gravidade e extensão da doença justificam mortalidade mais elevada. A curva de aprendizado é uma realidade. Esta abordagem permite abordar mais de dois segmentos de aorta em um estágio, mas se necessário segundo estágio, este é facilitado. .
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dissecção Aórtica/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Doença Aguda , Dissecção Aórtica/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/mortalidade , Doença Crônica , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar , Complicações Intraoperatórias , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
Introdução: O manejo das doenças da aorta torácica que envolvem a aorta ascendente, arco aórtico e aorta torácica descendente constituem um desafio técnico e é uma área em constante desenvolvimento e inovação. Objetivo: Analisar os resultados iniciais e a médio prazo do tratamento híbrido das doenças do arco aórtico. Métodos: Estudo retrospectivo de procedimentos realizados no período de janeiro de 2010 a dezembro de 2012, em que foram analisados o sucesso técnico e terapêutico, a morbimortalidade, os desfechos neurológicos, a taxa de vazamentos e de reintervenções. Resultados: Em um total de 95 pacientes tratados por doenças da aorta torácica no período, 18 realizaram o tratamento híbrido e adentraram neste estudo. A idade média foi de 62,3 anos. O sexo masculino esteve presente em 66,7%. O sucesso técnico e terapêutico foi de 94,5% obe 83,3%, respectivamente. A mortalidade perioperatória foi de 11,1%. Não houve óbito durante o acompanhamento de 1 ano. A taxa de reintervenção foi de 16,6%, devido a 2 casos de endoleak tipo Ia e um caso de endoleak tipo 2. Não foi observada oclusão dos enxertos anatômicos ou extra-anatômicos durante o período de seguimento. Conclusão: O tratamento híbrido das doenças do arco aórtico demonstrou ser uma alternativa viável à cirurgia convencional. As taxas de sucesso terapêutico e de reintervenções demonstram a necessidade do seguimento clínico rigoroso desses pacientes a longo prazo. .
Introduction: The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. Objective: To analyze early and midterm results of hybrid treatment of arch aortic disease. Methods: Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. Results: A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. Conclusion: In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time. .
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Procedimentos Endovasculares/métodos , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/mortalidade , Doenças da Aorta/diagnóstico por imagem , Complicações Pós-Operatórias , Fatores de Tempo , Angiografia/métodos , Tomografia Computadorizada por Raios X/métodos , Stents , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Artéria Carótida Primitiva/cirurgia , Artéria Carótida Primitiva/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/mortalidade , Complicações Intraoperatórias , Ilustração MédicaRESUMO
INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.
INTRODUÇÃO: Manejo de aneurisma da aorta ou dissecção da raiz tem sido objeto de muita discussão que levou a algumas modificações. A tendência atual é o uso da técnica de substituição valve-sparing (VSR). Nós comparamos o resultado da reparação da raiz utilizando a técnica de substituição valve-sparing com o procedimento de Bentall. MÉTODOS: Foram avaliados, retrospectivamente, 70 pacientes submetidos à substituição da raiz de aneurisma ou dissecção, comparando os resultados da técnica de substituição valve-sparing com os do procedimento Bentall de janeiro de 2007 a dezembro de 2011 em nossa instituição. RESULTADOS: Vinte e cinco pacientes foram submetidos à substituição da valva aórtica com o uso da técnica valve-sparing (VSR, incluindo o reimplante ou remodelação) (23 homens e duas mulheres), e 45 pacientes pelo procedimento de Bentall (34 homens e 11 mulheres). Pacientes que se submeteram à VSR eram mais jovens, com idade média de 55,4 ± 14,8 anos em comparação àqueles que foram submetidos ao procedimento Bentall, idade média de 60,6 ± 12,7 anos (P = ns). A insuficiência aórtica pré-operatória no grupo VSR foi moderada em oito (32%) pacientes e grave em seis (24%). Creatinina pré-operatória foi 1 ± 0,35 mg/dl, no grupo do VSR, e 1,1 ± 0,87 mg/dl, no grupo de Bentall. No grupo VSR, três (12%) pacientes foram operados em caráter de emergência e, no grupo de Bentall, oito (17%). Revascularização do miocárdio concomitante (excluindo reimplante coronariano) foi realizada em oito (32%) pacientes no grupo VSR e, em 12 (26,6%), no grupo de Bentall (P=0,78); procedimentos valvares adicionais foram realizados em 2 (8%) pacientes no grupo do VSR e em 11 (24,4%) no grupo de Bentall. A mortalidade perioperatória foi de 8% (n = 2) e 13,3% (n = 6), para os procedimentos de VSR e Bentall, respectivamente (P=0,7, ns). O tempo de internação na unidade de terapia intensiva foi de 116,6 ± 106,0 horas para pacientes VSR e 152,5 ± 218,2 horas para pacientes Bentall (P=0,5). O tempo de permanência no hospital foi de 10 ± 8,1 dias para VSR e 11 ± 9,52 dias para Bentall (P=0,89). A sobrevida em um ano foi de 92,0 % para o grupo VSR e 79,0% para o grupo de Bentall. A sobrevivência de sete anos para o grupo VSR foi de 92% e 79% para o grupo de Bentall (IC95% [1,215 a 0,1275], P=0,1). CONCLUSÃO: A técnica valve-sparing substituição da raiz aórtica pode ser realizada com a morbidade e mortalidade aceitáveis, e sobrevivência aceitável a longo prazo comparável com o procedimento de Bentall.
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dissecção Aórtica/cirurgia , Aneurisma Aórtico/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Tratamentos com Preservação do Órgão/métodos , Fatores Etários , Dissecção Aórtica/mortalidade , Aorta/cirurgia , Aneurisma Aórtico/mortalidade , Valva Aórtica/cirurgia , Bioprótese , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/mortalidade , Estimativa de Kaplan-Meier , Complicações Pós-Operatórias , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJETIVOS: O objetivo primário deste estudo é identificar preditores de óbito hospitalar em pacientes submetidos à cirurgia de aorta. O objetivo secundário é identificar fatores associados ao desfecho clínico composto hospitalar (óbito, sangramento, disfunção ventricular ou complicações neurológicas). MÉTODOS: Delineamento transversal com componente longitudinal; por meio de revisão de prontuários, foram incluídos 257 pacientes. Os critérios de inclusão foram: dissecção crônica de aorta tipo A de Stanford e aneurisma de aorta ascendente. Foram excluídos casos de dissecção aguda de aorta, qualquer tipo, e aneurisma de aorta não envolvendo segmento ascendente. As variáveis avaliadas foram demografia, fatores pré, intra e pós-operatórios. RESULTADOS: Variáveis com risco aumentado de óbito hospitalar (RC; IC95%; P valor): etnia negra (6,8; 1,54 30,2; 0,04), doença cerebrovascular (10,5; 1,12-98,7; 0,04), hemopericárdio (35,1; 3,73-330,2; 0,002), operação de Cabrol (9,9; 1,47-66,36; 0,019), cirurgia de revascularização miocárdica simultânea (4,4; 1,31-15,06; 0,017), revisão de hemostasia (5,72; 1,29-25,29; 0,021) e circulação extracorpórea (CEC) [min] (1,016; 1,007-1,026; 0,001). Dor torácica associou-se com risco reduzido de óbito hospitalar (0,27; 0,08-0,94; 0,04). Variáveis com risco aumentado do desfecho clínico composto hospitalar foram: uso de antifibrinolítico (3,2; 1,65-6,27; 0,0006), complicação renal (7,4; 1,52-36,0; 0,013), complicação pulmonar (3,7; 1,5-8,8; 0,004), EuroScore (1,23; 1,08-1,41; 0,003) e tempo de CEC [min] (1,01; 1,00-1,02; 0,027). CONCLUSÃO: Etnia negra, doença cerebrovascular, hemopericárcio, operação de Cabrol, revascularização miocárdica simultânea, revisão de hemostasia e tempo de CEC associaram-se com risco aumentado de óbito hospitalar. Dor torácica associou-se com risco reduzido de óbito hospitalar. Uso de antifibrinolítico, complicação renal, complicação pulmonar, EuroScore e tempo de CEC associaram-se ao desfecho clínico composto hospitalar.
OBJECTIVES: The primary objective was to identify predictors of hospital mortality in patients undergoing aortic surgery. The secondary objective was to identify factors associated with clinical outcome composed hospital (death, bleeding, neurologic complications or ventricular dysfunction). METHODS: A cross-sectional design with longitudinal component. Through chart review, 257 patients were included. Inclusion criteria were: aortic dissection Stanford type A and ascending aortic aneurysm. Exclusion criteria were acute aortic dissection, of any kind, and no aortic aneurysm involving the ascending segment. Variables assessed: demographics, preoperative factors, intraoperative and postoperative. RESULTS: Variables with increased risk of hospital mortality (OR, 95% CI, P value): black ethnicity (6.8, 1.54-30.2; 0.04), cerebrovascular disease (10.5, 1.12-98.7; 0.04), hemopericardium (35.1, 3.73-330.2; 0.002), Cabrol operation (9.9, 1.47-66.36; 0.019), CABG simultaneous (4.4; 1.31 to 15.06; 0.017), bleeding (5.72, 1.29-25.29; 0.021) and cardiopulmonary bypass (CPB) time [min] (1.016; 1.0071.026; 0.001). Thoracic pain was associated with reduced risk of hospital death (0.27, 0.08-0.94, 0.04). Variables with increased risk of hospital clinical outcome compound were: use of antifibrinolytic (3.2, 1.65-6.27; 0.0006), renal complications (7.4, 1.52-36.0; 0.013), pulmonary complications (3.7, 1.58.8, 0.004), EuroScore (1.23; 1.08-1.41; 0.003) and CPB time [min] (1.01; 1.00 to 1.02; 0.027). CONCLUSION: Ethnicity black, cerebrovascular disease, hemopericardium, Cabrol operation, CABG simultaneous, hemostasis review and CPB time was associated with increased risk of hospital death. Chest pain was associated with reduced risk of hospital death. Use of antifibrinolytic, renal complications, pulmonary complications, EuroScore and CPB time were associated with clinical outcome hospital compound.