Surgical intervention for chronic thoracoabdominal aortic dissecting aneurysms (cTAADA) is regarded as one of the most challenging procedures in the field of vascular surgery. For nearly six decades, open repair predominantly utilizing prosthetic grafts has been the treatment of choice for cTAADA. With advances in minimally invasive endovascular technologies, two novel surgical approaches have emerged: total endovascular stent-graft repair and hybrid procedures combining retrograde debranching of visceral arteries with endovascular stent-graft repair (abbreviated as hybrid procedure). Although total endovascular stent-graft repair offers reduced trauma and quicker recovery, limitations persist in clinical application due to hostile anatomical requirements of the aorta, high costs, and the lack of universally available stent-graft products. Hybrid repair, integrating the minimally invasive ethos of endovascular repair with visceral artery debranching techniques, has increasingly become a significant surgical modality for managing thoracoabdominal aneurysms, especially in cases unsuitable for open surgery or total endovascular treatment due to anatomical constraints such as aortic tortuosity or narrow true lumens in dissections. Recent enhancements in hybrid surgical approaches include ongoing optimization of visceral artery reconstruction strategies based on hemodynamic analyses, and exploration of the comparative benefits of staged versus concurrent surgical interventions.
The treatment of aortic dissection has already shifted to endovascular strategies. However, with the evolution of this disease and a deeper understanding of it, experts from various countries have developed a series of innovative endovascular techniques and devices in areas such as lumen reconstruction, false lumen embolization, entry sealing, and branch arteries reconstruction, targeting the long-term complication of chronic post-dissection thoracoabdominal aortic aneurysm. The past few decades have seen that Chinese vascular surgeons have gradually emerged on the world stage and contributed multiple “Chinese solutions” for post-dissection thoracoabdominal aortic aneurysm. The author in this review intends to provide an overview of these techniques and devices mentioned above.
The treatment of chronic thoracoabdominal aortic dissection aneurysm remains a major challenge in aortic surgery. Open surgery is the mainstream treatment at present. New devices for endovascular treatment of chronic thoracoabdominal aortic dissection are gradually applied in clinical practice. The hybrid procedure is a combination of open and endovascular procedures. The appropriate treatment should be selected according to the patient's age, anatomy, genetic aortic disease, and comorbidities.
Objective To determine risk factors associated with postoperative hypoxemia after surgery for acute aortic dissection. Methods We retrospectively analyzed clinical data of 116 patients with acute aortic dissection who underwent endovascular stent-graft exclusion or open surgery in Qingdao Municipal Hospital from February 2007 to February 2012. All the 116 patients were diagnosed as acute aortic dissection by CT angiography （CTA），including 60 patients with Stanford type A aortic dissection and 56 patients with Stanford type B aortic dissection. According to whether they had postoperative hypoxemia，all the 116 patients with acute aortic dissection were divided into hypoxemia group［arterial partial pressure of oxygen （PaO2） /fraction of inspired oxygen （FiO2） ＜200 mm Hg］：33 patients including 28 males and 5 females with their age of 52.7±11.4 years； and non-hypoxemia group（PaO2/FiO2≥200 mm Hg）：83 patients including 66 males and 17 females with their age of 55.0±13.8 years. Perioperative clinical data were analyzed and compared between the two groups. Multivariate logistic regression was performed to identify risk factors of postoperative hypoxemia after surgery for acute aortic dissection. Results The incidence of postoperative hypoxemia after surgery for acute aortic dissection was 28.4% （33/116）. Perioperative death occurred in 13 patients（11.2%，including 8 patients in the hypoxemia group and 5 patients in the non-hypoxemia group）. Univariate analysis showed that preoperatively the percentages of patients with body mass index（BMI） ＞ 25 kg/m2，smoking history，duration from onset to operation ＜24 h，preoperative PaO2/FiO2≤300 mm Hg，and patients undergoing open surgery in the hypoxemia group were significantly higher than those in the non-hypoxemia group（P＜0.05）. Deep hypothermic circulatory arrest（DHCA） ratio，blood transfusion in 24 hours postoperatively，mechanical ventilation time，length of ICU stay and hospital stay in the hypoxemia group were significantly higher or longer than those in the non-hypoxemia group（P＜0.05）. Logistic multivariate regression identified BMI＞25 kg/m2（RR=98.861，P=0.006），DHCA（RR=22.487，P=0.007），preoperative PaO2/FiO2≤300 mm Hg（RR=9.080，P=0.037） and blood transfusion＞6 U in 24 hours postoperatively（RR=32.813，P=0.003） as independent predictors of postoperative hypoxemia for open-surgery patients，while BMI＞25 kg/m2 （RR=24.984，P=0.036） and preoperative PaO2/FiO2 ratio≤300 mm Hg （RR=21.145，P=0.042） as independent predictors of hypoxemia for endovascular stent-graft exclusion patients. Conclusion Postoperative hypoxemia is a common complication after surgery for acute aortic dissection. Early interventions for obesity and preoperative hypoxemia，and reducing perioperative blood transfusion may decrease the incidence of postoperative hypoxemia after surgery for acute aortic dissection.
ObjectiveTo investigate the relationship between the changes in preoperative serum creatinine (Cr), myoglobin (Mb), alanine aminotransferase (ALT) and postoperative fibrinogen (Fib), C- reactive protein (CRP) expression levels and postoperative hypoxemia in patients with aortic dissection aneurysm (ADA), and construct a predictive model. Additionally, the study explores the role of transpulmonary pressure-guided positive end expiratory pressure (PEEP) in improving postoperative hypoxemia. MethodsA retrospective analysis was conducted on the clinical data of ADA patients admitted to Tianjin Chest Hospital from April 2021 to August 2023. Patients were divided into a hypoxemia group [partial pressure of oxygen/fraction of inspiration oxygen (PaO2/FiO2) ≤200 mm Hg] and a non-hypoxemia group (PaO2/FiO2 >200 mm Hg) based on whether they developed postoperative hypoxemia. Univariate and multivariate regression analyses were used to identify risk factors for postoperative hypoxemia in ADA patients and to construct a predictive model for postoperative hypoxemia. The receiver operating characteristic (ROC) curve was plotted, and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate the predictive value of the model. Furthermore, the impact of different ventilation modes on the improvement of postoperative hypoxemia was analyzed. From April 2021 to August 2023, 16 ADA patients with postoperative hypoxemia who received conventional mechanical ventilation were included in the control group. From September 2023 to December 2024, 28 ADA patients with postoperative hypoxemia who received transpulmonary pressure-guided PEEP were included in the experimental group. ICU stay duration, mechanical ventilation duration, hospital mortality rate, and respiratory and circulatory parameters were analyzed to evaluate the effect of transpulmonary pressure-guided PEEP on patients with postoperative hypoxemia after acute aortic dissection. ResultsA total of 98 ADA patients were included, of which 79 (80.61%) were males and 19 (19.39%) were females. Their ages ranged from 32 to 79 years, with an average age of (49.4±11.2) years. Sixteen (16.3%) patients developed postoperative hypoxemia. Body mass index (BMI), smoking history, cardiopulmonary bypass (CPB) duration, preoperative serum Cr, Mb, ALT, and postoperative Fib and CRP showed a certain correlation with postoperative hypoxemia in ADA patients (P<0.05). There was no statistical difference in other baseline data between the two groups (P>0.05). Logistic regression analysis results indicated that BMI [OR=1.613, 95%CI (1.260, 2.065)] and preoperative Mb [OR=2.344, 95%CI (1.048, 5.246)], ALT [OR=1.012, 95%CI (1.000, 1.024)], Cr [OR=1.752, 95%CI (1.045, 2.940)], postoperative Fib [OR=1.165, 95%CI (1.080, 1.258)] and intraoperative CPB time [OR=1.433, 95%CI (1.017, 2.020)] were influencing factors of postoperative hypoxemia in ADA patients (P<0.05). Based on this, a prediction model for postoperative hypoxemia in ADA patients was established. The area under the curve corresponding to the optimal critical point was 0.837 [95%CI (0.799, 0.875)], with a sensitivity of 87.5% and a specificity of 79.3%. The Hosmer-Lemeshow goodness of fit test showed P=0.536. Before treatment, there were no statistical differences in respiratory and circulatory parameters between the control group and the experimental group (P>0.05). After treatment, the levels of PEEP, PaO2/FiO2, end-expiratory esophageal pressure, and end-inspiratory transpulmonary pressure in the experimental group were higher than those in the control group (P<0.05). The duration of mechanical ventilation and ICU stay in the experimental group were shorter than those in the control group (P<0.05), while there was no statistical difference in mortality between the two groups (P=0.626). ConclusionThe hypoxia prediction model based on preoperative Cr, Mb, ALT and postoperative Fib levels, combined with transpulmonary pressure-guided PEEP optimization, provides a scientific basis for the precise management of postoperative hypoxemia in ADA. This approach not only improves the predictive ability of hypoxemia risk but also significantly improves the postoperative oxygenation status of patients through personalized mechanical ventilation strategies, providing new insights into the management of postoperative complications.
Abstract: Objective To evaluate surgical strategies for the treatment of acute Stanford type A aortic dissection with involvement of the aortic root. Methods From January 2005 to December 2010, 62 consecutive patients underwent emergency surgical intervention for acute Stanford type A aortic dissection with involvement of the aortic root in Renji Hospital Affiliated to Medical School of Shanghai Jiaotong University. According to different methods for the management of proximal aortic dissection, these patients were divided into 3 groups: group A, aortic valve commissural suspension＋supracommissural replacement of the ascending aorta （SCR）,including 28 patients （20 males and 8 females，mean age 45.2±15.6 years）; group B, partial sinus remodeling+ascending aortic replacement, including 10 patients （7 males and 3 females，mean age 44.6±14.9 years）；group C, Bentall procedure,including 24 patients （17 males and 7 females，mean age 46.2±15.6 years）. Clinical outcomes were compared among the three groups. Results Six patients died peri-operatively and in-hospital mortality was 9.67% （6/62）. Fifty-four patients were followed up, and the mean follow-up time was 27.3±15.7 months. During follow up, 2 patients died, one for lung cancer and the other for unknown reason. One patient in group A underwent CT scan 6 months after surgery which showed aortic root pseudo-aneurysm. Cardiopulmonary bypass time and aortic cross-clamping time of group C were significantly longer than those of group A and group B （274±97 min vs. 194±65 min, 210±77 min, t=22.482, 30.419, P=0.002， 0.122；150±56 min vs. 97±33 min, 105±46 min, t=12.630, 17.089, P=0.000，0.034）. There was no statistical difference in mortality （t=1.352，P=0.516）, incidence of postoperative reexploration for bleeding, acute renal failure and neurological complication （t=0.855, 0.342, 2.281; P=0.652, 0.863, 0.320） among the three groups. Conclusion For patients with acute aortic dissection involving the aortic root, aortic valve commissural suspension+SCR，partial sinus remodeling＋ascending aortic replacement and Bentall procedure may be considered the surgical treatment of choice with respective advantages and disadvantages. Satisfactory clinical outcomes can be achieveed if surgical indications and procedures are properly employed.