Abstract
OBJECTIVES
Non-A non-B aortic dissections are rare, and little is known about their natural history, indications for surgery and operative results. We aim to examine the literature to ...summarize what is known of the natural history of non-A non-B dissections and evaluate the outcomes of the therapeutic options available.
METHODS
An extensive literature search was performed using MEDLINE to find all published studies that report data on the natural history and outcomes of patients with non-A non-B aortic dissection. Data on patients treated with medical therapy were extracted to characterize the natural history. Primary end points included 30-day mortality, stroke and retrograde type A dissection.
RESULTS
Of the 423 studies found, 14 articles (433 patients) fulfilled the inclusion criteria for quantitative analysis. The proportion of medically treated patients ranged from 5 to 54% with a pooled rate of 36% (50/138). The 30-day mortality of patients treated with medical therapy was 14% (7/50). The overall estimated proportion of 30-day mortality for patients who underwent intervention was 3.6% 95% confidence interval (CI) 1.7–5.6%, retrograde type A dissection was 2.6% (95% CI 0.8–4.4%) and stroke was 2.8% (95% CI 1.0–4.5%).
CONCLUSIONS
Despite the likelihood of reporting and selection bias, patients with non-A non-B dissection often have a complicated course requiring some form of intervention. The 30-day mortality of patients treated with medical therapy seems higher than surgical or endovascular therapy. Ideally, further large prospective studies are necessary to confirm our suggestion that early intervention may be indicated in non-A non-B dissections.
Surgical and cerebral protection strategies in aortic arch surgery remain under debate. Perioperative results using deep hypothermic circulatory arrest (DHCA) have been associated with favorable ...short-term mortality and stroke rates. The present study focuses on late survival in patients undergoing aortic surgery using DHCA.
A total of 613 patients (mean age, 63.7 years) underwent aortic surgery between January 2003 and December 2015 using DHCA, with 77.3% undergoing hemiarch replacement and 20.4% undergoing arch replacement, with a mean DHCA duration of 29.7 ± 8.5 minutes (range, 10-62 minutes). We examined follow-up extending up to a mean of 3.8 ± 3.4 years (range, 0-14.1 years).
Operative mortality was 2.9%, and the stroke rate was 2%. Survival was 92.2% at 1 year and 81.5% at 5 years, significantly lower than the values in an age- and sex-matched reference population. In elective, nondissection first-time surgeries (n = 424), survival was similar to that of the reference group. Acute type A aortic dissection (hazard ratio HR, 4.84; P = .000), redo (HR, 4.12; P = .000), and descending aortic pathology (HR, 5.54: P = .000) were independently associated with reduced 1-year survival. Beyond 1 year, age (HR, 1.07; P = .000), major complications (HR, 3.11; P = .000), and atrial fibrillation (HR, 2.47; P = .006) were independently associated with poor survival. DHCA time was not significantly associated with survival in multivariable analysis.
Aortic surgery with DHCA can be performed with favorable late survival, with the duration of DHCA period having only a limited impact. However, these results cannot be generalized for very long durations of DHCA (>50 minutes), when perfusion methods may be preferable. In elective, nondissection first-time surgeries, a late survival comparable to that in a reference population can be achieved. Early survival is adversely affected by aortic dissection, redo status, and disease extent.
Abstract
Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries ...and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?
(1) Background: Systemic inflammation stands as a well-established risk factor for ischemic cardiovascular disease, as well as a contributing factor in the development of cardiac arrhythmias, notably ...atrial fibrillation. Furthermore, scientific studies have brought to light the pivotal role of localized vascular inflammation in the initiation, progression, and destabilization of coronary atherosclerotic disease. (2) Methods: We comprehensively review recent, yet robust, scientific evidence elucidating the use of perivascular adipose tissue attenuation measurement on computed tomography applied to key anatomical sites. Specifically, the investigation extends to the internal carotid artery, aorta, left atrium, and coronary arteries. (3) Conclusions: The examination of perivascular adipose tissue attenuation emerges as a non-invasive and indirect means of estimating localized perivascular inflammation. This measure is quantified in Hounsfield units, indicative of the inflammatory response elicited by dense adipose tissue near the vessel or the atrium. Particularly noteworthy is its potential utility in assessing inflammatory processes within the coronary arteries, evaluating coronary microvascular dysfunction, appraising conditions within the aorta and carotid arteries, and discerning inflammatory states within the atria, especially in patients with atrial fibrillation. The widespread applicability of perivascular adipose tissue attenuation measurement underscores its significance as a diagnostic tool with considerable potential for enhancing our understanding and management of cardiovascular diseases.
Reply to Karangelis and Tagarakis Carino, Davide; Nicolini, Francesco
European journal of cardio-thoracic surgery,
08/2019, Letnik:
56, Številka:
2
Journal Article
Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein ...grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.
The aim of our study is to compare the classical surgical tracheostomy (TT) technique with a modified surgical technique designed and created by the cardiothoracic surgery staff of our department to ...reduce surgical trauma and postoperative complications. This modified technique combines features of percutaneous TT and surgical TT avoiding the use of specialized tools, which are required in percutaneous TT.
From October 2008 to March 2014 we performed 67 tracheostomies using this New Modified Surgical Technique (NMST) and 56 TT with the Classical Surgical Technique (CST). We collected data about the early clinical complications, deaths TT-related, deaths due to other complications and the presence of late TT's complications were performed by a telephone follow-up. SPSS software (IMB version 21) was used for the statistical analysis. Categorical data were treated with chi-square test and continuous data were treated with
-test for independent samples.
NMST group had a significant lower number of early complications (P=0.005) compared to CST group (5
. 15). In-hospital mortality was significantly higher in CST group (18 deaths
. 4 in NMST group, P=0.001) but we registered only one case of TT-related mortality in CST group (P=0.280). We did not note other differences between the two groups regarding short or mid-long term complications.
In our experience the NMST demonstrated to be easily safe and reproducible with an amount of early, mid- and long-term complications similar to the CST; furthermore the aesthetic results of the procedure appear similar to those of percutaneous TT.
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