Management of Intraoperative Malperfusion Syndrome Using Femoral Artery Cannulation for Repair of Acute Type A Aortic Dissection

Shimokawa, Tomoki; Takanashi, Shuichiro; Ozawa, Noritaka; Itoh, Tsuyoshi

doi:10.1016/j.athoracsur.2008.01.048

Cited by 46 publications

(38 citation statements)

References 18 publications

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“…Despite acceptable results reported in the literature, 82,83) malperfusion occasionally occurs due to predominant perfusion into the false lumen leading to a compressed true lumen. When it takes place in the descending aorta, it causes sudden hypotension and is readily recognized.…”

Section: Perfusion Routementioning

confidence: 93%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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Section: Perfusion Routementioning

confidence: 93%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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“…On the other hand, femoral artery cannulation is the easiest and fastest accessible site, but leads to retrograde flow in the descending and ascending aorta and might have an impact on plaque rupture and cerebral embolism. In addition, malperfusion might occur with retrograde flow (8). The primary objective of the present study is to analyze outcome parameters in a singlecenter series of AADA repair with different cannulation techniques for initial bypass.…”

Section: Introductionmentioning

confidence: 99%

Is the outcome in acute aortic dissection type A influenced by of femoral versus central cannulation?

Klotz¹,

Bucsky²,

Richardt³

et al. 2016

Ann. Cardiothorac. Surg.

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Background: The purpose of this study was to evaluate the single-center experience in initial femoral versus central cannulation of the extracorporeal circulation for acute aortic dissection type A (AADA). Conclusions: AADA can be operated with both femoral and central cannulation with similar results. Risk for early mortality was driven by the preoperative clinical and hemodynamic status before operation rather than the cannulation technique. Methods

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“…If femoral perfusion is used, only the artery with the absent or diminished pulse should be cannulated since it is most likely to connect to the proximal aortic true lumen. The safety of femoral cannulation in general has been questioned, though, given concerns about pressurization of the false lumen and malperfusion, which could be compounded when the distal ascending aorta is cross-clamped (104,110,134). Evaluation of the risk associated with cross-clamping the aorta during the cooling phase and prior to PHCA have provided divergent results: some studies have reported increased risk (110,121,135), and others have failed to show excess morbidity or mortality (130,136).…”

Section: The Arch Cerebral Protection and Cannulation Strategymentioning

confidence: 99%

Evolution of surgical therapy for Stanford acute type A aortic dissection

Chiu

Miller

2016

Ann. Cardiothorac. Surg.

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Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small?The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

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Management of Intraoperative Malperfusion Syndrome Using Femoral Artery Cannulation for Repair of Acute Type A Aortic Dissection

Cited by 46 publications

References 18 publications

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Is the outcome in acute aortic dissection type A influenced by of femoral versus central cannulation?

Evolution of surgical therapy for Stanford acute type A aortic dissection

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