Clinical Study Of Total Arch Replacement Surgery And Arterial Cannulation Strategy And Reconstruction Of Aortic Dissection Root Mode

The aortic arch disease puts patients at fatal risk,and its surgical management remains a great challenge for cardiovascular surgeons owing to its complexity and diversity in pathological types,anatomical changes and hemodynamics.The treatment of aortic arch disease in China has made tremendous progress in the past decades,and the surgical strategy for national characteristics has become a self-contained system.Total aortic arch replacement based on deep hypothermic circulatory arrest is now considered as the standard procedure for complex aortic arch disease.Moreover,frozen elephant trunk is getting more and more applied by cardiovascular surgeons,with the advantages of eliminating the diseased aortic arch,dilating the true lumen,promoting thrombosis of the distal false lumen,and simplifying the second-stage approach.However,there might be still a certain degree of organ function injury caused by the deep hypothermic environment and circulatory arrest.Recently,the aortic balloon occlusion technique,a novel procedure based on frozen elephant trunk,was published to offer total arch replacement with shorter circulatory arrest time(3-5 minutes averagely)and higher nasopharyngeal temperature(around 28℃),which convinced us of certain protective effect on liver and kidney.On the other hand,hybrid arch repair,combined with endovascular repair and open surgery,has largely enriched the surgical strategy for treating aortic arch disease.It can construct a safe landing zone through open surgery,freedom from deep hypothermic circulatory arrest in total aortic arch replacement,and has become a recommended treatment for patients with a prohibitively high surgical risk.There has been research considering the comparison of clinical outcomes between hybrid repair and conventional open replacement,while hybrid approach fell to yield superiority as a less invasive alternative in published reports.Meanwhile,there is an absence of comparative analyses of clinical efficacy between aortic balloon occlusion technique versus hybrid procedure.Optional choices for total aortic arch replacement in patients with aortic arch disease need to be further explored.Therefore,the first part of this study aims to evaluate and compare the perioperative clinical outcomes of patients with aortic arch disease treated by total arch replacement with conventional frozen elephant trunk,aortic balloon occlusion technique and hybrid arch repair.The second part further comprehensively addresses the early-to-midterm survival associated with the application of aortic balloon occlusion technique and hybrid repair,and analyses the differences in various risk stratification levels.Additionally,the selection of an appropriate arterial cannulation strategy is critical to the prognostic of patients with aortic arch disease.It should be considered based on patient’s status,arterial anatomy and surgeon’s preference.Right axillary and femoral artery were well adopted as the preferred arterial cannulation in the current practice.Double arterial cannulation,on the other hand,is considered to provide adequate systemic perfusion,with the scarcity of research existing on its efficacy.Clinical outcomes of different cannulation strategies vary in different reports.Therefore,the third part of this study compared the early-to-midterm clinical outcomes among axillary artery cannulation,femoral artery cannulation and double arterial cannulation in patients undergoing frozen elephant trunk for Stanford type A aortic dissection.Acute Stanford type A aortic dissection often involves various important components of the aortic root,including aortic valve,aortic sinus,and coronary artery ostia.There are huge regional differences in the surgical management of acute Stanford type A aortic dissection in China,and the recognition and selection of surgical strategies are not standardized,especially in aortic root dissection.To provide cardiovascular surgeons with a clear and visual understanding of aortic root disease,the fourth part is an initial attempt to reconstruct the acute Stanford type A aortic dissection root model based on 3D printing technology,which can be used for the popularization of aortic disease,training of cardiovascular surgeons,and preoperative discussion and planning,and provide support for aortic disease management strategies and methods.The four parts of this study are summarized below:Objective:This study aimed to compare early clinical outcomes of patients treated by total arch replacement with conventional frozen elephant trunk(FET),FET with aortic balloon occlusion(ABO)technique and hybrid arch repair(HAR).Methods:Between January 2017 and July 2019,643 consecutive patients with aortic arch diseases were eligible for total arch replacement,including 356 in conventional FET(FET group),112 in FET with ABO technique(ABO group),and 175 in HAR(HAR group).A retrospective cohort analysis of perioperative results was undertaken,performed with inverse probability weighting(IPW).The primary endpoint was composite endpoints included 30-day mortality,stroke,paraplegia,hemodialysis,reintubation,and intra-aortic balloon pump or extracorporeal membrane oxygenation support,and secondary endpoint was visceral dysfunction included hepatic and renal dysfunction.Results:There was a significantly shorter circulatory arrest time in ABO group compared with FET group(5[interquartile range,IQR 3-6]min vs 16[IQR 13-18]min,P<0.001).The overall in-hospital mortality was 2.2%(FET vs ABO vs HAR:2.5%vs 0%vs 2.9%,P=0.210).Parallel early composite endpoints were demonstrated among three groups(P=0.113),with 57 patients in FET group(16.0%),12 patients in ABO group(10.7%),and 35 patients in HAR group(20.0%).A tendency toward decreasing composite endpoints was suggested in ABO group compared with FET and HAR groups(15.5%vs 7.2%vs 19.8%,P=0.025)after IPW adjustment.Furthermore,ABO and HAR groups showed a lower incidence of visceral dysfunction compared with FET group(45.2%vs 25.0%vs 30.3%,P<0.001).Patients receiving ABO suffered a significantly lower rate of prolonged ventilation(>72h)compared with other two groups(18.0%vs 8.0%vs 19.4%,P=0.025).The IPW method substantiated the foregoing results(visceral dysfunction:47.3%vs 25.1%vs 27.8%,P=0.003;ventilation time>72h:18.2%vs 5.9%vs 18.5%,P=0.014).Conclusions:FET with ABO technique obtains considerable or even better early clinical outcomes in total arch replacement compared with conventional FET and HAR,which could be a feasible and effective approach for patients with aortic arch diseases.Objective:The goal of this study was to compare the early-to-midterm outcomes of patients treated with the frozen elephant trunk procedure with aortic balloon occlusion(FET-ABO)versus hybrid arch repair(HAR)for aortic arch diseases.Methods:Patients who underwent total aortic arch replacement with FET-ABO(n=134)and HAR procedure(n=220)from 2017 to 2020 at our institution were analyzed retrospectively.Early-to-midterm outcomes were compared using inverse probability weighting.Low-risk and high-risk subgroup analyses were performed according to the cutoff of the additive European System for Cardiac Operative Evaluation value of 6.Results:The present study demonstrated similar 30-day mortality(FET-ABO vs HAR:3.7%vs 8.6%,P=0.118)and adverse events between the FET-ABO group and the HAR group.Decreased total hospital costs(177,933[interquartile range,IQR 152,698-208,753](?) vs 344,944[IQR 283,133-393,214](?),P<0.001)and considerable early-to-midterm survival(crude:hazard ratio[HR]:0.40,95%confidence interval[CI]:0.17-0.91,P=0.030;adjusted:HR:0.35,95%CI:0.13-0.91,P=0.032)were obtained with the FETABO compared to the HAR procedure.The IPW method substantiated the foregoing results.Adjusted subgroup analyses suggested that the FET-ABO procedure had a trend towards improved survival in low-risk patients(HR:0.17,95%CI:0.03-0.93,P=0.041)and achieved outcomes comparable to those of the HAR procedure in high-risk patients(HR:0.46,95%CI:0.15-1.42,P=0.176).Conclusions:The FET-ABO technique is effective and feasible for the treatment of patients with aortic arch disease in different surgical risk stratification.It might be more viable and cost-effective for selected patients compared with the hybrid procedure,which could be better used and promoted in hospitals lacking experience and equipment.Objective:The goal of this study was to compare clinical outcomes of double arterial cannulation(DAC),axillary cannulation,and femoral cannulation in patients undergoing frozen elephant trunk for Stanford type A aortic dissection.Methods:Between 2015 to 2020,the study included 488 patients and was divided into three groups according to cannulation site:171 in DAC group,217 in axillary group,and 100 in femoral group.Overall survival was the primary endpoint and the secondary endpoints were 30-day mortality,stroke,paraplegia,hepatic dysfunction,and acute kidney injury.Clinical outcomes were analyzed after inverse probability weighting.Results:The selection of cannulation site mainly depended on patient’s dissection-related anatomy and surgeon’s preference.DAC group presented higher percentages of coeliac trunk,renal,and iliac artery malperfusion,but early outcomes and overall survival did not differ among groups.Subgroup analyses suggested that in patients requiring cardiopulmonary bypass duration≥ 180 minutes,DAC approach was associated with a tendency to improved overall survival(log-rank P=0.054)compared with axillary(hazard ratio[HR]:0.35,95%confidence interval[CI]:0.14-0.90,P=0.029)and femoral cannulation(HR:0.38,95%CI:0.14-1.03,P=0.058).Inverse probability weighting adjustment(log-rank P=0.039;axillary as reference,HR:0.34,95%CI:0.13-0.86,P=0.022;femoral as reference,HR:0.33,95%CI:0.11-0.90,P=0.030)and multivariable Cox proportional hazards model(axillary as reference,HR:0.26,95%CI:0.10-0.68,P=0.006;femoral as reference,HR:0.33,95%CI:0.12-0.90,P=0.030;covariates including age,gender,acute dissection,any organ malperfusion,and deep hypothermic circulatory arrest)confirmed this result.Conclusion:DAC approach was commonly used in patients with branch artery malperfusion,which obtained comparable outcomes to axillary and femoral cannulation.It provides a flexible and effective option with adequate perfusion for cases with various dissection-involved status and prolonged cardiopulmonary bypass duration.Objective:To explore the clinical significance in the diagnosis and treatment of aortic root disease by reconstructing acute Stanford type A aortic dissection root model based on 3D printing technology.Methods:According to the pathological anatomy of aortic root involved by acute Stanford type A aortic dissection,systematically classifying seven types of acute type A aortic dissection root models.Scanning the tomographic image of aortic root by using 256 CT and importing the scanned data into 3D slicer software for image optimization,segmentation and three-dimensional reconstruction.Then using FreeCAD and Blender software for image simplification,adjustment and color preview.Finally printing the 3D model with Stratasys Objet J750 printer.Results:Seven types of acute type A aortic dissection root models were successfully reconstructed through 3D printing technology.With the characteristics of reusability,easy manipulation,and durability,these models can present the anatomical features and pathological changes of acute Stanford type A aortic dissection involving aortic root clearly and multi-angle.Conclusion:3D printing technology can effectively reconstruct acute Stanford type A aortic dissection root models,which provides support for the treatment strategy and method of acute Stanford type A aortic dissection root.