OBJECTIVE:The optimal surgical approach for acute type A aortic dissection involving the aortic arch remains controversial. This study aims to evaluate the long-term outcomes of acute type A aortic dissection treated with total arch replacement combined with frozen elephant trunk implantation in a large single-center cohort. METHODS:From 2010 to 2022, patients with acute type A aortic dissection who received total arch replacement with frozen elephant trunk implantation at Fuwai Hospital were selected for clinical data collection and long-term follow-up. Logistic regression and Cox regression analyses were performed to identify risk factors for operative mortality, long-term mortality, and reoperation. RESULTS:A total of 1672 patients underwent total arch replacement with frozen elephant trunk implantation, of whom 79.9% (1336/1672) were male with a median age of 48 years. The operative mortality rate was 6.3% (105/1672). The 10-year survival was 81.4%, and the most extended follow-up was over 13 years. Among the survivors, 89.7% (1303/1453) had complete self-care ability and were able to engage in general physical work. The 10-year cumulative incidence of reoperation was 13.3%. Multivariable logistic regression analysis revealed that male gender was associated with a reduced risk of operative death (odds ratio, 0.95, 95% CI, 0.92-0.98) and long-term death (hazard ratio, 0.68, 95% CI, 0.48-0.96). CONCLUSIONS:Total arch replacement with frozen elephant trunk implantation demonstrates acceptable operative mortality and promising long-term outcomes for acute type A aortic dissection. Female patients face higher risks of operative and long-term mortality compared with male patients. Total arch replacement with frozen elephant trunk implantation provides patients with encouraging long-term quality of life and is advisable for acute type A aortic dissection in experienced centers.

INTRODUCTION:Extracellular matrix disorder and cellular phenotype transformation are the major histopathological features associated with ascending aortic aneurysms. Rare studies have investigated the relationship between cellular phenotype transformation and the abnormalities of the matrix constituents. In this study, we investigated whether the cellular phenotype transformation resulted in the extracellular matrix disorder.METHODS:Aortic samples were obtained from 20 patients undergoing operations for ascending aortic aneurysms. Control aortic samples were obtained from 15 patients who underwent coronary artery bypass graft. The protein levels of osteopontin (OPN), collagen, and elastin were examined using Western blot, and quantitative reverse transcriptase-PCR was used to analyze the mRNA expression of collagen and elastin. In vitro experiment, vascular smooth muscle cells (VSMCs) were treated with recombinant human OPN (rh-OPN) or p38 MAPK inhibitor (SB203580) to investigate whether OPN and p38 MAPK regulated the expression of collagen and elastin.RESULTS:The protein level of OPN and collagen III increased in ascending aortic aneurysm samples, compared with controls (p < 0.05). There was no difference in the protein level of elastin between aneurysm tissues and the controls. VSMCs treated with rh-OPN increased the collagen III and elastin protein level and mRNA expression (p < 0.05). Cells treated with SB203580 decreased the collagen III and elastin protein level and mRNA expression (p < 0.05). Furthermore, VSMCs incubated with SB203580 reduced the rh-OPN-induced production of collagen III and elastin (p < 0.05).CONCLUSION:OPN, the proliferative VSMCs maker, increased the expression of extracellular matrix. OPN/p38 MAPK signaling pathways may protect against ascending aortic aneurysm progression.

Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications. Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are defined as type Ct. The Chi-square test was adopted for the pairwise comparison among the three types. Kaplan-Meier was used for the analysis of long-term survival and survival free of reoperation. Results: In total, 1,063 AcD patients were enrolled from 2010 to 2015: 54 patients were type Cp, 832 were type Ct, and 177 were type Cd. The highest operation proportion of Cp, Ct and Cd were partial arch replacement, total arch replacement, and TEVAR. The surgical mortality in type Ct was higher compared to type Cd (Ct vs. Cd = 9.38 vs. 1.69%, p < 0.01) and type Cp (Ct vs. Cp = 9.38 vs. 1.85%, p = 0.06). There was no difference in surgical mortality of type Cp and Cd (p = 0.93). There were no significant differences in the long-term survival rates (p = 0.38) and free of aorta-related re-operations (p = 0.19). Conclusion: The Fuwai classification is used to distinguish different AcDs. Different AcDs have different surgical mortality and use different operation methods, but they have similar long-term results.

Objective:To compare the mid-term result of two different valve-sparing root replacement techniques in acute type A aortic dissection: including reimplantation and remodeling.Methods:From March 2009 to December 2019, 41 patients with acute type A dissection and root involvement, who underwent a valve-sparing root replacement using reimplantation(36 cases) or remodeling(5 cases) were retrospectively analyzed in current study. The average age was(44.63±11.34) years old, 36 males. The differences of perioperative variables, postoperative aortic insufficiency and postoperative survival were compared between the two groups.Results:Thirty-day mortality for two groups was 2.8% and 20%( P=0.23). Remodeling group was significantly inferior to reimplantation group in terms of blood consumption(red blood cells, plasma and platelets), postoperative mechanical ventilation time, reoperation for bleeding and hemofiltration for acute renal failure. The median follow-up time of 39 discharged survivors was 34.56(3-121) months, and the follow-up rate was 100%. There was no follow-up death, no bleeding or embolism events, and no cardiovascular reoperation. Grade 2 or sever aortic regurgitation in remodeling group was significantly higher than that in reimplantation group( P=0.02). A Cox regression analysis identified that the remodeling technique was the independent risk factors of postoperative aortic regurgitation. Conclusion:Compared with remodeling technique, reimplantation technique has better perioperative and mid-term results in patients with acute type A aortic dissection. The rate of reoperation for bleeding, the blood consumption and the postoperative aortic regurgitation are significantly reduced. The long-term results need further follow-up.

Objective To evaluate the early and mid-term results after surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with DeBakey typeⅠor Ⅲ aortic dissection. Methods The clinical data of 130 patients who underwent TAAA repair for chronic DeBakey typeⅠ(groupⅠ, n=47)or type Ⅲ(group Ⅲ, n=83)aortic dissections in our center between January 2009 and December 2017 were retrospectively analyzed.Early postoperative results,midterm survival,and re-interventions were compared between these two groups. Results The 30-day mortality rate was 6.9%(n=9)in the overall cohort,with no statistic difference between groupⅠand group Ⅲ(10.6% vs. 4.8%;χ2=0.803, P=0.370).The incidence of major adverse events(38.3% vs. 51.8%;χ2=2.199, P=0.138),5-year actuarial survival rate [(81.7±5.9)% vs.(87.2±4.2)%;χ2=0.483, P=0.487],and 5-year actuarial freedom from all reinterventions [(84.5±6.7)% vs.(85.5±4.8)%;χ2=0.010, P=0.920] showed no significant differences between these two groups. Conclusions The early and mid-term outcomes after surgical repair of TAAA are similar for DeBakey typeⅠ and type Ⅲ patients.However,studies with larger sample sizes are still required.

Objective To investigate the risk factors associated with acute renal failure (ARF) after thoracoabdominal aortic aneurysm (TAAA) surgery. Methods A total of 156 patients underwent TAAA repair between January 2009 and December 2017. Renal failure was defined based on the Kidney Disease Improving Global Outcomes criteria. The patients were divided into ARF group and non-ARF group based on the presence/absence of postoperative ARF. The risk factors of ARF were analyzed by univariate analysis and multivariate logistic analysis. Results The subjects included 111 males and 45 females aged (40.4±10.9) years (range:19-65 years). The surgical reasons included aortic dissection (n=130,83.3%),aneurysm (n=22,14.1%),and pseudoaneurysm (n=4,2.6%). The degrees of repair included Crawford extent I in 6 patients (3.8%),extent Ⅱ in 128 patients (82.1%),extent Ⅲ in 20 patients (12.8%),and extent Ⅳ in 2 patients(1.3%). There were 3 patients presented with aortic rupture and 6 patients received emergent operations. Nine patients (5.8%) died within 30 days after surgery,and 8 patients (5.1%) suffered from permanent paraplegia. Thirty-six patients (23.1%) had ARF after surgery,and 18 of them needed dialysis. Multivariate logistic analysis showed that smoking (OR =2.637,95%CI=1.113-6.250,P=0.028),packed red blood cell usage in operation (≥6 U) (OR =5.508,95%CI=2.144-11.930,P=0.000),reoperation for bleeding (OR=3.529,95%CI=1.298-9.590,P=0.013) were independent risk factors for ARF after TAAA repair. Conclusion Smoking,packed red blood cell usage in operation (≥6 U),reoperation for bleeding are the independent risk factors of ARF after TAAA surgery.

Objective:To explore the clinical application of Fuwai aortic dissection classification, including comparing the difference between the diverse types, and its meaning of aortic surgery selection.Methods:Retrospectively collected 1 570 aortic dissection surgery patients from January 1, 2010 to December 31, 2015 in Fuwai Hospital. Fuwai classification includes four types. Type A restricted to the ascending aorta. Type B refers to the descending aorta dissection below the left subclavian artery. Type C refers to dissection involve the aortic arch. Type D refers to the dissection restricted to the abdominal aorta below the diaphragm. The subtype of the type C include type Cp, type Ct and type Cd. Type Cp refers to the proximal aortic arch is involved (at least the left subclavian artery was not implicated). Type Ct refers to total aortic arch is involved. Type Cd refers to the distal aortic arch is involved (at least the innominate artery was not implicated). We compared the differences among the four types (A/B/C/D) and three subtypes (Cp/Ct/Cd) aortic dissection in preoperative, intro and postoperative characteristics.Results:There were 78 cases (4.96%) Fuwai type A, 421 cases (26.82%) Fuwai type B, 1063 cases (67.71%) Fuwai type C, and 8 cases (0.51%) Fuwai type D. The operative mortality was 5.41%. The average age of the patients in type D was the oldest, which was (58.02 ± 11.93) years. The preoperative renal insufficiency in type C was the highest, (14.96%). Type A had the largest aortic sinus diameter (45.92 ± 12.88 mm). Type C had the highest mortality(7.71%), followed by 0.71% of type B, and no surgical deaths occurred in type A and type D. Among type C patients, 54 patients were type Cp, 832 patients were type Ct, 177 patients were type Cd. Surgery mortality between type Ct and type Cd was significant difference (9.38% vs. 1.69%, P<0.01). Type Ct had higher surgery mortality than type Cp, there was no difference (9.38% vs. 1.85%, P=0.06). Type Cp and type Cd had no significant statistical difference in surgical mortality (1.85% vs. 1.69%, P=0.94). Simply ascending aorta replacement accounted for 64.1% in type A , TEVAR accounted for 81.53% in type B , partial arch replacement accounted for 62.96% in type Cp, total aortic arch replacement accounted for 98.56% in type Ct, debranch+ TEVAR/TEVAR accounted for 70.62% in type Cd, EVAR accounted for 100% in type D. Conclusion:The Fuwai classification is more comprehensive and practical for clinical application than the traditional classification. Different classification had different clinical characteristics and prognosis. The classification was helpful for surgical methods selection.

BACKGROUND:Aortic arch disease with Kommerell's diverticulum is an uncommon but troublesome condition, and there are a variety of therapeutic modalities for treating this. We retrospectively analyzed cases who underwent open surgery to summarize different situations and approaches.METHODS:From November 2015 to January 2019, nine patients underwent operation for the mentioned disorder. Four patients with aortic dissection received total arch replacement. Two patients suffering from type B aortic dissection (TBAD) have accepted graft replacement from ascending aorta (aAO) to descending aorta. Two patients with true aneurysm and congenital malformation underwent graft bypass from aAO to descending aorta. One patient had graft replacement of descending aorta.RESULTS:There were nine (eight males and one female) patients with median age of 45 (from 14 to 54) years. The 30-day mortality was 11.1% (1 patient) due to refractory respiratory failure caused by compression of bronchus. One patient had complication of peripheral neuropathy and recovered eventually. Eight patients were followed-up for a median period of 20 [9-46] months. All patients were alive and had no long-term complications except one patient who received re-intervention due to delayed dilation of downstream aorta.CONCLUSIONS:Treatment for different arch lesions with Kommerell's diverticulum should follow corresponding indications. Open surgery is the preferred choice and detailed therapeutic strategy depends on the extension of aneurysm, classification and phase of dissection. Stenting might cause airway compression when right-sided arch and vascular ring exist.

OBJECTIVES:To determine the prognosis of Takayasu arteritis (TA) patients with moderate-to-severe aortic regurgitation treated with surgical vs conservative treatment and to identify independent prognostic factors of long-term outcomes.METHODS:Between January 2002 and January 2017, 101 consecutive TA patients with moderate-to-severe aortic regurgitation treated with either surgical (n = 38) or conservative (n = 63) treatments were investigated in this retrospective observational case-control study. The primary end point was all-cause mortality, and the secondary end point comprised the combined end points of death, non-fatal stroke and cardiac events (non-fatal myocardial infarction and congestive heart failure). Propensity score matching was used to reduce the bias of baseline risk factors.RESULTS:The unadjusted all-cause 10-year mortality in the conservative group was increased compared with the surgical group (28.2% vs 7.4%; log-rank P = 0.036), and the combined end points showed the same trend (52.1% vs 25.3%; log-rank P = 0.005). After an adjustment of baseline risk factors, the conservative treatment was associated with reduced survival rates of both all-cause mortality [hazard ratio (HR): 8.243; 95% CI: 1.069, 63.552; P = 0.007] and combined end points (HR: 6.341; 95% CI: 1.469, 27.375; P = 0.002). Conservative treatment (HR: 3.838, 95% CI: 1.333, 11.053; P = 0.013) and left ventricular end-diastolic diameter (HR: 1.036, 95% CI: 1.001, 1.071; P = 0.042) were risk factors for increased combined end points.CONCLUSION:Surgical treatment improves the outcomes of patients with moderate-to-severe aortic regurgitation due to TA. The dilated left ventricle indicated a worse prognosis.

Objective To evaluate the early and midterm results of surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with Marfan syndrome(MFS). Methods The clinical data of patients with MFS undergoing TAAA repair in Fuwai Hospital between January 2009 and December 2017 were retrospectively analyzed.These patients were divided into two groups:MFS group(n=58)and non-MFS group(n=98).The baseline data,early postoperative results,and midterm follow-up outcomes were compared between these two groups. Results MFS patients were significantly younger(32 years old vs. 45 years old,t=9.603,P=0.000)and more frequently had a history of aortic aneurysm or dissection(19% vs. 0,χ 2=19.996,P=0.000)than non-MFS patients.However,the proportions of males and smokers were significantly lower when compared with non-MFS patients(55.2% vs. 80.6%,χ 2=11.489,P=0.001;13.8% vs. 46.9%,χ 2=17.686,P=0.001).There was no significant difference in proportion of emergency operation,prophylactic cerebrospinal fluid drainage,operation time,intra-operative circulation management,and intra-operative blood transfusion(all P>0.05).The 30-day mortality rate was significantly lower in MFS group than in non-MFS group(0 vs. 9.2%, [Formula: see text]=5.034,P=0.025). Conclusions For patients with MFS,TAAA repair provides lower 30-day mortality and comparative middle-term survival.However,the re-intervention rate is higher among MFS patients,highlighting the importance of close follow-up.

OBJECTIVE:Kommerell diverticulum with aortic dissection involving aortic arch is a rare but troublesome condition. The purpose of this study is to summarize the experience and strategy of surgical treatment.METHOD:From November 2015 to January 2018, seven consecutive patients underwent surgical treatment in our institution. Three patients with acute type A aortic dissection and one patient with acute type B aortic dissection received total arch replacement and frozen elephant trunk (FET) implantation through median sternotomy. Three patients with chronic type B aortic dissection underwent total aortic arch and descending aorta replacement through median sternotomy and lateral thoracotomy.RESULT:There were seven male patients whose median age was 42.3 ± 11.7 (from 14 to 54) years old. There was no perioperative death in this study. One patient had postoperative critical illness polyneuropathy and required prolonged mechanical ventilation (485 hours) and recovered finally. Follow up was completed for all seven patients with a median follow-up time of 7 (3-46) months. One patient with type A dissection developed aneurysm of the descending aorta distal to the FET and received reintervention. No clinical events and abnormal computed tomography manifestations were found in the other seven patients.CONCLUSION:Total arch replacement and FET through single median incision is a reliable method for Kommerell diverticulum associated with acute dissection involving arch. For Kommerell diverticulum associated with chronic type A or B aortic dissection involving aortic arch, graft replacement by double or single incision is safe and appropriate.

Objective To analyze the characteristics of changes in diameters of ascending aorta and false lumen in patients with acute type-A aortic dissection, hereby to determine the risk factors of preoperative dissection rupture. Methods Between January 2010 and December 2016, a total of 794 patients with acute type A dissection were selected. The total diameters of aortic sinus, ascending aorta and the proximal arch as well as the diameter of the false lumen were measured in aortic enhanced CT images. And the competitive risk analysis was used to determine the independent risk factors for dissection rupture. Results 90 patients (11.3％) died of rupture before surgical treatment. The mean age of all patients was 52.2 years. The mean interval time from onset to endpoint was 90.9 h in the rupture group, which was shorter than that in the surgery group (119.7 h,P=0.058). More patients in the rupture group manifested with syncope than in the surgery group (11.1％ vs 1.3％, P<0.001). The preoperative shock in the rupture group was significantly higher than in the surgery group (7.8％vs 2.7％, P=0.021). The average diameter of the ascending aorta was 48.6 mm, and it was significantly greater in the rupture group than in the surgery group (50.0 mm vs 47.3 mm, P=0.003). The average diameter of the false lumen of the ascending aorta was 28.0 mm, which was significantly greater in the rupture group than in the surgery group (34.3 mm vs 22.4 mm, P<0.001). The average ratio of false lumen diameter/true lumen diameter of the ascending aorta was 2.9; it was significantly greater in the rupture group than in the surgery group (3.4 vs 2.5, P<0.001). The preoperative rupture rate increased with the diameter of the false lumen;For a diameter of the false lumen of≥31 mm, the degree of dominance ratio was the maximum under the premise of statistical significance with a rupture rate of 20％ (64/320), while the rupture rate was 6.82％(32/474) for a diameter of the false lumen of <31 mm. When the false lumen/true lumen ratio was ≥3.38, the degree of dominance ratio reached the maximum value under the premise of statistical significance. A multivariate regression analysis showed that a diameter of ascending aorta of <45 mm , the diameter of the false lumen (OR=1.04, 95％CI 1-1.10;P=0.041) and false lumen/true lumen ratio ≥4 (OR=1.24, 95％CI 1.06-5.28;P=0.029) were closely associated with preoperative rupture. Conclusions The rupture of acute type-A dissection is closely correlated to the diameter of false lumen of ascending aorta and false lumen/true lumen ratio. When the total diameter of ascending aorta is <45 mm, the risk of dissection rupture is closely associated with the diameter of false lumen and false lumen/true lumen ratio.

Objectives To evaluate the long-term results and relative risk factors of thoracoabdominal aortic aneurysm (TAAA)repair in patients with aortic dissection(AD). Methods Clinical and follow-up data of 110 patients with AD performed TAAA repairs between January 2009 and December 2017 in Fuwai Hospital were analyzed. Survival and freedom from reintervention were calculated using the Kaplan-Meier method,and the risk factors of late death were evaluated using Cox analysis. Results There were 77 male patients and 33 female patients with a mean age of (39.5±10.3)years. Prior DeBakey typeⅠAD occurred in 46(41.8%)patients,prior typeⅢAD occurred in 64(58.2%) patients. The degree of repair was Crawford extent Ⅱ in 99(90%)patients ,and Crawford extent Ⅲ in 11(10%) patients. There were 7(6.4%)early deaths. Permanent paraplegia developed in 5(4.5%)patients. All the patients were followed up,and the median follow-up duration was 42(15-72)months. There were 9(8.2%)late deaths. The actuarial survivals rate was 90.9%±2.7% and 86.8%±3.5% at 1 and 5 years,respectively. Multivariate risk factors for late death were age(β=0.062,Wald=5.254,P=0.022,OR=1.064,95%CI:1.009-1.122),maximal aortic diameter(β=0.283, Wald=6.331,P=0.012,OR=1.328,95%CI:1.065-1.655),paraplegia(β=1.803,Wald=4.166,P=0.041,OR=6.069, 95%CI:1.074-34.289). Freedom from reintervention was 93.9%±2.4% and 83.6%±4.4% at 1 and 5 years,respectively. Conclusions Open repair of thoracoabdominal aortic aneurysm in survivors of aortic dissection could have good long-term survival and low rate of reintervention. Age,maximal aortic diameter and paraplegia were the independent predic?tors of late death.

Objectives: To evaluate the efficacy of the less invasive hybrid zone 0 (Z0) total aortic arch repair (HAR, ascending repair thorn complete debranching thorn thoracic endovascular aortic repair [TEVAR]) without deep hypothermic circulatory arrest in management of DeBakey type I aortic dissection (IAD). The adverse outcome was defined as a single composite endpoint comprising peri-operative mortality, permanent neurological deficit, and renal failure necessitating haemodialysis at discharge. Methods: A retrospective review of prospectively collected data was conducted of 120 consecutive patients (mean EuroSCORE = 11.6%) with IAD undergoing HAR (urgent/emergency, n = 97, 80.8%) involving reconstruction of the ascending aorta (zone 0) and total arch exclusion with TEVAR during a 7.5 year period. Multivariable analysis of 27 potential pre-operative and intra-operative risk factors was performed to examine the early composite endpoint and short and long-term overall mortality. Results: The total early (30 day or in hospital) mortality was 9.2% (n = 11). The incidence of the composite endpoint was 11.7% (n = 14). On multivariable analysis, malperfusion syndromes were predictors of the composite endpoint (odds ratio [OR], 4.789; 95% CI 1.362-16.896; p = .015), and previous cerebrovascular accident (OR, 13.74; 95% CI 2.330-81.039; p = .004) and myocardial ischaemia time (OR, 1.038; 95% CI 1.015-1.061; p = .001) predicted short and long-term overall mortality. The overall survival was 84.7% during a median follow up of 3.4 years. Freedom from late aortic adverse events was 93.1% at 5 years, including secondary aortic intervention and endoleak. The maximum diameters of the true lumen increased significantly in stented thoracic (14.4 +/- 6.5 mm to 29.7 +/- 5.3 mm, p < .001), lower thoracic (14.2 +/- 6 mm to 21.6 +/- 7.2 mm, p < .001) and abdominal (11.7 +/- 4.8 mm to 17.4 +/- 4.1 mm, p < .001) aorta. Complete thrombosis of the peri-stent false lumen was achieved in 88.2% of CT scans (82/93) performed a mean of 12 +/- 17 months (median 5 months; 25-75% quartile, 2-12 months) post-operatively. Conclusions: IAD was treated safely and durably by Z0 HAR, and peri-operative mortality and morbidity were not substantially higher despite the older age and high risk of patients. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Objective Conventional technique with deep hypothermia circulatory arrest (DHCA) during extensive thoracoabdominal aortic aneurysm (TAAA) repair often complicated with high mortality and neurologi-cal complications, the optimal strategy for improving outcomes after TAAA repair remains unclear. We evalu-ated the protective effect of arterial bypass with normothermia technique during repair of extensive TAAAs. Methods From January 2005 to June 2017, a total of 190 patients with Crawford extend Ⅱ/Ⅲ underwent extensive thoracoabdominal aortic aneurysm (TAAA) repair and either with arterial bypass plus normothermia technique (group A) or with deep hypothermia circulatory arrest (group B). In group A, 75 patients (55 men;age 40.7years; 54 patients (72％) with dissection) underwent arterial bypass procedure. In group B, 115 pa-tients with DHCA procedure (87 men; age 38.8 years; 99 patients (66.1％) with dissection). The outcomes were compared by operative death (in-hospital death or death within 30 days of surgery) and permanent neu-rological complications (includes permanent stroke, paraplegia and cerebral hemorrhage). Results The opera-tive death occurred in 1 patient (1.3％) and 9 patients (7.8％) in group A and group B (P=0.045), respectively. The permanent neurological complications occurred in 5 patients (6.7％) and 19 patients (16.7％) in group A and group B (P=0.044), respectively. Gastrointestinal dysfunction occurred in 1 patient (1.3％) in group A and in 12 patients (10.5％) in group B (P=0.015), respectively, but there were no differences in occurrence of postoperative paraplegia, stroke and cerebral hemorrhage respectively between two groups (4 patients (5.4％) vs. 9 patients (7.8％), P=0.506; 1 patients (1.3％) vs. 7 patients (6.1％), P=0.111 and 1 patients (1.3％) vs. 3patients (2.6％), P=0.483). Multivariable analysis indicated that permanent neurological complications (OR:13.50,95％CI:3.48-52.36,P=0.000), DHCA(OR:15.85,95％CI:2.64-95.13, P=0.003),postoperative re-nal insufficiency (OR:8.47,95％CI:2.12-33.89,P=0.003)、gastrointestinal dysfunction (OR:15.11,95％CI:3.454-66.10,P=0.000)were independent predictors for early mortality. The overall postoperative survival rate between group A and B was 98.5％ vs. 90％,96.3％ vs. 90％ and 96.3％ vs. 83％ at 3 years, 5 years and 10 years respectively; there were no significant differences between two groups for survival rate (P=0.460). Con-clusions Arterial bypass with normothermia technique improved the early outcomes with lower risk of opera-tive death and permanent neurological complications in patients who had repair of extensive TAAAs.

Objective To investigate predictors for mortality among patients with Stanford type A acute aortic dissection (AAD) and to establish a predictive model to estimate risk of in-hospital mortality. Methods A total of 999 patients with Stanford type A AAD enrolled between 2010 and 2015 in our hospital were included for analysis. There were 745 males and 254 females with a mean age of 49.8±12.0 years. There were 837 patients with acute dissection and 182 patients (18.22％) were preoperatively treated or waiting for surgery in the emergency department and 817 (81.78％) were surgically treated. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. Results The overall in-hospital mortality was 25.93％. In the multivariable analysis, the following variables were associated with increased in-hospital mortality: increased age (OR=1.04, 95％ CI 1.02 to 1.05, P＜0.000 1), acute aortic dissection (OR=2.49, 95％ CI 1.30 to 4.77, P=0.006 1), syncope (OR=2.76, 95％ CI 1.15 to 6.60, P=0.022 8), lower limbs numbness/pain (OR=7.99, 95％ CI 2.71 to 23.52, P=0.000 2), type Ⅰ DeBakey dissection (OR=1.72, 95％ CI 1.05 to 2.80, P=0.030 5), brachiocephalic vessels involvement (OR=2.25, 95％ CI 1.20 to 4.24, P=0.011 7), acute liver insufficiency (OR=2.60, 95％ CI 1.46 to 4.64, P=0.001 2),white blood cell count (WBC)>15×109 cells/L (OR=1.87, 95％ CI 1.21 to 2.89, P=0.004 9) and massive pericardial effusion (OR=4.34, 95％ CI 2.45 to 7.69, P＜0.000 1). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusion Different clinical manifestations and imaging features of patients with Stanford type A AAD predict the risk of in-hospital mortality. This model can be used to assist physicians to quickly identify high risk patients and to make reasonable treatment decisions.

从 1975 年深低温停循环技术应用于临床以来,经过长期的临床实践及随着脑灌注技术的不断完善,深低温停循环下主动脉弓人工血管置换术已经成为治疗主动脉弓部病变,包括动脉瘤及主动脉夹层类病变通用术式.随着主动脉腔内修复术的进展,在腹主动脉与胸降主动脉疾病治疗中腔内修复术应用已经非常广泛.主动脉腔内修复术由于避免了主动脉病变部位的解剖和显露操作的风险,避免了人工血管置换术并发重要器官损伤的风险,已经在临床应用中显示出较大的优势. 但是,在主动脉弓部病变中,由于头臂动脉的开口部位常被动脉瘤与主动脉夹层类病变累及,安全的锚定区就变得比较有限. 腔内支架在主动脉弓部的锚定问题,成为主动脉腔内修复术在主动脉弓部取得技术成功的最具挑战性问题. 除了平行支架技术、分支型支架技术、支架主体开窗技术等腔内方法,另一种延展锚定区的方法是主动脉弓部杂交修复技术.

OBJECTIVES:Acute kidney injury (AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality. Total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation has been reported to produce satisfactory clinical outcomes, whereas several features of the surgical procedure may induce postoperative AKI. The authors aimed to clarify the incidence of and risk factors for postoperative AKI and the association of AKI with short-term outcomes.DESIGN:This study was a retrospective analysis of a prospectively collected cohort. A multivariate logistic regression model was used to identify predictors of postoperative AKI.SETTING:Single center.PARTICIPANTS:Clinical data were analyzed for 553 consecutive patients who underwent TAR combined with FET implantation between 2013 and 2016.INTERVENTIONS:None MEASUREMENTS AND MAIN RESULTS: Postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Postoperative AKI occurred in 77.6% of the whole cohort. Patients in stage 3 AKI were associated with a higher incidence of major adverse events and in-hospital and 90-day mortality (p < 0.001, p < 0.05, p < 0.01, respectively). In the multivariate analysis, male sex (odds ratio [OR] 1.94; 95% confidence interval [95% CI] 1.22-3.18; p = 0.005); older age (per 10 years) (OR 1.37; 95% CI 1.14-1.67; p = 0.001); elevated body mass index (per 5 kg/m2) (OR 1.41; 95% CI 1.08-1.87; p = 0.01); and prolonged cardiopulmonary bypass duration (per 30 minutes) (OR 1.17; 95% CI 1.01-1.37; p = 0.03) were identified as independent predictors of postoperative AKI.CONCLUSION:TAR combined with FET implantation carries a high-risk for postoperative AKI compared with other types of thoracic aortic surgeries. Cardiopulmonary bypass duration was identified as the only modifiable predictor of AKI, and patients may benefit from moderate hypothermic circulatory arrest instead of deep hypothermic circulatory arrest.

Objective To summarize the experience and strategy of surgical treatment of Kommerell diverticulum and related aortic dissection aneurysm.Methods From November 2012 to January 2018,4 patients(all males),with median age of 44 (from 40 to 49) years old,underwent surgical treatment in our institution.All the patients had fight-sided aortic arch and aberrant left subclavian artery.One patient had type A aortic dissection and other 3 had type B aortic dissection(one had chronic type B dissection).The patient with type A aortic dissection had Bentall procedure plus total arch replacement and frozen elephant trunk implantation.One patient with chronic type B aortic dissection received type 2 hybrid aortic arch repair.One patient with acute type B aortic dissection had ascending aorta and total arch replacement plus frozen elephant trunk implantation followed by TEVAR.The last patient underwent graft replacement of aorta,total arch and descending thoracic aorta.Results There was no operative mortality.The median mechanical ventilation time was 229 (from 13 to 485) hours,the median ICU stay was 12 (from 2 to 27) days.One patient died from respiratory and circulatory failure due to compression of left main bronchus on the 17th day after operation.One patient had irritating cough due to mild compression of bifucation of trachea and the symptom resolved spontaneously before discharge.One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours.He recovered through neurotrophic drug treatment.The median follow-up time is 15 (from 4 to 36) months.The patients with type A dissection had delayed dilation of descending thoracic aorta beyond the frozen elephant trunk and received TEVAR 6 months later.The CT scans of the other two patients during follow-up time showed good morphology and patency of graft and branches.There was no anastomotic leakage and pseudoaneurysm.Conclusion The decision making of treatment of Kommerell diverticulum and related aortic dissection should be on the basis of classification of aortic dissection.Operation combined with TEVAR is safe and effective.