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Surgical treatment of retrograde type A aortic dissection after thoracic endovascular aortic repair for Stanford type B aortic dissection

Objective To analyze the etiologies, surgical treatment and outcomes of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. Methods The clinical data of patients with RTAD after TEVAR for Stanford type B aortic dissection receiving operations in Changhai Hospital from March 2014 to August 2018 were analyzed. All patients were followed-up by clinic interview or telephone. Results A total of 16 patients were enrolled, including 13 males and 3 females with a mean age of 49.1±12.2 years. The main symptoms of RTAD were chest pain in 12 patients, headache in 1 patient, conscious disturbance in 1 patient, and asymptomatic in 2 patients. All the 16 patients received total arch replacement with the frozen elephant trunk technique. Bentall procedure was used in 2 patients, aortic root plasticity in 10 patients and aortic valve replacement in 1 patient. The primary tear in 10 patients was located in the area which were anchored by bare mental stent, and in the other 6 patients it was located in the anterior part of ascending aorta. The mean cardiopulmonary bypass time was 152.2±29.4 min, aortic cross-clamping time was 93.6±27.8 min and selective cerebral perfusion time was 29.8±8.3 min. There was no death in hospital or within postoperative 30 days. The follow-up period was 32-85 (57.4±18.3) months. No death occurred during the follow-up period. One patient underwent TEVAR again 3 years after this operation and had an uneventful survival. Conclusion Total arch replacement with the frozen elephant trunk technique is a suitable strategy for the management of RTAD after TEVAR for Stanford type B aortic dissection.

降主动脉“逆行”去分支与主动脉腔内修复术杂交治疗 Stanford A 型主动脉夹层

降主动脉置换治疗局部晚期食管癌一例

Surgical Treatment of Bicuspid Aortic Valve Combined with Toracic Aortic Dilation

ObjectiveTo analyze the clinical characteristics and surgical treatment of bicuspid aortic valve combined with thoracic aortic dilation. MethodsWe retrospectively analyzed the clinical data of 68 patients of bicuspid aortic valve combined with thoracic aortic dilation underwent surgical treatment in our hospital between January 2010 and June 2014. There were 47 males and 21 females at age of 26-77(44.5±16.3) years. Different surgical treatments including Wheat procedure(n=22), aortic valve replacement+ascending aortoplasty(n=10), Bentall procedure(n=13), aortic valve replacement+ascending aortic replacement+right hemi aortic arch replacement(n=13), Bentall procedure+ascending aortic replacement+right hemi aortic arch replacement(n=8), Bentall procedure+ascending aortic replacement+total arch replacement+stented elephant trunk(n=2) were carried out according to the type. ResultsAll 68 patients underwent surgical treatment. The mortality in hospital is at 4.4%(3/68). The postoperative complications were neurological and mental complications(n=3), pneumonia(n=2), and exploratory thoracotomy(n=2). We followed up 63 patients for 6 months to 4 years. A total of 62 patients were well without reoperation except one death at the end of following-up 2 years. ConclusionBicuspid aortic valve combined with thoracic aortic dilation has diversiform clinical characteristics. The surgical treatment should be chosen according to the aortic valve and thoracic aortic lesion characteristics.

Hybrid Procedures in Treatment for Aortic Arch Lesions: Short- and Long-Term Results

ObjectiveTo evaluate the short-and long-term results of hybrid procedures in the treatment for aortic arch lesions. MethodsFrom October 2002 to March 2011, 28 patients with thoracic aortic aneurysms or dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Twenty-two males and 6 females were in the series. The mean age of the patients was 68 years old. Of 28 patients, 15 were atherosclerotic thoracic aortic aneurysms and 13 were thoracic aortic dissection. Follow-up protocol consisted of computed tomography (CT) angiograms or ultrasound was performed in 3, 6, and 12 months, and annually thereafter. The main goal was to evaluate the operative mortality, morbidity, and the longterm survival of these patients. ResultsHybrid procedures included 12 totalarch transpositions, 3 left common carotid artery (LCCA)left subclavian artery (LSA) bypass, 11 right common carotid artery (RCCA)LCCA-LSA bypass, 2 RCCA-LCCA bypass. The technical success rate was 92.9% (26/28). The complications occurred in 10 patients (35.7%). Operative mortality was 7.1% (2/28). The apoplexia rate was 7.1% (2/28). The time of followup was (36±3) months. The patency rates of 1-year, 3-year, and 5-year were 100%, 92.9% (26/28), and 85.7% (24/28), respectively. The survival rates of 1-year, 3-year, and 5-year were 89.3% (25/28), 71.4% (20/28), and 60.7% (17/28), respectively. ConclusionsThe short-and long-term results with hybrid procedures in the treatment for aortic arch diseases are satisfactory. Further reducing the complications is the key to increase the survival rate.

对腔内修复Stanford B型主动脉夹层手术范围的质疑——应将“远端旷置”改为“全程修复”

胸主动脉瘤的外科治疗

目的　总结 19例胸主动脉瘤患者的外科治疗经验。　方法　 19例胸主动脉瘤患者 ,其中升主动脉瘤 9例 (马方综合征 8例 ) ,7例行 Bentall手术 ,2例行 Cabrol手术 ;降主动脉瘤 10例 ,均行降主动脉置换术。　结果　除 1例患者术中死亡外 ,其余患者经超声心动图检查均示主动脉瓣关闭良好 ,移植的冠状动脉、降主动脉通畅 ,无扭曲 ,无脊髓损伤和神经系统并发症。随访 18例 ,随访时间 0 .3～ 5 .4年 ,心功能恢复至 级 3例 , 级 15例 ,效果满意。　结论　手术治疗胸主动脉瘤安全有效。

Advancements in the treatment of chronic thoracoabdominal aortic dissection

Aortic dissection is a disease with high mortality rates. Due to the urgency of time, the diagnosis, treatment processes, and strategies of acute aortic dissection follow specific guidelines. However, patients with chronic aortic dissection are often neglected. Choosing the best medication therapy and surgical interventions remains challenging, and there is still a lack of guideline recommendations. With the improvement of imaging diagnostic methods for aortic diseases, the progress of endovascular surgical techniques, and the development of new endovascular graft devices in recent years, clinical data of the treatment of chronic aortic dissection is also gradually increasing. This article summarized the current new technologies and clinical research results for the diagnosis and treatment of chronic aortic dissection, aiming to provide new suggestions for the diagnosis and treatment of chronic aortic dissection.

The potential role of calnexin in the activation of cardiac fibroblasts

Calnexin is a lectin-like molecular chaperone protein on the endoplasmic reticulum, mediating unfolded protein responses, the endoplasmic reticulum Ca2+ homeostasis, and Ca2+ signals conduction. In recent years, studies have found that calnexin plays a key role in the heart diseases. This study aims to explore the role of calnexin in the activation of cardiac fibroblasts. A transverse aortic constriction (TAC) mouse model was established to observe the activation of cardiac fibroblasts in vivo, and the in vitro cardiac fibroblasts activation model was established by transforming growth factor β1 (TGFβ1) stimulation. The adenovirus was respectively used to gene overexpression and silencing calnexin in cardiac fibroblasts to elucidate the relationship between calnexin and cardiac fibroblasts activation, as well as the possible underlying mechanism. We confirmed the establishment of TAC model by echocardiography, hematoxylin-eosin, Masson, and Sirius red staining, and detecting the expression of cardiac fibrosis markers in cardiac tissues. After TGFβ1 stimulation, markers of the activation of cardiac fibroblast, and proliferation and migration of cardiac fibroblast were detected by quantitative PCR, Western blot, EdU assay, and wound healing assay respectively. The results showed that the calnexin expression was reduced in both the TAC mice model and the activated cardiac fibroblasts. The overexpression of calnexin relieved cardiac fibroblasts activation, in contrast, the silencing of calnexin promoted cardiac fibroblasts activation. Furthermore, we found that the endoplasmic reticulum stress was activated during cardiac fibroblasts activation, and endoplasmic reticulum stress was relieved after overexpression of calnexin. Conversely, after the silencing of calnexin, endoplasmic reticulum stress was further aggravated, accompanying with the activation of cardiac fibroblasts. Our data suggest that the overexpression of calnexin may prevent cardiac fibroblasts against activation by alleviating endoplasmic reticulum stress.

"J. D" technique: A method for in situ fenestration of left subclavian artery in thoracic endovascular aortic repair

ObjectiveTo report a simple and safe method for in situ fenestration of left subclavian artery in thoracic endovascular aortic repair (TEVAR).MethodsTwenty-eight patients received in situ fenestration of left subclavian artery in TEVAR from June 2018 to May 2019 in our center, including 23 males and 5 females at an average age of 57.7±9.6 years. Among them, 12 patients used adjustable sheath or guiding catheter (a group A) and 16 patients used "J. D"technique (a group B). The clinical efficacy of the two groups was compared.ResultsIn the group A, 1 patient failed to receive fenestration and was transferred to the chimney technique. In the group B, 1 patient due to the traction system shift during operation, was completed by traditional adjustable sheath puncture. The group B had shorter alignment-perforation time and trigger time and less complications. There was no significant difference in endoleak during short-term follow-up between the two groups.ConclusionThe "J. D" technique is simple, safe and easy to obtain materials. It effectively reduces the risk caused by difficult sheath alignment during the in situ fenestration of the left subclavian artery. Although the results of recent follow-up are not significantly different from traditional methods, it still needs to accumulate the cases to observe the possible risks and difficulties.