Vascular

Acute type A aortic dissection (AAAD) represents an emergency in cardiac surgery that requires immediate treatment to prevent death due to its fatal complications. The surgical approach is dependent on the involvement of AAAD.

Sixty-one patients were operated for AAAD at our clinic. 48 (78.7%) were male and 13 (21.3%) were female with a mean age of 51±12.3 yr (range, 21–80 yr). Only the ascending aorta was replaced in 33 (54.1%) patients (Group I) and aortic arch replacement was included in 28 (45.9%) patients (Group II). The aortic valve was preserved in 43 (70.5%) patients (Group A) and replaced in 18 (29.5%) patients (Group B).

Early mortality rate was 23% (14/61). Multivariate analysis revealed that previous cardiac operations (P=0.048), renal complications (P=0.024), pump time (P=0.024), and cardiac complications (P=0.017) were significantly factors increasing early mortality. Late mortality rate was 8.5% (4/47) and multivariate analysis revealed that pulmonary complication (P=0.015) was the only statistically significant independent risk factor. Arch replacement or aortic valve replacement was not a predictor for early or late mortality. Cumulative survival was 73.8±5.63% at 1 yr and 68.3±6.46% at 7.5 yr. Cumulative survival was not different between groups (P>0.05).

Both radical and conservative surgical approaches in AAAD do not differ in mean of early or late results. Surgery before development of hemodynamic instability and prevention of other system complications improves the outcome of surgical treatment in AAAD.

To demonstrate a direct operative approach to vascular lesions of the internal carotid artery (1CA) at the level of the skull base.

Between January 1993 and October 1999, five patients underwent lateral skull base resection with cervical-to-petrous carotid artery saphenous vein bypass for repair of distal 1CA lesions. This report describes operative methods, morbidity, graft patency, and long-term outcome with this experience.

Of the five patients with skull base ICA lesions, all had aneurysmal disease. Three were atherosclerotic and two were dysplastic. Preoperative neurologic symptoms including transient ischemic attacks (2) and Horner's syndrome with vascular headaches (1) were completely resolved after operation. Preoperative dysphagia (2) was resolved in one patient and clinically improved in the other. Postoperative complications included transient paresis in the cranial nerve (CN) VII distribution, as well as permanent loss of the eustachian tube and chorda tympani nerve in all five patients. One patient had lasting paresis in the CN XI distribution as well as a mild stroke resulting in arm weakness. No residual arm weakness was detected at one year. There were no graft occlusions by duplex ultrasound at 45.8 months mean objective follow-up, and no ipsilateral stroke or mortality at 51.2 months mean clinical follow-up.

Saphenous vein bypass from the cervical-to-petrous ICA is technically feasible and provides a valuable reconstruction option for patients with skull base ICA lesions.

The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection.

Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection (P=0.003), chronic ethiology (P=0.006), medial degeneration (P<0.001), and preoperative hemodynamic instability (P=0.004) were observed significantly more in Group A. In both groups RCP was used for cerebral protection.

Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1±11.55% in Group A and 91.67±5.64% in Group B at 5 yr (P=0.0113). while cumulative survival for all patients was 78.38±5.77% at 5 yr. RCP time was longer in Group A (62.7±16.8 versus 34.2±19.5 min; P<0.001). Forward stepwise logistic regression analysis showed that chronic obstructive pulmonary disease (P=0.014) and renal insufficiency (P=0.004) were significantly predictors for hospital mortality, whereas elephant trunk (P=0.052) and RCP (>60 min) (P=0.175) did not increase early mortality. Only hemodynamic instability was significantly (P=0.006) predictors for late mortality.

Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (<60–65 min) can improve surgical results.

Off-pump coronary artery bypass grafting (OPCAB) on a beating heart with a LIMA graft to the LAD is established for patients with one vessel disease. The aim of the study was to assess the LIMA patency noninvasive by transcutaneous duplex ultrasound.

25 patients (16 male, 9 female, mean age 58±13 yr) with LIMA grafts to LAD by OPCAB procedures were studied 7–20 days after surgery. Doppler velocity parameters were measured by use of a 7 MHz transducer placed in left intercostal space. The conventional coronary angiographies performed showed the LIMA graft patent.

In all cases a typical biphasic pattern of blood flow was recorded with forward flow in both systole and diastole respectively. Under basal conditions the mean peak velocities in systole were 0.36 m/s and the mean peak velocities in diastole were 0.27 m/s with a mean systolic/diastolic ratio of 1.33.

Transcutaneous Doppler ultrasound is useful in the detection of the LIMA graft flow. This non-invasive technique may find applications for routine postoperative follow-up of patients with LIMA grafts.