Application Of Balloon Occlusion In Elephant Trunk In Sun’s Procedure

BACKGROUNAortic dissection is the most common type of acute aortic disease.The disease is dangerous and it is also a cardiovascular disease that seriously threatens people’s health.This disease has a sudden onset,rapid progress,and a high fatality rate.The fatality rate grows at a rate of 1%per hour in 2 days,and can reach 70%in 1 week.There are many types of aortic dissection.The most commonly used types in the world are Stanford and Debakey.Stanford classification is mainly classified according to the extent of aortic dissection involvement.Aortic dissection is divided into two types:Regardless of the location of the aortic dissection,as long as the dissection lesion involves the ascending aorta,it is a type A aortic dissection;the lesion originates from the descending thoracic aorta,and the ascending aorta is not involved in the type B aortic dissection.Stanford classification is more concise and can guide clinical treatment,so Stanford classification is more commonly used.Among them,surgical treatment is an effective method for Stanford type A aortic dissection,which greatly reduces the mortality of this disease.However,Stanford type A aortic dissection has acute onset,extensive lesions,complicated surgical operations,and involves deep hypothermia circulatory arrest.Postoperative complications are still common.Postoperative delirium is one of the more serious complications after cardiopulmonary bypass in cardiovascular disease,and it is more common after total arch replacement under circulatory arrest.It often develops acutely,and manifests as specific disturbances of consciousness,changes in arousal levels,decreased orientation,decreased attention,mental and emotional disorders,and other neuropsychiatric syndromes.It can even be associated with irritability,anxiety,terror,and persecution delusions.Once it occurs,it can increase other serious postoperative complications and prolong the hospital stay of patients,increase the patient’s medical burden,and even severe patients may have a bad prognosis.The specific mechanism of postoperative delirium has not been studied.Early identification and intervention of risk factors for delirium after surgery can improve patient prognosis.Hepatic insufficiency is one of the main complications after cardiopulmonary bypass in cardiac surgery,and it is more common after total aortic arch replacement under deep hypothermic circulatory arrest.Once liver dysfunction occurs after surgery,it can increase the patient’s intensive care time and delay the patient’s rehabilitation.In severe cases,multiple organ dysfunction or failure can lead to death.We have also observed in clinical practice that postoperative liver dysfunction is often affected by a variety of adverse factors,and the patient’s prognosis is not necessarily positively correlated with an increase in serum aminotransferase or bilirubin.Sun’s surgery is a classic procedure for the treatment of type A aortic dissection.However,when the elephant trunk scaffold is implanted and the distal arch is open for anastomosis,and deep hypothermia circulatory stopping technique is needed.Prolonged deep hypothermia circulatory arrest can cause many serious postoperative complications.Shortening the deep hypothermia circulatory arrest technique is one of the effective measures to reduce the postoperative complications of type A aortic dissection,and it is also the current research hotspot.In recent years,balloon blocking technique in elephant trunk has been used for thoracoabdominal aorta replacement under normal temperature,which has expanded the indications for thoracoabdominal aorta replacement.We use this technique for arch anastomosis during aortic dissection.Avoiding deep hypothermia and significantly shortening the stop cycle time may help reduce the incidence of postoperative complications and improve the prognosis.Part one Clinical study of delirium after total arch replacement under deep hypothermia circulatory arrestObjectivesTo study the risk factors of delirium after total arch replacement under deep hypothermia circulatory arrest.MethodsStanford A-type aortic dissection patients who underwent Sun’s surgery under deep hypothermia circulatory arrest in our cardiovascular surgery from May 2014 to May 2017 were selected.All patients underwent a thorough examination and preoperative preparation for acute surgery.According to the symptoms of the patients,CAM-CR was used to evaluate whether delirium occurred.108 eligible patients with acute Stanford A aortic dissection were divided into two groups:delirium group(n=32)and non-delirium group(n=76).The data of age,gender,hypertension,smoking,diabetes,aortic occlusion time,and deep hypothermia circulatory time were collected in two groups of patients,and the differences were analyzed and compared.Then analyze statistics related indicators,such as preoperative vertebral artery ischemia,mean invasive traumatic arterial depression value below 50mmHg during operation,postoperative renal failure,hypoxemia,and liver insufficiency.Data analysis was performed using SPSS 17.0 statistical software.Measurement data such as age,aortic occlusion time,and deep hypothermia circulatory time are expressed as mean ± standard deviation(x ± s).For gender,smoking history,history of hypertension,diabetes,and other count data,the sample rate or composition ratio is used.Indicates that comparisons between groups were performed using the χ2 test.Related factors of delirium preoperative vertebral artery ischemia,mean invasive traumatic arterial depression is less than 50mmHg during operation,postoperative renal failure,hypoxemia,liver insufficiency.Multivariate logistic regression analysis was used to analyze risk factors.The difference was statistically significant when P<0.05.ResultsThe incidence of delirium after Sun’s surgery for Stanford A aortic dissection was 29.6%.Among then,32 patients had postoperative delirium.The clinical symptoms were more common with psychomotor excitement and restlessness,and abnormal behaviors such as self-extraction of the catheter or incision and drainage tube.Some patients required intensive monitoring and restraint braking;Disturbances in the sleep-wake cycle;or manifestations of acute consciousness changes,disordered thinking,and decreased orientation.Multivariate Logistic regression analysis of delirium after aortic dissection showed that factors related to the occurrence of delirium after surgery included mean intraoperative mean arterial valley value less than 50mmHg,hypoxemia,and vertebral artery ischemia.ConclusionsIntraoperative mean arterial pressure less than 50mmHg,hypoxemia,and vertebral artery ischemia were the risk factors for delirium after total arch replacement under deep hypothermic circulatory arrest.Part two Clinical study of hepatic dysfunction after total arch replacement under deep hypothermia circulatory arrestObjectivesThe related risk factors of liver dysfunction after arch replacement under deep hypothermia circulatory arrest were reviewed.MethodsCollect the case data of Stanford type A aortic dissection patients who underwent Sun’s operation under deep hypothermia circulatory arrest in cardiovascular surgery from February 2015 to August 2018.The cases were divided into two groups according to whether there was liver dysfunction after aortic dissection:liver dysfunction group(n=20)and non-liver dysfunction group(n=124).Collect possible related or risk factors:preoperative glutamate aminotransferase(ALT)is greater than 40U/L,preoperative blood creatinine(Cre)>104 μmoI/L,ischemia of celiac artery,the duration of cardiopulmonary bypass time,cardiac ischemia and circulatory arrest,red blood cell input within 24 hours after surgery,postoperative renal insufficiency,postoperative hypoxemia.SPSS 17.0 statistical software was used to statistically analyze the data of liver dysfunction group and non-liver dysfunction group.The measurement data of observation index age,gender,and circulatory time were expressed as mean±standard deviation(x ± s).For history of hypertension,history of diabetes,preoperative glutamate aninotransferase(ALT)greater than 40U/L,Anterior blood creatinine(Cre)>104 μmol/L,ischemia of celiac artery,cardiopulmonary bypass time,aortic occlusion time,red blood cell input within 24 hours after operation,renal insufficiency after operation,postoperative hypoxemia,count data were expressed by sample rate or composition ratio,and comparison between groups was performed byχ2 test.Multivariate Logistic regression analysis was used to analyze the risk factors related to liver dysfunction.The difference was statistically significant when P<0.05.ResultsThe incidence of postoperative liver dysfunction was 13.9%.Among 20 patients with aortic dissection with liver dysfunction,6 had sclera and skin yellow staining,2 had plasmapheresis.4 died with multiple organ failure,and liver function recovered in the rest patients.Risk factors for liver dysfunction after aortic dissection surgery include:preoperative glutamate aminotransferase(ALT)>40U/L,dissection of celiac artery,red blood cell input more than 10 U within 24 hours,the duration of cardiac ischemia,postoperative hypoxemia,and statistical results show that these factors have significant differences in the effects of liver dysfunction.Multivariate logistic regression analysis of postoperative liver function revealed that the risk factors related to the occurrence of postoperative liver dysfunction include red blood cell input more than 10U within 24 hours after operation,and preoperative ALT>40U/L.ConclusionsPreoperative ALT>40U/L and red blood cell input more than 10U within 24 hours were independent risk factors for liver dysfunction after total arch replacement under deep hypothermic circulatory arrest.Intervention according to factors that may affect postoperative liver function,such as early reconstruction of the aorta,increasing effective perfusion of important organs including the liver,shortening the aortic occlusion time as much as possible,and reducing massive blood transfusions,are beneficial to reduce the occurrence of postoperative liver dysfunction.Part three Application of balloon occlusion in elephant trunk in Sun’s procedureObjectivesA balloon occlusion technique in elephant trunk was used in Sun’s procedure for Stanford A aortic dissection.To study its impact on postoperative important organ complications and patient rehabilitation.Methods85 patients with Stanford type A aortic dissection who underwent Sun’s operation from January 2019 to January 2020 were selected.Aortic CTA was diagnosed before surgery,and all operations were performed by the same surgeon.Cases were divided into two groups based on whether or not balloon occlusion in elephant trunk was used:a balloon occlusion(BO)group and a non-balloon occlusion(NBO)group.Collect the patient’s gender,age,weight,past history,personal history,as well as the operation time,surgical method,extracorporeal circulation time,aortic occlusion time,circulatory arrest time,intensive care time,24h postoperative bleeding volume,and within 24h Red blood cell input and major postoperative complications.SPSS 17.0 statistical software was used to statistically analyze the data of balloon blocking group and non-balloon blocking group.The difference was statistically significant when P<0.05.ResultsBasic information of patients before operation:A total of 85 patients with type A aortic dissection underwent Sun’s operation.In the balloon occlusion group,there were 21 males and 8 females,with an average age of(53.21 ± 10.22)years and an average weight of(73.67± 13.41)Kg,14 cases of smoking history,20 cases of hypertension,2 cases of diabetes,and 10 cases of hyperlipidemia.In the non-balloon obstruction group,there were 41 males and 15 females,with an average age of(49.88± 10.94)years and an average weight of(75.69±13.36)Kg.There were 23 cases of smoking history,44 cases of hypertension,2 cases of diabetes,and 12 cases of hyperlipidemia.In the balloon occlusion group,ascending aorta replacement was performed in 18 cases,Bentall in 8 cases,aortic annuloplasty in 2 cases,and Wheat’s procedure in 1 case.The aortic occlusion time was 90(66-149)min,and the duration of circulatory arrest was(8.07 ± 2.33).min,extracorporeal circulation time(171.00 ±19.40)min,and operation time 7.5(5.5-12.67)h.In the non-balloon occlusion group,there were 36 cases of ascending aorta replacement,15 cases of Bentall,and 5 cases of aortic valve angioplasty.The duration of circulatory arrest was(26.82±5.59)min,extracorporeal circulation time(181.42±38.18)min,and operation time 7.5(5.5-12.25)h.Occurrence and recovery of negligent complications in the balloon occlusion group,24h drainage 370(190-770)ml,24h red blood cell input 0(0-6)u,14 patients with hypoxemia,and 3 patients with postoperative liver dysfunction 3 cases of renal insufficiency,tracheal intubation time 37(12.5-106)h,intensive care time 65(17-207)h.In non-balloon blocking group,24h drainage 500(200-2230)ml,24h red blood cell input 0(0-12)u,39 cases of postoperative hypoxemia,18 cases of postoperative liver dysfunction,11 cases of renal dysfunction,tracheal intubation time 61.25(11-175.5)h,and intensive care time 105.5(25-297)h.Overall postoperative complications were less frequent in BO group than NBO group(52%vs 75%,P=0.030).There were no deaths in 85 patients with type A aortic dissection.One patient in the non-balloon blocking group developed incomplete paraplegia,and the rest recovered smoothly.ConclusionsFor acute type A aortic dissection,during total aortic arch replacement and stent elephant trunk surgery,we use the right axillary artery(or innominate artery)and femoral artery perfusion,and the nasopharyngeal temperature drops to 28℃.After the stent implantation,a urinary balloon is placed in the appropriate position of the stent,and the saline is injected into the balloon to block the aorta,and then the femoral artery is perfused,and the distal arch anastomosis is performed,which avoids deep hypothermia and can effectively shorten circulatory arrest time,so that the circulatory arrest time is controlled in a few minutes,is beneficial to shorten the ischemic time of many organs such as spinal cord,liver,kidney,etc.It is helpful to reduce the incidence of postoperative complications,and shorten the time of intensive care.It also reduces the patient’s medical burden and enables patients to recover faster.