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Open in new tab Download slide Open in new tab Download slide The aim of this study was to investigate whether the 'bovine' arch [i.e. arch variant with a common origin of the innominate and left carotid artery (CILCA)] is associated with an increased risk of thoracic aortic disease (TAD). The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed, EMBASE and Cochrane databases were searched to identify all case series reporting about CILCA arch and TAD between January 2008 and December 2018. A total of 485 studies were screened. The prevalence of CILCA arch was assessed, and data analysis was performed considering the difference in the risk of TAD for presence versus absence of CILCA arch. Eight studies enrolling 11 381 subjects were retrieved for quantitative analysis. The proportion of TAD among CILCA arch patients was higher [41.5% (28.1–56.4)] than the proportion among patients with standard arch configuration 34.0% (20.1–51.4). The odds ratio of developing TAD was 1.4 times higher in subjects with CILCA arch (95% confidence interval 1.068–1.839). The test for an overall effect indicated a significant association between CILCA arch and TAD (P  < 0.015). The I 2 was 78.1% with a value of P < 0.001 for heterogeneity. The Egger test did not show evidence of publication bias (P  = 0.317). In conclusion, our meta-analysis supports the hypothesis of a correlation between the presence of CILCA arch and the onset of TAD. Our results warrant a specific and long-term surveillance for patients with this anatomical variant, and a thorough awareness of its potential clinical implications during image interpretation. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Our goal was to identify anatomical and physiological factors that could predict the amount of cerebrospinal fluid (CSF) drainage in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease. METHODS All consecutive elective endovascular procedures performed for descending thoracic or thoracoabdominal aortic disease between January 2015 and December 2017 were included in the study. Routine use of CSF drainage was established in all patients. The goal of drainage was to reach a spinal fluid pressure of 10–12 mmHg by draining in 5–15-ml aliquots. The number of visible intercostal and lumbar segmental arteries (SAs) was evaluated before and after endovascular repair. The covering ratio of SAs was calculated as covered preoperative SAs/total preoperative SAs. RESULTS Twenty-four consecutive patients were included in the final analysis. The indication for the intervention was a descending thoracic aneurysm in 13 cases, a thoracoabdominal aneurysm in 4 cases and a chronic type B dissection in 7 cases. The procedure performed was thoracic endovascular aortic repair in 20 cases and fenestrated endovascular aneurysm repair in 4 cases. None of the patients developed spinal cord ischaemia. The mean volume of CSF drained was 46 ml. The mean length of aortic coverage was 231 mm. The mean number of total preoperative SAs and of covered preoperative SAs was, respectively, 22 and 9. The volume of CSF drained was significantly correlated with all these variables (length of aortic coverage, total visible SAs and covered SAs), but the most powerful correlation was individuated with the covering ratio of SAs. CONCLUSIONS Our findings suggest that the percentage of intercostal and lumbar SAs covered by placement of a stent graft can predict the volume of CSF drained in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Cerebral malperfusion for patients with acute type A aortic dissection (AAAD) remains an unsolved problem. The present study aimed to evaluate our management of cerebral perfusion and identify predictors of perioperative cerebral malperfusion in patients undergoing surgical repair of AAAD. METHODS: Between January 2004 and December 2015, 137 consecutive patients with AAAD underwent aortic replacement at Tsuchiya General Hospital. The status of the dissected supra-aortic branch vessels (SABVs) was classified as patent or thrombosis by preoperative computed tomographic angiography. Intraoperative cerebral perfusion was monitored by transcutaneous carotid echo and regional oxygen saturation. In cases with neurological symptoms or cerebral malperfusion, quick cerebral perfusion was immediately started using a quick cutdown technique. We assessed clinical outcomes, including mortality and complications, and analysed predictors of early mortality and cerebral malperfusion. RESULTS: The early mortality rate was 8.0%. Postoperative cerebral injury was observed in 4 patients (2.9%). Nineteen patients had perioperative cerebral malperfusion. There were no postoperative cerebral injuries in the patients in whom intraoperative cerebral malperfusion was corrected. Multivariable analysis revealed that preoperative shock (odds ratio [OR] 22.60, P < 0.0001) and extension of dissection to the abdominal aorta (OR 9.31, P = 0.0064) were significant risk factors for early mortality. Preoperative neurological symptoms (OR 12.40, P = 0.0006) and partial or complete thrombosis of the SABV (OR 64.10, P < 0.0001) were identified as independent predictors of perioperative cerebral malperfusion. CONCLUSIONS: Perioperative cerebral perfusion should be carefully managed, especially in the patients with preoperative neurological symptoms or partial or complete thrombosis of the SABV. [ABSTRACT FROM AUTHOR]

Abstract: Objective: While isolated coronary artery bypass grafting (CABG) poses major risks as well as benefits to cardiovascular surgery, procedures such as thoracic aortic surgery and combined CABG surgeries are also important contributors to mortality and morbidity. The objective of this study was to create and validate risk models including high-risk cardiovascular procedures to improve quality. Methods: The Japan Cardiovascular Surgery Database of patients enrolled cardiovascular surgical patients between January 2005 and December 2007. Data were collected at presentation and by physician review of clinical records and were verified through third-party surgeons’ auditing. We analyzed 36780 procedures in 120 hospitals. Using logistic regression, risk models were generated and validated by split-sample validation. Results: In this analysis, 11948 procedures were isolated CABG, 11760 were valve surgeries, and 8440 were thoracic aortic surgeries. In a 30-day operative mortality risk model, 37 variables were significantly associated with outcome. In comparison to isolated CABG, the odds ratios (ORs) for a 30-day mortality were 1.81 for valve surgery (2.62 in mitral valve replacement and 2.72 in aortic valve plus mitral valve procedures) and 2.36 for thoracic aortic surgery (4.34 if indicated by rupture, 3.16 if involving only arch, 4.38 if involving distal aorta, 3.75 if descending, and 5.97 if thoraco-abdominal aorta). CABG combined with other procedures (n =3599) had increased risks in each morbidity risk model (OR: 1.21 in reoperation, 1.60 in stroke, 1.23 in dialysis, 1.97 in infection, and 1.40 in prolonged ventilation). The predictive power of our models is valued by a C-statistic of 0.830 for a 30-day postoperative mortality, 0.639 for reoperation, 0.726 for stroke, 0.817 for dialysis, 0.692 for infection, and 0.796 for prolonged ventilation. Conclusions: Though performance of isolated CABG surgery was stable in this era, CABG combined with valve or thoracic aortic surgery was still a high-risk procedure. Given better recognition of high patient risk from these models, earlier targeted perioperative interventions may reduce adverse effects. [Copyright &y& Elsevier]