ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Chojiro Yamashita
Masayoshi Okada
Keiji Ataka
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Yamashita, C.
Right arrow Articles by Yamashita, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yamashita, C.
Right arrow Articles by Yamashita, T.

Ann Thorac Surg 1997;64:665-669
© 1997 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Open Distal Anastomosis in Retrograde Cerebral Perfusion for Repair of Ascending Aortic Dissection

Chojiro Yamashita, MD, Masayoshi Okada, MD, Keiji Ataka, MD, Masato Yoshida, MD, Naoki Yoshimura, MD, Takashi Azami, MD, Keitarou Nakagiri, MD, Hidetaka Wakiyama, MD, Teruo Yamashita, MD

Division II, Department of Surgery, Kobe University School of Medicine, Kobe, Japan

Accepted for publication March 6, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background. In patients with aortic dissection, a patent distal false lumen at long-term follow-up leads to complications. We investigated the feasibility of performing an open distal anastomosis using retrograde cerebral perfusion.

Methods. Over a 10-year period, 41 patients with acute type A aortic dissection underwent 43 surgical repairs. In 1991, an open distal anastomosis using retrograde cerebral perfusion (group 2) was introduced to replace the standard aortic cross-clamp method (group 1). The mean retrograde cerebral perfusion time was 47.3 minutes (range, 22 to 67 minutes), and there were no neurologic sequelae in surviving patients.

Results. The operative mortality rate was 18.5% in group 1 and 18.7% in group 2. At long-term follow-up, dilatation of the false lumen (more than 50 mm in diameter) occurred in 9 of 18 patients (50%) in group 1, and 2 patients died of aortic rupture. There were no deaths in group 2, and dilatation of the distal false lumen occurred in only 15.4% of patients (p < 0.05).

Conclusions. The use of retrograde cerebral perfusion in patients with acute aortic dissection provides adequate time to perform a safe, open, distal anastomosis, and could decrease significantly the rate of enlarged, patent, false lumina.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The operative mortality rate for acute type A aortic dissection ranges from 10% to 40%. Therefore, improvements in operative technique are necessary to improve surgical results. DeBakey and Crawford reported that the subsequent development and rupture of an aneurysm accounts for 29.3% of all late deaths. Aortic cross-clamping on fragile, acutely dissected aortic tissue may create a new intimal tear and leave a residual patent false lumen in the aortic arch. In addition, a clamp injury to the fragile false lumen may produce rupture or bleeding at the graft anastomosis. Griepp and colleagues [1] reported on the usefulness of hypothermic circulatory arrest in the treatment of arch aneurysms. In 1990, we introduced the technique of retrograde cerebral perfusion (RCP) to lengthen the period for performing a safe, open, distal anastomosis in patients with acute type A dissection. This report compares the short- and long-term results of the standard cross-clamp technique with those of distal open anastomosis using RCP.


   Patients and Methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
From January 1986 to March 1996, 41 patients underwent 43 surgical repairs of acute type A aortic dissections. The patients were divided into two groups according to the type of adjuncts of cardiopulmonary bypass used.

In group 1, the operations were performed in 27 patients using standard aortic cross-clamping. The operations were performed within 48.7 ± 61.6 hours (range, 5 to 240 hours) from the onset of dissection. Four patients (13.3%) had preoperative shock as a result of tamponade or aortic regurgitation. The mean patient age was 56.5 ± 14.3 years (range, 27 to 75 years) (Table 1Go). The operations were performed using cardiopulmonary bypass and moderate hypothermia. Two-stage venous and femoral artery cannulation was used. The ascending aorta was encircled by dissection at the origin of the brachiocephalic artery. Cardiac arrest was induced by aortic cross-clamping and selective or retrograde blood cardioplegia. A ringed graft (USCI intraluminal vascular prosthesis; C.R. Bard, Inc, Billerica, MA) implanted in the ascending aorta was fixed with stay sutures, and the distal and proximal rings were tied with umbilical tape. For the graft replacement, the dissected lumen was obliterated using the inside and outside sandwich technique with Teflon felt (C.R. Bard, Inc, Haverhill, MA). Sixteen intraluminal ascending aorta graft inclusions, 5 ascending aorta graft replacements, and 4 primary repairs (in which the ascending aorta was incised completely and the distal and proximal false lumina were closed by the sandwich technique and anastomosed directly) were performed. Aortic valve involvement required 2 aortic root replacements and 4 aortic valve resuspensions (see Table 1Go).


View this table:
[in this window]
[in a new window]
  		Table 1. . Patient Characteristics
 
In group 2, open distal anastomosis with RCP was performed in 16 patients. The operations were performed within 59.8 ± 58.5 hours (range, 8 to 196 hours) from the onset of dissection. Six patients (37.5%) had preoperative shock as a result of rupture of the pulmonary artery or superior vena cava, or tamponade (see Table 1Go). The mean patient age was 54.1 ± 16.0 years (range, 28 to 70 years). Intraoperative transesophageal echocardiography was performed to determine the location and extent of intimal tears in this group. During core cooling, methylprednisolone (30 mg/kg) and thiopental (5 mg/kg) were administered intravenously to protect the cerebral microcirculation. The ascending aorta was dissected and mobilized completely from the pulmonary artery. Circulatory arrest was initiated when the rectal temperature reached 20°C. Retrograde cerebral perfusion through the superior vena caval cannula was begun at a rate of 150 to 300 mL/min, and the jugular vein pressure was maintained between 15 and 25 mm Hg. Continuous retrograde blood cardioplegia from the coronary sinus also was initiated. The dissected aorta then was opened and incised completely at the origin of the brachiocephalic artery. Returned blood from the carotid arteries was evacuated by suction and a dry operative field was obtained. Inspection of the aortic arch was performed to confirm complete resection of the intimal tear. When the intimal tear in the ascending aorta extended to the aortic arch, the incision was extended to the lesser curvature of the arch. The false lumen was obliterated by applying Teflon felt strips outside the aorta and inside the true lumen with horizontal interrupted 3-0 Ti-Cron sutures (Davis + Geck Cynamid of Great Britain, Ltd, Gosport, Hampshire, UK). The distal tip of the beveled arch anastomosis frequently extended distally to beneath the left common carotid artery. When the primary intimal tear in the arch could not be resected, total arch replacement was performed. The distal end of the collagen-coated, zero-porosity Dacron graft (Haemashield, Meadox Medicals, Inc, Oakland, NJ) was anastomosed using an open technique with continuous running 3-0 polypropylene (Prolene) sutures (Ethicon, Inc, Somerville, NJ). Air and debris were evacuated completely by returning blood from the cerebral vessels and femoral artery. Just before the termination of RCP, D-mannitol (300 mL) and deferoxamine mesylate (a radical scavenger; 30 mg/kg) were administered to prevent the brain edema that can result from reperfusion injury. Retrograde cerebral perfusion was terminated and the artificial graft was clamped. Arterial cannulation was changed to the branch graft and cardiopulmonary bypass with rewarming was reinstituted. Femoral artery cannulation then was removed. During rewarming, the proximal anastomosis was created using similar techniques. Six graft replacements of the ascending aorta, four proximal arch replacements, three arch graft replacements, and two ring (intraluminal) graft inclusions were performed. Aortic valve involvement required one aortic root replacement and one aortic valve resuspension (Table 2Go).


View this table:
[in this window]
[in a new window]
  		Table 2. . Surgical Procedures
 
Follow-up
Before discharge from the hospital, all patients were studied by angiography, magnetic resonance imaging (MRI), and computed tomographic (CT) scanning. All patients were followed up by MRI and CT scanning every 6 months after hospital discharge. No patients were lost to follow-up.

Statistical Analysis
The mortality rate and incidence of false lumina were examined by {chi}2 analysis, and p values less than 0.05 were considered to be significant.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Operative Mortality and Long-term Results
In group 1 (n = 27), 4 operative deaths and 1 hospital death occurred, for an overall mortality rate of 18.5%. In group 2 (n = 16), 3 operative deaths occurred, for an overall mortality rate of 18.7%. There was no significant difference between the two groups. Causes of death included intraoperative bleeding in 3 patients in group 1 and 2 patients in group 2, intraoperative myocardial infarction in 1 patient in each group, and multiple organ failure in 1 patient in group 1. However, 3 perioperative deaths in group 2 occurred in patients with deep hypotensive shock caused by intrapericardial rupture or tamponade. In group 1, 2 patients died of rupture of the false lumen and the anastomosis, respectively, 1 month after operation. In the postoperative period, 1 patient died of gastric cancer 6 years and 2 months after operation, and 1 patient died of renal failure 4 months after operation. In group 2, no patient died during the long-term follow-up period (Table 3Go). The mean cardiopulmonary bypass time (including RCP time) was 184 ± 94.6 minutes (range, 66 to 380 minutes) in group 1 and 267.5 ± 68.1 minutes (range, 180 to 437 minutes) in group 2. In group 2, the mean RCP time was 47.3 minutes (range, 22 to 67 minutes). There were no postoperative cerebral complications, except for 1 patient who had a perioperative stroke as a result of dissection extending to the left common carotid artery but recovered completely. No neurologic complications resulted from RCP.


View this table:
[in this window]
[in a new window]
  		Table 3. . Surgical Results: Early and Late Postoperative Deaths
 
Persistent Patent False Lumen
An enlarged false lumen (more than 50 mm in aortic diameter) occurred in 9 of 18 surviving patients (50%) in group 1, and in 2 of 13 surviving patients (15.4%) in group 2. There was a significant difference between the two groups (p < 0.05). The false lumina were demonstrated by MRI, CT scanning, or aortography. The locations of the enlarged false lumina were as follows: the sinus of Valsalva in 1 patient in group 1, the ascending aorta in 2 patients in group 1, the aortic arch in 4 patients in group 1, and the distal arch in 2 patients in each group. The locations of new or residual entry and anastomotic leakage accurately corresponded to the locations of the enlarged false lumina (Table 4Go). The characteristics and number of enlarged false lumina are shown in Table 5Go. Five of 9 patients with ring graft implants (intraluminal grafts) in group 1 had enlarged false lumina. The causes of enlarged false lumina were a new or residual intimal tear in the sinus of Valsalva or in the vicinity of the proximal arch, and leakage of the intraluminal graft. In 2 patients, a catheter was passed through the outside of the intraluminal graft. The intimal tears in group 1 were suspected to be newly caused by clamp injury to the fragile dissected aortic tissue or by a residual intimal tear near the proximal arch. In group 2, the intimal tear near the proximal arch was resected completely by extending the resection to the small curvature of the arch. This surgical procedure significantly reduced the incidence of enlarged distal false lumina. A new intimal tear around the proximal arch or leakage at the graft anastomosis could not be identified in group 2. The cause of the enlarged false lumina in 2 patients in group 2 was an intimal tear in the distal arch.


View this table:
[in this window]
[in a new window]
  		Table 4. . Type of Surgical Procedures: Outcome and Development of Enlarged False Lumina
 

View this table:
[in this window]
[in a new window]
  		Table 5. . Characteristics of Enlarged False Lumina
 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The operative mortality rate previously was reported to range from 7% to 39% for acute dissection, and from 2% to 17% for chronic dissection [2–5]. DeBakey and co-workers [6] and Haverich and associates [7] have reported that the most common cause of late death is the subsequent development and rupture of an aneurysm, accounting for 15% to 29.3% of all late deaths. Crawford and colleagues [8] also have reported that the most common cause of late death is rupture of a fusiform aneurysm of a segment of the dissected aorta that was not removed at the initial operation for acute dissection. This fatal complication accounted for 29% of all their late deaths. The incidence of late aneurysm formation in type I aortic dissection was 30%. Recently, Galloway and colleagues [9] have reported low mortality rates of 14% and 3% in acute and chronic dissection, respectively. These favorable results are thought to be due to the use of hypothermic circulatory arrest, a secure open distal anastomosis, and the suture method with the graft inclusion technique. Profound hypothermia and circulatory arrest in the operative management of aortic dissection allows bloodless inspection and repair of extensive intimal tears, complete intimal adventitial reapproximation or resection, and avoidance of clamp injury to fragile dissected aortic tissue.

From 1986 to 1990, we mainly used a ringed intraluminal graft inclusion into the ascending aorta in patients with acute dissection to prevent tamponade and reduce aortic cross-clamp time [10, 11]. This procedure was designed to reduce cardiopulmonary bypass time and thus mortality, especially in elderly patients. The cardiopulmonary bypass time was markedly shorter in group 1 (mean, 184 ± 94.6 minutes) than in group 2 (mean, 267.5 ± 70.5 minutes). However, 4 of 16 patients who underwent ringed intraluminal graft inclusion died of intraoperative bleeding or rupture of the false lumen 1 month after operation. When the operation was performed with an aortic cross-clamp and moderate hypothermia, dilatation of the distal false lumen was found in 47.3% of surviving patients. Graham and Stinnett [12] have reported that clamp injury to the fragile false lumen may produce rupture or bleeding distal to the clamp or the graft anastomosis. Compression of the aorta with the clamp may prevent accurate reapproximation of true and false lumina. Placement of a cross-clamp necessitates leaving a cuff of ascending aorta for an anastomosis. Release of the clamp allows for retention of an appreciable amount of dissected ascending aorta, which later may degenerate and dilate into a recurrent aneurysm.

Hypothermic circulatory arrest recently has gained widespread acceptance in the treatment of patients with arch aortic aneurysms [1, 13–18]. This approach has allowed for creation of the distal anastomosis using an open technique. Routine use of hypothermic circulatory arrest for the repair of ascending and aortic arch dissections also has been advocated by several investigators [9, 19]. However, the maximum period of circulatory arrest in adults is not well established. Previous reports have shown that cerebral ischemia times greater than 45 minutes were associated with a high risk of stroke, and that ischemia times greater than 65 minutes were associated with a low incidence of survival [20]. Ergin and colleagues [21] have reported that the incidence of temporary neurologic dysfunction with hypothermic circulatory arrest is 19%, and that it rises linearly in relation to patient age and the duration of arrest.

In 1990, we introduced RCP for the treatment of acute aortic dissection, at which time air emboli and thromboemboli were eliminated completely and a secure, open distal anastomosis with sufficient time became possible [22, 23]. In group 2, there were no postoperative cerebral complications, except for a dissection of the left common carotid artery in a 35-year-old man with an acute type A aortic dissection. He recovered completely 6 months after hospital discharge with physical therapy. Retrograde cerebral perfusion is a superior method to aortic cross-clamping with regard to cerebral complications.

Because RCP requires no arterial cannulation or aortic cross-clamping, the operative field is simplified and the risk of air and debris emboli to the brain is minimized. Ischemic damage to the brain may be reduced by RCP during circulatory arrest, allowing for extended arrest times. Another advantage of this method is that it requires only the standard cardiopulmonary circuit. The RCP technique is safe for up to 90 minutes and affords time to perform an adequate repair [24].

In group 2, the incidence of enlarged false lumina decreased to 15.3%. The reason was that complete resection of the intimal tear in the proximal arch and obliteration of the dissected lumen were performed within the afforded time. As a result, proximal arch graft replacement was performed in 4 patients. Two patients with enlarged false lumina in group 2 had a secondary intimal tear in the distal aortic arch. Both patients required reoperations for distal arch replacement and survived without complications. It remains controversial whether the initial procedure should be limited to replacing the ascending aorta, or whether the aortic arch repair should be performed simultaneously. Arch repair is necessary when the aortic arch shows actual rupture or impending rupture, or when the false lumen in the arch is markedly enlarged [25]. In our series, only 1 patient had an indication for total arch replacement in acute dissection.

In conclusion, in patients with acute type A aortic dissection, open distal anastomosis and proximal arch replacement using RCP decreased the development of enlarged patent false lumina at long-term follow-up.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Yamashita, Division II, Department of Surgery, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Japan 650.


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051–63.[Abstract]
  2. Jex PK, Schaff HV, Piehler JM, et al. Repair of ascending aortic dissection: influence of associated aortic valve insufficiency on early and late results. J Thorac Cardiovasc Surg 1987;93:375–84.[Abstract]
  3. Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984;70:I153–64.[Medline]
  4. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement: results of 172 operations. Ann Surg 1991;214:308–20.[Medline]
  5. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg 1991;102:62–75.[Abstract]
  6. DeBakey ME, McCollum CH, Crawford ES, et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982;92:1118–33.[Medline]
  7. Haverich A, Miller DC, Scott WC, et al. Acute and chronic dissections: determinants of long-term outcome for operative survivors. Circulation 1985;72(Suppl 2):22.
  8. Crawford ES, Crawford JL, Stowe CL. Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome. Ann Surg 1984;199:358–62.[Medline]
  9. Galloway AC, Colvin SB, Grossi EA, et al. Surgical repair of type A aortic dissection by the circulatory arrest-graft inclusion technique in sixty-six patients. J Thorac Cardiovasc Surg 1993;105:781–90.[Abstract]
  10. Ablaza GG, Ghosh SC, Crana VP. Use of a ringed intraluminal graft in the surgical treatment of dissecting aneurysms of the thoracic aorta. A new technique. J Thorac Cardiovasc Surg 1978;76:390–6.[Abstract]
  11. Dureau G, Villard J, George M, Deliry P, Froment JC, Clemont A. New surgical technique for the operative management of acute dissections of the ascending aorta. Report of two cases. J Thorac Cardiovasc Surg 1978;76:385–9.[Medline]
  12. Graham JM, Stinnett DM. Operative management of acute aortic arch dissection using profound hypothermia and circulatory arrest. Ann Thorac Surg 1987;44:192–8.[Abstract/Free Full Text]
  13. Crawford ES, Saleh SA. Transverse aortic arch aneurysm: improved results of treatment employing new modifications of aortic reconstruction and hypothermic cerebral circulatory arrest. Ann Surg 1981;194:180–8.[Medline]
  14. Ott DA, Frazier OH, Cooley DA. Resection of the aortic arch using deep hypothermia and temporary circulatory arrest. Circulation 1978;58:I227–31.[Medline]
  15. Livesay JJ, Cooley DA, Duncan JM, Ott DA, Walker WE, Reul GJ. Open aortic anastomosis: improved results in the treatment of aneurysms of the aortic arch. Circulation 1982;66(Suppl 1):I122–7.[Medline]
  16. Cooley DA, Ott DA, Frazier OH, Walker WE. Surgical treatment of aneurysms of the transverse aortic arch: experience with 25 patients using hypothermic techniques. Ann Thorac Surg 1981;32:260–72.[Abstract/Free Full Text]
  17. Galloway AC, Colvin SB, LaMendola CL, et al. Ten-year operative experience with 165 aneurysms of the ascending aorta and aortic arch. Circulation 1980;80(Suppl 1):249–56.
  18. Cooley DA. Experience with hypothermic circulatory arrest and the treatment of aneurysms of the ascending aorta. Semin Thorac Cardiovasc Surg 1991;3:166–70.[Medline]
  19. Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement: results of 172 operations. Ann Surg 1991;214:308–20.[Medline]
  20. Safi HJ, Brien HW, Winter JN, et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg 1993;56:270–6.[Abstract/Free Full Text]
  21. Ergin MA, Galla JD, Lansman SL, Quintana CS, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg 1994;107:788–99.[Abstract/Free Full Text]
  22. Yamashita C, Nakamura H, Nishikawa Y, Yamamoto S, Okada M, Nakamura K. Retrograde cerebral perfusion with circulatory arrest in aortic arch aneurysm. Ann Thorac Surg 1992;54:566–8.[Abstract/Free Full Text]
  23. Ueda U, Miki S, Kusuhara K, et al. Surgical treatment of the aneurysm or dissection involving the ascending aorta and aortic arch utilizing circulatory arrest and retrograde perfusion. J Jpn Assoc Thorac Surg 1988;36:162–7.
  24. Imamaki M, Hashimoto A, Hirayama T, et al. A clinical assessment of efficacy in continuous retrograde cerebral perfusion method. Jpn J Thorac Surg 1992;45:755–8.
  25. Andou M, Nakajima N, Adachi S, Nakaya M, Kawashima N. Simultaneous graft replacement of the ascending aorta and total arch for type A aortic dissection. Ann Thorac Surg 1994;57:669–76.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J Am Coll CardiolHome page
R. S. Bonser, A. M. Ranasinghe, M. Loubani, J. D. Evans, N. M. A. Thalji, J. E. Bachet, T. P. Carrel, M. Czerny, R. Di Bartolomeo, M. Grabenwoger, et al.
Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection
J. Am. Coll. Cardiol., December 6, 2011; 58(24): 2455 - 2474.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
T. Myrmel, D. T. M. Lai, and D. C. Miller
Can the principles of evidence-based medicine be applied to the treatment of aortic dissections?
Eur J Cardiothorac Surg, February 1, 2004; 25(2): 236 - 242.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
M. P. Ehrlich, M. Schillinger, M. Grabenwoger, A. Kocher, E. M. Tschernko, P. Simon, A. Bohdjalian, and E. Wolner
Predictors of Adverse Outcome and Transient Neurological Dysfuntion Following Surgical Treatment of Acute Type A Dissections
Circulation, September 9, 2003; 108(2011): II-318 - II-323.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Kirsch, C. Soustelle, R. Houel, M. L. Hillion, and D. Loisance
Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection
J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 318 - 325.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. Sinatra, G. Melina, I. Pulitani, B. Fiorani, G. Ruvolo, and B. Marino
Emergency operation for acute type A aortic dissection: neurologic complications and early mortality
Ann. Thorac. Surg., January 1, 2001; 71(1): 33 - 38.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Chojiro Yamashita
Masayoshi Okada
Keiji Ataka
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Yamashita, C.
Right arrow Articles by Yamashita, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yamashita, C.
Right arrow Articles by Yamashita, T.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS