Endovascular Aneurysm Repair With AFX Stent-Grafts or Tube Grafts for Sacciform Infrarenal Pathologies in a Narrow Aortic Anatomy.

PURPOSE: The objective of this study was to compare the outcomes of patients treated with tube grafts and AFX stent-graft in the narrow infrarenal aortic anatomy. MATERIALS AND METHODS: Patients with penetrating aortic ulcers (PAUs) or sacciform aneurysms of the infrarenal aorta and an aortic bifurcation diameter ≤20 mm who underwent endovascular aneurysm repair (EVAR) with bifurcated AFX or tube stent-grafts (TUBE) between 2012 and 2020 were included. Demographic data and the outcome of the AFX group were compared with the TUBE group. All morphological measurements in the preoperative and postoperative computed tomography scans were performed in the aortic centerline. RESULTS: Fifty-one patients (female: 12/51; 29%; median age: 72 years [63, 77]) with a median follow-up of 10 (3, 39) months, were included, of whom 35/51 (69%) had PAUs and 11/51 were symptomatic (22%). The aortic bifurcation diameter was 17 mm (15, 18) with severe calcifications in 25/51 (49%). The distal aortic landing zone was longer in the TUBE group (9 mm vs 24 mm; p<0.001). The technical success was 96% with a median aneurysm shrinkage of 8% (3, 13), which was comparable between the groups (p=0.264). Periprocedural mortality, conversion to open surgery, myocardial infarction, and stroke were not observed. Two type Ia endoleaks (EL) and 2 type Ib EL occurred, all in the TUBE group (Type 1 EL; 19 vs 0%; p=0.013). The limb patency in the AFX group was 100%. One patient with a tube graft developed an infrarenal aortic thrombosis 40 months after the intervention. The reintervention rate in the TUBE group was higher (14 vs 0%; p=0.032) and included 3 aortic cuff implantations and 1 covered endovascular aortic reconstruction of aortic bifurcation (CERAB). CONCLUSION: AFX stent-graft showed a lower rate of type I endoleaks and reinterventions in sacciform infrarenal aortic pathologies during the early and midterm follow-up.

Bare Stent Fracture After TEVAR With the Modified Restrictive Bare Stent (RBS) Technique in Type B Aortic Dissections.

PURPOSE: The aim was to assess the mid-term aortic remodeling and bare-metal stent (BMS) integrity of the restricted bare stent (RBS) technique reconstruction in aortic dissections. MATERIALS AND METHODS: This retrospective cohort study included prospectively collected patients treated with the modified RBS technique between 2017 and 2020. The preoperative, postoperative, and last follow-up computed tomographic (CT) scans were analyzed in the centerline at the mid-descending, celiac trunk (CeT), and the mid-abdominal levels for false lumen (FL) patency, aortic diameter, and true lumen (TL) diameter changes. Bare-metal stent integrity was assessed in the 3-dimensional multiplanar reformats. RESULTS: The median follow-up of the cohort (n=17) was 26 (11, 45) months. The procedure was mainly performed with the Relay NBS endograft (15/17; 88%) + E-XL BMS (17/17; 100%). Postoperative mortality, paraplegia, stroke, renovisceral vessel loss, and type I and III endoleaks were not observed. BMS fractured in 6 patients (6/17; 36%), damaged the dissection flap in 4/17 (24%), and led to the reperfusion of the FL and re-interventions with TEVAR (4/17; 24%). Two patients without FL reperfusion showed stable CT follow-ups 13 and 17 months after the fracture diagnosis. The TL expansion was seen at all landmarks and peaked in the thoracic aorta (+10; 6, 15; p<0.001). The FL thrombosis after modified RBS was only relevant in the thoracic aorta (p<0.001) and at CeT (p=0.003). The aortic diameter was stable in the thoracic aorta and increased at distal landmarks (CeT [+5; 1, 10; p=0.001]; mid-abdominal [+3; 1, 5; p=0.004]). CONCLUSION: The modified RBS technique could not stop aortic growth below the diaphragm and prevent new membrane rupture due to the fractures of the BMS and consecutive flap damage with the reperfusion of the FL. CLINICAL IMPACT: The treatment of complicated type B aortic dissections with TEVAR has become a standard. Particularly, patients with true lumen collapse and malperfusion may benefit from a more aggressive treatment strategy including proximal TEVAR and distal bare-metal stent implantation to re-open the true lumen and to prevent distal stent-induced new entry. However, this study reports the challenges of this approach with a high rate of bare-metal stent fractures during the follow-up. The fractures that occurred at the site of vertical nitinol bridges led to the dissection membrane ruptures and the reperfusion of the false lumen with consecutive dilatation. A close follow-up is mandatory to detect this complication and to treat the patients with TEVAR extension.

Impact of Whole-Body Perfusion in Postoperative Outcomes After Aortic Arch Reconstruction Surgery in Neonates and Infants.

INTRODUCTION: The aim of this study was to determine whether whole-body perfusion (WBP) consisting of a combined antegrade cerebral perfusion (ACP) and lower body perfusion (LBP) improves the outcome after aortic arch reconstruction surgery in neonates compared with ACP. METHODS: Sixty-five consecutive patients under one year of age who underwent aortic arch reconstruction as the main procedure or as part of a more complex surgery from 2014-2020 in our center were included. The patients were separated into two groups, according to the perfusion strategy, either ACP (34 patients) as the control group or WBP (31 patients) as the intervention group. LBP was achieved through an arterial sheath in the femoral artery. Outcome parameters were postoperative renal, gastrointestinal, and neurological complications and 30-day mortality. RESULTS: The patients in the WBP group showed lower intraoperative lactate levels and close to normal early postoperative renal and hepatic enzymes and LDH at PICU admission compared with the patients in the ACP group. The number of patients suffering from postoperative neurological complications and multiorgan failure was lower in the WBP group. CONCLUSION: In our experience, the combined use of ACP and LBP through the femoral artery showed an improvement, regarding postoperative neurologic complications in neonates and infants undergoing aortic arch surgery.

Routine Detachment of the Anterior and Septal Tricuspid Leaflets Simplifies VSD Closure and Improves the Outcomes.

Background and Objectives: The closure of perimembranous ventricular septal defects (VSDs) is one of the most common surgeries performed in infancy. The technique of detachment of the anterior and septal leaflets of the tricuspid valve (TV) with subsequent leaflet augmentation is frequently used for isolated as well as non-isolated VSD closure. In this study, we compared the incidence of tricuspid regurgitation (TR) in patients who underwent a VSD repair with and without detachment of the TV in the short- and long-term follow-up. Materials and Methods: A retrospective study that included 140 patients who underwent perimembranous VSD closure at our center from 2011-2016, where 102 of these patients underwent the procedure with detachment of the TV, was performed. The follow-up data were obtained from postoperative echocardiography performed in the follow-up visits. A total of 62 patients underwent follow-up at our center, where the follow-up time ranged from 1 to 9 years, with a mean of 71 ± 2.47 months. Results: Regarding patients who underwent a VSD repair with a detachment of the TV, 98.1% of the patients had none to mild TR, compared to 94.7% in patients without intraoperative TV detachment at the time of discharge. There were no reported cases of moderate to severe TR, atrioventricular blocks, aortic insufficiency, or deaths. A total of 98.1% of patients who underwent follow-up at our center with a TV detachment had none to mild TR compared to 94.7% in the group without TV detachment. Conclusion: TV detachment with leaflet augmentation for VSD closure is safe and effective and does not increase the incidence of TR in the short- and long-term follow-up.

Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself-A Retrospective Double Center Analysis of Short-Term Outcomes.

Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates.

Left ventricular unloading with transaortic Impella 2.5 implantation in a pediatric patient supported by extracorporeal life support.

We report the case of a 12-year old female patient with Friedreich's ataxia and diabetes mellitus. Due to a progressive multiorgan failure, a veno-arterial extracorporeal membrane oxygenation was implanted through the axillary vessels. However, due to a lack of ejection and severe dilatation of the left ventricle, an Impella 2.5 was implanted. Due to the small diameter of the femoral arteries, we performed a trans-aortic implantation through a median sternotomy via a Dacron tube graft. We report on the procedure and perioperative outcome.

Carotid-axillary bypass as an alternative revascularization method for zone II thoracic endovascular aortic repair.

BACKGROUND: We investigated the mid-term results of carotid-axillary bypass (CAB) in the setting of zone II thoracic endovascular aortic repair as an alternative method for the left subclavian artery (LSA) revascularization. METHODS: Our retrospective, single cohort study included all 69 patients from March 2015 to December 2018 with zone II thoracic endovascular aortic repair and CAB for the revascularization of the LSA. Demographics and clinical data were collected. We assessed several clinical outcomes: local complications (hematoma, injury of the brachial plexus, vagus and sympathetic chain nerve palsies, chyle leakage), subclavian steal, arm ischemia, paraplegia, mortality, and stroke. Follow-up computed tomography scans were analyzed for CAB and vertebral artery (VA) patency and the extent of thrombus formation in the LSA. RESULTS: The in-hospital mortality was 3% and the perioperative stroke rate was 4%. Permanent paraplegia occurred in 3%. Perioperative morbidity included irritation of the brachial plexus (1%), sympathetic chain nerve palsy (1%), and wound hematoma in 3% of the cases. Phrenic and vagus nerve lesions and chyle leakage were not observed. Bypass patency was 97% at mean follow-up of 333 ± 39 days. VA occlusion was found in 6% of all cases. Strokes did not occur during the follow-up. Morbidity at follow-up included arm claudication (3%) in two patients with bypass thrombosis. Subclavian steal was observed in 3%. The LSA ostium was ligated (44%), plugged (22%), or left open (35%) in patients without a type II endoleak. Subgroup analysis of LSA thrombosis to the level of the VA was more prevalent after surgical ligature (P = .02), but had no negative effects on CAB or VA patency or stroke. CONCLUSIONS: CAB is a safe alternative to classic debranching procedures, with distinctive advantages regarding local complication rates described in the literature.

Carotid endarterectomy versus conservative management of the asymptomatic carotid stenosis before coronary artery bypass grafting: a retrospective study.

BACKGROUND: Our retrospective single-center study aimed to evaluate the safety of the carotid endarterectomy (CEA) in comparison to patients with untreated asymptomatic carotid stenosis ≥60% before CABG. METHODS: This single-center retrospective study included 174 patients with asymptomatic unilateral carotid stenosis treated between 2004 and 2017 with CABG. Thereof 106 patients had CEA before cardiac surgery either by a simultaneous (n = 62) or staged (n = 44) approach. Patients with untreated carotid stenosis served as control (no-CEA group; n = 68). RESULTS: The mean stenosis grade was higher in the CEA group (CEA 83% (±1), no-CEA 71% (±1) p < 0.0001). The overall stroke rate was 5/174 (3%) and was due to a high incidence of stroke in the no-CEA group (CEA: 0/106 (0%); No-CEA 5/68 (7%) p = 0.0083). The overall mortality was 1% and comparable between the groups (CEA: 2/106 (2%); No-CEA 0/68 (0%) p = 0.5211). Stroke related mortality was not observed. The groups were similar regarding the incidence of myocardial infarction (p = 1.0), atrial fibrillation (p = 0.1931), delirium (p = 0.2106) and IMC/ICU stay (p = 0.1542). No significant difference in the subgroup analysis was found between the simultaneous and staged approach regarding the myocardial infarction (simultaneous: 1/62 (1%); staged: 1/44 (1%); p = 1.0). CONCLUSIONS: CEA performed as a staged procedure in local anesthesia or a simultaneous procedure in general anesthesia, may reduce the stroke risk prior to CABG.

Off-Pump Coronary Artery Bypass Grafting in Acute Coronary Syndrome: Focus on Safety and Completeness of Revascularization.

BACKGROUND: Emergency coronary artery bypass grafting (CABG) in the setting of acute coronary syndrome (ACS) has been associated with increased morbidity and mortality. Avoiding cardiopulmonary bypass might be advantageous, but the role of off-pump CABG (OPCAB) remains controversial, as it has been associated with incomplete revascularization in several studies. The objective of this study was to evaluate the feasibility, efficacy, and outcome of OPCAB surgery in ACS patients. METHODS: We performed a retrospective review of ACS patients who underwent on-pump CABG (ONCAB) or OPCAB, either emergently or delayed, at our institution. RESULTS: Between January 2015 and December 2016, a total of 205 consecutive ACS patients underwent either ONCAB (109 patients, 53.2%) or OPCAB surgery (96 patients, 46.8%). EuroSCORE II levels (5.6 ± 7.2 vs 4.9 ± 6.5, p = 0.226) and demography were comparable between groups.A trend towards lower postoperative mortality was observed in OPCAB patients (2.1 vs 5.5%). The incidence of postoperative stroke and low cardiac output syndrome, as well as the duration of inotropic support and the need for re-sternotomy, was significantly lower in the OPCAB group (p < 0.05).CABG performed instantly in an emergency situation was not associated with increased mortality or morbidity when compared with delayed procedures, and OPCAB surgery in emergency patients was associated with lower postoperative morbidity and shorter stays in the intensive care unit (p < 0.05).There were no differences in completeness of revascularization between groups (median 1 [1-1.33;0.33-1.67] OPCAB versus median 1 (1-1.33;0.67-2) ONCAB, p = 0.617), even in the emergency setting. CONCLUSION: OPCAB surgery is safe and effective in ACS and may be considered in hemodynamically stable patients in the emergency setting.

Perioperative Assessment of Cerebral Oxygen Metabolism in Infants With Functionally Univentricular Hearts Undergoing the Bidirectional Cavopulmonary Connection.

OBJECTIVES: The transition from single-ventricle lesions with surgically placed systemic-to-pulmonary artery shunt to the circulation following a bidirectional cavopulmonary connection results in higher pressure in the superior vena cava when compared with the preceding circulation. The aim of this study was to evaluate the impact of this transition on the perioperative cerebral oxygen metabolism. DESIGN: Prospective observational cohort study. SETTING: Pediatric critical care unit of a tertiary referral center. PATIENTS: Sixteen infants after bidirectional cavopulmonary connection. INTERVENTION: Cardiac surgery (bidirectional cavopulmonary connection). MEASUREMENTS AND MAIN RESULTS: We measured regional cerebral oxygen saturation, amount of hemoglobin, blood flow velocity, and microperfusion immediately before, 12-24 hours, and 36-48 hours following bidirectional cavopulmonary connection. Based on these measurements, we calculated cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen. Mean pressure in the superior vena cava increased significantly (8 vs 17 mm Hg; p < 0.001) following bidirectional cavopulmonary connection. Mean cerebral oxygen saturation increased from 49.0% (27.4-61.0) to 56.9% (39.5-64.0) (p = 0.008), whereas mean cerebral blood flow velocity decreased from 80.0 arbitrary units (61.9-93.0) to 67.3 arbitrary units (59.0-83.3) (p < 0.001). No change was found in the cerebral amount of hemoglobin and in the cerebral microperfusion. Mean cerebral fractional tissue oxygen extraction (0.48 [0.17-0.63] vs 0.30 [0.19-0.56]; p = 0.006) and approximated cerebral metabolic rate of oxygen (5.82 arbitrary units [2.70-8.78] vs 2.27 arbitrary units [1.19-7.35]; p < 0.001) decreased significantly. CONCLUSIONS: Establishment of bidirectional cavopulmonary connection is associated with postoperative improvement in cerebral oxygen metabolism. Cerebral amount of hemoglobin did not increase, although creation of the bidirectional cavopulmonary connection results in significant elevation in superior vena cava pressure. Improvement in cerebral oxygen metabolism was due to lower cerebral blood flow velocity and stable microperfusion, which may indicate intact cerebral autoregulation.

Dynamic Radial MR Imaging for Endoleak Surveillance after Endovascular Repair of Abdominal Aortic Aneurysms with Inconclusive CT Angiography: A Prospective Study.

Background/Objectives: To assess free-breathing, dynamic radial magnetic resonance angiography (MRA) for detecting endoleaks post-endovascular aortic repair (EVAR) in cases with inconclusive computed tomography angiography (CTA). Methods: This prospective single-center study included 17 participants (mean age, 70 ± 9 years; 13 males) who underwent dynamic radial MRI (Golden-angle RAdial Sparse Parallel-Volumetric Interpolated BrEath-hold, GRASP-VIBE) after inconclusive multiphasic CT for the presence of endoleaks during the follow-up of EVAR-treated abdominal aortic aneurysms. CT and MRI datasets were independently assessed by two radiologists for image quality, diagnostic confidence, and the presence/type of endoleak. Statistical analyses included interrater and intermethod agreement, and diagnostic performance (sensitivity, specificity, area under the curve (AUC)). Results: Subjective image analysis demonstrated good image quality and interrater agreement (k ≥ 0.6) for both modalities, while diagnostic confidence was significantly higher in MRA (p = 0.03). There was significantly improved accuracy for detecting type II endoleaks on MRA (AUC 0.97 [95% CI: 0.87, 1.0]) compared to CTA (AUC 0.66 [95% CI: 0.41, 0.91]; p = 0.03). Although MRA demonstrated higher values for sensitivity, specificity, AUC, and interrater agreement, none of the other types nor the overall detection rate for endoleaks showed differences in the diagnostic performance over CT (p ≥ 0.12). CTA and MRA revealed slight to moderate intermethod concordance in endoleak detection (k = 0.3-0.64). Conclusions: The GRASP-VIBE MRA characterized by high spatial and temporal resolution demonstrates clinical feasibility with good image quality and superior diagnostic confidence. It notably enhances diagnostic performance in detecting and classifying endoleaks, particularly type II, compared to traditional multiphase CTA with inconclusive findings.

Does dose matter? Effect of two different neoadjuvant protocols in advanced NSCLC.

BACKGROUND: For stage III, NSCLC neoadjuvant protocols have been intensified up to full dose protocols but up till now the effect of more intensive protocols in a trimodal setting could not be compared directly because of different selection criteria or experience of involved facilities in different studies or multicenter studies. We analyzed our experience with two different neoadjuvant protocols, consistent selection criteria, and surgical teams over 17-year time period. METHOD: Single-center retrospective study in 159 patients concerning survival, recurrence, and downstaging effect. RESULTS: Overall median survival was 32 months, with 26 months for protocol 1, and 35 months for protocol 2, respectively. Hospital mortality was 5%. Log-rank test showed significant difference between the protocols for UICC-downstaging-effect, ypT-stage, ypN-stage, and ypUICC-stage, respectively, but only ypN-stage and ypUICC-stage were significant risk factors for survival using Cox regression. CONCLUSION: The median survival benefit of 9 months is evident but (probably still) not significant. The more aggressive protocol 2 shows a significant better downstaging effect concerning N- and UICC-stage if R0-resection can be achieved. Insofar dose does matter!

Intramural hematoma in the proximal sealing zone of the thoracic endovascular aneurysm repair: frequency and safety in acute and subacute type B dissections.

Introduction: To assess the outcomes after thoracic endovascular aneurysm repair (TEVAR) in the presence of intramural hematoma (IMH) in the proximal sealing zone. Material and methods: Patient data were retrospectively extracted from the hospital records of patients treated with TEVAR for acute and chronic aortic dissection type B in one single center. The initial, preoperative, first postoperative, and last follow-up CT scans were evaluated in the aortic 3D multiplanar reformats and the centerline regarding IMH presence in the proximal sealing zone, anatomical preconditions, and the morphological TEVAR complications including migration and bird-beak. Groups with (IMH) and without IMH (no-IMH) were compared. Results: Overall, 84 patients (IMH:42; no-IMH:42) were treated at the age of 63(55; 72) years, of whom 23/84 (27%), 34/84 (40%), and 27/84 (32%) were in the hyperacute, acute and subacute dissection phases, respectively. The bovine arch was found in 10/84(12%) and the type III arch was most common (43/84;51%). IMH maximum extent was found in zones 0, 1, 2, and 3 in 14/84 (17%), 17/84 (20%), 18/84 (21%), and 6/84 (7%), respectively. Sealing was achieved in zone II in 71/84 (85%) and LSA was revascularized in 66/84 (79%) of the overall cohort. Early mortality and paraplegia were 2/84 (2%) each; stroke rate was 3/84 (4%). During the 22 months median follow-up (22;4;43) no RTAD was observed. Migration ≥10 mm (IMH: 11/82; no-IMH: 10/82; P = 1.0) and bird-beaks (IMH: 10/82; no-IMH: 12/82; P = 0.8036) were comparable in both groups and accompanied by a low aorta related mortality (1/82) in both groups. Conclusion: The presence of the IMH in the proximal TEVAR sealing zone is frequent and may not be relevant for the occurrence of the RTAD, stent-graft migration, or bird-beak formation.

Mid-Term Outcomes of a Pre-Cannulated Iliac Branched Device in the Treatment of Abdominal Aortoiliac Aneurysms: A Retrospective Analysis from a Single Center.

The aim was to assess the mid-term results of the E-iliac branched device. Baseline and follow-up data of this monocentric retrospective cohort study including all consecutive patients with aortoiliac aneurysms treated with iliac branched devices between 2016 and 2023 were extracted from the hospital records. Preoperative and follow-up CT scans were analyzed regarding endoleaks, migration, aneurysm sac remodeling, and device patency. Overall, 50 devices were implanted in 38 patients with a median age of 69 (IQR 62-78) years, and 1.6 bridging stent grafts per vessel were implanted through transfemoral (22/50; 44%) or upper extremity access (28/50; 56%). Primary technical success and assisted technical success were 97% (37/38) and 100% (38/38), respectively. No migration, no type I or III endoleaks, no stroke, colonic ischemia, aneurysm rupture, or conversion during the early and mid-term follow-ups (11 months, IQR 5-26) were observed. Aneurysm sac enlargement or shrinkage was observed in 0% (0/38) and 16% (6/38) patients, respectively. E-iliac-related re-interventions were seen only during the early follow-up: two thrombectomies with bare-metal stent relining after thrombosis of the iliac limb. Bridging stent graft and E-iliac patency during the mid-term follow-up were 100%. E-iliac showed encouraging mid-term results in the treatment of aortoiliac aneurysms with high technical success and a low re-intervention rate.

Whole-body perfusion improves intraoperative transfusions in neonatal aortic arch surgery.

OBJECTIVES: Whole-body perfusion is the combination of lower body perfusion and antegrade cerebral perfusion. This perfusion technique is used in some centres when performing aortic arch reconstruction surgery in neonates and infants. Several studies have shown intra- and postoperative benefits of this technique. However, no studies have analysed the impact it may have on the transfusion of blood products and coagulation factors. METHODS: We retrospectively analysed 65 consecutive neonates and infants who underwent aortic arch reconstruction surgery from January 2014 to July 2020. Patients operated from 2014 to 2017 underwent surgery with antegrade cerebral perfusion; in patients who underwent surgery from 2017 to 2020 a whole-body perfusion strategy was used. Demographic, intra- and postoperative parameters were compared as well as intraoperative blood product and coagulation factor transfusions, chest-tube output in the first 24 h and postoperative bleeding complications. RESULTS: Both groups required intraoperative transfusion of red blood cells, fresh frozen plasma, and platelets, as well as substitution of coagulation factors. The amount of transfused volumes of red blood cells, fresh frozen plasma and platelets (P-values 0.01, <0.01 and <0.01) and intraoperative transfusions of fibrinogen and von Willebrand factor were significantly lower in the whole-body perfusion group (P-value 0.04 and <0.01). CONCLUSIONS: A whole-body perfusion strategy may lead to fewer intraoperative blood product and coagulation factor transfusions when compared to antegrade cerebral perfusion alone in neonates and infants undergoing complex aortic arch reconstruction surgery.

On- vs. Off-Pump CABG in Heart Failure Patients with Reduced Ejection Fraction (HFrEF): A Multicenter Analysis.

OBJECTIVE: This study aimed to compare postoperative outcomes and 30-day mortality in patients with reduced ejection fraction (<40%) who underwent isolated coronary artery bypass grafting (CABG) with (ONCAB) and without (OPCAB) the use of cardiopulmonary bypass. METHODS: data from four university hospitals in Germany, spanning from January 2017 to December 2021, were retrospectively analyzed. A total of 551 patients were included in the study, and various demographic, intraoperative, and postoperative data were compared. RESULTS: demographic parameters did not exhibit any differences. However, the OPCAB group displayed notably higher rates of preoperative renal insufficiency, urgent surgeries, and elevated EuroScore II and STS score. During surgery, the ONCAB group showed a significantly higher rate of complete revascularization, whereas the OPCAB group required fewer intraoperative transfusions. No disparities were observed in 30-day/in-hospital mortality for the entire cohort and the matched population between the two groups. Subsequent to surgery, the OPCAB group demonstrated significantly shorter mechanical ventilation times, reduced stays in the intensive care unit, and lower occurrences of ECLS therapy, acute kidney injury, delirium, and sepsis. CONCLUSIONS: the study's findings indicate that OPCAB surgery presents a safe and viable alternative, yielding improved postoperative outcomes in this specific patient population compared to ONCAB surgery. Despite comparable 30-day/in-hospital mortality rates, OPCAB patients enjoyed advantages such as decreased mechanical ventilation durations, shorter ICU stays, and reduced incidences of ECLS therapy, acute kidney injury, delirium, and sepsis. These results underscore the potential benefits of employing OPCAB as a treatment approach for patients with coronary heart disease and reduced ejection fraction.

Total transfemoral access in a new off-the-shelf thoracoabdominal inner-branched endograft.

Branched endovascular aneurysm repair (BEVAR) is increasingly being performed with the off-the-shelf devices. We evaluated the use of the wire-assisted sheath stabilization technique for the new inner branch-based (iBEVAR), off-the-shelf E-nside endograft in 2 patients. The cannulation of the 8 reno-visceral target vessels and the BSG implantation were successfully performed using the total transfemoral approach. Complications were not observed during the 3-month follow-up. The wire-assisted sheath stabilization technique was shown feasible in an off-the-shelf iBEVAR.

Longitudinal morphological changes of the aorta and the endograft position before and after distal stent graft-induced new entry in aortic dissections.

OBJECTIVES: The aim of this study was to assess the endograft position and aortic geometry changes after thoracic endovascular aortic repair (TEVAR) and frozen elephant trunk (FET) in distal stent-induced new entry (dSINE) patients. METHODS: In this retrospective cohort study, the baseline demographic and the follow-up data were extracted from the hospital records, and computed tomography scans of dSINE patients after TEVAR or FET between 2011 and 2021 were analysed regarding endograft oversizing, length and migration, taper ratio, aortic diameter at the endograft end, aortic elongation (thoracic inner and outer curvature), wedge apposition angle and tortuosity angle in the distal landing zone. RESULTS: dSINE was found in 22/213 (10%) of TEVAR and 10/31 (32%) of FET patients. The total follow-up time was 45 (27; 59) months. TEVAR was mainly performed with Relay NBS endograft (77%) and FET with Evita open prosthesis (80%). Paraplegia and stroke rates were 3%. dSINE occurred 17 (7; 35) months post-TEVAR and was instantly treated in 18 patients (56%) or followed up for 21 (11; 34) months (n = 14). Migration [+5 mm (1; 11; P < 0.001)], birdbeak angle [+9° (0; 27; P = 0.039)] and aortic diameter +5 mm (1; 11; P < 0.001) increased after dSINE, whereas aortic elongation increased already before [+12 mm (0; 27; P = 0.015)] and peaked after dSINE [+30 mm (9; 38; P < 0.001)]. The aortic elongation was more pronounced in the outer aortic curvature before and after dSINE (before: P = 0.039, after: P = 0.024). Postoperative wedge apposition [17° (12; 20)] increased before dSINE [21° (16; 35; P < 0.001)] and peaked thereafter [31° (21; 40; P < 0.001)]. CONCLUSIONS: Aortic elongation may influence the endograft position and provoke TEVAR failure in the distal and proximal landing zones.

The impact of dissection membrane motility on mid-term aortic remodelling after thoracic endovascular repair.

OBJECTIVES: The aim of this study was to assess preoperative dissection flap motility and to evaluate its impact on the aortic remodelling and the development of distal stent-induced new entry after thoracic endovascular aneurysm repair (TEVAR)/frozen elephant trunk (FET). METHODS: Patients with primary or residual type B dissections were included in a retrospective study with transoesophageal echocardiography analysis of the preoperative dissection flap motility assessed by the true lumen (TL) strain. Three-dimensional computing tomography centreline reconstructions before TEVAR/FET and during the follow-up were conducted to measure aortic remodelling: false lumen thrombosis, TL expansion and aortic diameters at 10 and 20 cm downstream the left subclavian artery, at the coeliac trunk and in the infrarenal aorta. All continuous variables are reported as median with first and third quartiles. RESULTS: Fifty-six consecutive patients were treated with TEVAR (n = 45) or FET (n = 11) in the acute (n = 16), subacute (n = 16) and chronic (n = 24) dissection phase. At a median follow-up of 6 (3-12) months, they showed a favourable TL expansion in the descending aorta, significantly higher in the acute [+9 mm (5-12); P < 0.001] and subacute groups [+5 mm (3-8); P = 0.039] than in the chronic group [+2 mm (0-5)]. The dissection flap motility parameter TL strain was superior in the acute (P = 0.006) and subacute (P = 0.035) groups in comparison to the chronic group. The motile flap [TL strain >22.5% (median)] was associated with a higher TL expansion rate in the thoracic aorta (P = 0.009) and a comparable distal stent-induced new entry incidence (overall: 16%) in comparison to the immobile flap (P = 0.89). CONCLUSIONS: The intraoperative assessment and the inclusion of the dissection flap motility parameters in the decision-making during TEVAR/FET may refine the distal endograft sizing for an improved remodelling of the TL.

Thoracoscopic mesh implantation as a definitive treatment approach for peritoneal dialysis-associated hydrothorax.

Pleuroperitoneal leakage with the formation of hydrothorax is a rare complication of peritoneal dialysis, usually necessitating termination of peritoneal dialysis. We hypothesized that implantation of a polypropylene mesh on the diaphragm using video-assisted thoracoscopic surgery might induce permanent closure of pleuroperitoneal leakage. We report a case series of n = 12 peritoneal dialysis patients with pleuroperitoneal leakage and right-sided hydrothorax who underwent video-assisted thoracoscopy with mesh implantation from 2011 to 2020. Pleuroperitoneal leakage had been confirmed before surgery by intraperitoneal administration of toluidine blue, contrast-enhanced computer tomography or glucose determination from the pleural effusion. Median time from the start of peritoneal dialysis to manifestation of pleuroperitoneal leakage was 52 days. Video-assisted thoracoscopic surgery revealed multiple penetration points in the tendinous part of the diaphragm in all patients, which appeared as blebs. These were closed by covering the whole diaphragm with a polypropylene mesh. In all patients, peritoneal dialysis was paused for three months and bridged by hemodialysis. After restarting peritoneal dialysis and a median follow-up time of 1.9 years, none of the patients experienced a recurrence of pleuroperitoneal leakage. This case series demonstrates that pleuroperitoneal leakage in peritoneal dialysis patients can be permanently closed using thoracoscopic mesh implantation and allows peritoneal dialysis to be continued as renal replacement therapy.