Minimally Invasive Video-Assisted Surgery for Concomitant Ascending Aorta and Aortic Valve Replacement via Right Infra-Axillary Thoracotomy.

OBJECTIVE: This study aims to assess the safety, efficacy, and esthetic outcomes of an innovative 4 cm right infra-axillary incision approach for concomitant ascending aorta and aortic valve replacement (AAR and AVR), with a specific focus on achieving optimal surgical outcomes while ensuring minimal visible scarring. METHODS: We retrospectively examined all elective cases of concomitant AAR and AVR surgery performed at our institution from July 2021 to June 2023. Exclusions encompassed emergency surgery, acute type A aortic dissection, active aortic valve endocarditis, redo cardiac surgery, the necessity for concurrent mitral valve replacement, or left ventricular assist device implantation. We collected and analyzed perioperative data for the patients. RESULTS: The study comprised 24 consecutive patients. Cardiopulmonary bypass time and aortic cross-clamp time averaged 215.0 (interquartile range [IQR], 38.0) and 158.0 (IQR, 37.0) min, respectively. No instances of reoperation due to postoperative bleeding or need for permanent pacemaker implantation were recorded. Initial 24-h postoperative drainage volume averaged 186.9 ± 76.9 mL. Average follow-up duration was 21.7 ± 6.2 months (range, 5 to 30 months). Throughout short-term follow-up, no occurrences of valve dysfunction, paravalvular leak, cardiovascular events necessitating readmission, or mortality were observed. CONCLUSIONS: The right infra-axillary incision approach effectively yields secure, successful, and cosmetically pleasing outcomes for concomitant AAR and AVR. Further research and comparisons are warranted to validate these findings.

Anatomical Study of Abdominal Wall Muscle Innervation to Optimize Retroperitoneal Vascular Approach.

INTRODUCTION: Different surgical approaches are used in aortic surgery. Retroperitoneal approaches can result in abdominal wall weakness and flank bulging. These approaches often require dissection of the anterolateral or anteromedial muscles of the abdominal wall. During dissection, the underlying nerves are at great risk of injury, which induces significant complications in abdominal wall muscles. Few studies have been conducted to minimize the risk of injury to these nerves. OBJECTIVES: This study aims to describe the trajectory of abdominal muscle motor nerves and their relationship to ribs and other anatomical landmarks. The secondary objective is to optimize surgical approaches by preserving the nerves. METHOD: We conducted 12 dissections on fresh cadavers. Nerve trajectories, communication between the intercostal nerves (9th-10th-11th) and the subcostal nerve (12th), and the distance from the nerve to the estimated projection point of intersection with the abdominal midline, umbilicus, and iliac crest was recorded. RESULTS: Our dissections identified the 12th subcostal nerve as the largest nerve. The 11th intercostal nerve exhibits more accessory branches than other nerves. Multiple communications and branches were observed between the 10th and 11th intercostal nerves and between the 11th and 12th nerves in the region from the anterior axillary line to the mid-clavicular line. The estimated projection point of intersection with the midline was 7.92 ± 1.24 cm supraumbilical for the 9th intercostal nerve, 3.92 ± 1.18 cm supraumbilical for the 10th, 1.08 ± 1.52 cm at the umbilical level for the 11th, and -3.33 ± 0.83 cm infraumbilical for the subcostal nerve. The distance between the iliac crest and the iliohypogastric nerve in the lateral jackknife position was 2.54 ± 0.65 cm. The 11th nerve had an angle in relation to the rib of between -45° and -10° (average: -24.6°), and the 12th nerve had a similar angle of between -30° and 0° (average: -18.3°). For the 11th nerve, the distance was between 0 and 5.5 cm (average: 2.92 cm); for the 12th nerve, it was between 0 and 3.0 cm (average: 1.71 cm). CONCLUSION: To preserve the 11th nerve, the optimal approach is a straight incision starting from the upper edge of the 11th rib towards the midline, 4 cm above the umbilicus; for the 12th nerve, the optimal approach is a straight incision starting from the upper edge of the 12th rib towards the midline, 1 cm below the umbilicus; for the iliohypogastric nerve, the optimal approach is an incision close to the iliac crest at a distance <1.5 cm. The estimated projection point of intersection between the nerve directions towards the midline can indicate the anatomical trajectory of nerves. A nerve projection towards the midline can provide valuable information about the anatomical location of a nerve. This study has utility in optimizing surgical approaches. A clinical study can confirm these anatomical results.

Early clinical outcomes in men and women undergoing proximal thoracic aortic surgery - A Swedish population-based cohort study.

OBJECTIVE: To investigate the association between female sex and 30-day mortality and postoperative complications in patients undergoing scheduled proximal thoracic aortic surgery in Sweden. METHODS: In a nationwide population-based cohort study, all patients who underwent scheduled proximal thoracic aortic surgery in Sweden between 2016 and 2020 were included. The primary outcome measure was 30-day mortality. Secondary outcome measure included a combined endpoint including 30-day all-cause mortality, postoperative new onset dialysis, perioperative stroke or a prolonged need of postoperative ventilation (>48 hours). Logistic regression models and propensity score matching were used to estimate the association between female sex and primary and secondary outcomes adjusted for differences in baseline characteristics. RESULTS: 2000 patients (29% women) were analyzed. The crude 30-day all-cause mortality rate was higher in women compared to men (3.1 vs. 1.4%, p<0.001). Women were older at time of surgery (65.6 vs. 60.2 years, p<0.001), had more comorbidities and a larger maximum indexed aortic diameter (cm/m body height) at time of surgery (3.4 ± 0.56 vs. 3.0 ± 0.48, p<0.001). The adjusted risk for 30-day mortality for women compared to men was not significant (OR 1.41 CI 95% (0.70-2.83)), neither was the secondary composite endpoint (OR 0.89 CI 95% (0.62-1.27)). The propensity score matched analysis showed similar results. CONCLUSIONS: Women who underwent proximal thoracic aortic surgery had a two-fold higher unadjusted 30-day mortality risk, but the mortality risk was not significantly higher when age and comorbidities was taken into consideration.

Influence of vascular graft type for ascending aorta replacement on the early postoperative outcome.

BACKGROUND: Aim of this study was to find out if the type of vascular prosthesis used, especially collagen impregnated polyester versus gelatin impregnated woven fabric graft, has any impact on the early postoperative bleeding rate, blood product consumption and re-thoracotomy rate in isolated ascending aortic surgery. METHODS: n = 46 consecutive patients who received a supra-commissural replacement of the ascending aorta between 01/2016 - 01/ 2021 were included in this retrospective single-center study. The underlying pathology was an aortic aneurysm in 36 (81 %) and/or an acute type A aortic dissection (ATAAD) limited to the ascending aorta in 7 (15 %) and/or a penetrating aortic ulcer (PAU) with intramural hematoma in 6 (13 %) patients. According to the type of vascular graft used, the cohort was divided as follows: 25 patients (54%) received a double velour woven, collagen impregnated polyester graft (Hemashield, Getinge; CI-Group) whereas in 21 patients (46 %) a gelatin impregnated woven fabric graft was used (Gelweave, Vascutek / Terumo; GI-group). As primary endpoints class 3 bleeding according to the Valve Academic Research Consortium (VARC3) criteria and freedom from re-intervention were assessed. As secondary endpoints, 30-day mortality and stroke were defined. RESULTS: Preoperative risk assessment (EuroSCORE II), gender-, BMI-stratification and NYHA-classification as well as mean CPB-times (114 ± 44 min vs 110 ± 48 min) and aortic cross-clamp times (71 ± 28 min vs 66 ± 30 min) were similar in both groups. Bleeding, measured by drainage volume output within the first postoperative 24 h (480 ± 426 mL vs 389 ± 169 mL), erythrocytes concentrate consumption (2,4 vs 2,3) and similar re-thoracotomy rates (4 vs 4.7 %) showed no difference between groups. 30- day mortality (12 vs 5 %; p = 0.614) and stroke rates (4 vs 9.5; p = 0,4) showed no differences between groups. CONCLUSIONS: Regarding postoperative bleeding no difference were seen between the two graft types. Long-term follow-up and larger prospective randomized studies are requested to prove these findings.

Urgent hybrid repair of a symptomatic dissection-related type II thoracoabdominal aortic aneurysm.

Emergency repair of type II thoracoabdominal aortic aneurysms is burdened by high perioperative morbidity and mortality. We report the case of a symptomatic type II post-dissection thoracoabdominal aortic aneurysm that was treated using a hybrid technique. The repair was carried out in 2 stages. In the first stage, we deployed 2 imbricated stent grafts in the descending thoracic aorta. A left carotid-to-left subclavian artery bypass was pre-emptively performed to obtain a proper proximal landing zone and as part of the manoeuvres to protect the spinal cord. The endovascular first stage was effective in obtaining proximal sealing but, as expected, it did not prevent distal reperfusion of the aneurysmatic false lumen. A few hours later, we moved on to the second stage in which we repaired the aneurysmal distal thoracic and abdominal aortic segment by means of a multibranched synthetic graft. The repair was carried out through a left thoracophreno-laparotomy in the seventh intercostal space. A left passive arterial bypass and selective cold renal and warm visceral perfusion were adopted to provide organ protection. Technical success was achieved and confirmed radiologically. The patient experienced mild postoperative paraplegia, which almost completely regressed after a neuromotor rehabilitation program.

Correlation Between Intraoperative Near-infrared Spectroscopy Values and Neurologic Outcomes in Patients Undergoing Total Aortic Arch Replacement Using the Frozen Elephant Trunk Technique.

OBJECTIVE: To correlate intraoperative near-infrared spectroscopy (NIRS) values with neurologic outcomes in patients undergoing total aortic arch replacement using the frozen elephant trunk (FET) technique. DESIGN: Retrospective, single-center registry study using a two-way repeated-measures analysis of variance. SETTING: Between November 2013 and December 2023, 427 patients were treated for acute and chronic aortic pathologies using the FET procedure. PARTICIPANTS: A total of 166 patients with complete NIRS data at all predefined time points were included and retrospectively divided into two groups: patients diagnosed by experienced radiologists and clinicians with stroke and without stroke after FET. MEASUREMENTS: Bilateral NIRS values were recorded continuously and at seven critical time points in each patient, and correlations were made between left- and right-sided NIRS values and stroke. MAIN RESULTS: A total of 23 patients (13.9%) were diagnosed with stroke. There was a significantly higher in-hospital mortality in patients with stroke (21.7%) compared with patients without stroke (7.7%, p = 0.037). Left-sided regional cerebral oxygenation did not show significant difference in patients with versus without stroke (p = 0.550). Differences were detected in right-sided regional cerebral oxygenation trends (p < 0.001) and interhemisphere NIRS at specified time points (p = 0.009). The interaction, time × stroke, however, did not show significant results in any analysis (p > 0.05). CONCLUSION: NIRS is a reliable tool to monitor intraoperative frontal lobe cerebral oxygen saturation. However, its use to predict postoperative stroke remains limited. Further refinements are needed to develop the technique into a prediction tool.

Type a aortic dissection after aortic wrapping performed 26 years ago: a case report.

BACKGROUND: Aortic wrapping (AW) has been performed as a less invasive alternative to aortoplasty. However, AW can also cause long-term aortic complications. In this report, we present a rare case of a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction after AW. CASE PRESENTATION: A female patient had undergone urgent aortic valve replacement with a 19-mm mechanical valve to treat infective endocarditis and AW to treat an enlarged ascending aorta 26 years prior. At the age of 71 years, the patient was diagnosed with a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction. We performed graft replacement of the ascending aorta, including complete resection of the wrap. The patient was discharged on postoperative day 10, and there have been no cardiovascular events during her ongoing follow up. CONCLUSIONS: AW in younger patients can lead to late aortic complications. Careful consideration should be paid when performing AW in young patients, and patients who have previously undergone AW require strict life-long follow-up.

Early injection laryngoplasty for acute unilateral vocal fold paralysis after thoracic aortic surgery.

OBJECTIVE: Unilateral vocal fold paralysis (UVFP) following open thoracic aortic surgery increases pulmonary complications and hospital stays. An intervention protocol with early injection laryngoplasty (IL) and swallowing maneuvers was developed for acute UVFP following thoracic aortic surgery. This study aimed to compare the incidence of complications and length of medical care between the non-VFP and the IL-UVFP group managed under this protocol. METHODS: Patients who underwent open thoracic aortic surgery from March 2020 to February 2023 were included, excluding those with preoperative VFP or postoperative bilateral VFP. Under the protocol, patients with UVFP and incomplete glottic closure received IL and swallowing maneuvers within one week after diagnosis, while those without a glottic gap started a soft diet along with swallowing maneuvers. Postoperative complications, including reintubation, ICU re-transfer, pneumonia, stroke, delirium, wound infection, and bleeding, as well as hospital and ICU stay, were assessed. RESULTS: Of the 355 patients included in the study, 51 (14.4%) developed postoperative UVFP, while 304 (85.6%) had normal VF function. In the UVFP group, 42 patients underwent IL, while 9 patients without a glottic gap did not undergo IL. The incidence of complications and length of medical care were analyzed in the non-VFP and the IL-UVFP groups. The IL-UVFP group had a longer median hospital stay compared to the non-VFP group (20.5 vs. 16.0 days), though this difference was not statistically significant (P = .0681). ICU stay (P = .5396) and ICU re-transfer rates (P = 1.00) were also comparable between the groups. There was no significant difference in the incidence of pneumonia between the IL-UVFP group (4.8%) and the non-VFP group (9.5%) (P = .4003). Additionally, no significant differences were observed in the incidence of stroke, delirium, wound infection, or bleeding between the groups. No IL-related complications were reported. CONCLUSIONS: The protocol with early IL appears to help reduce complication rates in acute UVFP patients following thoracic aortic surgery to levels comparable to those in patients without VFP. This protocol could serve as a guideline for otolaryngologists in managing UVFP patients. LEVEL OF EVIDENCE: 2b/Individual cohort study.

How to improve patient recovery after complex endovascular aortic repair: the experiences of patients and healthcare professionals.

OBJECTIVE: Complex endovascular aortic repair (EVAR) involves tertiary surgical care, with short in-hospital recovery. This study aimed to explore patients' and healthcare professionals' experiences of what can improve patient recovery after complex EVAR. METHODS: Three qualitative data collection stages building on each other were analysed with thematic analysis. Stages 1 and 2 separately explored patients' and healthcare professionals' experiences of what works well and what can be improved with current care. In stage 3, participants reviewed the relevance and feasibility of intervention suggestions. RESULTS: Three matching themes were identified in stages 1 and 2: Adequate information; Patient involvement; Continuity and follow-up. In stage 3: Individual care plan, Team meetings, and Contact nurse were all found relevant, while only Information routines was found both relevant and feasible. CONCLUSION: What patients and healthcare professionals experienced could improve patients recovery after complex EVAR seem universal for complex surgical patients, and relevant interventions were identified. However, the feasibility of person-centred interventions seem affected by various contextual factors, like current routines and availability of staff. PRACTICE IMPLICATIONS: Interventions that facilitate communication, both involving and supporting the patient, should be tested to strengthen patients' ability to self-care, and ensure access to care and support when needed.

Non-circulatory arrest aortic arch replacement.

The definitive management of combined aortic arch and descending aortic pathologies such as aneurysms and dissections is either a single or staged operation associated with high morbidity and mortality. Stroke, kidney dysfunction, coagulopathy and high blood transfusion requirements are all affiliated with hypothermic circulatory arrest and prolonged cardiopulmonary bypass times. Considering the perilous nature of these operations, the authors describe a step-by-step zone 2 arch replacement as a staged frozen elephant trunk procedure, which provides an adequate landing zone for a later-placed endovascular stent yet maintains a short cardiopulmonary bypass time and no circulatory arrest.

Safety and validity of selective cerebrospinal fluid drainage in open and endovascular aortic repair.

OBJECTIVES: Although cerebrospinal fluid drainage has been shown to reduce the risk of ischemic spinal cord injury, serious complications have also been reported. We have been using it selectively in a pressure- and volume-regulated method and aimed to evaluate its safety, and its validity in elective thoracic endovascular aortic repair in a propensity-matched cohort. METHODS: Among the 450 patients who underwent open surgery (n = 169) or thoracic endovascular aortic repair (n = 281) on the descending or thoracoabdominal aorta, 147 underwent cerebrospinal fluid drainage, which was prophylactic in 135 and therapeutic in 12. Prophylactic drainage was performed in elective open surgery under distal aortic perfusion (n = 67) or in selected patients undergoing thoracic endovascular aortic repair (n = 68). RESULTS: Drainage-related complications were observed in 13 (9.6%), one of which was graded severe (0.74%). In patients undergoing prophylactic drainage, spinal cord injury was detected in 2/135 (1.5%). In patients without prophylactic drainage, 15/315 (4.8%) developed spinal cord injury. Therapeutic drainage was performed in 12 of these 15 patients, 10 of whom remained paralytic in varying degree. In the inverse probability weighted analysis of the patients undergoing elective thoracic endovascular aortic repair, the incidence of spinal cord injury was lower with prophylactic drainage (p = 0.028). CONCLUSIONS: Pressure- and volume-regulated spinal drainage rarely causes serious complications. Its prophylactic use seems beneficial in selected patients, including those undergoing thoracic endovascular aortic repair with high risk for spinal cord injury.

Aortoenteric Fistula with Digestive Contrast Material Leaking in the Aneurysmal Sac.

Teaching point: Aortoenteric fistula, a major complication of aortic surgery, can be identified with certainty on CT scan with opacification of the intestinal tract.

Atrial Septal Defect Occlusion Device Closure of Ascending Aortic Pseudoaneurysm: Can Percutaneous Treatment Become the Solution?

This paper presents 2 cases of middle-aged men submitted to aortic valve replacement surgery that were complicated with ascending aortic pseudoaneurysms treated percutaneously with an atrial septal defect occlusion device (Amplatzer, Abbott Cardiovascular). Percutaneous closure may be an effective treatment in selected patients with high surgical risk.

Prevalence and Influence of Genetic Variants on Follow-Up Results in Patients Surviving Thoracic Aortic Therapy.

Background/Objective: To investigate the prevalence and effects of genetic variants (GVs) in survivors of thoracic aortic dissection/aneurysm repair. Methods: Patients aged 18-80 years who survived follow-up after cardiosurgical or endovascular repair of thoracic aortic aneurysm or dissection at a single tertiary center between 2008 and 2019 and underwent genetic testing were enrolled. The exclusion criteria were age >60 years, no offspring, and inflammatory- or trauma-related pathogenesis. Follow-up entailed computed tomography-angiography at 3 and 9 months and annually thereafter. All patients underwent genetic analyses of nine genes using next-generation sequencing. In cases of specific suspicion, the analysis was expanded to include 32 genes. Results: The study included 95 patients. The follow-up period was 3 ± 2.5 years. GVs were detected in 40% of patients. Correlation analysis according to primary diagnosis showed no significant correlation in disease persistence, progression, or in reintervention rates in aneurysm patients and a correlation of disease persistence with genetic variants according to variant class in dissection patients (p = 0.037). Correlation analysis according to follow-up CD finding revealed that patients with detected dissection, irrespective of original pathology, showed a strong correlation with genetic variants regarding disease progression and reintervention rates (p = 0.012 and p = 0.047, respectively). Conclusions: The prevalence of VUS is high in patients with aortic pathology. In patients with dissected aorta in the follow-up, irrespective of original pathology, genetic variants correlate with higher reintervention rates, warranting extended-spectrum genetic testing. The role of VUS may be greater than is currently known.

Off-pump ascending aorta-abdominal aorta bypass in patient with endoleak.

Thoracic endovascular aortic repair is commonly used in the surgical treatment of patients with aortic coarctation, but complications such as endoleaks can occur. This video tutorial presents a case study involving the exclusion of a stent graft from the bloodstream through total transection of the aortic arch and abdominal aorta, with off-pump aortic grafting and debranching of the left carotid and subclavian arteries.

Long-Term Results and Quality of Life after Surgery for Acute Aortic Dissection Type A: Contemporary Single-Centre Experience.

Background: Aortic dissection is still afflicted with significant morbidity and mortality. This research seeks to assess long-term outcomes and quality of life after emergency surgery for acute aortic dissection type A. Methods: A total of 413 patients were analysed, who had been operated upon between 2000 and 2016 at our centre. We compared our results of the early (2000-2007) versus late (2008-2016) period with regards to 30-day and follow-up mortality and need for reoperation, including risk factor analysis. Quality of life was assessed via the SF-36 survey. Results: Calculated perioperative risk by EuroSCORE increased significantly from early, 24.9%, to late, 38.0%, p < 0.001. Thirty-day rates of mortality decreased significantly from 26.7% to 17.4%, p = 0.03. Survival at 1-, 5-, and 10-years was 92.3% vs. 91.8% (p = 0.91), 75.2% vs. 81.0% (p = 0.29), and 53.4% vs. 69.7% (p = 0.04). Freedom from reoperation was comparable between groups at follow-up: 74.0% vs. 85.7%, p = 0.28. Quality of life was impaired. Conclusions: Despite more complex severity of disease and operative procedures, the results of surgery for type A aortic dissection improved significantly over time at 30-day and 10-year follow-up. Quality of life was significantly impaired compared to a healthy reference population.

The Effect of Obesity on Short- and Long-Term Outcome after Surgical Treatment for Acute Type A Aortic Dissection.

BACKGROUND: A paradox of lower morbidity and mortality in overweight or obese patients undergoing cardiac surgery has been described; however, knowledge about the influence of obesity in patients with acute Type A aortic dissection (AAD) is limited. This study aimed to evaluate the effect of obesity on short- and long-term outcomes after surgical treatment for AAD. METHODS: Between 01/2004 and 12/2022, 912 patients with a BMI of 18.5 or greater were operated on for AAD. Patients were grouped according to their BMI (normal weight: BMI 18.5-24.9, n = 332; overweight: BMI 25-29.9, n = 367; obesity class I: BMI 30-34.9, n = 133; obesity class II+: BMI ≥ 35, n = 67), and the obtained clinical and surgical data were compared. RESULTS: Obese patients were younger at the time of AAD (p = 0.001) and demonstrated higher rates of typical cardiovascular comorbidities (arterial hypertension, p = 0.005; diabetes mellitus, p < 0.001). The most important preoperative parameters, as well as the surgical approach, were similar between all four groups. The occurrence of renal failure requiring dialysis was higher in patients with BMI ≥ 35 (p = 0.010), but the in-hospital (p = 0.461) and long-term survival (p = 0.894) showed no significant differences. CONCLUSIONS: There are no indications that the obesity paradox is applicable in the setting of AAD. Since obese patients are affected by AAD at a younger age, obesity might constitute a risk factor for AAD. However, obesity does not influence short- or long-term survival. Regardless of body weight, immediate surgical therapy remains the treatment of choice for AAD.