Clinical predictive value of the age, creatinine, and ejection fraction score in patients in acute type A aortic dissection after total arch replacement.

The age, creatinine, and ejection fraction (ACEF) score has been accepted as a predictor of poor outcome in elective operations. This study aimed to investigate the predictive value of ACEF score in acute type A aortic dissection (AAAD) patients after total arch replacement. A total of 227 AAAD patients from July 2021 and June 2022 were enrolled and divided into Tertiles 1 (ACEF ≤ 0.73), Tertiles 2 (0.73 < ACEF ≤ 0.95), and Tertiles 3 (ACEF > 0.95). Using inverse probability processing weighting (IPTW) to balance the baseline characteristics and compare the outcomes. Cox logistic regression was used to further evaluate the survival prediction ability of ACEF score. The in-hospital mortality was 9.8%. After IPTW, in the baseline characteristics reached an equilibrium, a higher ACEF score before operation still associated with higher in-hospital mortality. After 1 year follow-up, 184 patients (90.6%) survival. Multivariable analysis revealed that ACEF score (adjusted hazard ratio 1.68; 95% confidence interval 1.34-4.91; p = 0.036) and binary ACEF score (adjusted HR 2.26; 95% CI 1.82-6.20; p < 0.001) was independently associated with 1-year survival. In addition, net reclassification improvement (NRI) and integrated differentiation improvement (IDI) verified that the ACEF score and binary ACEF score is an accurate predictive tool in clinical settings. In conclusions, ACEF score could be considered as a useful tool to risk stratification in patients with AAAD before operation in daily clinical work.

Aortic arch surgery for DeBakey type 1 aortic dissection in patients aged 60 years or younger.

BACKGROUND: Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. METHODS: The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. RESULTS: Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). CONCLUSIONS: In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.

[Analysis of the effect and safety of lumen reshaping after endovascular repair of Stanford B type aortic dissection at different intervention times].

Objective: To Compare the effects and safety of lumen reshaping after thoracic endovascular aortic repair (TEVAR) for Stanford B type aortic dissection (AD) at different intervention times. Methods: A retrospective analysis was conducted on the clinical data of 189 patients with Stanford type B aortic dissection treated with TEVAR at the Affiliated Hospital of Chengde Medical College from January 2016 to December 2020.Based on the time from onset to surgery, patients were divided into an early intervention group (≤14 days, n=127) and a delayed intervention group (>14 days, n=62).The diameters of the total aorta, true lumen and false lumen at different times and planes (S1 plane: at the bifurcation of the pulmonary artery; S2 plane: at the lower edge of the left atrium; S3 plane: at the upper edge of the celiac trunk) post-surgery were compared between the two groups, and the rate of change in diameters of true and false lumens across these planes was calculated. The patients were followed until December 1st, 2023, and the median follow-up time was 45(40, 49) months. The postoperative complications and survival of the two groups were compared. Results: The early intervention group comprised 86 men and 41 women, with an average age of (58.3±10.7) years. The delayed intervention group included 41 men and 21 women, with an average age of (58.5±9.2) years. Both groups had an operation success rate of 100%. Six months post-surgery, the early intervention group had an expansion rate of the true lumen diameter at planes S2 and S3 of 40.1%(25.5%, 56.1%) and 5.3%(-2.5%, 15.8%), respectively, which was superior to the delayed intervention group's 18.5%(10.6%, 39.8%) and 1.0%(-8.2%, 9.6%) (both P<0.05).The early intervention group had a reduction rate of the false lumen diameter at planes S1, S2, and S3 of -56.2%(-61.3%, -48.8%), -70.4%(-81.8%, -56.6%), and -5.4%(-17.4%, 0.1%), respectively, better than the delayed intervention group's -44.2%(-53.7%, -38.3%), -49.0%(-57.6%, -35.8%), and -3.1%(-6.7%, 1.8%) (all P<0.05).At plane S1, the true lumen diameter of patients in both groups showed an increasing trend over 36 months post-surgery, while the false lumen diameter showed a decreasing trend (both P<0.05).At plane S2, the true lumen diameter of patients in the early intervention group exhibited an increasing trend over 36 months post-surgery, and the false lumen diameter exhibited a decreasing trend (both P<0.05).At plane S3, the total aortic diameter of patients in the delayed intervention group showed a slight increasing trend over 36 months post-surgery (P<0.05).The overall survival time were 45.0 months (95%CI: 42.9-47.1) for patients in the early intervention group and 46.0 months (95%CI: 43.5-48.5) for those in the delayed intervention group, with no statistically significant difference observed (P>0.05).The incidence rates of complications such as aortic rupture, retrograde Type A dissection, new distal endograft dissection, endoleak, paraplegia, and others showed no statistically significant difference between the two groups (all P>0.05), with no cases of stent migration or deformation observed. Conclusion: Early intervention for Stanford type B aortic dissection provides a better aortic remodeling outcome than delayed intervention, with similar safety.

Redo partial aortic root remodelling in type A dissection with an aorto-left atrial fistula.

A 72-year-old male with a history of a triple-vessel coronary artery bypass graft years ago presented with a DeBakey type 2 aortic dissection and an aorto-left atrial fistula with patent bypass grafts (left internal mammary artery and saphenous vein grafts). He developed pulmonary oedema and required intubation. The right axillary artery was cannulated. After the ascending aorta and left internal mammary artery were clamped, the aorta was transected, leaving aortic tissue around two saphenous vein grafts as two separate patches. An entry tear was found adjacent to the proximal anastomosis of the saphenous vein graft to the posterior descending artery. A fistula, which was located between a false lumen in the non-coronary sinus and the dome of the left atrium, was primarily closed. Because the adventitia was thinned out in the non-coronary sinus due to aortic dissection, partial aortic root remodelling was performed with resuspension of the commissures. Hemiarch repair was performed under moderate hypothermia and unilateral antegrade cerebral perfusion. After systemic perfusion was resumed, the locations of the saphenous vein graft buttons were determined. The ascending graft was cross-clamped again; the saphenous vein graft to the obtuse marginal branch graft was reimplanted using the Carrel patch technique while a saphenous vein graft to the posterior descending artery required interposition of a 10-mm Dacron graft to accommodate the length.

Study on risk factors and treatment strategies of hypoxemia after acute type a aortic dissection surgery.

Acute type A aortic dissection is a life-threatening cardiovascular disease characterized by rapid onset and high mortality. Emergency surgery is the preferred and reliable treatment option. However, postoperative complications significantly impact patient prognosis. Hypoxemia, a common complication, poses challenges in clinical treatment, negatively affecting patient outcomes and increasing the risk of mortality. Therefore, it is crucial to study and comprehend the risk factors and treatment strategies for hypoxemia following acute type A aortic dissection to facilitate early intervention.

A Severe and Fatal Type A Aortic Dissection in an Adult with a Repaired Tetralogy of Fallot.

We report a case of a 44-year-old woman surgically treated for tetralogy of Fallot who experienced an acute and extensive Stanford A type aortic dissection despite the meticulous follow-up. While aortic dilatation is prevalent in individuals with repaired tetralogy of Fallot, aortic dissection represents a rare consequence, that when it appears, is progressive and usually detected during the check-up visits. In the case reported, the dissection was unexpected and severe, and the patient's clinical state worsened suddenly, leading to death after a few days. Constant awareness for aortic aneurysms is essential in the Fallot tetralogy population, nevertheless, several causes may contribute to the acute worsening of the clinical condition until the patient's death.

[Retrograde Stanford Type A Aortic Dissection of Marfan Syndrome Long After Thoracic Endovascular Aortic Repair:Report of a Case].

A 52-year-old woman with Marfan syndrome developed Stanford type B aortic dissection and was treated with thoracic endovascular aortic repair. However, 29 months later, she presented with retrograde Stanford type A aortic dissection. We successfully performed aortic arch replacement with the frozen elephant trunk technique and valve-sparing aortic root replacement. The advantages of the frozen elephant trunk technique are that the distal anastomosis can be created without stent-graft resection and the cardiac arrest time is shortened. Therefore, the frozen elephant trunk technique was considered valuable and safe in this potentially lethal situation.

Clinical Outcome of the Type A Acute Aortic Dissection Repair Using the "Tailored Stand-Up Collar" Technique.

PURPOSE: Achieving a secure anastomosis and complete hemostasis is essential for surgically treating type A acute aortic dissection (TAAAD). This study assessed the clinical feasibility of "tailored stand-up collar (TSC)" technique for constructing the distal stump. METHODS: We enrolled 68 patients who underwent ascending aortic repair for TAAAD. Patients were categorized according to the technique for distal stump construction: conventional (C) group using only a felt strip (32 cases); post-aortotomy (P) group, with a Hydrofit-felt strip attached after aortotomy (18 cases), and TSC group, where a Hydrofit-felt strip attached during cooling (18 cases). Pre-operative characteristics, procedural profiles, and post-operative outcomes were evaluated. RESULTS: The pre-operative characteristics were identical among the groups. The durations of cardiopulmonary bypass, hemostasis, and surgery were significantly shorter in the P and TSC groups. The duration of open distal in the TSC group (21 min) was significantly shorter than the other two groups. Post-operative additional procedures were not required for the TSC group and their post-operative hospital stay was significantly shorter (47.1% of patients were discharged within 2 weeks). CONCLUSION: The TSC technique would be practical because of its high reproducibility in terms of ease of use, shorter anastomotic time, and secure hemostasis.

Deep learning-based radiomics of computed tomography angiography to predict adverse events after initial endovascular repair for acute uncomplicated Stanford type B aortic dissection.

PURPOSE: This study aimed to construct a predictive model integrating deep learning-derived radiomic features from computed tomography angiography (CTA) and clinical biomarkers to forecast postoperative adverse events (AEs) in patients with acute uncomplicated Stanford type B aortic dissection (uTBAD) undergoing initial thoracic endovascular aortic repair (TEVAR). METHODS: We retrospectively evaluated 369 patients treated with TEVAR for acute uTBAD from January 2015 to December 2022. A three-dimensional (3D) deep convolutional neural network (CNN) automated radiomic feature extraction from CTA images. Feature selection, using Analysis of Variance (ANOVA) and the Least Absolute Shrinkage and Selection Operator (LASSO) algorithms, refined a radiomic score (Rad-Score). This score, alongside clinical parameters, was modelled via Extreme Gradient Boosting (XGBoost) analysis. Model calibration was assessed by calibration curves. RESULTS: The integration of the Rad-Score with clinical factors including albumin and C-reactive protein levels moderately enhanced predictive efficiency, exhibiting an area under the curve (AUC) of 1.000 (95%CI, 1.000-1.000) in the training cohort and 0.990 (95%CI, 0.966-1.000) in the internal validation cohort. In an independent validation cohort from another hospital, the combined model yielded an AUC of 0.985 (95%CI, 0.965-1.000), with an accuracy, precision, sensitivity, and specificity of 0.92, 0.92, 0.94, and 0.91, respectively. CONCLUSIONS: The synergistic application of deep learning-based radiomics from CTA and clinical indicators holds promise for anticipating AEs post-initial thoracic endovascular aortic repair in patients with acute uTBAD. The clinical utility of the constructed combined model, offering prognostic foresight during follow-up, has been substantiated.

The frozen elephant trunk: seeking a more definitive treatment for acute type A aortic dissection.

OBJECTIVES: Conventional treatment for type A aortic dissection includes replacement of the ascending aorta with an open distal anastomosis in the hemiarch position. The frozen elephant trunk (FET) is a hybrid technique that extends the repair to the descending thoracic aorta. The goal is to improve resolution of malperfusion syndrome and to induce positive aortic remodelling and reduce the need for reintervention on the downstream aorta. We aim to summarize the data on the short and long-term outcomes of this technique. METHODS: A thorough search of the literature was conducted isolating all articles dealing with aortic remodelling after the use of FET in case of type A acute aortic dissection. Keywords 'aortic dissection', 'frozen elephant trunk', 'aortic remodelling' and 'false lumen thrombosis' were used. Data for type B and chronic aortic dissections were excluded. RESULTS: FET use favourably influences aortic remodelling. The main advantages lie in the exclusion of distal entry tears in either the aortic arch or descending aorta thus restoring antegrade blood flow in the true lumen and inducing false lumen thrombosis. False lumen thrombosis is not only induced at the level of the stent deployment but also lower in the distal descending aorta. Moreover, it offers an adequate landing zone in the mid-descending aorta for second-stage endovascular or open surgical aortic repair, if needed. CONCLUSIONS: FET can be advantageous in the treatment of acute type A aortic dissection dealing with extended aortic pathology.

Inflammation in aortic surgery: postoperative evolution of biomarkers according pathologies and segments of the aorta.

OBJECTIVES: Aortic pathologies often present with elevated inflammatory biomarkers due to the nature of the disease. Open aortic surgery causes significant trauma to the body due to often mandatory ischemic periods, long cardiopulmonary bypass times and polytransfusion. We aim to determine postoperative trends on inflammation biomarkers for different aortic pathologies and type of surgery in different segments of the aorta. METHODS: Retrospective review of prospectively collected data of 193 consecutive patients who underwent aortic surgery in our centre between 2017 and 2021, grouped according to the type of aortic intervention: (1) Type A aortic dissection (AD) repair with ascending aorta/hemiarch replacement, (2) Aortic root replacement (ARR), (3) Aortic arch + Frozen elephant trunk (FET), (4) Descending thoracic aorta (DTA)/Thoraco-Abdominal aortic repair (TAA). Primary outcomes were daily values of white blood cells (WBC) and C-Reactive Protein (CRP) during the first 15 postoperative days. RESULTS: All groups had a similar inflammatory peak in the first 2-4 days (WBC 12-15 × 109 c/L). AD and FET groups show similar trends with WBC and CRP peaks on days 2 and 10. The ARR group didn't experience the 2nd peak as most patients were already discharged. DTA/TAA patients experienced a more prolonged inflammatory response, reaching a plateau by day 5-10. AD group shows the highest WBC levels and the DTA/TAAA group the highest CRP levels. CRP levels remain elevated (100-200 mg/L) in all groups after 15 postoperative days. CONCLUSIONS: Inflammatory biomarkers show different postoperative trends depending on the clinical presentation and complexity of the aortic procedure performed. Further understanding of the inflammatory response to different aortic pathologies and surgical procedures will permit reduction on the liberal use of antibiotics that this cohort of patients are usually exposed to. An earlier version of the data included in this manuscript was presented as Oral Abstract in the UK Society of Cardiothoracic Surgery Annual meeting in 2021.

Transcatheter aortic valve implantation for pure aortic insufficiency in a patient following David-type aortic valve-sparing root replacement after aortic dissection-A successful off-label procedure.

Transcatheter aortic valve implantation (TAVI) has traditionally been indicated for the treatment of aortic stenosis. However, in this case report, we describe a successful TAVI procedure in a 46-year-old male patient who had previously undergone David aortic valve-sparing aortic root replacement for type 1 aortic dissection. The patient presented with aortic valve insufficiency 4 years after the initial surgery and was subsequently treated with a 34 mm Medtronic CoreValve Evolut R prosthesis via TAVI. This case highlights the feasibility of TAVI as a viable treatment option for postoperative aortic valve insufficiency in patients with prior ascending aortic or aortic arch surgery.

Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms.

BACKGROUND: Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma. CASE PRESENTATION: A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery. CONCLUSION: Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.

Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections.

OBJECTIVES: The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. METHODS: Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. RESULTS: A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. CONCLUSIONS: Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.

[Long-term result of aortic root remodeling using the Florida sleeve technique in a patient with connective tissue dysplasia and aortic root aneurysm without aortic insufficiency]. / Otdalennyi rezul'tat ekzoprotezirovaniya kornya aorty po metodike Florida Sleeve u bol'nogo s soedinitel'notkannoi displaziei i anevrizmoi kornya aorty bez aortal'noi nedostatochnosti.

Aortic root remodeling using the Florida sleeve technique was proposed as a simpler alternative to classical reconstructive interventions in patients with aortic root aneurysm without aortic insufficiency. We present a 10-year result of valve-sparing surgical treatment using the Florida sleeve technique in a patient with connective tissue dysplasia and aortic root aneurysm.

A challenging case of emergency redo surgery for acute type A aortic dissecting aneurysm of ascending and aortic arch with frozen elephant trunk following aortic root replacement.

Redo ascending and aortic arch surgeries following previous cardiac or aortic surgery are associated with high risk of morbidity and mortality due to multiple factors included sternal re-entry injury, extensive aortic arch surgery, emergency aortic surgery, prolonged cardiopulmonary bypass duration, poor heart function, and patients with older age. Therefore, appropriate surgical strategies are important. We report a case of a 72-year-old gentleman with previous surgery of aortic root replacement who presented with acute Type A aortic dissecting aneurysm of ascending and aortic arch complicated with left hemothorax, which was successfully treated by emergency redo aortic surgery with frozen elephant trunk (FET) technique.

Experience with aortic arch inclusion technique using artificial blood vessel for type A aortic dissection: an application study.

BACKGROUND: This study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD). METHODS: We conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular "inclusion" between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The 'inclusion' total aortic arch replacement and stented elephant trunk (SET) surgery were performed. RESULTS: Four patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient's false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up. CONCLUSIONS: Incorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.

Mid-term results of a prospective study for aortic dissection with a gutter-plugging chimney stent graft.

OBJECTIVES: Our goal was to access early and mid-term outcomes of a gutter-plugging chimney stent graft for treatment of Stanford type B aortic dissections in the clinical trial Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology (PATENCY). METHODS: Between October 2018 and March 2022, patients with Stanford type B aortic dissections were treated with the Longuette chimney stent graft in 26 vascular centres. The efficiency and the incidence of adverse events over 12 months were investigated. RESULTS: A total of 150 patients were included. The technical success rate was 99.33% (149/150). The incidence of immediate postoperative endoleak was 5.33% (8/150, type I, n = 6; type II, n = 1; type IV, n = 1) neurologic complications (stroke or spinal cord ischaemia); the 30-day mortality was 0.67% (1/150) and 1.33% (2/150), respectively. During the follow-up period, the median follow-up time was 11.67 (5-16) months. The patent rate of the Longuette graft was 97.87%. Two patients with type I endoleak underwent reintervention. The follow-up rate of the incidence of retrograde A type aortic dissection was 0.67% (1/150). There was no paraplegia, left arm ischaemia or stent migration. CONCLUSIONS: For revascularization of the left subclavian artery, the Longuette chimney stent graft can provide an easily manipulated, safe and effective endovascular treatment. It should be considered a more efficient technique to prevent type Ia endoleak. Longer follow-up and a larger cohort are needed to validate these results. CLINICAL TRIAL REGISTRY NUMBER: NCT03767777.