Vascular Closure Devices For Axillary Artery Access: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. MATERIALS AND METHODS: MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient-level data. RESULTS: Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%-89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%-10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%-7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%-5.7%, I2=0%), infection <1% (95% CI: 0%-5.7%, I2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%-4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80-0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04-1.40, p=0.013). CONCLUSIONS: Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. CLINICAL IMPACT: Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.

Abdominal Aortic Endograft Implantation Immediately Induces Vascular Stiffness Gradients That May Promote Adverse Aortic Neck Dilatation: Results of A Porcine Ex Vivo Study.

PURPOSE: Endovascular aortic repair (EVAR) is the method of choice for most abdominal aortic aneurysm (AAA) patients requiring intervention. However, chronic aortic neck dilatation (AND) following EVAR progressively weakens the structural seal between vessel and endograft and compromises long-term results of the therapy. This experimental ex vivo study seeks to investigate mechanisms of AND. MATERIALS AND METHODS: Porcine abdominal aortas (n=20) were harvested from slaughterhouse pigs and connected to a mock circulation. A commercially available endograft was implanted (n=10) or aortas were left untreated as controls (n=10). Vascular circumferential strain was assessed via ultrasound in defined aortic segments as a parameter of aortic stiffness. Histology and aortic gene expression analysis were performed to investigate potential changes of aortic wall structure and molecular differences due to endograft implantation. RESULTS: We found that endograft implantation acutely induces a significant stiffness gradient directly at the interface between stented and unstented aortic segments under pulsatile pressure. Comparing stented aortas with unstented controls, we detected increased aortic expression levels of inflammatory cytokines (Il6 and Ccl2) and matrix metalloproteinases (Mmp2 and Mmp9) after 6 hours of pulsatile pressurization. This effect, however, was abolished when repeating the same experiment under 6 hours of static pressure. CONCLUSIONS: We identified endograft-induced aortic stiffness gradients as an early trigger of inflammatory aortic remodeling processes that might promote AND. These results highlight the importance of adequate endograft designs to minimize vascular stiffness gradients and forestall late complications, such as AND. CLINICAL IMPACT: AND may compromise the long-term results following endovascular aortic repair. However, the mechanisms behind the underlying detrimental aortic remodeling are still unclear. In this study we find that endograft-induced aortic stiffness gradients induce an inflammatory aortic remodeling response consistent with AND. This novel pathomechanistic insight may guide the design of new aortic endografts that minimize vascular stiffness gradients and forestall late complications such as AND.

Apoptotic Cell Death in Bicuspid-Aortic-Valve-Associated Aortopathy.

The bicuspid aortic valve (BAV) is the most common cardiovascular congenital abnormality and is frequently associated with proximal aortopathy. We analyzed the tissues of patients with bicuspid and tricuspid aortic valve (TAV) regarding the protein expression of the receptor for advanced glycation products (RAGE) and its ligands, the advanced glycation end products (AGE), as well as the S100 calcium-binding protein A6 (S100A6). Since S100A6 overexpression attenuates cardiomyocyte apoptosis, we investigated the diverse pathways of apoptosis and autophagic cell death in the human ascending aortic specimen of 57 and 49 patients with BAV and TAV morphology, respectively, to identify differences and explanations for the higher risk of patients with BAV for severe cardiovascular diseases. We found significantly increased levels of RAGE, AGE and S100A6 in the aortic tissue of bicuspid patients which may promote apoptosis via the upregulation of caspase-3 activity. Although increased caspase-3 activity was not detected in BAV patients, increased protein expression of the 48 kDa fragment of vimentin was detected. mTOR as a downstream protein of Akt was significantly higher in patients with BAV, whereas Bcl-2 was increased in patients with TAV, assuming a better protection against apoptosis. The autophagy-related proteins p62 and ERK1/2 were increased in patients with BAV, assuming that cells in bicuspid tissue are more likely to undergo apoptotic cell death leading to changes in the wall and finally to aortopathies. We provide first-hand evidence of increased apoptotic cell death in the aortic tissue of BAV patients which may thus provide an explanation for the increased risk of structural aortic wall deficiency possibly underlying aortic aneurysm formation or acute dissection.

Effects of fluids vs. vasopressors on spinal cord microperfusion in hemorrhagic shock induced ischemia/reperfusion.

OBJECTIVE: Spinal cord injury induced by ischemia/reperfusion is a devastating complication of aortic repair. Despite developments for prevention and treatment of spinal cord injury, incidence is still considerably high majorly impacting patient outcome. Microcirculation is paramount for tissue perfusion and oxygen supply and often dissociated from macrohemodynamic parameters used to guide resuscitation. Effects of fluids vs. vasopressors in the setting of hemodynamic resuscitation on spinal cord microperfusion are unknown. Aim of this study was to compare the effects of vasopressor and fluid resuscitation on spinal cord microperfusion in a translational acute pig model of hemorrhagic shock induced ischemia/reperfusion injury. METHODS: We designed this study as prospective randomized explorative large animal study. We induced hemorrhagic shock in 20 pigs as a model of global ischemia/reperfusion injury. We randomized animals to receive either fluid or vasopressor resuscitation. We measured spinal cord microperfusion using fluorescent microspheres as well as laser-Doppler probes. We monitored and analyzed macrohemodynamic parameters and cerebrospinal fluid pressure. RESULTS: Spinal cord microperfusion decreased following hemorrhagic shock induced ischemia/reperfusion injury. Both fluids and vasopressors sufficiently restored spinal cord microperfusion. There were no important changes between groups (percentage changes compared to baseline: fluids 14.0 (0.31-27.6) vs. vasopressors 24.3 (8.12-40.4), p = .340). However, cerebrospinal fluid pressure was higher in animals receiving fluid resuscitation (percentage changes compared to baseline: fluids 27.7 (12.6-42.8) vs. vasopressors -5.56 ((-19.8)-8.72), p = .003). Microcirculatory resuscitation was in line with improvements of macrohemodynamic parameters. CONCLUSIONS: Both, fluids and vasopressors, equally restored spinal cord microperfusion in a porcine acute model of hemorrhagic shock induced ischemia/reperfusion injury. However, significant differences in cerebrospinal fluid pressure following resuscitation were present. Future studies should evaluate these effects in perfusion disruption induced ischemia/reperfusion conditions of microcirculatory deterioration.

Comparison of periodontal parameters between patients with ischemic and dilative cardiomyopathy.

BACKGROUND: This cross-sectional study aimed in the comparison of periodontal parameters, number of remaining teeth and oral behaviour between patients with ischemic- (ICM) and non-ischemic dilative cardiomyopathy (DCM). METHODS: Patients with HF from the Department for Cardiac Surgery at the Heart Center Leipzig were included. The two groups (ICM and DCM) were composed by matching according to age, gender and smoking habits. All participants received a comprehensive periodontal examination, including a periodontal probing on six measurement points of each tooth. RESULTS: A total of 226 patients (n = 113 each group) was included. Patients in DCM group used interdental cleaning significantly more often than ICM (23.9% vs. 12.5%, p = 0.04). The majority of patients in both groups (ICM: 83.6%, DCM: 84.6%, p = 0.23) were diagnosed with stage III-IV periodontitis. Periodontal parameters were comparable between groups (p > 0.05). Variance analysis revealed no influence of the group (ICM vs. DCM) on the number of remaining teeth (p = 0.16), periodontitis stage (p = 0.27) or the periodontal inflamed surface area (p = 0.62). CONCLUSIONS: Patients with severe HF show high periodontal burden, without any differences between ICM and DCM group. Therefore, increased attention should be payed to periodontal health of patients with severe heart disease, irrespective of their underlying disease.

Management of aortic root in type A dissection: Bentall approach.

BACKGROUND: We analyzed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD). METHODS: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n = 314) were analyzed. Mechanical composite conduits were used in 45%, and biological ones using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%. RESULTS: Concomitant arch procedures consisted of hemiarch in 56% and total arch/elephant trunk in 34%, while concomitant coronary artery surgery was required in 20%. The average cross-clamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 min, respectively, while the average circulatory arrest times were 29 ± 17 min. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). The in-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6), and sepsis (n = 2). The independent predictors of in-hospital mortality were critical preoperative state (odds ratio [OR], 5.6; p < .001), coronary malperfusion (OR, 3.6; p = .002), coronary artery disease (OR, 2.6; p = .033), and prior cerebrovascular accident (OR, 5.6; p = .002). CONCLUSIONS: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high-risk ATAAD patients presenting.

Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery.

OBJECTIVES: To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes. METHODS: In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively. RESULTS: Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X2 = 17.9; p < 0.001; AUC, 0.83 vs. 0.73). CONCLUSION: The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP. KEY POINTS: • Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.

Postoperative Changes in the Distal Residual Aorta after Surgery for Acute Type A Aortic Dissection: Impact of False Lumen Patency and Size of Descending Aorta.

Objective In the present study, we retrospectively identified and analyzed the factors that influenced progressive dilatation of the residual distal aorta after surgical repair for acute type A aortic dissection (acute type A). Methods A total of 477 patients underwent surgical repair for acute type A aortic dissection between 1995 and 2012. Postoperative and follow-up computed tomography (CT) scans of the descending aorta were available in 105 patients. We analyzed the maximum aortic diameter, total luminal area, and true luminal area of the descending thoracic and abdominal aorta. Results The mean follow-up time was 4.5 ± 3 years, and the mean time interval between CT scan investigations was 2.0 ± 2.3 years. A residual dissection membrane was observed in 80 (76%) patients, with presence of a patent false lumen (FL) in 52 patients (50%) and a thrombosed FL in 28 patients (26%).Progression of aortic disease with an increase in aortic diameter greater than 10 mm was observed in 14.3% (n = 15) of patients during follow-up. The independent predictors that influenced progressive dilation of the descending aorta by 10 mm or more were postoperative descending aortic diameter greater than 40 mm (p = 0.006; odds ratio [OR], 5.6; 95% confidence interval [CI], 1.6-19) and postoperative patent FL (p = 0.002; OR, 8.5; 95% CI, 2.2-32.3).The unadjusted 1- and 5-year freedom from reoperation was 96.9 ± 2 and 80.1 ± 5%, respectively. Marfan syndrome (p = 0.006; OR, 5.2; 95% CI, 1.6-16.9) and postoperative descending aortic diameter greater than 40 mm (p = 0.07; OR, 4.1; 95% CI, 1.4-11.6) were independent predictors of aorta-related reoperations.The mean survival at 1, 5, and 8 years was 90.7 ± 3, 82.5 ± 4, and 70 ± 6%, respectively. Previous cardiac surgery was independent predictor of midterm survival (hazard ratio, 3.6; 95% CI, 1.03-2.8; p = 0.04). Conclusions A regular follow-up CT scan is mandatory to assess progressive dilatation of the distal residual aortic arch, descending thoracic, and abdominal aorta after surgical repair of acute type A dissection, particularly in patients with a patent FL, descending aortic diameter greater than 40 mm, and/or Marfan syndrome.

Gender-Based Long-Term Surgical Outcome in Patients with Active Infective Aortic Valve Endocarditis.

BACKGROUND The aim of this observational, single-center study was to evaluate the impact of gender on surgical outcome in patients with active infective endocarditis (AIE) of the aortic valve. MATERIAL AND METHODS Between October 1994 and January 2011, 755 patients (558 men and 297 women) underwent surgery for AIE at the Leipzig Heart Center, Germany, according to the modified Duke criteria. Data were collected before surgery and as the study was ongoing. Gender influence on survival was evaluated (Kaplan-Meier curves). Cox proportional models were used to evaluate gender differences in relation to early mortality (within 30 days) and late mortality (up to 10 years). RESULTS The early mortality rate was 15.0% among men and 23.0% among women, which was statistically significant different (p=0.01). In male patients, variables associated with overall mortality were age (HR 1.63, 95% CI 1.43-1.86; p<0.001), insulin-dependent diabetes mellitus (HR 2.02, 95% CI 1.48-2.75; p<0.001), preoperative low ejection fraction (OR 0.99, 95% CI 0.98-0.99; p=0.002), previous cardiac surgery (OR 1.62, 95% CI 1.22-2.13; p=0.001), preoperative ventilation (OR 1.77, 95% CI 1.14-2.75; p=0.012), preoperative dialysis (OR 1.89, 95% CI 1.20-2.98; p=0.006), NYHA Class IV (OR 1.56, 95% CI 1.12-2.15; p=0.008), and involvement of multiple valves (OR 1.65, 95% CI 1.24-2.19; p=0.001) had a statistically significant influence on the late mortality. Focus identification (OR 1.75, 95% CI 1.08-2.77; p=0.023), involvement of multiple valves (OR 1.52, 95% CI 1.02-2.26; p=0.040), preoperative dialysis (OR 3.65, 95% CI 1.96-6.77; p<0.001), and age (OR 1.53, 95% CI 1.28-1.82; p<0.004) were predictive risk factors for late mortality in women with AIE (OR 3.6, 95% CI 1.5-8.4; p<0.004). CONCLUSIONS This study demonstrated distinct gender-based differences in risk of mortality in patients with AIE (who were undergoing surgical treatment) with different early and long-term outcomes.

Indirect Neuromonitoring of the Spinal Cord by Near-Infrared Spectroscopy of the Paraspinous Thoracic and Lumbar Muscles in Aortic Surgery.

Paraplegia remains the most devastating complication of open and endovascular thoracic/thoracoabdominal aortic aneurysm (TAA/A) repair. However, the assessment of currently available neuromonitoring modalities remains challenging and difficult to interpret. Near-infrared spectroscopy (NIRS) has been introduced as a strategy for noninvasive, real-time monitoring of the paraspinous collateral network (CN) to detect potential spinal cord ischemia at our institution. Prior to TAA/A repair, a cerebrospinal fluid catheter is placed and four NIRS optodes are bilaterally positioned on the patient's back to transcutaneously monitor regional muscle oxygenation at the thoracic and lumbar levels. Indirect surveillance of the spinal cord by NIRS seems to be a tempting option with increasing evidence supporting the CN concept.

Longevity after aortic root replacement: is the mechanically valved conduit really the gold standard for quinquagenarians?

BACKGROUND: The choice of the best conduit for root/ascending disease and its impact on longevity remain controversial in quinquagenarians. METHODS AND RESULTS: A total of 205 patients (men=155) between 50 and 60 years (mean, 55.7 ± 2.9 years) received either a stentless porcine xenoroot (n=78) or a mechanically valved composite prosthesis (n=127) between February 1998 and July 2011. Of these, 166 patients underwent root replacement for aneurysmal disease (porcine: 39% [n=65]; mechanical: 61% [n=101]; P=0.5), 25 for acute type A aortic dissection (porcine: 32% [n=8]; mechanical: 68% [n=17]; P=0.51), and 14 for endocarditis/iatrogenic injury involving the aortic root (6.4% [n=5] versus 7.1% [n=9]; P=1.0). The predominant aortic valve pathology was stenosis in 19% (n=38), regurgitation in 50% (n=102), combined valvular dysfunction in 26% (n=54), and normal aortic valve function in 5% (n=11). Concomitant procedures included coronary artery bypass grafting (13%), mitral valve repair (7%), and partial/complete arch replacement (12%/4%), with no significant differences between porcine and mechanical root replacement. Overall hospital mortality was 7.3%, with no difference between the 2 types of valve prostheses (7.7% for porcine and 7.1% for mechanical root replacement; P=1.0). Follow-up averaged 5.4 ± 3.7 years (1096 patient-years) and was 100% complete. Freedom from aorta-related reoperation at 12 years was not statistically different between the groups (porcine: 94.9% versus mechanical: 96.1%; P=0.73). Survival was equivalent between both groups, with a 5-year survival of 86 ± 3% (porcine: 88 ± 4%; mechanical: 85 ± 3%; P=0.96) and a 10-year survival of 76% (porcine: 80 ± 7%; mechanical: 75 ± 5%; P=0.84). The linearized mortality rate was 3.1%/patient-year (porcine: 2.9%/patient-year; mechanical: 3.2%/patient-year). CONCLUSIONS: In quinquagenerians, long-term survival after stentless porcine xenograft aortic root replacement is equivalent to that after a mechanical Bentall procedure. These results bring into question the predominance of mechanical composite conduits for root replacement in quinquagenerians, particularly in the current era of transcatheter valve-in-valve procedures for structural valve deterioration.

Extracorporeal membrane oxygenation: experience in acute graft failure after heart transplantation.

INTRODUCTION: Acute graft failure is the leading cause of early mortality after heart transplantation (HTx). Extracorporeal membrane oxygenation (ECMO) is an efficient therapeutic option to treat various pathologies, unburden the left and right ventricle, and allow for functional recovery of the transplanted heart. We reviewed our ECMO experience and outcomes in HTx patients. METHODS: Retrospectively, we analyzed all patients who received an orthotopic HTx (n = 298) in our department over a 15-yr period (1997 through 2011) to assess the incidence of post-HTx ECMO implantation, perioperative complications, early and one-yr mortality as well as causes of death. RESULTS: ECMO therapy was utilized to treat graft failure in 28 patients (10.6%) with a mean duration of ECMO support of 4.2 d (six h to 9.4 d). Multivariate analysis revealed as independent predictors for mortality low cardiac output (p = 0.028; odds ratio (OR) = 11.3) and stroke (p = 0.008; OR = 19.7). Cumulative survival rates were 46.4 ± 9.4% within 30 d and 25.0 ± 8.2% at one yr. Causes of death were multiorgan failure (n = 9), sepsis (n = 9), lung failure (n = 2), and intracerebral bleeding (n = 2). ECMO was implanted due to primary graft failure (PGF, n = 16), sepsis (n = 4), and right heart failure (n = 6). CONCLUSION: Temporary ECMO support for postoperative output failure is an acceptable option as a last resort for otherwise doomed patients with fatal graft failure after HTx. The small fraction of patients surviving appear to have a decent long-term prognosis.

Frequent protein kinase A regulatory subunit A1 mutations but no GNAS mutations as potential driver in sporadic cardiac myxomas.

PURPOSE: Cardiac myxomas (CMs) are the second most common benign primary cardiac tumors, mainly originating within the left atrium. Approximately 5% of CM cases are associated with Carney Complex (CNC), an autosomal dominant multiple neoplasia syndrome often caused by germline mutations in the protein kinase A regulatory subunit 1A (PRKAR1A). Data concerning PRKAR1A alterations in sporadic myxomas are variable and sparse, with PRKAR1A mutations reported to range from 0% to 87%. Therefore, we investigated the frequency of PRKAR1A mutations in sporadic CM using next-generation sequencing (NGS). Additionally, we explored mutations in the catalytic domain of the Protein Kinase A complex (PRKACA) and examined the presence of GNAS mutations as another potential driver. METHODS AND RESULTS: This study retrospectively collected histological and clinical data from 27 patients with CM. First, we ruled out the possibility of underlying CNC through clinical evaluations and standardized interviews for each patient. Second, we performed PRKAR1A immunohistochemistry (IHC) analysis and graded the reactivity of myxoma cells semi-quantitatively. NGS was then applied to analyze the coding regions of PRKAR1A, PRKACA, and GNAS in all 27 cases. Of the 27 sporadic CM cases, 13 (48%) harbored mutations in PRKAR1A. Among these 13 mutant cases, six displayed more than one mutation in PRKAR1A. Most of the identified mutations resulted in premature stop codons or affected splicing. In PRKAR1A mutant CM cases, the loss of PRKAR1A protein expression was significantly more common. In two cases with missense mutations, protein expression remained preserved. Furthermore, a single mutation was detected in the catalytic domain of the protein kinase A complex, while no GNAS mutations were found. CONCLUSION: We identified a relatively high frequency of PRKAR1A mutations in sporadic CM. These PRKAR1A mutations may also represent an important oncogenic mechanism in sporadic myxomas, as already known in CM cases associated with CNC.

Risk factors for long-term mortality after acute aortic dissection-results of the German registry for acute aortic dissection type a long-term follow-up.

OBJECTIVES: Several short-term analyses from German Registry for Acute Aortic Dissection Type A (GERAADA) have been published. This study investigated whether short-term risk factors are transferable to the long-term prognosis of patients. METHODS: Thirty-three centres with 2686 patients participated in the long-term follow-up. A total of 1164 patients died, 1063 survived and 459 were lost to follow-up during the follow-up timeframe (mean duration: 10.2 years). Long-term mortality of the cohort was compared with an age-stratified, German population. RESULTS: One, 5 and 10 years after initial surgery, the survival of the GERAADA patient cohort was 71.4%, 63.4% and 51%, respectively. Without the early deaths (90-day mortality 25.4%), survival was calculated after 1, 5 and 10 years: 95.6%, 83.5% and 68.3%. Higher age, longer extracorporeal circulation time, shorter perioperative ventilation time and postoperative neurologic deficits were predictive of long-term prognosis. In an age-divided landmark analysis, the mortality of aortic dissection surgery survivors was found to be similar to that of the general German population. If patients are sorted in risk groups according to the GERAADA score, long-term survival differs between the risk groups. CONCLUSIONS: If patients have survived an acute postoperative period of 90 days, life expectancy comparable to that of the general German population can be assumed in lower- and medium-risk patients. Whether the GERAADA score can provide valuable insights into the long-term prognosis of patients undergoing surgery for acute aortic dissection type A is still unclear.

Minimally invasive staged segmental artery coil embolization (MIS2ACE) for spinal cord protection.

Minimally invasive staged segmental artery coil embolization (MIS2ACE) is an emerging technology for priming of the paraspinous collateral network prior to open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Its safety and efficacy have been previously proven in various experimental settings and confirmed in numerous multicentric pilot studies for open and endovascular repair. MIS2ACE is safe and has the potential to decisively reduce the risk of postoperative paraplegia, the most devastating complication of open and endovascular TAAA repair, still affecting up to 20% of patients. Up to now, MIS2ACE has been clinically implemented with excellent results, and is currently being investigated in the international, multicenter, randomized controlled trial PAPAartis, funded by the German Research foundation, and the European Union. MIS2ACE can be performed under local anesthesia, enabling continuous monitoring of neurological function, and in case of clinical signs of imminent ischemia, preemptive interruption of the procedure. A thorough evaluation of preoperative computed tomography (CT) imaging for identification of open and accessible segmental arteries (SAs) is critical. Segmental artery occlusion can be achieved with either micro coils, or vascular plugs. A maximum number of seven SAs is currently recommended to be occluded in the same session, and a minimum interval of 5 days should be awaited between either two MIS2ACE sessions or between MIS2ACE and the final repair. Adjuvant side-effects of MIS2ACE are the reduction in segmental back-bleeding during open repair leading to harmful steal phenomenon and the reduction of the incidence of type II endoleaks in endovascular repair. Current contraindications for MIS2ACE are emergency cases, hostile anatomy, and a shaggy aorta. Other neuroprotective adjuncts such as cerebrospinal fluid (CSF) drainage, permissive hypertension, motor-evoked potentials (MEP)/somato-sensory evoked potentials (SSEP) and monitoring of paraspinous muscle oxygenation by near-infrared spectroscopy should also be applied independent of prior MIS2ACE procedure.

Rationale of the PAPAartis trial.

Surgical and interventional repair of thoracoabdominal aortic aneurysms improve survival significantly compared to the natural history of the disease. However, both strategies are associated with a substantial risk of spinal cord ischemia, which has been reported to occur-even in contemporary series by expert centers-in up to 12% of patients, depending on the extent of the disease. Following improved neurological outcomes after staged approaches in extensive clinical and long-term large animal studies, and the description of the "collateral network", the concept of "Minimally Invasive Staged Segmental Artery Coil Embolization" (MIS2ACE) was introduced by Etz et al. This concept of priming the collateral network in order to improve spinal cord blood supply showed promising experimental and early clinical outcomes, and consequently led to the initiation of the randomized controlled multicenter PAPAartis trial (Paraplegia Prevention in Aortic Aneurysm Repair by Thoracoabdominal Staging). This Keynote Lecture describes the background and rationale for this trial and gives an update on the current status.

Near-Infrared Spectroscopy for Spinal Cord Monitoring-A Roadmap to Translational Research in Aortic Medicine.

Extensive aortic aneurysms represent a unique challenge necessitating interdisciplinary efforts for safe and effective treatment. Despite various adjunctive neuroprotective strategies, ischemic spinal cord injury remains a devastating complication. This article describes the implementation of collateral network near-infrared spectroscopy as the first noninvasive spinal cord monitoring modality in the setting of extensive open and endovascular aortic repair, from early conceptualization to clinical utilization. Potential capabilities and remaining uncertainties based on current evidence are outlined and discussed.

Aortic arch redo surgery: early and mid-term outcomes in 120 patients.

OBJECTIVES: The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo arch surgery. METHODS: Between January 1996 and December 2022, 120 patients underwent aortic arch reoperations after primary proximal aortic surgery. We retrospectively analysed perioperative data, as well as early and mid-term outcomes in these patients. RESULTS: Indications for arch reintervention included new aortic aneurysm in 34 patients (28.3%), expanding post-dissection aneurysm in 36 (30.0%), aortic graft infection in 39 (32.5%) and new aortic dissection in 9 cases. Two patients underwent reoperation due to iatrogenic complications. Thirty-one patients (25.8%) had concomitant endocarditis. In-hospital and 30-day mortality rates were 11.7% and 15.0%, respectively. Stroke was observed in 11 (9.2%) and paraplegia in 1 patient. Prior surgery due to aneurysm [odds ratio 4.5; 95% confidence interval (CI) 1.4-17.3] and critical preoperative state (odds ratio 5.9; 95% CI 1.5-23.7) were independent predictors of 30-day mortality. Overall 1- and 5-year survival was 65.8 ± 8.8% and 51.2 ± 10.6%, respectively. Diabetes mellitus (hazard ratio 2.4; 95% CI 1.0-5.1) and peripheral arterial disease (hazard ratio 4.7; 95% CI 1.1-14.3) were independent predictors of late death. The cumulative incidence of reoperations was 12.6% (95% CI 6.7-20.4%) at 5 years. Accounting for mortality as a competing event, connective tissue disorders (subdistribution hazard ratio 4.5; 95% CI 1.6-15.7) and interval between primary and redo surgery (subdistribution hazard ratio 1.04; 95% CI 1.02-1.06) were independent predictors of reoperations after redo arch surgery. CONCLUSIONS: Despite being technically demanding, aortic arch reoperations are feasible and can be performed with acceptable results.

Sex-Related Differences After Proximal Aortic Surgery: Outcome Analysis of 1773 Consecutive Patients.

BACKGROUND: Guidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta. METHODS: A total of 1773 patients underwent nonemergency surgical procedures on the aortic valve (AV) and proximal aorta at our institution between 2000 and 2018. Of these, 772 patients (21.8% women) received a Bentall procedure, 349 (20.3% women) had AV-sparing root replacement, and 652 (31.1% women) underwent AV and supracommissural ascending aorta replacement. Primary outcomes were in-hospital mortality and midterm survival. RESULTS: When assessing sex-related differences within the entire group of patients that received an operation on the proximal aorta, women were found to be older, had a lower body mass index, and were smokers less often. Despite shorter procedural times, median ventilation times and intensive care unit length of stay were longer in women. In-house mortality was also higher in women (3.6% vs 0.9%, P < .001). Multivariable logistic regression revealed age (odds ratio [OR], 1.8; 95% CI, 1.4-2.3 per 5 years added; P < .001), female sex (OR, 2.6; 95% CI, 1.2-5.8; P = .02), and urgent surgery (OR, 3.1; 95% CI, 1.2-7.3; P = .01) as independent risk factors for in-house death. Midterm survival was lower for women in the entire cohort (P = .02) and particularly within the Bentall subgroup (P = .004). CONCLUSIONS: Female sex is an independent risk factor for operative mortality in patients undergoing proximal aortic surgery but is currently not addressed in guidelines. More research should focus on etiology and prevention of these worse outcomes in female patients.

Is perioperative fast-track management the future of proximal aortic repair?

OBJECTIVES: The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS: We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS: Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS: In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety.