Mid-Term Outcomes of Late Open Conversion with Endograft Preservation for Sac Enlargement after Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: Late open conversion has sometimes been required for sac enlargement after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. Though the open repair with endograft preservation is considered less invasive compared to endograft removal, the mid-term outcomes are still unclear. The aim of this study is to evaluate the mid-term outcomes of late open conversion with endograft preservation after EVAR. METHODS: We reviewed patients who underwent late open conversion with endograft preservation for sac enlargement or rupture in our institution from May 2007 to December 2020. The open repair mainly consisted of ligation of lumber arteries or the median sacral artery and sacotomy. We additionally performed wrapping of plicated aneurysm with equine pericardium as much as possible. Patients were followed-up by a computed tomography scan and duplex ultrasound 1 and 6 months postoperatively, and each year thereafter. RESULTS: Of the 1,087 patients who underwent EVAR, 23 patients with a mean age of 81.5 years were included in this study. The mean duration post-EVAR was 35.6 months. Sac wrapping with equine pericardium was performed in 14 patients (60.9%). We additionally performed wrapping of the endograft junction by a Dacron knitted fabric in 1 case with type III endoleak and aortic neck banding in 4 cases with type I endoleak. The 30-day mortality was 0% and the rate of major complications was 4%. All-cause mortality was 21.7% which included 1 aneurysm-related death during a mean follow-up of 38.5 months. Sac re-enlargement was observed in 4 patients without the wrapping method. At 3 years, the aneurysmal diameter in the nonwrapping group significantly increased, compared with the wrapping group (P = 0.011). CONCLUSIONS: Late open conversion with endograft preservation is a feasible treatment; however, at times re-enlargement of the sac aneurysm occurs. The wrapping method has the potential to prevent sac re-enlargement after open conversion.

Clinically Optimal Neuropsychological Tests for Postoperative Cognitive Dysfunction in Heart Valve Surgeries.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is widely recognized and reported, but the lack of a uniform definition makes it difficult to evaluate its clinical impact. The aim of this study is to establish the optimal neuropsychological tests and definition of POCD relevant to clinical outcomes in heart valve surgeries.Methods and Results: Between June 2015 and December 2019, 315 patients undergoing elective heart valve surgeries (age ≥65 years) were enrolled. The Mini-Mental Status Examination, Montreal Cognitive Assessment (MoCA), and the Trail Making Test A and B were performed to evaluate cognitive function. Clinical endpoints were defined as readmission and death. The postoperative readmission and death rate were 17% and 3% (54/315 and 8/315; follow-up 266-1,889 days). By multivariable Cox hazard analysis, Short Physical Performance Battery (adjusted hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.49-0.98, P=0.001), MoCA change rate (adjusted HR: 0.64, 95% CI: 0.01-1.22, P=0.024), and intensive care unit stay (adjusted HR: 0.55%, 95% CI: 0.99-1.12, P=0.054) were detected as independent risk factors for combined events. The cutoff value was -12% in the change rate of MoCA. CONCLUSIONS: MoCA was the only neuropsychological test that predicted the clinical impact on complex events and has the potential to define POCD.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

BACKGROUND AND AIM: After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. METHODS: Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. RESULTS: Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients' age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038-0.068] vs. 0.041 mmHg/ml, [0.031-0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = -0.37, p < .001). CONCLUSIONS: Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes.

BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Clinical impact of the repair technique for posterior mitral leaflet prolapse: Resect or respect?

BACKGROUND AND AIM: Leaflet resection and chordal reconstruction are established repair techniques for posterior mitral valve (MV) prolapse. This study aimed to compare the clinical results of the resect and respect approaches, with a particular focus on MV hemodynamics. METHODS: Overall, 291 patients who underwent elective MV repair for isolated posterior leaflet prolapse between 2012 and 2020 were enrolled. Patients who underwent leaflet resection alone were classified as the "resection" group (n = 166), while patients who underwent neochordal replacement with/without limited leaflet resection were classified as the "respect" group (n = 125). Early postoperative MV hemodynamics and midterm repair durability were compared between the groups. RESULTS: The annuloplasty ring size was significantly larger in the respect group than in the resection group (31.0 ± 2.1 vs. 30.4 ± 2.0 mm, p = .028). The respect group showed significantly lower mean MV gradient (2.6 ± 1.1 vs. 3.0 ± 1.4 mmHg, p = .03) and larger effective orifice area (EOA) (1.86 ± 0.48 vs. 1.66 ± 0.47 cm2 , p < .001) than the resection group. Multivariable analysis identified the respect approach, younger age, female sex, larger ring size, and partial band as independent determinants of larger EOA. The rate of freedom from moderate or greater recurrent mitral regurgitation 5 years postoperatively was 90.9% in both groups. CONCLUSIONS: The respect approach allowed for a lower MV gradient and a larger EOA than the resection approach, which is possibly due to the capability of implanting a larger annuloplasty ring.

Thoracic endovascular repair for disseminated intravascular coagulation associated with chronic type B aortic dissection.

OBJECTIVES: Chronic disseminated intravascular coagulation is a rare complication of aortic dissection, and its optimal treatment remains controversial. METHODS: We present a 78-year-old man with repeated hemorrhagic events by disseminated intravascular coagulation due to chronic aortic dissection treated by thoracic endovascular aortic repair. RESULTS: Computed tomography angiography at three months revealed a completely thrombosed false lumen from the distal aortic arch to the descending aorta at the celiac artery level. Platelets and D-dimer levels remained stable, and the patient was doing well without hemorrhagic complications. CONCLUSIONS: Endovascular repair was effective for disseminated intravascular coagulation due to chronic type B aortic dissection.

Stepwise mitral valve repair for Barlow's disease via a minimally invasive approach.

BACKGROUND AND AIM: Mitral regurgitation (MR) in Barlow's disease is complicated because of its mixed pathophysiology, leaflet billowing with or without organic prolapse, and abnormal annular dynamics that cause functional prolapse. Complex repair techniques, including aggressive leaflet resection and implantation of multiple artificial chordae, are conventionally performed; nevertheless, these are technically demanding, especially when performed using a minimally invasive approach. We aimed to standardize the repair technique for Barlow's disease and developed stepwise repair techniques. METHODS: Of 292 patients who underwent isolated minimally invasive mitral valve repair for MR, 29 patients (seven females, age 49 ± 10 years) were found to have Barlow's disease. Our repair technique consists of the following three steps: (a) stabilization of the mitral annulus by placing annuloplasty ring sutures; (b) distinction between organic and functional prolapse by a saline injection test; and (c) targeted repair for organic prolapse by leaflet resection or chordal replacement. RESULTS: Surgical techniques included leaflet resection in 22 patients, chordal replacement in 19 patients, and ring annuloplasty only in one patient. These procedures were applied to the anterior leaflet in one, posterior leaflet in eight, and both leaflets in 19 patients. The median annuloplasty ring size was 34 mm. The repair success rate was 100%. No patients developed moderate or greater MR during a mean follow-up period of 36 ± 21 months. CONCLUSIONS: A stepwise repair strategy facilitates mitral valve repair in patients with Barlow's disease and provides excellent outcomes even via a minimally invasive approach.

Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis.

Because of concerns about the high risk of perioperative complications, the feasibility of minimally invasive aortic valve replacement (MIAVR) for elderly patients remains controversial. Here, we review our results of MIAVR in octogenarians with aortic valve stenosis (AS). Between October 2012 and December 2017, 110 patients with AS underwent MIAVR via a right anterolateral mini-thoracotomy; 41 patients were octogenarian (Group O). The perioperative outcomes of these patients were compared with those of the 69 patients who were less than 80 years of age (Group Y). A preoperative contrast-enhanced computed tomography (CT) scan was performed in all patients to guide the patient selection and aid the decision regarding cannulation sites. Among all cases of isolated aortic valve replacement, MIAVR accounted for 47% cases during this study period. The mean age of Group O was 83.6 ± 2.9 years, with a maximum age of 89. In Group O, there were no in-hospital deaths or morbidity, including stroke. The rate of blood transfusion was significantly higher in Group O than in Group Y (P = 0.01). However, there was no significant difference in ventilation time, the length of intensive care unit stay, the length of hospital stay, or in the rates of cumulative survival and freedom from valve-related complications. With careful patient selection and a perfusion strategy based on preoperative CT scan, equivalent outcomes of MIAVR were even achieved in octogenarians.

Giant aneurysm of the right atrial appendage repaired by minimally invasive approach.

A 59-year-old female patient who was diagnosed with giant right atrial appendage aneurysm (75 × 87 mm) underwent minimally invasive repair via right mini-thoracotomy. The aneurysm was completely excluded by linear method under beating heart without cardiac arrest. The postoperative recovery was uneventful and she was discharged home without symptoms 16 days after surgery.

Mitral annuloplasty for atrial functional mitral regurgitation in patients with chronic atrial fibrillation.

BACKGROUND: Surgical ring annuloplasty is generally performed in patients with symptomatic atrial functional mitral regurgitation (MR) caused by long-standing atrial fibrillation (AF). However, its clinical results have not been well reported. METHODS: Twenty consecutive patients with atrial functional MR (mean age of 68 ± 9 years) and a left ventricular (LV) ejection fraction (EF) greater than 50% underwent mitral annuloplasty. Concomitant procedures included tricuspid valve surgery in 16 patients, AF ablation in 13 patients, and coronary artery bypass grafting in 2 patients. We reviewed the clinical outcomes of those patients and investigated the specific preoperative echocardiographic findings related to MR recurrence. RESULTS: At discharge, the mean left atrial (LA) volume index and mean tricuspid regurgitation peak gradient had significantly decreased from 94 ± 59 mL/m 2 to 58 ± 30 mL/m 2 and from 34 ± 11mm Hg to 23 ± 5mm Hg, respectively. During the follow-up period of 28 ± 17 months, the New York Heart Association functional class significantly improved from 2.3 ± 0.6 to 1.3 ± 0.6. Four patients developed recurrent MR, and of those, two required reoperation. Those with recurrent MR had a significantly larger preoperative LV dimension than those without recurrent MR. Preoperative three-dimensional transesophageal echocardiography was performed in 12 patients, revealing a greater degree of leaflet tethering in patients with recurrent MR than that in patients without recurrent MR. CONCLUSIONS: In patients with the combination of atrial functional MR, left ventricular dilatation and excessive leaflet tethering, mitral annuloplasty alone may not be sufficient to achieve long-term correction of MR.

[Replacement of the Aortic Root with Stentless Bioprosthesis for Prosthetic Valve Endocarditis with Aortic Root Abscess;Report of a Case].

An 81-year-old man who had undergone aortic valve replacement was transferred to our hospital due to suspected prosthetic valve endocarditis(PVE) from the regional hospital. Transesophageal echocardiography findings showed severe aortic regurgitation with mobile vegetation on the right coronary cusp and annular abscess corresponding to left-none coronary cusps. Urgent operation was performed under the diagnosis of PVE with aortic root abscess. Intraoperative findings demonstrated tiny vegetation on one of the bio-prosthetic leaflets and abscess formation beneath the left sinus of valsalva( LSOV). Complete debridement of the infected tissue followed by patch closure of the cavity below the LSOV and reconstruction of the aortic root with Freestyle stentless aortic bioprosthesis was performed. His postoperative course was uneventful. Aortic root replacement using a stentless bioprosthesis seems to represent one of the useful options for PVE with aortic root abscess.

Feasibility of three-dimensional fusion imaging with multimodality roadmap system during endovascular aortic repair.

OBJECTIVE: Endovascular procedures for aortic aneurysm repair have become widely accepted as safe and effective surgical options. We investigated the efficacy of the multimodality roadmap (MMR) system with biplane fluoroscopy to attempt to reduce the use of contrast medium and exposure to radiation during surgery. METHODS: We retrospectively reviewed 263 consecutive cases with elective endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Patients were categorized into two groups, with and without introduction of the MMR system, which was applied in 164 patients (62.4%). The MMR- group included 62 EVAR and 37 TEVAR cases, and the MMR+ group consisted of 81 EVAR and 83 TEVAR cases. Radiation dose, contrast medium use, and complications were compared between the MMR- and MMR+ groups in the respective EVAR and TEVAR groups. RESULTS: There was a significantly lower amount of contrast medium use in the MMR+ group compared with the MMR- group in EVAR (32.9 ± 10.6 g and 28.2 ± 10.2 g; P = .009) and TEVAR (31.7 ± 11.5 g and 26.9 ± 7.8 g; P = .009). In addition, significantly lower radiation exposure was observed in the MMR+ group of TEVAR (872 ± 623 mGy vs 638 ± 463 mGy; P = .033). The operative time of the MMR+ group was significantly shorter for patients with TEVAR compared with the MMR- group (96.4 ± 27.0 minutes vs 86.2 ± 23.9 minutes; P = .023). The incidence of access injury and other complications was similar in both EVAR and TEVAR groups. CONCLUSIONS: The MMR system with three-dimensional fusion imaging can reduce the contrast medium dose in EVAR and the exposure to contrast medium and radiation in TEVAR.

Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy　- 11-Year Single Institute Experience.

BACKGROUND: Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR. CONCLUSIONS: MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

Minimally Invasive Aortic Valve Replacement Following Root Enlargement on too Narrow Annulus to Perform Transcatheter Aortic Valve Implantation.

An 88-year-old woman was diagnosed with aortic stenosis and an aortic annulus that was too narrow to perform transcatheter aortic valve implantation. Surgery was performed through a 7-cm right mini-thoracotomy at the fourth intercostal space. A 19-mm aortic valve bioprosthesis was implanted after root enlargement. The fourth intercostal space was a suitable site for aortic root enlargement because of the shorter skin-to-root distance and the detailed exposure of the aortic valve after cutting the aortic wall. This study concluded that minimally-invasive aortic valve replacement following root enlargement can be an option for the treatment of elderly patients with aortic stenosis accompanied by an annulus that is too small to perform transcatheter aortic valve implantation.

Preoperative Coil Embolization of Side Branches and Postoperative Antifibrinolytic Therapy in Endovascular Aneurysm Repair: A Propensity Score Analysis.

PURPOSE: To demonstrate feasibility and efficacy of preoperative coil embolization of side branches and postoperative tranexamic acid (TXA) therapy for management of type II endoleak and aneurysmal sac regression after endovascular aortic repair (EVAR). MATERIALS AND METHODS: This study included 284 patients who underwent EVAR between 2007 and 2014. In 133 patients (group A), since March 2012, preoperative coil embolization of side branches and postoperative TXA therapy had been introduced as a modified strategy after EVAR, including combined coil embolization and TXA therapy (n = 41), coil embolization only (n = 17), and TXA therapy only (n = 75). The remaining 151 patients (group B) underwent EVAR with no coil embolization and TXA therapy. After propensity score matching, postoperative results were retrospectively compared between 92 matched pairs (group A vs group B). RESULTS: Matched comparison revealed no significant difference in incidence rate of type II endoleak at 6 months after EVAR between group A and group B (19.6% [18/92] vs 29.4% [27/92]; P = .1172). A significantly greater shrinkage of sac size at 6 months after EVAR (-8.5% ± 11.6 vs -3.6% ± 8.4; P = .0011) and significantly more rapid pace of sac shrinkage (change of size per year; -4.2 mm/y ± 7.6 vs -1.9 mm/y ± 6.1; P = .0301) were observed in group A. CONCLUSIONS: Combined preoperative coil embolization of side branches and postoperative TXA therapy were associated with significantly more rapid aneurysmal sac regression after EVAR.

Clinical outcomes of different approaches to aortic arch disease.

OBJECTIVE: The aim of this study was to evaluate the midterm clinical outcomes of various approaches, including hybrid procedures, to aortic arch pathologies. METHODS: Of 305 consecutive patients who underwent aortic arch repair between 2005 and 2013, 244 underwent conventional open total aortic arch repair (CTAR) with antegrade cerebral perfusion under circulatory arrest, 35 underwent debranching of the arch with thoracic endovascular aortic repair (DTEVAR), and 26 underwent staged TEVAR after TAR with elephant trunk (TARET). We retrospectively evaluated the outcomes of the three groups. RESULTS: The DTEVAR group had a greater percentage of patients with preoperative comorbidities. Significant differences were observed in 30-day mortality (DTEVAR, 14.3% [5 of 35] vs TARET TEVAR, 0% [0 of 26] vs CTAR, 5.3% [13 of 244]; P = .045) and stroke (DTEVAR, 28.6% [10 of 35] vs TARET TEVAR, 7.7% [2 of 26] vs CTAR, 8.2% [20 of 244]; P = .001). In overall midterm survival, the DTEVAR group had a lower survival rate (63.9% 3-year survival) compared with the CTAR (90.1% 7-year survival) and the TARET TEVAR (95.5% 2.5-year survival) groups. In elective cases, better midterm results were observed in CTAR and TARET TEVAR groups. An increased number of debranching graft and emergency operations resulted in a much lower follow-up survival rate in the DTEVAR group. Atherosclerotic disease had a great effect on midterm outcomes in the DTEVAR (P = .045) and CTAR groups (P = .002). CONCLUSIONS: The clinical feasibility of DTEVAR for high-risk patients requiring zone 0 landing or emergency surgery is still controversial. Atherosclerotic disease of the aorta has a significant negative effect on midterm outcomes in any surgical approach.

Impact of Age and Intraluminal Thrombus Volume on Abdominal Aortic Aneurysm Sac Enlargement after Endovascular Repair.

BACKGROUND: Abdominal aneurysmal sac enlargement after endovascular aortic repair (EVAR) is a critical issue. However, the predictors have not yet been fully determined. Although unrecognized, intraluminal thrombus volume (ITV) is an important index. Therefore, we retrospectively evaluated the correlation among preoperative ITV, residual type II endoleak, and sac enlargement after EVAR, based on the long-term follow-up. METHODS: Between 2006 and 2011, 151 consecutive patients underwent EVAR at a single cardiovascular institute. Emergency surgery was performed on 7 patients (4.7%). Of 148 patients excluding 3 patients with residual type I endoleak, sac enlargement (≥5 mm progression) after EVAR was observed in 24 patients (16.2%) and 8 patients required reintervention. The mean follow-up period was 2.4 ± 1.4 years. The outer volume and enhanced luminal volume were calculated from enhanced 1-mm slice computed tomography, and the difference was defined as ITV. RESULTS: Age (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.04-1.20, P = 0.0007), outer volume (HR 1.04, 95% CI 1.01-1.07, P = 0.0118), percentage of ITV (HR 0.90, 95% CI 0.84-0.96, P = .0027), and type II endoleak (HR 10.15, 95% CI 3.55-31.10, P < 0.0001) were isolated as predictors of sac enlargement by multivariate analysis. Also, patent inferior mesenteric artery (odds ratio [OR] 4.45, 95% CI 1.38-20.07, P = 0.0105) and percentage of ITV < 30.1% (OR 3.52, 95% CI 1.32-10.30, P = 0.0112) were detected as independent risk factors for residual type II endoleaks. Additionally, in patients without endoleak, patient age (≥83 years) was an independent risk factor for sac enlargement after EVAR (P = 0.0056). CONCLUSION: Age and ITV percentage had significantly great impact on sac enlargement and type II endoleak after EVAR.

Efficacy of right axillary artery perfusion for antegrade cerebral perfusion in open total arch repair.

OBJECTIVE: Right axillary artery (RAxA) perfusion was introduced for selective antegrade cerebral perfusion in total aortic arch repair to prevent cerebral embolism derived from arterial cannulation. However, the strategic benefits and long-term results regarding the cannulation site remain controversial. We retrospectively compared the outcomes between propensity score-matched patients with and without using RAxA cannulation. METHODS: Between 2006 and 2012, 260 consecutive patients underwent total arch repair with antegrade cerebral perfusion and moderate hypothermia at a single institution. RAxA cannulation was added in 142 patients (54.6%), and 70 propensity score-matched pairs were obtained. RESULTS: There were no significant differences in 30-day (2.9% [2 of 70] vs 5.7% [4 of 70]; P = .415 and in-hospital death (5.7% [4 of 70] vs 5.7% [4 of 70]; P = 1.000) between matched pairs. Although there was no significant difference in the occurrence of postoperative stroke (8.6% [6 of 70] vs 8.6% [6 of 70]; P = 1.000), the new rate of new occurrence of postoperative paraparesis was lower in patients with RAxA perfusion (0% [0 of 70] vs 4.3% [3 of 70]; P = .067). With a mean follow-up period of 1057 ± 686 days, the overall 5-year survival was 90.6% and was 89.6% for patients with RAxA perfusion. Thee difference in survival between patients with and without RAxA perfusion was not significant. CONCLUSIONS: RAxA perfusion is a useful option for total aortic arch repair, and the midterm outcomes were satisfactory. However, RAxA perfusion did not completely prevent stroke in patients with an atherothrombotic aorta.