The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis.

OBJECTIVE: Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure). METHODS: We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS). RESULTS: The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications. CONCLUSIONS: Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

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.

Early Intraluminal Frozen Elephant Trunk Stent Graft Thrombosis After Aortic Arch Surgery.

BACKGROUND: Partial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis. METHODS: Retrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event. RESULTS: A total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3). CONCLUSIONS: Early postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis.

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.

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.

Iatrogenic Type A Aortic Dissection: Challenges and Frontiers-Contemporary Single Center Data and Clinical Perspective.

Iatrogenic aortic dissection (IAD) is a rare but devastating complication in cardiac surgery and related procedures. Due to its rarity, published data on emergency surgery following IAD are limited. Herein, we discuss IAD occurring intra- and postoperatively, including those occurring during transcatheter aortic valve replacement and cardiac catheterization, and present benchmark data from our consecutive, single-center experience. We demonstrate changes in patient characteristics, surgical approaches, and outcomes over a 23-year period.

Aortic root replacement in bicuspid versus tricuspid aortic valve patients.

Background: Concomitant replacement of the aortic root and aortic valve is a widely used treatment strategy in elective patients with aortic valve stenosis and root aneurysm. It is also a strategy frequently employed in patients with acute aortic dissection type A (AADA), involving the aortic root. Although more patients have undergone valve sparing procedures over the past decades, the classic 'modified Bentall technique' remains a valid option, particularly for patients with a bicuspid aortic valve (BAV). We aimed to compare the results of elective and emergency modified Bentall procedures in patients with bicuspid and tricuspid aortic valves (TAVs). Methods: We retrospectively reviewed our database for patients undergoing either elective or emergency modified Bentall procedures between 2000 and 2018 and identified 827 elective cases (44% BAV) and 258 emergency cases (15% BAV). Analysis of intra- and postoperative outcomes and early mortality was performed. Due to inequality of the groups, a matching analysis was performed. Results: We found BAV patients to be significantly younger (elective: 58±18 vs. 65±14, P<0.001; emergency: 49±17 vs. 62±19, P<0.001) and healthier at time of surgery. In the AADA cohort, malperfusion rate was not different between bicuspid and tricuspid patients, however bicuspid AADA patients presented more often with an entry in the aortic root. After matching, procedure times and early outcomes did not differ between the groups, except for significantly higher rates of respiratory failure in elective TAV patients (10% vs. 5%, P=0.033). The 30-day mortality was 2% in elective cases and 22% in emergency AADA surgery. A subgroup analysis of elective patients with aortic diameter <55 mm also showed excellent outcomes. Conclusions: After adjustment for preoperative inequalities, no differences in early mortality and outcomes were found between bicuspid and tricuspid patients receiving elective or emergency modified Bentall surgery.

Basic principles of cardiothoracic surgery training: a position paper by the European Association for Cardiothoracic Surgery Residents Committee.

OBJECTIVES: Across Europe there are significant variations in the fundamental structure and content of cardiothoracic surgery (CTS) training programmes. Previous efforts have been made to introduce a Unified European Training System, which outlined the fundamentals of the ideal programme and supported a paradigm shift from an apprenticeship to a competency-based model. This article's goal was to define key structural, administrative and executive details of such a programme to lay the foundations for the standardization of cardiothoracic surgical training across Europe. METHODS: The European Association for Cardiothoracic Surgery Residents Committee had previously conducted a residents' training survey across Europe in 2020. Training curricula from the twelve most represented countries across Europe were either searched online or obtained from the countries' national trainee representative and reviewed by the committee. Information was collated and placed into one of the following categories to develop the position paper: (i) selection of eligible candidates, (ii) guidance for an outcome-based syllabus, (iii) documentation and evaluation of training progress, (iv) mandatory rotations and training courses, (v) number of independent or assisted cases and (vi) requirements and quality assurance of teachers. RESULTS: An independent professional body should promote an outcome-based syllabus and take responsibility for the training programme's quality assurance. Trainees should be selected on merit by an open and transparent process. Training should be delivered within a defined period and supervised by an appointed training committee to ensure its implementation. This committee should review the trainees progression regularly, provide feedback and offer trainees the opportunity to experience various training environments and trainers. A common electronic portal be used by trainees to record their agreed objectives and to evidence their completion. Trainees should regularly attend specialty-relevant courses and conferences to promote professional and academic development. The end of training is reached when the formal requirements of the training programme are met and the trainee is able to perform at the level expected of a day-1 independent surgeon. CONCLUSIONS: This article defines the key structural, administrative, and executive principles for CTS training. Programmes are encouraged to review and modify their training curricula, if necessary, to ensure the delivery of high-quality, standardized, outcome-orientated CTS training across Europe.

Impact of distal aortic perfusion on 'segmental steal' depleting spinal cord blood flow-a quantitative experimental approach.

OBJECTIVES: Aortic steal is an underestimated risk factor for intraoperative spinal cord ischaemia. A negative effect on spinal cord perfusion in thoraco-abdominal aneurysm repair has been suspected if blood drains away from the cord initiated by a reversal of the arterial pressure gradient. The amount of blood and pressure loss via back-bleeding of segmental arteries and the impact of distal aortic perfusion (DaP) have not been analysed yet. The aim of our study was to quantify 'segmental steal' in vivo during simulated thoraco-abdominal aneurysm repair and to determine the impact of DaP on steal and spinal cord perfusion. METHODS: Ten juvenile pigs were put on cardiopulmonary bypass with DaP and visceral arteries were ligated. 'Segmental steal' was quantified by draining against gravity with/without DaP. Blood volume of 'segmental steal' was quantified and microspheres were injected for Post mortem spinal cord perfusion analysis. 'Segmental steal' was quantified with/without DaP-and with stopped DaP. RESULTS: Quantification revealed a significantly higher steal on cardiopulmonary bypass with DaP with a mean difference of 24(11) ml/min. In all spinal cord segments, blood flow was diminished during steal drainage on DaP, compared to 'no steal'. The least perfused region was the low thoracic to upper lumbar segment. CONCLUSIONS: 'Segmental steal' is a relevant threat to spinal cord perfusion-even with the utilization of DaP-diminishing spinal cord perfusion. The blood volume lost by back-bleeding of segmental arteries is not to be underestimated and occlusion of segmental arteries should be considered in thoraco-abdominal aneurysm repair.

Mapping the collateral network: Optimal near-infrared spectroscopy optode placement.

BACKGROUND: Paraplegia after extensive aortic procedures is a disastrous complication, and maintenance of adequate spinal cord perfusion/oxygenation is pivotal to its prevention. Collateral network (CN) near-infrared spectroscopy (cnNIRS) has been introduced as a noninvasive method for indirect spinal cord oxygenation monitoring. However, the CN has not been investigated in its entirety using this monitoring modality. This study aimed to identify the optimal cnNIRS positioning in an acute large animal model for routine clinical use. METHODS: The paraspinous CN was measured from the high thoracic region to the low lumbar region (T4-L5) using cnNIRS in 10 juvenile pigs (plus reference data from 7 animals) during aortic ischemia and reperfusion. These data were compared with data on direct regional tissue perfusion of the CN and the spinal cord. RESULTS: After aortic cross-clamping, cnNIRS at the mid-thoracic to the low lumbar level decreased rapidly to a nadir at 10 minutes of distal ischemia (mean difference, 18.3 ± 11% to 44.5 ± 9%; P < .001 to .045), with more pronounced changes in the caudal regions. High thoracic cnNIRS remained stable (mean difference, 4.3 ± 4%; P = .915). Measurements of cnNIRS, CN, and spinal cord regional perfusion demonstrated comparable curve progressions starting from the mid-thoracic region (r = 0.5-0.7; P < .001). CONCLUSIONS: cnNIRS is capable of detecting relevant changes during ischemia and reperfusion from the mid-thoracic level downward with characteristic oxygenation patterns corresponding to CN and spinal cord regional perfusion. For extensive aortic procedures, noninvasive cnNIRS placement appears to be useful from the mid-thoracic level (T7-T9) to the lower lumbar level (L3-L5) and also may serve as a versatile monitoring method for procedures limited to the proximal thoracic aorta.

Supracommissural replacement of the ascending aorta and the aortic valve via partial versus full sternotomy-a propensity-matched comparison in a high-volume centre.

OBJECTIVES: Full sternotomy (FS) is the common surgical access for patients undergoing open aortic valve replacement (AVR) with concomitant supracommissural replacement of the tubular ascending aorta. Since minimally invasive approaches are being used with increasing frequency in cardiac surgery, the aim of this study was to compare outcomes of patients undergoing AVR with supracommissural replacement of the tubular ascending aorta via FS versus partial upper sternotomy (PS). METHODS: We included all patients who underwent elective AVR with concomitant supracommissural replacement of the tubular ascending aorta at our institution between 2000 and 2015. Exclusion criteria were emergency surgery, other major concomitant procedures and reoperations. After 2:1 propensity score matching, outcomes of patients with PS and FS were compared. RESULTS: A total of 652 consecutive patients were included, 117 patients operated via PS and 234 patients operated via FS. Cardiopulmonary bypass time and aortic cross-clamp time of the PS and FS groups were 89 vs 92 min (P = 0.2) and 65 vs 70 min (P = 0.3), respectively. Postoperative morbidity was low and there were no significant differences in postoperative outcomes between patient groups. In-hospital mortality was 1.7% in the PS vs 0.4% in the FS group (P = 0.3). Kaplan-Meier analysis revealed no difference in mid-term survival (P = 0.3). Reoperation rates for valve or aortic complications were very low with no significant difference between groups. CONCLUSIONS: In a high-volume centre with extensive experience in minimally invasive cardiac surgery, AVR with concomitant supracommissural replacement of the tubular ascending aorta via PS results in similar outcomes with regard to safety and longevity when compared to conventional FS.

Ischemic Spinal Cord Injury-Experimental Evidence and Evolution of Protective Measures.

BACKGROUND: Paraplegia remains one of the most devastating complications of descending and thoracoabdominal aortic repair. The aim of this review is to outline the current state of art in the rapidly developing field of spinal cord injury research. METHODS: A review of PubMed and Web of Science databases was performed using the following terms and their combinations: spinal cord, injury, ischemia, ischemia-reperfusion, ischemic spinal cord injury, paraplegia, paraparesis. Articles published before July 2019 were screened and included if considered relevant. RESULTS: The review focuses on the topic of spinal cord injury and the developments concerning methods of monitoring, diagnosing, and preventing spinal cord injury. CONCLUSIONS: Translation of novel technologies from bench to bedside and into everyday clinical practice is challenging; however, each of the developing areas holds great promise in spinal cord injury prevention.

Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion.

OBJECTIVES: Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure. METHODS: Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis. RESULTS: DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment. CONCLUSIONS: Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.

Proximal aortic aneurysms: correlation of maximum aortic diameter and aortic wall thickness.

OBJECTIVES: The goal of therapy of proximal aortic aneurysms is to prevent an aortic catastrophe, e.g. acute dissection or rupture. The decision to intervene is currently based on maximum aortic diameter complemented by known risk factors like bicuspid aortic valve, positive family history or rapid growth rate. When applying Laplace's law, wall tension is determined by pressure × radius divided by aortic wall thickness. Because current imaging modalities lack precision, wall thickness is currently neglected. The purpose of our study was therefore to correlate maximum aortic diameter with aortic wall thickness and known indices for adverse aortic events. METHODS: Aortic samples from 292 patients were collected during cardiac surgery, of whom 158 presented with a bicuspid aortic valve and 134, with a tricuspid aortic valve. Aortic specimens were obtained during the operation and stored in 4% formaldehyde. Histological staining and analysis were performed to determine the thickness of the aortic wall. RESULTS: Patients were 62 ± 13 years old at the time of the operation; 77% were men. The mean aortic dimensions were 44 mm, 41 mm and 51 mm at the aortic root, sinotubular junction and ascending aorta, respectively. Aortic valve stenosis was the most frequent (49%) valvular dysfunction, followed by aortic valve regurgitation (33%) and combined dysfunction (10%). The maximum aortic diameter at the ascending level did not correlate with the thickness of the media (R = 0.07) or the intima (R = 0.28) at the convex sample site. There was also no correlation of the ascending aortic diameter with age (R = -0.18) or body surface area (R = 0.07). The thickness of the intima (r = 0.31) and the media (R = 0.035) did not correlate with the Svensson index of aortic risk. Similarly, there was a low (R = 0.29) or absent (R = -0.04) correlation between the aortic size index and the intima or media thickness, respectively. There was a similar relationship of median thickness of the intima in the 4 aortic height index risk categories (P < 0.001). CONCLUSIONS: Aortic diameter and conventional indices of aortic risk do not correlate with aortic wall thickness. Other indices may be required in order to identify patients at high risk for aortic complications.

Experimental near-infrared spectroscopy-guided minimally invasive segmental artery occlusion.

OBJECTIVES: Minimally invasive staged segmental artery (SA) coil- and plug embolization is a new method for paraplegia prevention associated with extensive aortic procedures. Near-infrared spectroscopy of the paraspinal collateral network (cnNIRS) has emerged as a non-invasive method for spinal cord monitoring. The aim of this study was to evaluate cnNIRS to guide minimally invasive SA occlusion. METHODS: In a chronic large animal experiment, 18 juvenile pigs underwent two-stage minimally invasive staged SA coil- and plug embolization for complete SA occlusion. Coil-embolization was performed either by SA main stem occlusion (characteristic of pig anatomy) or separately for the left- and right SA. Lumbar cnNIRS was recorded during and after the procedure. Neurological status was assessed up to 3 days after complete SA occlusion. RESULTS: Mean time from SA coil embolization to minimum cnNIRS values was 11 ± 5 min with an average decrease from 101 ± 2% to 78 ± 8% of baseline (difference: -23 ± 9, P < 0.001). Lumbar cnNIRS demonstrated significant differences between left and right when SAs were occluded separately in all cases (-7 ± 4%, 1 min after first SA occlusion; P = 0.001). Permanent paraplegia occurred in 2 (11%) and any kind of neurological deficit-temporary or permanent-in 7 animals (39%). Association between lumbar cnNIRS and neurological outcome after minimally invasive staged SA coil- and plug embolization suggests positive correlation (R = 0.5, P = 0.052). CONCLUSIONS: Lumbar cnNIRS independently reacts to unilateral SA occlusion. cnNIRS-guided SA occlusion is feasible and may become a useful adjunct facilitating adequate and complete vessel occlusion.

Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach.

Spinal cord injury (SCI) is one major complication of open and endovascular thoracic and thoracoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and noninvasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.

Gender-related differences in patients with acute aortic dissection type A.

OBJECTIVE: Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A. METHODS: Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery. RESULTS: Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21). CONCLUSIONS: Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders.