Resection of Renal Cell and Prostate Carcinoma Sternum Metastases with Long-Term Follow-Up: A Report of 2 Cases.

Introduction: Rarely solitary sternum metastases are addressed by resection. Two additional cases are presented as they are interesting because of their long-term follow-up. Case Presentation: Case 1: A renal cell carcinoma was treated by transabdominal nephrectomy at age 64. Right iliac bone and sternum metastases were diagnosed 7 months later and treated by internal hemipelvectomy followed by sternum metastasectomy 6 weeks after the internal hemipelvectomy. At 12-year follow-up, the patient appears disease free. Case 2: Prostate cancer was treated by prostatectomy at age 67. A subsequent solitary sternum metastasis was resected 10 years later for persistent PSA-activity despite repeated radiotherapy. The patient remains asymptomatic for 3 years now. Conclusion: Resection of sternum metastases may have curative potential and should be considered in tumours known to be rather resistant to chemo- and/or radiotherapy.

How to counteract the lack of donor tissue in cardiac surgery? Initial experiences with a newly established homograft procurement program.

Homograft heart valves may have significant advantages and are preferred for the repair of congenital valve malformations, especially in young women of childbearing age, athletes and in patients with active endocarditis. A growing problem, however, is the mismatch between tissue donation and the increasing demand. The aim of this paper is to describe the initiation process of a homograft procurement program to attenuate the shortage of organs. A comprehensive description of the infrastructure and procedural steps required to initiate a cardiac and vascular tissue donation program combined with a prospective follow-up of all homografts explanted at our institution. Between January 2020 and May 2022, 28 hearts and 12 pulmonary bifurcations were harvested at our institution and delivered to the European homograft bank. Twenty-seven valves (19 pulmonary valves, 8 aortic valves) were processed and allocated for implantation. The reasons for discarding a graft were either contamination (n = 14), or morphology (n = 13) or leaflet damage (n = 2). Five homografts (3 PV, 2 AV) have been cryopreserved and stored while awaiting allocation. One pulmonary homograft with a leaflet cut was retrieved by bicuspidization technique and awaits allocation, as a highly requested small diameter graft. The implementation of a tissue donation program in cooperation with a homograft bank can be achieved with reasonable additional efforts at a transplant center with an in-house cardiac surgery department. Challenging situations with a potential risk of tissue injury during procurement include re-operation, harvesting by a non-specialist surgeon and prior central cannulation for mechanical circulatory support.

A Very Rare Cause of Dyspnea in a Child: A Hydatid Cyst From Echinococcus.

Hydatid cyst is a human parasitic disease caused by echinococcus granulosus that affects mainly the liver or the lungs but may be found in any organ, including the heart in up to 2% of the cases. Humans are infected as accidental hosts by contaminated vegetables or water and by contact with saliva from infected animals. Although cardiac echinococcosis can be fatal, it is rare and often asymptomatic in the early stage. We present the case of a young boy living on a farm who suffered from mild exertional dyspnea. He suffered from pulmonary and cardiac echinococcosis and was treated surgically through median sternotomy to prevent potential cystic rupture.

Evolving technology: the TRIFLO tri-leaflet mechanical valve without oral anticoagulation: a potential major innovation in valve surgery.

The aortic valve is the most frequently diseased valve and aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. The diseased native aortic valve can be replaced by either a biological or mechanical valve prosthesis. The main concerns relate to durability, the need for oral anticoagulants and the incidence of complications related to this medication. Experimental, computational and biomolecular blood flow studies have demonstrated that the systolic forward flow but also the reverse flow phase at the end of the systole and leakage during the diastolic phase is mainly responsible for platelet activation and thrombosis. Better design of mechanical prosthetic heart valves must ensure smooth closing during flow deceleration and must eliminate high-shear hinge flow during diastole to prevent life-threatening thrombosis. A novel tri-leaflet valve should combine the favorable hemodynamics and the durability of existing mechanical heart valves and eliminate the less favorable characteristics, including the extremely rapid closing. In this paper, we discuss some issues of current mechanical heart valve prostheses and present a new valve design with the potential for significant innovation in the field. The TRIFLO Heart Valve, is a rigid, three-leaflet central flow heart valve prosthesis consisting of an alloyed titanium housing, and three rigid polymer (PEEK) cusps. This valve has a physiological operating mode. During the forward flow phase, the intraventricular pressure opens the leaflets so that blood can freely flow through with little obstruction, and with the deceleration of the blood flow, the leaflets close early and smoothly, minimizing blood flow regurgitation, blood cell damage, and activation of the coagulation cascade. Pre-clinical studies have shown pretty favorable results and a first-in-man study should start very soon.

Dismal prognosis of patients with operative indication without surgical intervention in active left-sided infective endocarditis.

Introduction: Around 25% of patients with left-sided infective endocarditis and operative indication do not undergo surgery. Baseline characteristics and outcomes are underreported. This study describes characteristics and outcomes of surgical candidates with surgical intervention or medical treatment only. Methods: Retrospective analysis of ongoing collected data from a single-center from an observational cohort of patients with infective endocarditis (ENVALVE). Kaplan-Meier estimates for survival was calculated. Factors associated with survival were assessed using a bivariable Cox model. To adjust for confounding by indication, uni- and multivariable logistic regression for the propensity to receive surgery were adjusted. Results: From January 2018 and December 2021, 154 patients were analyzed: 116 underwent surgery and 38 received medical treatment only. Surgical candidates without surgery were older (70 vs. 62 years, p = 0.001). They had higher preoperative risk profile (EuroSCORE II 14% (7.2-28.6) vs. 5.8% (2.5-20.3), p = 0.002) and more comorbidities. One patient was lost-to-follow-up. Survival analysis revealed a significant higher one-year survival rate among patients following surgery (83.7% vs. 15.3% in the non-surgical group; log-rank test <0.0001). In the final multivariable adjusted model, surgery was less likely among patients with liver cirrhosis [OR = 0.03 (95% CI 0.00-0.30)] and with hemodialysis [OR = 0.014 (95% CI 0.00-0.47)]. Conclusion: Patients with left-sided infective endocarditis who do not undergo surgery despite an operative indication are older, have more comorbidities and therefore higher preoperative risk profile and a low 1-year survival. The role of the Endocarditis Team may be particularly important for the decision-making process in this specific group.

Twenty-five year experience with aortic valve-sparing root replacement in a single teaching center.

Objectives: Aortic valve-sparing root replacement (AVSRR) is a technically demanding procedure. In experienced centers it offers excellent short- and long-term results, making the procedure an attractive alternative for aortic root replacement especially in young patients. The aim of this study was to analyze long-term results of AVSRR using the David operation in our institution over the last 25 years. Methods: This is a single-center retrospective analysis of outcomes of David operations performed in a teaching institution not running a large AVSRR-program. Pre-, intra- and postoperative data were collected from the institutional electronic medical record system. Follow-up data were collected through direct contact of the patients and their cardiologists/primary care physicians. Results: Between 02/1996 and 11/2019, 131 patients underwent David operation in our institution by a total of 17 different surgeons. Median age was 48 (33-59), 18% were female. Elective surgery was performed in 89% of the cases, 11% were operated as emergency in the setting of an acute aortic dissection. Connective tissue disease was present in 24% and 26% had a bicuspid aortic valve. At hospital admission 61% had aortic regurgitation grade ≥3, 12% were in functional NYHA-class ≥III. 30-day mortality was 2%, 97% of the patients were discharged with aortic regurgitation ≤2. In 10-year follow-up, 15 (12%) patients had to be re-operated because of root-related complications. Seven patients (47%) received a transcatheter aortic valve implantation, 8 (53%) required surgical replacement of the aortic valve or a Bentall-De Bono operation. Estimated reoperation-free survival at 5 and 10 years was 93.5% ± 2.4% and 87.0% ± 3.5%, respectively. Subgroup analysis showed no differences in reoperation-free survival for patients presenting with a bicuspid valve or preoperative aortic regurgitation ≥3. However a preoperative left ventricular end diastolic diameter of ≥5.5 cm was associated with worse outcome. Conclusion: David operations can be performed with excellent perioperative and 10-year follow-up outcomes in centers not running large AVSRR-programs.

Case report: Eighteen nails gun shots in the head, thorax and abdomen but still conscious at admission: A challenging patient for the cardiac surgeon!

We report an unusual case of multiple penetrating cerebral, cardiac and abdominal injuries following a suicidal attempt using a nail gun. Successful treatment required several emergency procedures and resulted from a wise interdisciplinary management and timing of surgery.

A case series of rare pathologies of the aorta and the aortic arch in adolescents and younger adults: Transfer of experience for an individualized approach.

Objective: While aneurysm of the aortic root, interrupted aortic arch, and aortic coarctation are the most frequent aortic diseases in adolescents and younger adults, there are a number of rare pathologies of the thoracic aorta that need individualized treatment. Patients: We present a small case series of unusual aortic pathologies in patients presenting with a broad spectrum of symptoms: tiredness, dysphagia, dyspnea, arterial hypertension, renal failure, and claudication. (1). Segmental agenesia of the descending aorta. (2). Balanced double aortic arch with complete vascular ring. (3). Right descending aortic arch, left lusorian artery with Kommerell diverticulum. (4). Large patent ductus (2.5 cm) and ventricular septal defect. (5). Aneurysm of the aortic arch in the presence of tuberous sclerosis. (6). Pseudo-aneurysm of the proximal descending aorta following coarctation patch plasty. (7). Supravalvular aortic stenosis combined with severe aortic valve stenosis. (8). Pseudo-aneurysm following ascendens-to-descendens bypass because of recurrent coarctation. (9). Takayasu arteriitis with severe stenosis in the thoraco-abdominal aorta. Results: The following procedures were performed, using individualized cardiopulmonary bypass, canulation and cerebral protection strategies. (1). Ascending to supraceliac extra-anatomic bypass. (2). Division of the ductus ligament and of the anterior aortic arch distally to the left subclavian artery. (3). Excision of the Kommerell diverticulum and translocation of the left subclavian artery. (4). Patch closure of the aorto-pulmonary window (patent ductus) and closure of the ventricular septal defect. (5). Complete aortic arch replacement combined with debranching of the supra-aortic vessels. (6). Graft interposition of the proximal descending aorta. (7). Enlargement of the ascending aorta and aortic valve replacement. (8). Exclusion of the pseudo-aneurysm, end-to-side graft interposition. (9). Ascending aorta to infrarenal aorta or ascending to bi-iliac artery bypass (planned). All patients were operated on without operative mortality. One patient died in-hospital from pulmonary complications one week after surgery. One patient is still awaiting surgery. All other patients recovered very well from the operation and did not show any residual symptoms. Conclusion: Rare pathologies of the thoracic aorta in younger patients may cause a broad spectrum of unusual symptoms; in some of them, diagnosis is delayed. Cross-sectional imaging is mandatory for optimal operative planning Surgical treatment can be performed with very satisfying results. The prognosis of these patients is usually favorable following surgery.

Aortic wrapping is life-saving in high-risk acute aortic dissection and intramural haematoma.

Aortic wrapping is a controversial repair in patients presenting with acute type A aortic dissection or intramural haematoma, but this method may be a potential alternative to medical treatment or conventional repair in patients aged >80 years and in those presenting with prohibitive co-morbidities such as stroke, circulatory collapse, full oral anticoagulation with the last generation drugs. We report on 5 high-risk and/or patients over 80 years who received external aortic wrapping with or without cardiopulmonary bypass during the last 18 months. All survived the procedure and could be extubated early postoperatively. No patient remained on the intensive care longer than 2 days and all were discharged without additional complications. Postoperative radiological control was acceptable and no patient had any new aortic event up to 18 months postoperatively.

Porcelain aorta does not mean inoperability but needs special strategies.

Porcelain aorta is not an absolute contraindication for aortic valve and/or coronary bypass grafting but it requires a special strategy and individualized approach to minimize the risk of embolic complications and technical problems during opening and/or closing the aortotomy.

The impact of age and sex on in-hospital outcomes in acute type A aortic dissection surgery.

Background: Older age and female sex are thought to be risk factors for adverse outcomes after repair of acute type A aortic dissection (AAAD). The aim of this study is to analyze age- and sex-related outcomes in patients undergoing AAAD repair. Methods: Retrospective analysis of patients undergoing emergency AAAD repair. Patients were divided in Group A, patients aged ≥75 years and Group B <75. Intraoperative and postoperative data were compared between groups before and after propensity score matching. Sex differences were analyzed by age group. Results: Between January 2006 and December 2018, 638 patients underwent emergency AAAD repair. Group A included 143 patients (22.4%), Group B 495 (77.6%). More patients in Group A presented with circulatory collapse (Penn C 26.6% vs. 9.7%, P=0.001) while Group B presented with circulatory collapse-branch malperfusion (Penn BC 29.3% vs. 15.4% P=0.001). After propensity score matching, Group B patients received more complex aortic root (33.6% vs. 23.2%, P=0.019) and concomitant bypass surgery (12.3% vs. 6.3%, P=0.042). There was no significant difference in in-hospital mortality between age groups (18% vs. 12% P=0.12). In Group B, in-hospital mortality was significantly higher in females (22.2% vs. 8.2%, P=0.028). Differences in mortality disappeared after the age of 75 (18.3% vs. 19.4% P=0.87). Conclusions: Morbidity and mortality are comparable between patients under and over 75 years after AAAD repair. Female patients <75 had higher in-hospital mortality than their male counterparts.

Barlow disease: effect of mitral valve repair on ventricular arrhythmias in 82 patients in a retrospective long-term study.

BACKGROUND: Patients (pt) with mitral valve prolapse (MVP) due to Barlow disase (BD) have an increased incidence of ventricular arrhythmias (VA; including ventricular tachycardias VT) and sudden cardiac death (SCD). Data on the effect of MV repair on VA are scarce. METHODS: Pre- and postoperative VA in severe mitral regurgitation (MR) with MVP due to BD undergoing surgical mitral valve repair were analyzed. Patients with degenerative mitral valve disease not fulfilling BD criteria were excluded. Information was from charts, ECG/Holter ECG and/or pacemaker/ implantable cardioverter defibrillator (ICD) data. SCD, sustained VT>30 sec and/or ventricular fibrillation necessitating an ICD-shock were considered major events. Event probability was calculated using the Kaplan-Meier estimator throughout the follow-up period of 20.7 years. RESULTS: There were 82 pts (61% males), mean age at surgery 62±14 years. Bileaflet MVP was present in 54%, mitral annular dysjunction (MAD) in 37% and left ventricular ejection fraction (LVEF) <50% in 12%. MV repair included ring annuloplasty in all and artificial chords in 48%. Mean follow-up was 3.1 years (0.2 to 14.2 years). Postoperative rhythm surveillance by Holter ECG and/or pacemaker was available in 67%. A VA load of ≥10% and/or any VT was noted in 26% before and 32% after surgery (P=0.44). Postoperative VA load was not predicted by MAD, artificial chords, LVEF of <50%, age at surgery >50 years and/or residual ≥moderate MR (all P<0.05), it correlated only with bileaflet MVP (P=0.009). Major events occurred in 3 pts: SCD in 2 pts and ICD for sustained polymorphic VT in 1 pt (incidence 1.2%/year). The event probability of receiving a SCD or an ICD-shock was 4.9%. CONCLUSIONS: VA burden does not seem to change after MV repair in MVP due to BD. The occurrence of major arrhythmic events can not be predicted reliably, thus, patients with MVP due to BD may need lifelong postoperative follow-up, especially in bileaflet MVP which was an independent risk factor for increased VA burden in this retrospective long-term study in a small but well selected patient group.

Prior intake of new oral anticoagulants adversely affects outcome following surgery for acute type A aortic dissection.

OBJECTIVES: Oral anticoagulation prior to emergency surgery is associated with an increased risk of perioperative bleeding, especially when this therapy cannot be discontinued or reversed in time. The goal of this study was to analyse the impact of different oral anticoagulants on the outcome of patients who underwent emergency surgery for acute type A aortic dissection (ATAAD). METHODS: This was a single-centre retrospective study of patients treated with oral anticoagulation at the time of surgery for ATAAD. Outcomes of patients on new oral anticoagulant (NOAC) therapy were compared to respective outcomes of patients on Coumadin. Additionally, a survival analysis was performed comparing these 2 groups with patients who were operated on with no prior anticoagulation. RESULTS: Between January 2013 and April 2020, a total of 437 patients (63.8 ± 11.8 years, 68.4% male) received emergency surgery for ATAAD; 35 (8%) were taking oral anticoagulation at the time of hospital admission: 20 received phenprocoumon; 14, rivaroxaban; and 1, dabigatran. Compared to Coumadin, NOAC was associated with a greater need for blood-product transfusions and haemodynamic compromise. Operative mortality was 53% in the NOAC group and 30% in the Coumadin group. A 5-year survival analysis showed no significant difference between the NOAC and the Coumadin group (P = 0.059). Compared to 402 patients treated during the study period without anticoagulation, patients taking NOAC had significantly worse survival (P = 0.001), whereas that effect was not observed in patients undergoing surgery who were taking Coumadin (P = 0.99). CONCLUSIONS: Emergency surgery for ATAAD in patients taking NOAC is associated with high morbidity and mortality. NOAC are a major risk factor for uncontrollable bleeding and haemodynamic compromise. New treatment strategies must be defined to improve surgical outcomes in these high-risk patients.

Routine early postoperative computed tomography angiography after coronary artery bypass surgery: clinical value and management implications.

OBJECTIVES: Computed tomography angiography (CTA) is broadly used for long-term follow-up of graft patency after coronary artery bypass graft surgery (CABG). However, its clinical value in the early postoperative setting has not been established yet. We evaluated the benefit of adding CTA to the routine clinical work-up after CABG on patient management. METHODS: A total of 305 consecutive patients (269 males, median age 68 years) underwent CABG and postoperative CTA with a median of 6 days after surgery. Graft patency and additional imaging findings were assessed and their influence on diagnosis and clinical management was evaluated. RESULTS: Graft occlusion or high-grade stenosis was found in 15% of the patients. Additional findings were reported in 44% of the patients, including pericardial (2%) and pleural effusion (27%), large pneumothorax (11%), pulmonary infection (4%), cardiac or vascular thrombus (2%), pulmonary embolism (2%), sternal dehiscence (1%) and additional incidental findings requiring follow-up (6%). CT findings initiated new diagnostic and/or therapeutic measures in 15% of the patients, 47% of those with diseased grafts and 19% of patients with non-graft-related findings. No adverse events related to CTA were documented. CONCLUSIONS: Early routine postoperative assessment of CABG with CTA reveals both cardiac and non-cardiac findings with a high frequency, affecting clinical management in a substantial proportion of patients.

Late outcome after surgical and topical treatment for Aspergillus mediastinitis after heart transplantation.

The 7-year long-term survival after Aspergillus fumigatus mediastinitis after heart transplantation, an uncommonly described condition, is herein reported. A 66-year-old male developed an infection with A. fumigatus covering the entire thoracic cavity with a fungal turf after orthotopic heart transplantation. Repeated surgical removal of infectious and necrotic tissue together with innovative topical treatment using voriconazole and chlorhexidine combined with systemic antifungal treatment, helped in controlling the infection. Definitive wound closure was achieved by standard sternal refixation and latissimus dorsi muscle flap plasty. Survival after A. fumigatus mediastinitis after heart transplantation was achieved with sequential debridement in combination with topical application of antifungal agents.

Direct sternal administration of Vancomycin and Gentamicin during closure prevents wound infection.

OBJECTIVES: Deep sternal wound infection is still a major complication in patients undergoing cardiac surgery. We previously identified mammary artery harvesting as a risk factor for decreased antibiotic tissue penetration. In addition, other risk factors including diabetes may inhibit sufficient tissue penetration of perioperative antibiotic prophylaxis. A novel closure protocol applying 2 topical antibiotics and further recommendations for sternal wiring was introduced at our department to decrease the incidence of sternal wound infections. METHODS: A 12-month period prior to (March 2013-February 2014) and after (July 2014-June 2015) the introduction of a novel sternal closure protocol was studied. All sternal wound infections resulting from an operation during this period were analysed. The closure protocol consisted of the intra-sternal application of vancomycin and the subcutaneous application of gentamicin. Furthermore, we increased the number of sternal wires for more uniform distribution of lateral forces. RESULTS: Patients in both groups were comparable regarding demographic data and risk factors. Fifty-three out of 919 patients operated prior to the protocol change developed an infection (5.8%). The introduction of the novel sternal closure protocol reduced this number to 19 out of 932 patients (2.0%; P < 0.001). A binary regression including common risk factors revealed a strong independent risk reduction by the novel protocol (OR 0.322, P < 0.001). The number of sternal wires was not significant in this analysis. CONCLUSIONS: The topical application of 2 antibiotic agents significantly reduced sternal wound infection. However, the results of this trial should be confirmed in a randomized trial.

Arterial allografts in treating aortic graft infections: something old, something new.

Surgical treatment of major aortic infection remains the most demanding challenge in aortic surgery. Excellent results with cryopreserved allograft heart valves in the treatment of acute infectious endocarditis prompted the use of allografts for in situ replacement of mycotic aortic aneurysms and prosthetic aortic graft infection. This review summarizes the indications for use of allografts in the management of major aortic infection, describes technical pitfalls at the time of implantation, presents clinical results, and analyzes the findings in explanted segments of failed allografts. In addition, the current status of the use of allografts will be compared with competitive techniques for treatment of vascular infections.

Antiplatelet therapy early after bioprosthetic aortic valve replacement is unnecessary in patients without thromboembolic risk factors.

BACKGROUND: The use of antithrombotic therapy during the postoperative period after biological aortic valve replacement (AVR) in patients without thromboembolic risk factors remains controversial. Treatment with warfarin is recommended for the first 3 months after biological AVR. The use of antiplatelet therapy - mainly aspirin (ASA) - is suggested as an alternative treatment but its efficacy is still unsettled. Due to the increased risk of bleeding complications even no use of any antithrombotic or antiplatelet therapy was advocated. Given this ongoing dispute, the aim of this retrospective double-institutional study was to evaluate the necessity of antiplatelet treatment by ASA with no postoperative antiplatelet therapy in terms of survival, major bleedings and cerebral thromboembolism of patients undergoing biological AVR without thromboembolic risk factors. METHODS: From January 2001 to December 2003, 288 consecutive patients (72.8+/-7.5 years, 134 males) with sinus rhythm and no other thromboembolic risk factors underwent single biological AVR with porcine or bovine pericardial valves without concurrent coronary artery bypass graft surgery. By surgeons preference, 100 mg ASA was given to 132 patients, and 156 patients received no antiplatelet therapy. Patients were followed for cerebral ischemic events, major bleedings, need for repeat operation, NYHA class and survival at three time intervals postoperatively (30 days, 3 and 12 months). RESULTS: None of all patients died during the operation. Mortality within 30 days was 3.8% in the ASA and 3.9% in the no ASA group (p=0.777). There were no statistically significant differences for cerebral ischemia within 3 months after AVR (ASA 0.8% vs no ASA 1.3%: p=0.884) and 3 to 12 months after AVR (ASA 0.8% vs no ASA 0%; p=0.933). Major bleedings occurred in two ASA-treated patients and in one patient without antiplatelet therapy (p=0.884). The incidence of NYHA class III-IV after 3 months (1.5% vs 1.9%; p=0.850) and 12 months (9.0% vs 5.1%; p=0.278) were similar, as were the need for repeat operative AVR after 12 months (0.8% vs 0.6%; p=0.553). Survival rates at 12-month follow-up were 95.5% for ASA treatment and 94.9% for no ASA treatment (p=0.963). CONCLUSIONS: In patients without thromboembolic risk factors undergoing biological AVR administration of ASA confers no advantage compared to no antiplatelet therapy. Functional status, thromboembolic events and survival were not adversely affected by withholding any antiplatelet therapy. Guidelines need to be reviewed for the antithrombotic therapy of patients without risk factors undergoing bioprosthetic AVR.

Hybrid treatment for complex aortic problems combining surgery and stenting in the integrated operating theater.

OBJECTIVES: Conventional surgical treatment of complex aortic pathologies involving several thoracoabdominal aortic segments necessitates extended incisions or subsequent surgeries, resulting in significant mortality and morbidity rates. The combination of surgery and simultaneous stenting in the operating theater may reduce the surgical trauma. METHODS: A total of nine patients (62 +/- 10 years, range 44-70) underwent a combined surgical and endovascular treatment of thoracic or thoracoabdominal aortic aneurysms or chronic dissection. Five patients were treated with viscero-renal artery translocation followed by transfemoral stenting of the entire thoracoabdominal aorta. Two patients underwent debranching of the supraaortic vessels followed by immediate transfemoral stenting of the aortic arch, and two patients with a history of an ascending aortic aneurysm repair were treated with open surgical debranching of the supraaortic trunks and repair of the ascending aorta and aortic arch with elephant trunk technique. Preoperatively, magnetic resonance imaging was used to check supraaortic and intracranial vessels as well as the completeness of the Circle of Willisi prior to arch stenting and/or supraaortic vessel surgery. Cerebrospinal fluid drainage and induced mild hypertension have been used for one-step thoracoabdominal aortic stenting. RESULTS: Thirty-day mortality rate and incidence of paraplegia was 0%. There was a single reversible perioperative stroke after aortic arch stenting. One patient required temporary renal replacement therapy using continuous arterio-venous hemofiltration. There was one early reoperation at the superior mesenteric artery after viscero-renal translocation. Four type I endoleaks occurred in three patients requiring two interventions. All patients have been discharged to home. CONCLUSION: The innovative combination of simultaneous conventional surgery and stenting reduces the operative burden for patients with complex aortic pathologies involving several segments of the thoracic and thoracoabdominal aorta. Arch debranching and viscero-renal artery translocation may avoid the use of thoracoabdominal incisions, cardiopulmonary bypass techniques, deep hypothermia, and circulatory arrest.