Persistent malperfusion after central aortic repair in acute type I aortic dissections.

OBJECTIVE: Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention. METHODS: Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death. RESULTS: There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion. CONCLUSIONS: One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.

Vascular surgery presence in carotid endarterectomy YouTube videos.

OBJECTIVE: YouTube videos have become a common resource for trainees to learn about surgical procedures. Carotid endarterectomy (CEA) is one example procedure that may be performed by multiple specialties and with a variety of techniques. Little is known about educational content and the representation of vascular surgeons in these videos. We sought to compare the educational quality of CEA YouTube videos, techniques demonstrated, and prevalence of each specialty. METHODS: YouTube was programmatically searched for the terms "carotid endarterectomy," "carotid endarterectomy surgery," "carotid endarterectomy technique," "carotid endarterectomy CEA," and "carotid artery surgery." Videos that met inclusion criteria were analyzed for surgical technique, procedural steps, surgeon specialty, video length, and date. Videos were determined to have high-quality educational content if the video included English-language captions or narration and demonstrated key steps of the procedure: division of the common facial vein; exposure of the common, external, and internal carotid arteries; vascular control and clamping; and arteriotomy, endarterectomy, and arteriotomy closure. RESULTS: Forty-six videos met inclusion criteria. Vascular surgery was associated with 12 (26.1%) CEA videos, cardiac surgery with 13 (28.3%), and neurosurgery with 14 (30.4%). Surgeon specialty was unknown for seven (17.4%) videos. Eight videos were high quality, of which vascular surgery was associated with three (37.5%). Conventional endarterectomy was the most common technique demonstrated, whereas a total of seven videos demonstrated eversion technique. Vascular and cardiac surgeons were more likely to demonstrate patch angioplasty than neurosurgeons, who exclusively performed primary closure (P < .05). Compared with cardiac surgeons, vascular surgeon CEA videos had more views (25,956 ± 9613 vs 1200 ± 368; P < .05) and were more likely to be published by user accounts with an academic affiliation (11 vs 6; P < .05). Vascular surgery videos were older than videos by cardiac surgeons (6.0 ± 1.1 years vs 3.0 ± 0.5 years; P < .05) and neurosurgeons (6.0 ± 1.1 years vs 3.1 ± 0.8 years; P < .05). CONCLUSIONS: Despite more views, the field of vascular surgery is under-represented in YouTube videos demonstrating CEA. Vascular surgery videos tend to be older and make up a minority of high-quality videos. As more learners turn to YouTube for information about surgical procedures, vascular surgeons should expand their online presence through the production and collection of high-quality videos for trainees.