Stanford type B aortic dissection in a patient with aberrant right subclavian artery.

An aberrant right subclavian artery is a rare aortic arch anomaly where the right subclavian artery arises from the proximal part of the descending thoracic aorta and distal to origin of left subclavian artery. It usually courses behind the esophagus. Type B aortic dissection along with aberrant right subclavian artery is not common. A middle-aged man presented with complaints of epigastric pain and on evaluation was found to have aberrant right subclavian artery with type B aortic dissection. A total arch replacement with frozen elephant trunk surgery and an extra-anatomic bypass of right subclavian artery were performed. Type B aortic dissection is more often an incidental finding and its association with aberrant right subclavian artery is unusual. Such association should be identified and treated accordingly to avert clinical complications.

Open aortic arch surgery-how we do it.

Open aortic arch surgery is still challenging even in the present era with the Achilles' heel being the neurological complication. The variety of approaches and surgical techniques used to reconstruct the aortic arch, protecting the vital organs, the extent of aortic replacement, and the options of reimplanting the supra-aortic arch vessels indicate the challenges involved in the procedure. Though open surgery still remains the 'gold standard', in the last two decades, endo-prostheses and stents have emerged as alternate options. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01574-9.

Nature always sides with the hidden flaw: importance of the 'aortic team' approach.

Blunt thoracic aortic injuries (BTAI) are highly lethal, though their incidence is < 1%. The treatment options for BTAI have evolved over the years, where non-operative management is advised even in grade II injuries. In patients undergoing thoracic endovascular aortic repair, it is of vital importance that the left subclavian artery is revascularized. Many authors have opted for selective revascularization of the left subclavian artery in case of an emergency situation where the clinical condition of the patient is unstable. A joint team effort involving the diagnostic radiologist, cardiologist, interventional cardiologist/radiologist/vascular surgeon, cardiac surgeon and anaesthesiologist, referred to as the 'aortic team', is vital in complex aortic interventions.

Surgical techniques in acute Type A aortic dissection: How we do it.

Acute Type A aortic dissection (ATAAD), a surgical emergency, has high mortality and morbidity. More than half of the patients dies within 2 weeks and the 30-day mortality is 90%. Here we describe our technique of ATAAD repair.

Structural abnormalities in the non-dilated ascending aortic wall of bicuspid aortic valve patients.

BACKGROUND: A bicuspid aortic valve (BAV) is the most common congenital cardiac malformation. The development of the aortic valve is closely related to the development of the ascending aorta, associated with structural differences in the bicuspid aorta. Here we describe the non-dilated ascending aortic wall in bicuspid aortic valve patients. METHODS: BAV (n=41) and tricuspid aortic valve (TAV) (n=18) non-dilated ascending aortic wall samples were studied. We investigated the following features of the aortic wall: vessel wall thickness, endothelial cell morphology, atherosclerosis, and elastic lamellae organization. Medial pathologic features encompassing elastic fiber thinning, fragmentation and degeneration, overall medial degeneration, mucoid extracellular matrix accumulation, and smooth muscle cell nuclei loss were studied. Furthermore, we included apoptosis, periaortic inflammation, and the level of expression of differentiated vascular smooth muscle cells. RESULTS: The non-dilated BAV ascending aortic wall is characterized by a significantly thinner intimal layer, without features of atherosclerosis (P<.001). The medial layer is significantly thicker (P<.001) with more mucoid extracellular matrix accumulation (P<.001). All other medial pathologic features were more prominent in the TAV (P<.001). The media has significantly less differentiated vascular smooth muscle cells (P<.001) between the neatly regulated elastic lamellae which are thinner in the BAV as compared to the TAV (P<.0001). CONCLUSIONS: The BAV ascending aorta without dilatation is characterized by a differentiation defect of vascular smooth muscle cells in the media and a significantly thinner intimal layer without overt pathologic features.

Risk Prediction Models for Management of Patients following Acute Aortic Dissection.

Risk prediction of adverse outcomes post aortic dissection is dependet not only on the postdissection-associated clinical factors but on the very foundation of the risk factors that lead up to the dissection itself. There are various such risk factors existing prior to the dissection which impact the postdissection outcomes. In this paper, we review the literature to critically analyze various risk models, burdened by their significant limitations, that attempt to stratify risk prediction based on postdissection patient characteristics. We further review several studies across the literature that investigate the diverse set of predissection risk factors impacting postdissection outcomes. We have discussed and appraised numerous studies which attempt to develop a tool to stratify risk prediction by incorporating the impacts of different factors: malperfusion, blood biochemistry, and perioperative outcomes. The well-validated Penn classification has clearly demonstrated in the literature the significant impact that malperfusion has on adverse outcomes postdissection. Other risk models, already severely hindered by their limitations, lack such validation. We further discuss additional alluded risk factors, including the impact of predissection aortic size, the syndromic and nonsyndromic natures of dissection, and the effects of family history and genetics, which collectively contribute to the risk of adverse outcomes postdissection and prognosis. To achieve the goal of a true risk model, there remains the vital need for appreciation and appropriate consideration for all such aforementioned factors, from before and after the dissection, as discussed in this paper. By being able to incorporate the value of true risk prediction for a patient into the decision-making framework, it will allow a new page of precision medical decision-making to be written.

The motivators and barriers to a career in cardiothoracic surgery: a cross-sectional study among surgical residents in India.

Introduction: A consistent decline in the number of applicants to cardiothoracic and vascular surgery (CTVS) training programs has been observed across the country over the last few years. This disenchantment with the speciality will lead to a shortage of trained CTVS surgeons at a time when incidence of cardiovascular diseases is continuously rising in India. Aims/Objectives: The aim of the study was to reflect on the reasons that averted applicants from pursuing a career in CTVS and measures that would make CTVS a more attractive option to future applicants. Methods: An online nationwide prospective cross-sectional survey was conducted. The participants were from a pool of general surgery residents/residents who had just completed the training. A 5-point Likert scale was utilized to rate and evaluate the factors influencing CTVS as the primary choice, factors influencing any super-speciality, and factors that would aid in decision-making and encourage an interest in CTVS. Results: A total of 618 responses were obtained, 25.6% (N = 158) of the responses were from female residents. Only 10.7% (N = 66) of the respondents wanted to pursue CTVS as their primary choice. While interest in CTVS among the 1st year residents was 26%, it was further observed to decline to 18.72% after completion of training. The main disincentives for pursuing CTVS were the need for a hospital with required infrastructure and the dependence on a multi-disciplinary team. The perception of the participants that the cardiologist will take over CTVS procedures was another misguided but important factor. Those residents interested in pursuing CTVS identified the dynamic nature of the speciality as well as the thrills of being a cardiac surgeon as important motivators. Participants felt that adding catheter-based technology to the CTVS curriculum, mandatory CTVS rotation during surgical training, and closer interaction with CTVS residents will generate more interest in CTVS. Conclusion: Although surgical residents report early interest in CTVS, a lack of adequate exposure to the speciality leads to a decline in interest in CTVS. An overhaul of the surgical training that mandates rotating to CTVS, increased interactions with medical students and surgical trainees by CTVS faculty, and incorporation of catheter-based training in the CTVS syllabus is urgently required to increase the number of applicants to CTVS. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01406-2.

Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis.

BACKGROUND: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. MATERIALS AND METHODS: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. RESULTS: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01-0.06, I2 = 78%) and 3% (95% CI 0.01-0.11, I2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I2 = 89%) while the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I2 = 92%). After subgroup analysis, heterogeneity for distal stent-graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E-Vita stent-grafts were used (both I2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I2 = 15.1%) and Frozenix stent-grafts (I2 = 1%). CONCLUSION: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results.

Total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Aggressive versus conservative.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 h of onset, with the mortality rate is increasing by 1%-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable. AIMS: This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients. METHODS: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE, and Scopus to collate the relevant research evidence. RESULTS: The more aggressive TAR approach for treating ATAAD seems to yield more favorable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique. CONCLUSION: It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients.

Retroaortic left renal vein in open thoracoabdominal aneurysm repair: A modified approach.

The incidence of retroaortic left renal vein (RLRV) is less than 6%. This anatomical variation hinders the exposure and anastomosis of visceral arteries during open thoracoabdominal aneurysm repair. This situation may warrant division and ligation of the RLRV using the conventional retroperitoneal approach. This report describes a modified approach wherein the vein is not divided, thereby improving its surgical exposure.

Malperfusion syndrome in acute type A aortic dissection: It's not what you know, it's what you can prove!

Organ malperfusion after type A aortic dissection represents a high-risk group for open surgical repair. This is particularly the case when mesenteric ischemia occurs. Central aortic repair should be considered for all presenting with malperfusion as many are due to dynamic obstruction. However, depending on imaging and clinical appearance many should be considered for adjunctive techniques including catheter-based endovascular and even open surgical revascularisation may be appropriate. This is due to as many as 20% with a static component to the malperfusion syndrome. Improving methods of ascertaining the type of malperfusion being treated and presenting symptoms requires a multidisciplinary team with access to a hybrid theater where all techniques can be accessed 24/7. This would only be achieved by centralization of vascular units whereby sufficient funding and organization are in place to deal with the consequences of this unpredictable and invariably deadly aortic pathology.

Frozen elephant trunk in acute type A aortic dissections: frontiers and challenges.

Acute type A aortic dissection (ATAAD), a surgical emergency, has high mortality and morbidity. More than half of the patients die within 2 weeks and the 30-day mortality is 90%. Frozen elephant trunk in ATAAD addresses the primary and secondary goals - resection of the primary tear in the ascending aorta and promoting remodelling in the downstream aorta. Though the literature supports this fact, in reality these literatures emerge from high-volume centres. But in the "real world" most of the ATAAD are operated on in the low-volume centres. Furthermore, in India, there are unique challenges including the financial burden, transport, emergent availability of the hybrid prosthesis and aortic supercentres.

Type A aortic dissection during in pregnancy: Confront without aversion or delay.

Type A aortic dissection (TAAD) is a life-threatening clinical emergency requiring timely surgical intervention. Concomitant with pregnancy at any stage, it adds an additional level of complexity which mandates careful planning for the management strategy that will yield the optimal outcomes. It is life-threatening pathology to both the mother and fetus, with mortality rates of up to 30% and 50% reported, respectively. Safe imaging modalities that do not expose the fetus to radiation and contrast are recommended to reach an accurate diagnosis. In addition, meticulous multidisciplinary team planning is pivotal to ensure optimal outcomes are achieved through careful choice of surgical technique as well as strict control of medications. Although TAAD in pregnancy is associated with high mortality and morbidity to both the mother and her fetus, success in the treatment of this small subset of patients can certainly be achieved.