Multilayer Flow Modulator Stent for Aortic Pathology: A Meta-Analysis and Additional Data from a Single-Centre Retrospective Cohort.

Background: Thoracoabdominal aneurysms and aortic dissections are a challenge for vascular surgeons. Open surgery, fenestrated or branched endograft, and the chimney technique are not possible in some patients, because of comorbidities or anatomical restrictions. However, the multilayer flow modulator (MFM) can be implanted in some of these patients. In this systematic review, we will describe the experience with the multilayer stent. To augment the limited number of studies available, we will include a cohort of patients from our hospital. Methods: We retrieved data on all consecutive patients treated using the MFM between May 2013 and August 2020. This included patients with type B dissections and thoracoabdominal or thoracic aneurysms who were unfit for open surgery. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all the studies that used the MFM in the aortic segment. Single-arm meta-analyses were performed using OpenMeta (Brown University, Providence, RI, USA). Results: A total of 37 patients were treated in our hospital during the study period. The technical success was 97.3% and the 30-day mortality was 5.4%. In 40.5% of the included patients, the instructions for use were not followed. Off-label implantation was associated with a higher aneurysm-related mortality. A total of 12 studies were included in the meta-analysis and the technical success was 97.8%. In 68.5%, the aneurysm sack or false lumen remained perfused, 97% of all the covered side branches remained patent. After a follow-up period of 1 year, five patients in the meta-analysis presented with a ruptured aneurysm. Conclusions: The overall quality of evidence is poor because long-term results are lacking, patients are frequently lost during follow-up and all the studies were non-comparative. Our retrospective study suggests a relatively low incidence of perioperative complications, although there was a high incidence of persistent perfusion in the aneurysm sac (102 of 149 patients). The risk of rupture at the 1-year follow-up was 2.1%.

Innovation in pathogenesis and management of aortic aneurysm.

Aortic aneurysm (AA) refers to the persistent dilatation of the aorta, exceeding three centimeters. Investigating the pathophysiology of this condition is important for its prevention and management, given its responsibility for more than 25000 deaths in the United States. AAs are classified based on their location or morphology. various pathophysiologic pathways including inflammation, the immune system and atherosclerosis have been implicated in its development. Inflammatory markers such as transforming growth factor ß, interleukin-1ß, tumor necrosis factor-α, matrix metalloproteinase-2 and many more may contribute to this phenomenon. Several genetic disorders such as Marfan syndrome, Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease. Recent years has seen the investigation of novel management of AA, exploring the implication of different immune suppressors, the role of radiation in shrinkage and prevention, as well as minimally invasive and newly hypothesized surgical methods. In this narrative review, we aim to present the new contributing factors involved in pathophysiology of AA. We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Hospital Incidence, Sex Disparities, and Perioperative Mortality in Open Surgically Treated Patients with Aneurysms of the Ascending Aorta and Aortic Arch in Switzerland.

OBJECTIVE: To analyze the epidemiological shifts in the incidence of ascending and arch aortic aneurysms (AA) treated with open surgery in the context of evolving endovascular options on a national basis. METHODS: Between 1 January 2009 and 31 December 2018, 4388 cases were admitted to the hospital with either ruptured (r)AA or non-ruptured (nr)AA as the primary or secondary diagnosis. Patients were classified as having AA based on inclusion and exclusion criteria. RESULTS: The age-standardized hospital incidence rates for treatment of nrAA were 7.8 (95% confidence interval (CI): 6.9 to 8.7) in 100,000 men and 2.9 (2.4 to 3.4) in 100,000 women and were stable over time. The overall raw in-hospital mortality rate was 2.0% and was significantly lower in males compared to women (1.6% vs. 2.8%, p = 0.015). Higher van Walraven scores (OR: 1.08 per point; 95%CI: 1.06 to 1.11; p = 0.001) and higher age (OR 1.05 per year; (95%CI: 1.02 to 1.07, p = 0.045) were significantly associated with hospital mortality. CONCLUSIONS: Endovascular surgery seems to have no influence on hospital incidence in patients treated with conventional surgery for AA in Switzerland. There was a significant reduction in in-hospital mortality in both men and women, with age and the von Walraven score being independent factors for worse outcomes.

Presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, existing gaps, and future directions: A descriptive review.

Thoracic and thoracoabdominal aortic aneurysms are more common in men. Yet, females often have worse outcomes, fewer interventions, and lower treatment rates. Females have also benefited less from the research and treatment of those diseases than men. Understanding sex- and sex-specific differences in thoracic and thoracoabdominal aortic aneurysms can improve care delivery, reduce disparities, and optimize outcomes for females with thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. The authors reviewed the literature on the presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, discussing the existing gaps and future directions to address them.

Reduced Levels of Selenium and Thioredoxin Reductase in the Thoracic Aorta Could Contribute to Aneurysm Formation in Patients with Marfan Syndrome.

Marfan syndrome (MFS) is an autosomal dominant disorder caused by a heterozygous mutation of the FBN1 gene. MFS patients present oxidative stress that disturbs redox homeostasis. Redox homeostasis depends in part on the enzymatic antioxidant system, which includes thioredoxin reductase (TrxR) and glutathione peroxidases (GPx), both of which require an adequate concentration of selenium (Se). Therefore, the aim of this study was to determine if Se levels are decreased in the TAA of patients with MFS since this could contribute to the formation of an aneurysm in these patients. The results show that interleukins IL-1ß, IL-6 TGF-ß1, and TNF-α (p ≤ 0.03), and carbonylation (p ≤ 0.03) were increased in the TAA of patients with MFS in comparison with control subjects, while Se, thiols (p = 0.02), TrxR, and GPx (p ≤ 0.001) were decreased. TLR4 and NOX1 (p ≤ 0.03), MMP9 and MMP2 (p = 0.04) and NOS2 (p < 0.001) were also increased. Therefore, Se concentrations are decreased in the TAA of MFS, which can contribute to a decrease in the activities of TrxR and GPx, and thiol groups. A decrease in the activities of these enzymes can lead to the loss of redox homeostasis, which can, in turn, lead to an increase in the pro-inflammatory interleukins associated with the overexpression of MMP9 and MMP2.

An Escherichia coli-Induced Distal Arch Aneurysm Presenting With Hemoptysis.

Infected thoracic aneurysms are a rare and potentially life-threatening condition that present with non-specific symptoms. We describe here a case of an 83-year-old female who presented to the emergency department with the chief complaint of vomiting blood. The patient had presented to the emergency department 40 days earlier with abdominal pain, fever, and leukocytosis. She had a medical history of traumatic liver injury resulting in bile duct stenosis, necessitating percutaneous transhepatic gallbladder drainage and subsequent bile duct-jejunal anastomosis 25 years ago. Emergency contrast-enhanced computed tomography (CT) revealed an irregular distal arch aneurysm. According to the patient's present symptoms, CT findings, and medical history, infected thoracic aneurysm was suspected. Total arch replacement was performed promptly, followed by thorough antibiotic therapy. Following successful treatment, the patient's condition stabilized, and she was transferred to a rehabilitation facility for further recovery.

Pulmonary Artery Aneurysm: A Rarity and Surgical Enigma.

Given the low incidence of pulmonary artery aneurysms (PAAs), proven surgical indications do not yet exist. We present a patient with a 6.3 cm PAA who underwent an open sternotomy, pulmonary artery aneurysmectomy, and repair with an aortic homograft. We discuss surgical indications, including pain, growth in diameter, and diameter of 5.5 cm and larger. The current recommended surgical indication for the size of PAAs is based on recommendations for aortic aneurysms and observation in a small number of operable patients, highlighting the need for more discussion and reporting of this rare presentation.

Targeted Proteomic Analysis of Patients with Ascending Thoracic Aortic Aneurysm.

BACKGROUND: There is a need for clinical markers to aid in the detection of individuals at risk of harboring an ascending thoracic aneurysm (ATAA) or developing one in the future. OBJECTIVES: To our knowledge, ATAA remains without a specific biomarker. This study aims to identify potential biomarkers for ATAA using targeted proteomic analysis. METHODS: In this study, 52 patients were divided into three groups depending on their ascending aorta diameter: 4.0-4.5 cm (N = 23), 4.6-5.0 cm (N = 20), and >5.0 cm (N = 9). A total of 30 controls were in-house populations ethnically matched to cases without known or visible ATAA-related symptoms and with no ATAA familial history. Before the debut of our study, all patients provided medical history and underwent physical examination. Diagnosis was confirmed by echocardiography and angio-computed tomography (CT) scans. Targeted-proteomic analysis was conducted to identify possible biomarkers for the diagnosis of ATAA. RESULTS: A Kruskal-Wallis test revealed that C-C motif chemokine ligand 5 (CCL5), defensin beta 1 (HBD1), intracellular adhesion molecule-1 (ICAM1), interleukin-8 (IL8), tumor necrosis factor alpha (TNFα) and transforming growth factor-beta 1 (TGFB1) expressions are significantly increased in ATAA patients in comparison to control subjects with physiological aorta diameter (p < 0.0001). The receiver-operating characteristic analysis showed that the area under the curve values for CCL5 (0.84), HBD1 (0.83) and ICAM1 (0.83) were superior to that of the other analyzed proteins. CONCLUSIONS: CCL5, HBD1 and ICAM1 are very promising biomarkers with satisfying sensitivity and specificity that could be helpful in stratifying risk for the development of ATAA. These biomarkers may assist in the diagnosis and follow-up of patients at risk of developing ATAA. This retrospective study is very encouraging; however, further in-depth studies may be worthwhile to investigate the role of these biomarkers in the pathogenesis of ATAA.

[Complex endovascular repairs of the aortic arch.] / Komplex endovascularis rekonstrukciók az aortaíven.

Thoracic endovascular aneurysm repair (TEVAR) of the aortic arch has started to spread in recent years. We present our initial experience with TEVAR involving supra-aortic branches using parallel and branched grafts. Parallel grafts are typically used in emergency cases. In the case of Z0 proximal fixation, we can perform a combined hybrid surgery with Z1 debranching and securing of the innominate artery with chimney graft, which can also be used instead of Z0 debranching when the patient is unfit for sternotomy. In the case of TEVAR with planned Z2 position with inadvertent covering of the left common carotid artery, we can perform chimney conversion to rapidly recover the circulation of the left common carotid artery (LCCA). Instead of prior revascularization of the left subclavian artery, chimney graft can be used to recover the lumen, in the case of left upper limb ischemia after Z2 TEVAR. Exclusion of penetrating aortic ulcers located in the lesser curvature can be facilitated by use of a custom-made graft, where a scallop is placed around the origin of the supra-aortic vessel, thus increasing the length of the proximal neck. For elective interventions, custom-made branching grafts can be allowed to save all three branches with Z0 fixation. Technical success was obtained in all cases. Orv Hetil. 2023; 164(11): 426-431.

FN (Fibronectin)-Integrin α5 Signaling Promotes Thoracic Aortic Aneurysm in a Mouse Model of Marfan Syndrome.

BACKGROUND: Marfan syndrome, caused by mutations in the gene for fibrillin-1, leads to thoracic aortic aneurysms (TAAs). Phenotypic modulation of vascular smooth muscle cells (SMCs) and ECM (extracellular matrix) remodeling are characteristic of both nonsyndromic and Marfan aneurysms. The ECM protein FN (fibronectin) is elevated in the tunica media of TAAs and amplifies inflammatory signaling in endothelial and SMCs through its main receptor, integrin α5ß1. We investigated the role of integrin α5-specific signals in Marfan mice in which the cytoplasmic domain of integrin α5 was replaced with that of integrin α2 (denoted α5/2 chimera). METHODS: We crossed α5/2 chimeric mice with Fbn1mgR/mgR mice (mgR model of Marfan syndrome) to evaluate the survival rate and pathogenesis of TAAs among wild-type, α5/2, mgR, and α5/2 mgR mice. Further biochemical and microscopic analysis of porcine and mouse aortic SMCs investigated molecular mechanisms by which FN affects SMCs and subsequent development of TAAs. RESULTS: FN was elevated in the thoracic aortas from Marfan patients, in nonsyndromic aneurysms, and in mgR mice. The α5/2 mutation greatly prolonged survival of Marfan mice, with improved elastic fiber integrity, mechanical properties, SMC density, and SMC contractile gene expression. Furthermore, plating of wild-type SMCs on FN decreased contractile gene expression and activated inflammatory pathways whereas α5/2 SMCs were resistant. These effects correlated with increased NF-kB activation in cultured SMCs and mgR aortas, which was alleviated by the α5/2 mutation or NF-kB inhibition. CONCLUSIONS: FN-integrin α5 signaling is a significant driver of TAA in the mgR mouse model. This pathway thus warrants further investigation as a therapeutic target.

A phenotypic screen of Marfan syndrome iPSC-derived vascular smooth muscle cells uncovers GSK3ß as a new target.

Marfan syndrome (MFS) is a rare connective tissue disorder caused by mutations in FBN1. Patients with MFS notably suffer from aortic aneurysm and dissection. Despite considerable effort, animal models have proven to be poorly predictive for therapeutic intervention in human aortic disease. Patient-derived induced pluripotent stem cells can be differentiated into vascular smooth muscle cells (VSMCs) and recapitulate major features of MFS. We have screened 1,022 small molecules in our in vitro model, exploiting the highly proteolytic nature of MFS VSMCs, and identified 36 effective compounds. Further analysis identified GSK3ß as a recurring target in the compound screen. GSK3ß inhibition/knockdown did not ameliorate the proliferation defect in MFS-VSMCs but improved MFS-VSMC proteolysis and apoptosis and partially rescued fibrillin-1 deposition. To conclude, we have identified GSK3ß as a novel target for MFS, forming the foundation for future work in MFS and other aortic diseases.

Angiopoietin-like protein 8 deficiency attenuates thoracic aortic aneurysm/dissection development in ß-aminopropionitrile monofumarate-induced model mice.

Thoracic aortic aneurysm/dissection (TAAD) is a life-threatening cardiovascular disorder. Endoplasmic reticulum stress (ERS) and vascular smooth muscle cell (VSMC) apoptosis are involved in TAAD progression. The Protein kinase R (PKR)-like endoplasmic reticulum kinase (PERK) pathway is associated with VSMC apoptosis. Serum Angiopoietin-Like Protein 8 (ANGPTL8) levels are associated with aortic diameter and rupture rate of TAAD. However, a direct role of ANGPTL8 in TAAD has not been determined. ß-Aminopropionitrile monofumarate (BAPN) was used to induce TAAD in C57BL/6 mice. ANGPTL8 knockout mice were used to detect the effects of ANGPTL8 on TAAD development. ANGPTL8knockdown in vitro was used to analyze the role of ANGPTL8 in VSMCs and ERS. In addition, over-expression of ANGPTL8 in VSMCs and a PERK inhibitor were used to assess the effect of ANGPTL8 on the PERK pathway. ANGPTL8 levels were increased in the aortic wall and VSMCs of BAPN-induced TAAD mice. Compared with BAPN-treated wild-type mice, ANGPTL8 knockout significantly reduced the rupture rate of TAAD to 0 %. In addition, the protein levels of proinflammatory cytokines and matrix metalloproteinase 9 (MMP9) and ERS proteins were decreased in the aorta wall. Angptl8 shRNA decreased MMP9 and ERS protein levels in VSMCs in vitro. Overexpression of ANGPTL8 significantly increased the levels of ERS proteins and MMPs, while a PERK inhibitor significantly decreased the effects of ANGPTL8 in VSMCs. ANGPTL8 contributed to TAAD development by inducing ERS activation and degradation of extracellular matrix in the aorta wall. Inhibition of ANGPTL8 may therefore represent a new strategy for TAAD therapy.

Celiac Artery Coverage After Thoracic Endovascular Aortic Procedure: A Meta-Analysis of Early and Late Results.

BACKGROUND/AIM: Clinical outcomes of celiac artery (CA) coverage during aortic procedures are often contradicting and the fate of this additional maneuver is still unclear. This study summarizes the results of available literature and aims to clarify the impact of CA coverage during thoracic endovascular aneurysm repair (TEVAR) in patients with inadequate distal sealing zone. METHODS: Prospective and retrospective, observational original articles focused on CA coverage during elective/urgent TEVAR for descending thoracic aortic pathology (DTAP) were included. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials database were examined to identify articles published from January 2007 to December 2020, according to PRISMA guidelines. Early and late visceral (any sign or symptom reported) and neurological (both transient and permanent) complications were considered as primary outcomes. Onset of any endoleak, type IB endoleak, need of reintervention, and TEVAR-related mortality were considered as secondary outcomes. RESULTS: A total of 5618 articles were extracted for analysis and 13 studies were finally included in the synthesis. A total of 178 CAs were covered during 2653 TEVAR (7%). Spinal cord ischemia was 8% (95% CI, 5-14%, I2 0%) Any endoleak and type IB endoleak was observed in 12% (95% CI, 6-21%, I2 17%) and 5% (95% CI, 2-11%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reoperation was necessary in 8% (95% CI, 4-14%, I2 0%), the majority of which (14/18, 78%) performed for distal sealing failure; mortality rate was 9% (95% CI, 5-14%, I2 0%). Out of 178 patients, 168 (94%) were available for follow-up, ranged 12 to 42 months. Visceral complications, any endoleak, and type IB endoleak were identified in 15% (95% CI, 10-23%, I2 45%), 20% (95% CI, 13-29%, I2 8%), and 8% (95% CI, 4-15%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reintervention was required in 8% (95% CI, 4-14%, I2 0%). Mortality rate was 17% (95% CI, 12-25%, I2 4%). CONCLUSIONS: Celiac artery coverage in DTAP should be regarded as a "bailout" procedure especially in urgent/emergent settings but requires caution in elective cases. Even if transient visceral ischemia is frequent, life-threatening complications are rare. Early and late mortality rates are similar to standard TEVAR although the risk of type IB endoleak and reintervention may be an issue.

Inferior Vena Cava-Balloon Occlusion and Its Effect on the Myocardium During Endograft Deployment in the Arch.

PURPOSE: To evaluate the impact of cava balloon occlusion on the myocardium during endovascular repair of thoracic aortic pathologies. MATERIAL AND METHODS: A prospective observational cohort study of 21 patients who underwent endovascular repair of aortic arch and thoracic aorta in a single tertiary referral center with use of inferior vena cava (IVC) balloon occlusion as a method of intraoperative cardiac output reduction. Pre-, intra-, and postoperative measurements of heart rate, blood pressure, stroke volume index, and central venous oxygen saturation were noted. High-sensitive serum troponin levels were also analyzed according to a pre-established protocol. Endpoints were cardiac troponin T levels after induced hypotension and left ventricular ejection fraction during follow-up. Secondary endpoints were procedure technical success and overall survival. RESULTS: Twenty-one patients (18 male, median age 69, (62-75, IQR)) enrolled in the study between May 2015 and January 2019. Indication for endovascular treatment was an aortic arch aneurysm (n=10), descending aortic aneurysm (n=8), lusorian artery aneurysm (n=2), and thoracoabdominal aortic aneurysm (n=1). Median time to reach half mean arterial pressure was 60 seconds while median recovery time of blood pressure was 135 seconds. In 5 (24%) cases, we observed a > 50% change of Troponin T on the reference level. Technical success was achieved in all cases. Two (10%) patients developed new and persistent atrial fibrillation and 1 (5%) suffered a peri-operative ST-elevation myocardial infarction. CONCLUSION: The use of IVC balloon occlusion is a feasible technique for cardiac output reduction during endovascular repair of thoracic aortic pathologies. One fourth of the patients develop significant troponin leakage but the significance of the finding needs further studies.

A case of unexpected intraoperative airway obstruction in a patient with an aneurysm of the ascending aorta and aortic arch.

Upper airway compression is one of the clinical manifestations of thoracic aortic aneurysm, which is associated with poor prognosis and high mortality. A 44-year-old patient with ascending aortic and arch aneurysm who was scheduled for Bentall surgery and total arch replacement under cardiopulmonary bypass suffered difficult ventilation after endotracheal intubation. The patient did not exhibit any positional dyspnoea or orthopnoea, did not show any difficulties in the supine position, and had no noteworthy medical history. However, we encountered unexpected hypoventilation after intubation. Isoprenaline infusion was effective while emergency cardiopulmonary bypass was established to deal with this crisis. Fibreoptic bronchoscopy revealed complete obstruction of the carina and confirmed the supracarinal position of the tube. Complete airway obstruction may occur even if there are no symptoms before surgery in patients with thoracic aortic aneurysm. Comprehensive preoperative assessment, a well-developed airway management plan, and responses to possible emergencies are essential to reduce unnecessary events or complications.

A Single-Center Experience With Total Percutaneous Implantation of a Low-Profile Thoracic Aortic Stent-Graft.

PURPOSE: To evaluate the safety and effectiveness of total percutaneous implantation of the Zenith Alpha Thoracic (ZTA) endograft in the treatment of diseases of the descending thoracic aorta. MATERIALS AND METHODS: A retrospective cohort study of 56 consecutive patients undergoing total percutaneous ZTA implantation between 2018 and 2020 was performed in a single center. Patients' demographics, clinical characteristics, anatomical parameters, operative details, device features, and postoperative outcomes were assessed. The primary endpoint was ongoing clinical success. A Cox regression model was used to determine the predictive factors of worse postoperative outcomes. RESULTS: Eighty-three ZTA endografts were implanted in 35 men and 21 women with a mean age of 69±11 years for the treatment of 26 degenerative aneurysms, 15 type B dissections, and 8 penetrating ulcers, among others. Primary technical success was 100%, with a 30-day ongoing clinical success rate of 94.6%. The 1-year ongoing clinical success rate was 91.1% (51 patients), and freedoms from all-cause mortality, type 1 and 3 endoleaks, and any unplanned reintervention were, respectively, 95.3%, 91.4%, and 88.2% at 1 year. During follow-up, there was one case of surgical conversion for an aorto-esophageal fistula. On the contrary, neither aneurysmal rupture nor significant aneurysmal expansion was recorded. Repair of ruptured thoracic aorta and a high ratio of sheath outer diameter to external iliac artery diameter were found to be independently associated with worse outcomes, with adjusted odds ratios of 4.4 [1.5-15.3] and 4.9 [1.1-23.9], respectively. CONCLUSION: The outcomes of total percutaneous implantation of ZTA endograft show excellent primary technical success and favorable midterm ongoing clinical success. Factors associated with worse outcomes include the repair of ruptured aorta and a high sheath to access vessel ratio.

DeBakey Type II Acute Aortic Dissection Distant From the Proximal Edge of a Stent Graft: A Case Report Nine Years After Thoracic Endovascular Aortic Repair.

An 84-year-old male with a medical history notable for prior thoracic endovascular aortic repair for thoracic aneurysm nine years ago presented to the emergency department with a chief complaint of transient loss of consciousness. A brain computed tomography showed no remarkable findings. A subsequent computed tomography scan for comprehensive evaluation revealed DeBakey type II acute aortic dissection as evidenced by contrast-enhanced imaging. An intimal tear was found on the ascending aorta distant from the proximal edge of a stent graft. Due to the urgency of the situation, the patient underwent emergent ascending aortic replacement. Following the successful intervention, the patient was transferred to a specialized rehabilitation facility with the goal of facilitating further improvement in their condition.

Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair.

Objective: The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm. Methods: From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival. Results: After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation. Conclusions: Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

Hypothermic circulatory arrest versus aortic clamping in thoracic and thoracoabdominal aortic aneurysm repair.

BACKGROUND: To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia. METHODS: From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis. RESULTS: Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p < 0.0001) while the AC group had more TAAAs (80% vs. 30%, p < 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p < 0.0001) but shorter cross-clamp time (39 vs. 120 min, p < 0.0001) and lower temperatures (18°C vs. 34°C, p < 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36). CONCLUSIONS: Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.