Open aortic arch repair without circulatory arrest by frozen elephant trunk in Ishimaru zone 0.

BACKGROUND: Open arch surgery is technically demanding for the surgeon and surgically and biologically invasive for the patient, requiring a variably long period of hypothermic circulatory arrest. CASE PRESENTATION: Here we present a case of an elderly patient with chronic renal failure and multiple splanchnic artery disease successfully treated for a rupturing pseudoaneurysm of the aortic arch with a technique that we developed for particularly frail patients. The procedure includes: triple supra-aortic vessel perfusion; distal thoracic aorta antegrade perfusion; balloon endo-clamping of the descending aorta; and anastomosis of an off-the-shelf hybrid arch prosthesis in Ishimaru zone 0. These maneuvers allowed to maintain an extracorporeal circulation in the phase of distal anastomosis, instead of a period of circulatory arrest, employing just mild hypothermia: technical details are depicted and discussed also in comparison with other methods proposed in the literature. CONCLUSIONS: Being able to take advantage of both open surgery advancements and endovascular methods is the key to cardiovascular surgery success today in front of complex pathologies of the aorta: increasing safety and reducing invasiveness of therapeutic options may progressively extend surgical candidacy to the frailest patients.

Transesophageal Echocardiography-Guided Elephant Trunk Procedure for Repair of Descending Thoracic Aorta: A Case Report.

ABSTRACT: The elephant trunk procedure, an endovascular strategy for retrograde type A acute aortic dissection, is associated with several complications, hemolytic anemia being a rare one. We performed endovascular stent-graft insertion in a patient who developed hemolytic anemia. Transesophageal echocardiography (TEE) detected turbulent jet flow and stenosis position, which was not detected by angiography and intravascular ultrasound (IVUS). This imaging technique proved effective for malperfusion diagnosis and enabled us to confirm its resolution after the endovascular procedure. Intraoperative TEE is a useful adjunct to angiography and IVUS for diagnosis and therapeutic assessment during endovascular repair of a stenosed elephant trunk.

[Right aortic arch with mirror image branching : a rare cause of dysphagia]. / L'image du mois. Arc aortique droit avec image en miroir : une cause rare de dysphagie.

We report the case of a 36-year-old female whose dysphagia revealed a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image branching. This is a rare embryonic developmental anomaly where the aorta wraps around the right bronchus and the supra-aortic trunks emerge from the arch in the opposite order to normal. Most of the patients are asymptomatic unless there is a significant compression of mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, dissection of the thoracic aorta, or the presence of a Kommerell diverticulum larger than 2 cm may require a surgical repair. There is no standard treatment and it must be adapted to the clinical presentation and the anatomic configuration of each patient. Our patient did not receive any treatment for her condition.

Nous rapportons le cas d'une patiente de 36 ans dont le tableau de dysphagie a permis de mettre en évidence une anomalie congénitale de l'aorte thoracique : l'arc aortique droit avec image en miroir. Il s'agit d'une anomalie de développement embryonnaire rare où l'aorte s'enroule autour de la bronche souche droite et où les troncs supra-aortiques émergent de la crosse dans l'ordre inverse et opposé à la normale. La grande majorité des patients est asymptomatique, à moins qu'il existe une compression des structures médiastinales. Une compression majeure de l'oesophage ou de la trachée, une maladie anévrismale, une dissection de l'aorte thoracique ou la présence d'un diverticule de Kommerell de plus de 2 cm peuvent justifier une sanction chirurgicale. Il n'y a pas de traitement standard et celui-ci doit être adapté à la présentation clinique et à la configuration anatomique du patient. Notre patiente n'a bénéficié d'aucun traitement pour son affection.

Devastating fungal endocarditis involving ascending aorta in a patient with a history of aortic valve replacement: a case report.

BACKGROUND: Fungal endocarditis is a rare but serious condition associated with high mortality rates. Various predisposing factors contribute to its occurrence, such as underlying cardiac abnormalities, cardiac surgeries, prosthetic cardiac devices, and central venous catheters. Diagnosing fungal endocarditis, particularly Aspergillus, poses challenges, often complicated by negative blood cultures. CASE PRESENTATION: This report details a case of extensive ascending aorta involvement in Aspergillus endocarditis (AE) in a 24-year-old man with a history of bioprosthesis aortic valve replacement (AVR). Three months post-AVR, he presented with pericardial effusion and aortic rupture, leading to a redo biological valved conduit aortic root replacement (Bentall surgery). Despite the intervention, the tubular graft exhibited extensive Aspergillus involvement, resulting in graft disruption and significant peri-aortic infection. A second redo procedure involving aortic homograft root replacement was performed. Unfortunately, the patient succumbed two days after the surgery. CONCLUSION: A combined approach of medical and surgical therapies is recommended to manage fungal endocarditis. Despite efforts, the mortality rate associated with Aspergillus endocarditis remains unacceptably high, with no significant difference observed between combination therapy and antifungal treatment alone. Further research is essential to explore novel therapeutic strategies and improve outcomes for patients with this challenging condition.

Inflammation in aortic surgery: postoperative evolution of biomarkers according pathologies and segments of the aorta.

OBJECTIVES: Aortic pathologies often present with elevated inflammatory biomarkers due to the nature of the disease. Open aortic surgery causes significant trauma to the body due to often mandatory ischemic periods, long cardiopulmonary bypass times and polytransfusion. We aim to determine postoperative trends on inflammation biomarkers for different aortic pathologies and type of surgery in different segments of the aorta. METHODS: Retrospective review of prospectively collected data of 193 consecutive patients who underwent aortic surgery in our centre between 2017 and 2021, grouped according to the type of aortic intervention: (1) Type A aortic dissection (AD) repair with ascending aorta/hemiarch replacement, (2) Aortic root replacement (ARR), (3) Aortic arch + Frozen elephant trunk (FET), (4) Descending thoracic aorta (DTA)/Thoraco-Abdominal aortic repair (TAA). Primary outcomes were daily values of white blood cells (WBC) and C-Reactive Protein (CRP) during the first 15 postoperative days. RESULTS: All groups had a similar inflammatory peak in the first 2-4 days (WBC 12-15 × 109 c/L). AD and FET groups show similar trends with WBC and CRP peaks on days 2 and 10. The ARR group didn't experience the 2nd peak as most patients were already discharged. DTA/TAA patients experienced a more prolonged inflammatory response, reaching a plateau by day 5-10. AD group shows the highest WBC levels and the DTA/TAAA group the highest CRP levels. CRP levels remain elevated (100-200 mg/L) in all groups after 15 postoperative days. CONCLUSIONS: Inflammatory biomarkers show different postoperative trends depending on the clinical presentation and complexity of the aortic procedure performed. Further understanding of the inflammatory response to different aortic pathologies and surgical procedures will permit reduction on the liberal use of antibiotics that this cohort of patients are usually exposed to. An earlier version of the data included in this manuscript was presented as Oral Abstract in the UK Society of Cardiothoracic Surgery Annual meeting in 2021.

A challenging case of emergency redo surgery for acute type A aortic dissecting aneurysm of ascending and aortic arch with frozen elephant trunk following aortic root replacement.

Redo ascending and aortic arch surgeries following previous cardiac or aortic surgery are associated with high risk of morbidity and mortality due to multiple factors included sternal re-entry injury, extensive aortic arch surgery, emergency aortic surgery, prolonged cardiopulmonary bypass duration, poor heart function, and patients with older age. Therefore, appropriate surgical strategies are important. We report a case of a 72-year-old gentleman with previous surgery of aortic root replacement who presented with acute Type A aortic dissecting aneurysm of ascending and aortic arch complicated with left hemothorax, which was successfully treated by emergency redo aortic surgery with frozen elephant trunk (FET) technique.

Clinical outcome of a branch-first approach with a novel continuous whole-brain perfusion strategy for total arch surgery.

BACKGROUND: Cerebral protection strategies have been investigated since the introduction of aortic arch surgery and have been modified over the centuries. However, the cerebral protective effects of unilateral and bilateral antegrade cerebral perfusion are similar, with opportunities for further improvement. METHODS: A total of 30 patients who underwent total arch surgery were enrolled in this study. Patients were assigned to the novel continuous whole-brain or unilateral antegrade cerebral perfusion group according to the cerebral perfusion technique used. Preoperative clinical data and 1-year postoperative follow-up data were collected and analyzed. RESULTS: There were no significant differences between the two groups in terms of the incidence of permanent neurological deficit, mortality, or therapeutic efficacy. However, the incidence of temporary neurological dysfunction in the novel whole-brain perfusion group was significantly lower than that in the unilateral antegrade cerebral perfusion group. CONCLUSIONS: In this study, the branch-first approach with a novel whole-brain perfusion strategy had no obvious disadvantages compared with unilateral antegrade cerebral perfusion in terms of cerebral protection and surgical safety. These findings suggest that this new technique is feasible and has application value for total arch surgery.

Sex-related differences in outcome of thoracic aortic surgery.

BACKGROUND: Sex-related dissimilarities' influence on outcomes following thoracic aortic surgery is poorly understood. Our aim is to examine sex-related disparities in patients undergoing thoracic aortic aneurysm (TAA). METHODS: A total of 455 cases undergoing thoracic aortic aneurysm (TAA) surgery were consecutively enrolled between December 2009 and December 2015 in a Chinese hospital. Primary outcomes, including overall mortality and related risk factors, were evaluated. Cox regression is utilized to recognize the independent risk factor of these consequences. RESULTS: Females, compared to males, had greater indexed aortic diameters and higher aortic transvalvular pressure differences. For the location of aortic aneurysms, females had a higher rate of aortic arch involvement, while males had a higher rate of root involvement. Females underwent less frequent complex proximal aortic operations compared with males (29.5% versus 46.9%; p < 0.001). Women and men both had a lower rate of aortic transvalvular pressure difference and LV volume index 7 days after thoracic aortic surgery. The overall mortality for the women's groups (11%) was suggestively greater compared to 4.9% for the men's groups (p = 0.026). Renal failure and aortic arch involvement were the main risk factors associated with males' survival, while maximum indexed aortic diameter and cross-clamp time were the risk factors associated with females' survival. CONCLUSIONS: The outcome after TAA surgery was less favorable in women with significantly increased overall mortality. It highlights the need to focus on implementing personalized surgery strategies and gender-specific guidelines in treating female patients following TAA surgery.

Experience with aortic arch inclusion technique using artificial blood vessel for type A aortic dissection: an application study.

BACKGROUND: This study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD). METHODS: We conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular "inclusion" between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The 'inclusion' total aortic arch replacement and stented elephant trunk (SET) surgery were performed. RESULTS: Four patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient's false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up. CONCLUSIONS: Incorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.

Successful Percutaneous Thoracic Duct Embolization for Chylothorax After Total Arch Replacement.

Chylothorax after cardiac surgery is a rare complication associated with severe morbidity and mortality. This report documents successful treatment with percutaneous thoracic duct embolization for chylothorax after total arch replacement. A 69-year-old man underwent replacement of the aortic arch to treat a ruptured aortic aneurysm. After surgery, the left thoracic drain discharged 2,000 to 3,000 mL serosanguineous fluid per day, even though the patient took nothing orally and was administered subcutaneous octreotide therapy. On postoperative day 9, percutaneous thoracic duct embolization was performed, and the drain could be removed. The chylothorax did not recur, and the patient was discharged on postoperative day 17.

Predicting adverse events after thoracic endovascular aortic repair for patients with type B aortic dissection.

The potential of adverse events (AEs) after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) has been reported. To avoid the occurrence of AEs, it is important to recognize high-risk population for prevention in advance. The data of 261 patients with TBAD who received TEVAR between June 2017 and June 2021 at our medical center were retrospectively reviewed. After the implementation of exclusion criteria, 172 patients were finally included, and after 2.8 years (range from 1 day to 5.8 years) of follow up, they were divided into AEs (n = 41) and non-AEs (n = 131) groups. We identified the predictors of AEs, and a prediction model was constructed to calculate the specific risk of postoperative AEs at 1, 2, and 3 years, and to stratify patients into high-risk (n = 78) and low-risk (n = 94) group. The prediction model included seven predictors: Age > 75 years, Lower extremity malperfusion (LEM), NT-proBNP > 330 pg/ml, None distal tear, the ratio between the diameter of the ascending aorta and descending aorta (A/D ratio) > 1.2, the ratio of the area of the false lumen to the total aorta (FL ratio) > 64%, and acute TEVAR, which exhibited excellent predictive accuracy performance and discriminatory ability with C statistic of 82.3% (95% CI 77.3-89.2%). The prediction model was contributed to identify high-risk patients of postoperative AEs, which may serve to achievement of personalized treatment and follow-up plans for patients.

Thoraflex Hybrid Prosthesis (THP): the profile.

INTRODUCTION: With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority. AREAS COVERED: This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted. EXPERT OPINION: THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.

Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report.

RATIONALE: Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft. PATIENT CONCERNS: A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours. DIAGNOSES: Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA. INTERVENTIONS: Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery. OUTCOMES: The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery. LESSONS: This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

Heritable thoracic aortic disease: a literature review on genetic aortopathies and current surgical management.

Heritable thoracic aortic disease puts patients at risk for aortic aneurysms, rupture, and dissections. The diagnosis and management of this heterogenous patient population continues to evolve. Last year, the American Heart Association/American College of Cardiology Joint Committee published diagnosis and management guidelines for aortic disease, which included those with genetic aortopathies. Additionally, evolving research studying the implications of underlying genetic aberrations with new genetic testing continues to become available. In this review, we evaluate the current literature surrounding the diagnosis and management of heritable thoracic aortic disease, as well as novel therapeutic approaches and future directions of research.

Computed Tomography Angiography After Transcatheter and Surgical Aortic Interventions.

This comprehensive article reviews the complex realm of aortic surgical and endovascular interventions, focusing on the aortic root, ascending aorta, aortic arch, descending aorta, and abdominal aorta. It outlines the nuances of various procedures, emphasizing the importance of computed tomography angiography acquisition for an accurate assessment. Detailed discussions encompass expected postsurgical/endovascular findings and complications, covering various scenarios, from hematoma and infection to pseudoaneurysms and graft-related issues. This article serves as a crucial resource for radiologists, offering invaluable insights into the complexities of aortic interventions and their subsequent imaging, fostering a comprehensive understanding of diagnostic and management strategies.

Six-year clinical and computed tomography angiography follow-up after Nexus implantation.

Endovascular aortic arch repair (Ar-TEVAR) with single-branch, off-the-shelf Nexus aortic arch system has shown promising early and 3-year outcomes. There is lack of data regarding long-term results of this specific device, particularly regarding patency of supra-aortic bypasses and stability of the connection between the 2 modules. This case report describes 6-year clinical and imaging follow-up of a 74-year-old patient who underwent Ar-TEVAR with Nexus. Over 6 years, the patient experienced minor complications unrelated to the device. The patency of supra-aortic bypasses and integrity of the device's connection were confirmed. Computed tomography angiography constantly showed exclusion of the aneurysm and reduction of the aneurysmal sac. In conclusion, although extended research and broader data are needed, this case provides encouraging evidence of long-term results of Ar-TEVAR with Nexus.

Predictive value of preoperative platelet count and D-dimer levels for spinal cord injury following acute type a aortic dissection.

BACKGROUND: This study aims to identify the risk factors contributing to spinal cord injury (SCI) following a type A acute aortic dissection (TA-AAD). METHODS: This retrospective study was conducted at a single center and involved 481 patients who received frozen elephant trunk stent implantation for TA-AAD. Additionally, these patients underwent total arch replacement with deep hypothermic circulatory arrest. This study was performed at Fuwai Hospital between September 2016 and April 2020. RESULTS: The resulting data of the multivariate logistic regression analysis demonstrated that preoperative platelet count (odds ratio [OR] = 0.774) and D-dimer levels (OR = 2.247) could serve as independent predictors for postoperative SCI in patients with TA-AAD. CONCLUSION: The findings indicate that preoperative platelet count and D-dimer levels are independent risk factors for postoperative SCI in patients with TA-AAD. This study holds significant clinical implications regarding the prognosis and therapeutic responses for patients with TA-AAD.