Comparison of bare and nonbare stent grafts during thoracic endovascular aneurysm repair of the aortic arch.

OBJECTIVE: We compared the outcomes of patients treated with nonbare stents (NBS) and proximal bare stents (PBS) endografts with a proximal landing zone in the aortic arch during thoracic endovascular aortic repair (TEVAR). METHODS: We conducted a retrospective cohort, observational, multicenter study that included 361 consecutive TEVAR procedures undertaken between November 2005 and December 2021. TEVAR patients with both BS and NBS Relay stent graft configurations with proximal landing in zones 1, 2, or 3 were enrolled. Preoperative anamnestic and morphological data, clinical outcomes, and aortic modifications 30 days after surgery and at the latest follow-up available were collected. The primary outcome was freedom from proximal endoleak (type IA) comparing the two configurations. Total and detailed endoleak rates, clinical and technical success, intraoperative additional maneuvers, major adverse events, and reinterventions were secondary outcomes. RESULTS: The median follow-up was 4.9 (interquartile range, 2.0-8.1) years. No statistically significant difference between NBS and PBS patients concerning 30-day major adverse events, retrograde aortic dissection, disabling stroke, or late type IA endoleak (10.8% vs 7.8%; P = .597). Aneurysmal disease (P = .026), PLZ diameter of >34 mm (P = .026), aortic tortuosity index of >1.4 (P = .008), type III aortic arch (P = .068), and PLZ thrombus (P = .014) identified as risk factors by univariate Cox regression analysis. PLZ thrombus was the only type IA endoleak risk factor at multivariate Cox regression (P = .016). CONCLUSIONS: We found no statistically significant difference in freedom from type IA endoleak, retrograde dissection, or disabling stroke observed between the NBS and the BS configuration of the Relay endograft. Proximal landing zone thrombotic apposition was a prominent risk factor for type IA endoleak after TEVAR.

Outcome of Revascularizing the Left Subclavian Artery via Carotid-Subclavian Bypass.

BACKGROUND: Endovascular thoracic aortic treatment frequently requires extending the proximal landing zone up into the aortic arch with consecutive covering of the left subclavian artery orifice. Our aim was to report on our outcome of left subclavian artery revascularization using carotid-subclavian bypass via lateral access to the subclavian artery. METHODS: Patients' charts in our aortic center were screened for all those who had undergone carotid-subclavian bypass during endovascular thoracic aortic repair procedures. We analyzed perioperative complications such as cervical plexus nerve or phrenic nerve injury, bleeding, and primary and follow-up graft patency. RESULTS: Between 2001 and 2020, 118 patients underwent carotid-subclavian bypass implantation. Postoperative complications included left-sided stroke in 3% and axillary, phrenic, and recurrent laryngeal nerve palsy in 3, 2, and 3%, respectively. Carotid-subclavian bypass-related death rate was 0%. Bypass patency was 92 ± 7% at 5 years. We documented nine (8%) bypass late occlusions with one left upper extremity ischemia and one late stroke due to an embolized thrombus formed at the bypass anastomosis. All others were asymptomatic. CONCLUSION: Carotid-subclavian bypass surgery is associated with very low risk of death, stroke, or any nerve palsy. Lateral access to the left subclavian artery reduces the risk of phrenic nerve injury.

Acute aortic dissection: evidence, uncertainties, and future therapies.

Remarkable progress has become especially apparent in aortic medicine in the last few decades, leading to essential changes in how thoracic aortic dissection is understood and treated. This state-of-the-art review article addresses the mechanisms of acute aortic dissection, explaining the role of its primary entry location, proximal, and distal dissection extension in their clinical presentation and impact on the decision-making process towards the best treatment approach. The latest evidence on novel treatment methods for acute aortic syndromes is presented, and the diverse dissection classification systems that remain uncertain are discussed, which reveals the need for shared terminology and more clarity. Finally, future aspects are discussed in treating acute aortic dissection, such as the endovascular treatment of aortic dissection Type A and biomarkers for acute aortic syndromes.

Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy.

PURPOSE: To evaluate the closure success rate's outcomes with suture-mediated vascular closure device Perclose ProGlide in patients undergoing aortic or iliac artery endovascular repair using large delivery systems (>21F). MATERIALS AND METHODS: We screened all the patient records in aortic databases at 2 centers who had undergone vascular interventions via ProGlide for percutaneous femoral access >21F between 2016 and 2020. Patients were divided into 2 groups according to the delivery system size: large (L) (22F-23F) and extra-large (XL) (24F-26F). Demographics, anatomical details, and outcome of percutaneous access were evaluated. RESULTS: Included were 239 patients: 121 in the L group and 118 the XL group. Intraprocedural conversion to open surgery because of bleeding was necessary in 2% L and 6% XL patients (p=0.253). Severe femoral artery calcification was the sole risk factor for converting to open surgery (odds ratio=23.44, 95% confidence interval=1.49-368.17, p=0.025). In all, 2% of L and 3% of XL (p=0.631) did require late percutaneous intervention due to stenosis (all treated with balloon angioplasty). Overall, 3% developed pseudoaneurysm treated conservatively in all except one patient requiring surgical repair. Hematoma and groin infection were observed in 9% and 1%, respectively; none required surgical therapy. CONCLUSION: A femoral arterial defect after accessing the artery via a large bore sheath (22F-26F) can be closed successfully with ProGlide in more than 90% of patients. Severe femoral artery calcification is a risk factor for conversion to open surgery caused by bleeding. CLINICAL IMPACT: This study adds evidence on efficacy of accessing the artery via a large bore sheath (22-26F) secured by ProGlide. In more than 200 patients conversion to open surgery was necessary in only 4%. Severe femoral artery calcification was the sole risk factor for converting to open surgery. Our findings encourage physicians to choose the percutaneous access even in patients requiring the use of large bore sheath.

Perioperative Mass Transfusion Affects In-Hospital but Not Follow-Up Survival in Patients with Acute Type A Aortic Dissection.

Background and Objectives: The aim of this study was to analyze the influence of mass transfusion on the postoperative outcome and survival in patients presenting with acute Type A aortic dissection. Materials and Methods: Between 2002 and 2020, a total of 505 patients were surgically treated for an acute Type A aortic dissection. Mass transfusion was defined as the peri- and postoperative replacement by transfusion of 10 units. Patient characteristics and outcomes were analyzed and compared between patients with and without mass transfusion. Results: Mass transfusion occurred in 105 patients (20%). The incidences of symptomatic coronary malperfusion (p = 0.017) and tamponade (p = 0.043) were higher in patients with mass transfusion. There was no statistically significant difference in the distal extension of the aortic dissection between the two groups. A valved conduit was significantly more common in patients with mass transfusion (p = 0.007), while the distal aortic repair was similar between the two groups. Cardiopulmonary bypass time (p < 0.001), cross clamp time (p < 0.001) and in-hospital mortality were significantly higher in patients with mass transfusion (p < 0.001), but the survival after discharge (landmark-analysis) showed equal survival between patients with and without mass transfusion (log rank: p = 0.4). Mass transfusion was predictive of in-hospital mortality (OR: 3.308, p < 0.001) but not for survival after discharge (OR: 1.205, p = 0.661). Conclusions: Mass transfusion is necessary in many patients with acute Type A aortic dissection. These patients present sicker and require longer surgery. However, mass transfusion does not influence survival after discharge.

Training in Aortic Arch Surgery as a Blueprint for a Structured Educational Team Approach: A Review.

Background and objectives: The treatment of pathologies of the aortic arch is a complex field of cardiovascular surgery that has witnessed enormous progress recently. Such treatment is mainly performed in high-volume centres, and surgeons gain great experience in mastering potential difficulties even under emergency circumstances, thereby ensuring the effective therapy of more complex pathologies with lower complication rates. As the numbers of patients rise, so does the need for well-trained surgeons in aortic arch surgery. But how is it possible to learn surgical procedures in a responsible way that, in addition to surgical techniques, also places particular demands on the overall surgical management such as perfusion strategy and neuro-protection? This is why a good training programme teaching young surgeons without increasing the risk for patients is indispensable. Our intention was to highlight the most challenging aspects of aortic arch surgery teaching and how young surgeons can master them. Materials and Methods: We analysed the literature to find out which methods are most suitable for such teaching goals and what result they reveal when serving as teaching procedures. Results: Several studies were found comparing the surgical outcome of young trainees with that of specialists. It was found that the results were comparable whether the procedure was performed by a specialist or by a trainee assisted by the specialist. Conclusions: We thus came to the conclusion that even for such a complex type of intervention, the responsible training of young surgeons by experienced specialists is possible. However, it requires a clear strategy and team approach to ensure a safe outcome for the patient.

Editor's Choice - Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival.

OBJECTIVE: The extent of aortic replacement during surgery for acute type A aortic dissection (ATAAD) is an important matter of debate. This meta-analysis aimed to evaluate the short and long term outcomes of a proximal aortic repair (PAR) vs. total arch replacement (TAR) in the treatment of ATAAD. DATA SOURCES: A systematic search of PubMed and Embase was performed. Studies comparing PAR to TAR for ATAAD were included. REVIEW METHODS: The primary outcomes were early death and long term actuarial survival at one, five, and 10 years. Random effects models in conjunction with relative risks (RRs) were used for meta-analyses. RESULTS: Nineteen studies were included, comprising 5 744 patients (proximal: n = 4 208; total arch: n = 1 536). PAR was associated with reduced early mortality (10.8% [95% confidence interval (CI) 8.4 - 13.7] vs. 14.0% [95% CI 10.4 - 18.7]; RR 0.73 [95% CI 0.63 - 0.85]) and reduced post-operative renal failure (10.4% [95% CI 7.2 - 14.8] vs. 11.1% [95% CI 6.7 - 17.5]; RR 0.77 [95% CI 0.66 - 0.90]), but there was no difference in stroke (8.0% [95% CI 5.9 - 10.7] vs. 7.3% [95% CI 4.6 - 11.3]; RR 0.87 [95% CI 0.69 - 1.10]). No statistically significant difference was found for survival after one year (83.2% [95% CI 77.5 - 87.7] vs. 78.6% [95% CI 69.7 - 85.5]; RR 1.05 [95% CI 0.99 - 1.11]), which persisted after five years (75.4% [95% CI 71.2 - 79.2] vs. 74.5% [95% CI 64.7 - 82.3]; RR 1.02 [95% CI 0.91 - 1.14]). After 10 years, there was a significant survival benefit for patients who underwent TAR (64.7% [95% CI 61.1 - 68.1] vs. 72.4% [95% CI 67.5 - 76.7]; RR 0.91 [95% CI 0.84 - 0.99]). CONCLUSION: PAR appears to lead to an improved early mortality rate and a reduced complication rate. In the current meta-analysis, the suggestion of an improved 10 year survival benefit of TAR was found, which should be interpreted in the context of potential confounders such as age at presentation, comorbidities, and haemodynamic stability. In any case, PAR seems to be intuitive in older patients with limited dissections, and in those presenting in less stable conditions.

Diameter Changes in Traumatic Aortic Injury: Implications for Stent-Graft Sizing.

OBJECTIVES: The aim of this study was to compare aortic diameters from admission computed tomography angiography (CTA) scans to postoperative aortic diameters in patients with traumatic aortic injury (TAI) and evaluate the influence of substantial blood loss on aortic diameter. METHODS: The aortic databases of two tertiary university centers were retrospectively screened for patients with TAI between February 2002 and February 2019. Concomitant organ injuries, bone fractures, blood loss, and clinical outcomes were evaluated. Aortic diameters were measured in CTA upon admission and were compared with the CTA before discharge at three different aortic levels (mid-ascending, 5 cm distal to the end of the stent graft, and at the celiac trunk level). RESULTS: We identified 45 patients, aged 43 (first quartile; third quartile [26; 55]) years with a TAI treated by thoracic endovascular aortic repair. The most frequent cause of TAI was a car accident (n = 24). Concomitant injuries were seen in all but one patient. Bone and pelvic fractures were seen in 40 (89%) and 15 (33%) patients, respectively. Type III aortic injury was present in 25 patients (56%). Increase of aortic diameter after stabilization was +1.7 mm (-0.6 mm; 2.5 mm; p = 0.004) at the mid-ascending aorta, +2.1 mm (0.2 mm; 3.8 mm; p < 0.001) 5 cm distal to the stent graft, and +1.5 mm (0.5 mm; 3.2 mm; p < 0.001) at the celiac trunk level. CONCLUSION: In patients with TAI, the aortic diameter is significantly reduced as compared with the aortic diameter at discharge. The reduction of aortic diameter might be caused by hemorrhagic shock and should be kept in mind for appropriate stent-graft sizing.

Subsequent cardiac surgery after transcatheter aortic valve implantation: Indications and outcomes.

BACKGROUND: Aim of this study was to report on indications and clinical outcomes of patients who underwent subsequent open-cardiac surgery after transcatheter aortic valve implantation TAVI. METHODS: Between 01/2011 and 12/2020 our centre performed 4043 TAVI procedures. Twenty-seven patients (including patients in whom TAVI was performed in other centres) underwent subsequent open-heart surgery via cardiopulmonary bypass. Demographic, intraprocedural data, indications for, and outcomes after surgery were evaluated. RESULTS: Indications for cardiac surgery (aged 79 [IQR 76-84]; 59.3% male) were endocarditis (n = 11; 40.7%), annular rupture, severe paravalvular leak and severe stenosis in three (11.1%) patients, respectively as well as in one patient each (3.7%) severe tricuspid valve regurgitation, valve thrombosis, valve malposition, valve migration, ostial right coronary artery obstruction, left ventricular rupture and type A aortic dissection. The interval between the index TAVI procedure to open surgery was 3 months (IQR 0-26 months). Eight patients underwent emergent surgical conversions. Immediate procedural and procedural mortality was 25.9% and 40.7%, respectively and all-cause mortality was 51.9% (11/12 died for cardiovascular reasons). No disabling stroke was observed postoperatively. New permanent pacemaker implantation was required in three patients (11.1%). CONCLUSIONS: Subsequent open-cardiac surgery after TAVI is rare, but may urgently become necessary due to TAVI related complications or progressing other cardiac pathologies. Despite a substantial early attrition rate clinical outcome is acceptable and a relevant number of these high-risk patients can be discharged even after emergency conversions. The option of subsequent surgical conversion remains.

The Frozen Elephant Trunk Technique for the Treatment of Type B and Type Non-A Non-B Aortic Dissection.

OBJECTIVE: To evaluate outcomes of patients with acute complicated or chronic Type B or non-A non-B aortic dissection who underwent the frozen elephant trunk (FET) technique. METHODS: Between April 2013 and July 2019, 41 patients presenting with acute complicated (n = 29) or chronic (n = 12) descending thoracic aortic dissection were treated by the FET technique, which was the treatment of choice when supra-aortic vessel transposition would not suffice to create a satisfactory proximal landing zone for endovascular aortic repair, when a concomitant ascending or arch aneurysm was present, or in patients with connective tissue diseases. RESULTS: One patient (2%) died intra-operatively secondary to an aortic rupture in dwnstream aortic segments. No post-operative deaths occurred. Four patients (10%) suffered a non-disabling posto-operative stroke and were discharged with no clinical symptoms (modified Rankin Scale [mRS] 0, n = 1), no significant disability (mRS 1, n = 2), or with slight disability (mRS 2, n = 1). No spinal cord ischaemia was observed. The primary entry tear was either surgically resected or excluded from circulation in all patients. During follow up, one patient (2%) died after two years (not aorta related) and 16 patients (39%) underwent an aortic re-intervention after 7.7 [interquartile range 0.7, 15.8] months (endovascular aortic repair: n = 14; open thoraco-abdominal aortic replacement: n = 1, hybrid approach: n = 1). CONCLUSION: The FET technique is an effective treatment option for acute complicated and chronic Type B or non-A non-B aortic dissection in patients in whom primary endovascular aortic repair is non-feasible. While the post-operative outcome is acceptable with a relatively low incidence of non-disabling strokes, this study also underlines the considerable need for aortic re-interventions. Continuous follow up of all patients undergoing the FET procedure is essential.

What Is the Best Method to Achieve Safe and Precise Stent-Graft Deployment in Patients Undergoing TEVAR?

Thoracic endovascular aortic repair (TEVAR) for aortic pathologies requires sufficient landing zone of ideally more than 25 mm for safe anchoring of the stent-graft and prevention of endoleaks. In the aortic arch and at the thoracoabdominal transition, landing zone length is usually limited by the offspring of the major aortic side-branches. Exact deployment of the stent-graft to effectively use the whole length of the landing zone and to prevent occlusion of one of the side-branches is key to successful TEVAR. There are numerous techniques described to lower blood pressure and to reduce or eliminate aortic impulse to facilitate exact deployment of stent-grafts including pharmacologic blood pressure lowering, adenosine-induced asystole, inflow occlusion, and rapid pacing. Aim of this review was to assess the current literature to identify which of the techniques is best suited to prevent displacement and allow for precise placement of the stent-graft and safe balloon-molding.

Management of acute and chronic aortic disease during the COVID-19 pandemic-Results from a web-based ad hoc platform.

BACKGROUND: To share the results of a web-based expert panel discussion focusing on the management of acute and chronic aortic disease during the coronavirus (COVID-19) pandemic. METHODS: A web-based expert panel discussion on April 18, 2020, where eight experts were invited to share their experience with COVID-19 disease touching several aspects of aortic medicine. After each talk, specific questions were asked by the online audience, and results were immediately evaluated and shared with faculty and participants. RESULTS: As of April 18, 73.3% answered that more than 200 patients have been treated at their respective settings. Sixty-four percent were reported that their hospital was well prepared for the pandemic. In 57.7%, the percentage of infected healthcare professionals was below 5% whereas 19.2% reported the percentage to be between 10% and 20%. Sixty-seven percent reported the application of extracorporeal membrane oxygenation in less than 2% of COVID-19 patients whereas 11.8% reported application in 5%-10% of COVID-19 patients. Thirty percent of participants reported the occurrence of pulmonary embolism in COVID-19 patients. Three percent reported to have seen aortic ruptures in primarily elective patients having been postponed because of the anticipated need to provide sufficient ICU capacity because of the pandemic. Nearly 70% reported a decrease in acute aortic syndrome referrals since the start of the pandemic. CONCLUSION: The current COVID-19 pandemic has-besides the stoppage of elective referrals-also led to a decrease of referrals of acute aortic syndromes in many settings. The reluctance of patients seeking medical help seems to be a major driver. The number of patients, who have been postponed due to the provisioning of ICU resources but having experienced aortic rupture in the waiting period, is still low. Further, studies are needed to learn more about the influence that the COVID-19 pandemic has on the treatment of patients with acute and chronic aortic disease.

Landing Zone Remodelling after Endovascular Repair of Dissected Descending Aorta.

OBJECTIVE: The aim of this study was to determine geometric changes in the proximal and distal aortic landing zones after thoracic endovascular aortic repair (TEVAR) for acute descending aortic dissection. METHODS: This was a retrospective analysis of clinical and radiological data. Included are patients who underwent TEVAR for acute descending aortic dissection between 2004 and 2018. Analysed are the proximal and distal landing zones' initial geometries and their change at follow up. Median follow up time was 2.3 (first quartile 0.9, third quartile 4.5) years. RESULTS: One hundred and one patients were included (93 type B and 8 non-A non-B dissections, aged 65 (57, 74) years old, and 29% female). Dissection extended down to the abdominal aorta in 69% patients. The proximal landing zone was non-dissected in 92 patients. The diameters of non-dissected proximal landing zones increased by 3 (-1, 5; p < .001) mm at follow up. The distal landing zone was dissected in 84% of patients. The diameters of dissected distal landing zones had increased at follow up by 7 (3, 12) mm and 4 (1, 10; both p < .001) mm measured in true lumen and total aorta, respectively, observed one year after TEVAR. Stent grafts reached their nominal diameter at follow up in 22% and 17% of proximal and distal landing zones, respectively. There were seven proximal and 10 distal stent graft induced new entries at follow up. Aortic re-intervention was necessary in 23 patients entailing 19 TEVAR extensions and four open aortic repairs. CONCLUSION: The distal landing zone in patients undergoing TEVAR for descending aortic dissection is frequently dissected and is associated with the risk of d-SINE at follow up and the need for re-interventions after TEVAR - factors that emphasise the importance of long term follow up.

Impact of Intermittent Functional Internal Iliac Artery Occlusion on Spinal Cord Blood Supply during TEVAR.

BACKGROUND: Measuring transcranial motor evoked potentials (EPs) and somatosensory EPs is a well-established method to assess spinal cord function during thoracic endovascular aortic repair (TEVAR). Functional occlusion of one or both internal iliac arteries by large bore sheaths during TEVAR can cause unilateral intermittently EP loss. METHODS: Between 2006 and 2016, 194 patients underwent TEVAR entailing EP monitoring. The ISIS IOM System (Inomed Medizintechnik GmbH, Emmendingen, Germany) was employed in all patients. EPs were recorded after inducing anesthesia, during the procedure, and before discontinuing anesthesia. RESULTS: We observed a unilateral intermittently EP decrease or loss in 12 (6.2%) patients. Most events were ipsilateral (9 of 12). The underlying pathologies were descending aortic aneurysm in six patients and type B dissection in six patients. An evoked-potential decrease or loss was always associated with the insertion of large bore stent-graft-introducing sheaths. The median duration of the unilaterally EP decrease or loss was 16 (10; 31) minutes (range, 2-77 minutes) with baseline values re-established at the end of the procedure after sheath removal in all cases. No patient developed irreversible symptomatic spinal cord ischemia. CONCLUSION: A functional occlusion of internal iliac arteries via large bore TEVAR-introducing sheaths is associated with a unilateral intermittent decrease in or loss of EPs returning to baseline after sheath removal. This observation highlights the importance of the internal iliac arteries as one of the major spinal cord's blood supply territories, and may serve as a stimulus to reduce the duration of sheath indwelling to a minimum.

[Traumatic aortic rupture - diagnosis and managment]. / Die traumatische Aortenruptur.

Road traffic accidents are the main cause of traumatic aortic ruptures, mostly in combination with other severe injuries. The pre-hospital mortality rate is high. Suspected aortic trauma, following a high traumatic aortic injury score, is an indication for computer tomography. Injuries are triaged and the treatment priority of the aortic trauma is ascertained based on the severity of the aortic and concomitant injuries and the condition of the patient. Until definitive treatment of the aortic lesion is completed, the blood pressure of the patient must be kept low. Grade I and II lesions can be managed under strict monitoring with initial conservative treatment in individual cases. Grade III (contained perforation) and grade IV (open rupture) lesions need surgical or interventional treatment as swiftly as possible. In selected cases, a delayed treatment can also be advantageous.The endovascular stent graft therapy has established itself as the preferred form of treatment.

Morphologic performance analysis of the Relay nonbare stent graft in dissected thoracic aorta.

OBJECTIVE: The aim of this study was to evaluate morphologic changes in dissected aortas after thoracic endovascular aortic repair (TEVAR) with the use of the Relay Nonbare stent graft stent graft by focusing on the geometric stent graft's performance in remodeling aortas. METHODS: We conducted a retrospective three-dimensional computed tomography analysis preoperatively, postoperatively, and 6 months after TEVAR in patients with residual dissection after type A and those with acute and chronic type B dissections at two German centers. RESULTS: Thirty-nine acute and 54 chronic aortic dissections were included. Median follow-up was 200 (interquartile range, 109-617) days. TEVAR induced aortic remodeling in both groups. Complete false lumen thrombosis along the stent graft (postoperative, 73%; follow-up, 84%; P < .0001) led to a decrease in aortic diameter at the middle stent graft level (preoperative, 45.9 mm [38.6-56.6] vs follow-up, 43.6 [37.4-52.4] mm; P = .009). True lumen expansion was observed in both groups and peaked in acute dissections in the distal landing zone (acute, +9.3 mm vs chronic, +5.8 mm; P < .0001). Migration was 2 (0-5) mm, and bird-beak and endoleak type IA rates were 20% and 4%, respectively. There was no retrograde type A dissection. Distal stent graft-induced new entry occurred in 15%; the major risk factor for incidence was the stent graft's wedge apposition angle (odds ratio, 1.365 [confidence interval, 1.115-1.671]; P = .003). CONCLUSIONS: TEVAR with the use of the Relay NBS promotes aortic remodeling in acute and chronic dissections, entailing a low risk of migration, type IA endoleaks, and retrograde type A dissections. Wedge apposition was the predominant risk factor for distal stent graft-induced new entry.

Outcomes of Early-Onset Acute Type A Aortic Dissection　- Influence of Etiologic Factors.

BACKGROUND: Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively. CONCLUSIONS: Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.

Outcome of Near-Infrared Spectroscopy-Guided Selective Shunting During Carotid Endarterectomy in General Anesthesia.

BACKGROUND: To analyze the outcome of near-infrared spectroscopy (NIRS)-guided selective shunting during carotid endarterectomy and the procedural outcome. METHODS: In this retrospective single-center study, patients undergoing carotid endarterectomy in general anesthesia and receiving bihemispheric NIRS as single neuromonitoring tool between January 2009 and January 2014 were included. Shunting was applied if the reduction in the NIRS values after cross-clamping on the ipsilateral side exceeded 15%. Patients with contralateral occlusion of the internal carotid artery (ICA) were excluded, as were patients operated on by surgeons performing routine shunting. All patients underwent intraoperative angiography after vessel recanalization. RESULTS: NIRS trend was available in 441 patients. Twenty-eight were excluded from this study (14 due to preference for general shunting, 13 due to contralateral ICA occlusion, and 1 due to intraoperative ICA occlusion), resulting in a final sample of 413 patients. We observed a >15% drop in NIRS values on the ipsilateral side in 29 (7%) patients. Accordingly, an intraluminal shunt was placed into the ICA. Shunting was not performed in 384 patients (<15% drop in NIRS values). Interestingly, the NIRS values on the contralateral side were significantly elevated after cross-clamping compared with baseline in the group without shunt (P < 0.0001). On the contrary, patients requiring an ICA shunt revealed a statistically significant reduction in the rSO2 on the contralateral side compared with the baseline (after ipsilateral clamping) (P = 0.047). Three patients overall suffered a stroke, all of whom were in the no-shunt group (combined stroke rate of 0.8% [3/384] with no significant intergroup difference). There was no difference in morbidity factors between the two groups. However, surgical revision after intraoperative angiography was significantly more frequent in the shunt group (17.2%, 5/29) versus the no-shunt group (6%, 23/384), (P < 0.037). CONCLUSIONS: An NIRS-guided selective shunting strategy was associated with excellent clinical outcomes and has the potential to identify patients at risk for hypoperfusion during the clamping period. However, a potentially shunt-associated higher rate of requiring local revisions (due to flaps, twisting, stenosis, and kinking) in ICA was observed. Additional studies are needed to further refine cut-off values for NIRS, indicating the need for shunting.

Local and Lower Limb Complications during and after Femoral Cannulation for Extracorporeal Life Support.

OBJECTIVE: The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation. METHODS: Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016. RESULTS: In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) (p = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients (p = 0.45). CONCLUSION: Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut-down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled.

Benefits and Risks of Prophylactic Cerebrospinal Fluid Catheter and Evoked Potential Monitoring in Symptomatic Spinal Cord Ischemia Low-Risk Thoracic Endovascular Aortic Repair.

BACKGROUND: To assess risks and benefits of a standardized strategy to prevent symptomatic spinal cord ischemia (SSCI) after thoracic endovascular repair (TEVAR) using routine cerebrospinal fluid (CSF) catheter placement and evoked potential (EP) monitoring. METHODS: One hundred and ninety-five patients underwent 223 SSCI low-risk TEVAR procedures between 1998 and 2014. CSF catheter was used to measure CSF pressure and drain CSF if necessary throughout the procedure and up to 24 hours thereafter. EPs were used to monitor spinal cord integrity throughout the procedure. RESULTS: Underlying pathologies included descending thoracic aortic aneurysm in 115 (52%), type B aortic dissection in 85 (38%), traumatic aortic rupture in 16 (7%), and others in 7 (3%) patients. CSF catheter was inserted before TEVAR in 116 procedures (52%). Active CSF draining was required in 29 patients (25%). The CSF catheter caused no major and 11 (10%) minor complications. EP were monitored during 88 (40%) procedures. We observed a reduction in the amplitude, prolonged latencies, or complete signal loss in nine procedures. There were no EP monitoring-related complications. SSCI incidence was higher in patients without CSF drainage (0.8% vs 4.7%, p = 0.031). CONCLUSION: Use of CSF drainage is associated with a significant lower incidence of SSCI after SSCI low-risk TEVAR than nonuse, whereas the complication rate associated with CSF drainage insertion or removal is very low. Routine EP monitoring is a useful tool to detect immediate arterial inflow obstruction to the spinal cord. The combination of these two methods serves as a safe and reliable standardized strategy in reducing the incidence of SSCI to a minimum.