Risk assessment for aortic dissection in Turner syndrome: The role of the aortic growth rate.

OBJECTIVE: The risk of aortic dissection (AoD) is increased in Turner syndrome (TS) but predicting those at risk is difficult. Based on scarce evidence, preventive aortic surgery is recommended when aortic diameter increases >5 mm/year. To investigate the aortic growth rate in TS and TS-related conditions associated with aortic growth. We also reported our experience of women who suffered aortic dissection (AoD), and who had preventive aortic replacement. METHODS: 151 adult TS were retrospectively identified. Women who had more than one transthoracic echocardiogram (TTE) after age 16 years were included in the aortic growth study. Aortic diameters at sinuses of Valsalva (SoV) and ascending aorta (AA) were analysed by two experts. RESULTS: 70/151 women had more than one TTE (interscan interval 4.7 years). Mean aortic growth was 0.13 ± 0.59 mm/year at SoV and 0.23 ± 0.82 mm/year at AA. Known risk factors for aortic dilatation and TS-related conditions were not associated with aortic growth. 4/151 women experienced AoD (age 25±8 years): two had paired scans for aortic growth, which was 0.67 mm/year at both SoV and AA in the first woman, and 11 mm/year (SoV) and 4 mm/year (AA) in the second. Only 1/4 of women with AoD survived; she used a TS cardiac-alert card to inform emergency personnel about her risk of AoD. 5/151 had a preventive aortic replacement, but one died post-operatively. CONCLUSIONS: Mean aortic growth in our TS population was increased compared to non-TS women and was not associated with currently known risk factors for AoD, suggesting that aortic growth rate itself could be a useful variable to stratify who is at risk for AoD.

A Novel Predictive Model for Acute Kidney Injury Following Surgery of the Aorta.

Background: Acute kidney injury (AKI) frequently occurs after aortic surgery and has a significant impact on patient outcomes. Early detection or prediction of AKI is crucial for timely interventions. This study aims to develop and validate a novel model for predicting AKI following aortic surgery. Methods: We enrolled 156 patients who underwent on-pump aortic surgery in our hospital from February 2023 to April 2023. Postoperative levels of eight cytokines related to macrophage polarization analyzed using a multiplex cytokine assay. All-subset regression was used to select the optimal cytokines to predict AKI. A logistic regression model incorporating the selected cytokines was used for internal validation in combination with a bootstrapping technique. The model's ability to discriminate between cases of AKI and non-AKI was assessed using receiver operating characteristic (ROC) curve analysis. Results: Of the 156 patients, 109 (69.87%) developed postoperative AKI. Interferon-gamma (IFN- γ ) and interleukin-4 (IL-4) were identified as candidate AKI predictors. The cytokine-based model including IFN- γ and IL-4 demonstrated excellent discrimination (C-statistic: 0.90) and good calibration (Brier score: 0.11). A clinical nomogram was generated, and decision curve analysis revealed that the cytokine-based model outperformed the clinical factor-based model in terms of net benefit. Moreover, both IFN- γ and IL-4 emerged as independent risk factors for AKI. Patients in the second and third tertiles of IFN- γ and IL-4 concentrations had a significantly higher risk of severe AKI, a higher likelihood of requiring renal replacement therapy, or experiencing in-hospital death. These patients also had extended durations of mechanical ventilation and intensive care unit stays, compared with those in the first tertile (all p for group trend < 0.001). Conclusions: We successfully established a novel and powerful predictive model for AKI, and demonstrating the significance of IFN- γ and IL-4 as valuable clinical markers. These cytokines not only predict the risk of AKI following aortic surgery but are also linked to adverse in-hospital outcomes. This model offers a promising avenue for the early identification of high-risk patients, potentially improving clinical decision-making and patient care.

Laparoscopy versus endovascular aneurysm repair for abdominal aortic aneurysm: A systematic review.

Minimally invasive surgery is a useful alternative to open repair for patients with nonruptured abdominal aortic aneurysms (AAA). We aim to compare the clinical outcomes for three different minimally invasive techniques: hand-assisted laparoscopic surgery (HALS), total laparoscopic surgery (TLS), and endovascular aneurysm repair (EVAR). The electronic databases MEDLINE, Embase, Web of Science, Google Scholar, and the Cochrane Library were searched between January and March 2023. Cohort studies and randomized controlled trials (RCTs) comparing two minimally invasive techniques were eligible for inclusion. Primary outcomes were mortality (in-hospital, 30-day, or 1-year) and reintervention rates (30-day or 1-year). Length of surgery, blood loss, transfusion volume, conversion to open surgery, major complication rates, length of hospital stay, and length of intensive care unit (ICU) stay were also evaluated. Eight cohort studies and one RCT were included comparing patients undergoing HALS (n = 500), TLS (n = 263), and EVAR (n = 438) for elective AAA repair. The TLS group had the highest rate of 30-day postoperative reinterventions (p = 0.00056), the longest surgical duration (p = 0.0311), and the highest rate of conversion to open surgery (p < 0.001). TLS was also associated with the most blood loss during surgery, the highest blood transfusion volumes, and the longest length of ICU stay, although these results did not reach statistical significance. Subgroup analysis revealed superior contemporary EVAR outcomes compared to TLS. Laparoscopic surgery (LAS) and EVAR have comparable mortality rates. However, LAS, particularly TLS, is significantly less efficacious than EVAR in terms of intraoperative conversions to open surgery and 30-day reintervention rates. Further controlled trials with larger sample sizes are needed to confirm the evidence.

Computed tomography angiography assessment of Adamkiewicz artery with sublingual nitroglycerin administration.

PURPOSE: Identification of the Adamkiewicz artery before aortic surgery is important for preventing postoperative complications due to spinal cord ischemia. The Adamkiewicz artery is difficult to identify due to its small diameter. Nitroglycerin has a vasodilatory effect and is used clinically to improve visualization of blood vessels on coronary computed tomography (CT) angiography. We investigated whether the vasodilatory effect of nitroglycerin could improve the ability to visualize the Adamkiewicz artery. METHODS: We extracted 33 cases wherein contrast-enhanced CT images were taken before and after aortic aneurysm surgery. Nitroglycerin was administered for coronary artery evaluation on the preoperative CT. However, no nitroglycerin was administered before the postoperative CT. Aortic contrast-to-noise ratio, CT value, image noise, and diameter of the Adamkiewicz artery and anterior spinal artery were measured. The depiction of the Adamkiewicz artery was graded into four grades and evaluated. These measurements were performed by two independent reviewers. RESULTS: In nitroglycerin-administered cases, the contrast-to-noise ratio and CT values were significantly higher (P < 0.001, P < 0.001, respectively); the Adamkiewicz artery and anterior spinal artery diameters were dilated (P = 0.005, P = 0.001, respectively). The Adamkiewicz artery score also improved significantly (P < 0.001). No significant difference was found in image noise. CONCLUSION: Nitroglycerin contributed to improving the Adamkiewicz artery's visualization.

The role of hemoadsorption in cardiac surgery - a systematic review.

BACKGROUND: Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting. METHODS: A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view. RESULTS: The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability. CONCLUSIONS: The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy.

The Year in Aortic Surgery: Selected Highlights From 2023.

This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.

Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index During Open Abdominal Aortic Surgery.

OBJECTIVE: To investigate the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and the mini invasive pulse-power device LiDCOrapid as compared to thermodilution cardiac output (TDCO) as measured by pulmonary artery catheter when assessing cardiac index (CIx) in the setting of elective open abdominal aortic (AA) surgery. DESIGN: A prospective method-comparison study. SETTING: Oulu University Hospital, Finland. PARTICIPANTS: Forty patients undergoing elective open abdominal aortic surgery. INTERVENTIONS: Intraoperative CI measurements were obtained simultaneously with TDCO and the study monitors, resulting in 627 measurement pairs with Starling SV and 497 with LiDCOrapid. MEASUREMENTS AND MAIN RESULTS: The Bland-Altman method was used to investigate the agreement among the devices, and four-quadrant plots with error grids were used to assess trending ability. The agreement between TDCO and Starling SV was associated with a bias of 0.18 L/min/m2 (95% confidence interval [CI] = 0.13 to 0.23), wide limits of agreement (LOA = -1.12 to 1.47 L/min/m2), and a percentage error (PE) of 63.7 (95% CI = 52.4-71.0). The agreement between TDCO and LiDCOrapid was associated with a bias of -0.15 L/min/m2 (95% CI = -0.21 to -0.09), wide LOA (-1.56 to 1.37), and a PE of 68.7 (95% CI = 54.9-79.6). The trending ability of neither device was sufficient. CONCLUSION: The CI measurements achieved with Starling SV and LiDCOrapid were not interchangeable with TDCO, and the ability to track changes in CI was poor. These results do not support the use of either study device in monitoring CI during open AA surgery.

Recombinant Activated Factor VII (rFVIIa) for Bleeding After Thoracic Aortic Surgery: A Scoping Review of Current Literature.

BACKGROUND: Bleeding after surgery on the thoracic aorta is a frequent complication, and can be associated with a significant increase in morbidity and mortality. Recombinant activated factor VII (rFVIIa) was developed initially for treating patients with hemophilia; however, it has been used increasingly "off-label" to achieve hemostasis after thoracic aortic procedures. OBJECTIVE: This scoping review aimed to present the available literature on the role of rFVIIa in the management of refractory postoperative bleeding after thoracic aortic surgery. METHODS/RESULTS: An electronic database search was conducted using Medline, Embase, Cochrane Library, and Google Scholar in June 2023. The authors included studies that reported the use of rFVIIa in patients undergoing surgical repair of ascending or descending aortic aneurysm or dissection. Single-case reports were excluded. Ten publications with a pooled number of 649 patients (319 patients received rFVIIa and 330 in the control groups) were identified: 3 case series, 6 retrospective studies, and 1 nonrandomized clinical trial. All studies reported the potential role of rFVIIa in correcting coagulopathy and reducing postoperative blood loss in this group of patients. Overall, there was not enough evidence to suggest that rFVIIa was associated with higher rates of thromboembolic complications or mortality. CONCLUSION: Limited evidence suggests that rFVIIa may be useful in managing postoperative refractory bleeding in patients undergoing thoracic aortic surgery. However, the impact of rFVIIa on thromboembolic complications and mortality rates remains unclear.

Relationship between indexed surgery and postcardiotomy extracorporeal life support outcomes.

OBJECTIVES: Veno-arterial extracorporeal life support (V-A ECLS) is increasingly being utilized for postcardiotomy shock (PCS), though data describing the relationship between type of indexed operation and outcomes are limited. This study compared V-A ECLS outcomes across four major cardiovascular surgical procedures. METHODS: This was a single-center retrospective study of patients who required V-A ECLS for PCS between 2015 and 2022. Patients were stratified by the type of indexed operation, which included aortic surgery (AoS), coronary artery bypass grafting (CABG), valve surgery (Valve), and combined CABG and valve surgery (CABG + Valve). Factors associated with postoperative outcomes were assessed using logistic regression. RESULTS: Among 149 PCS patients who received V-A ECLS, there were 35 AoS patients (23.5%), 29 (19.5%) CABG patients, 59 (39.6%) Valve patients, and 26 (17.4%) CABG + Valve patients. Cardiopulmonary bypass times were longest in the AoS group (p < 0.01). Regarding causes of PCS, AoS patients had a greater incidence of ventricular failure, while the CABG group had a higher incidence of ventricular arrhythmia (p = 0.04). Left ventricular venting was most frequently utilized in the Valve group (p = 0.07). In-hospital mortality was worst among CABG + Valve patients (p < 0.01), and the incidence of acute kidney injury was highest in the AoS group (p = 0.03). In multivariable logistic regression, CABG + Valve surgery (odds ratio (OR) 4.20, 95% confidence interval 1.30-13.6, p = 0.02) and lactate level at ECLS initiation (OR, 1.17; 95% CI, 1.06-1.29; p < 0.01) were independently associated with mortality. CONCLUSIONS: We demonstrate that indications, management, and outcomes of V-A ECLS for PCS vary by type of indexed cardiovascular surgery.

A precise blood transfusion evaluation model for aortic surgery: a single-center retrospective study.

Cardiac aortic surgery is an extremely complicated procedure that often requires large volume blood transfusions during the operation. Currently, it is not possible to accurately estimate the intraoperative blood transfusion volume before surgery. Therefore, in this study, to determine the clinically precise usage of blood for intraoperative blood transfusions during aortic surgery, we established a predictive model based on machine learning algorithms. We performed a retrospective analysis on 4,285 patients who received aortic surgery in Beijing Anzhen Hospital between January 2018 and September 2022. Ultimately, 3,654 patients were included in the study, including 2,557 in the training set and 1,097 in the testing set. By utilizing 13 current mainstream models and a large-scale cardiac aortic surgery dataset, we built a novel machine learning model for accurately predicting intraoperative red blood cell transfusion volume. Based on the transfusion-related risk factors that the model identified, we also established the relevant variables that affected the results. The results revealed that decision tree models were the most suitable for predicting the blood transfusion volume during aortic surgery. In particular, the mean absolute error for the best-performing extremely randomized forest model was 1.17 U, while the R2 value was 0.50. Further exploration into intraoperative blood transfusion during aortic surgery identified erythrocytes, estimated operation duration, body weight, sex, red blood cell count, and D-dimer as the six most significant risk factors. These factors were subsequently analyzed for their influence on intraoperative blood transfusion volume in relevant patients, as well as the protective threshold for prediction. The novel intraoperative blood transfusion prediction model for cardiac aorta surgery in this study effectively assists clinicians in accurately calculating blood transfusion volumes and achieving effective utilization of blood resources. Furthermore, we utilize interpretability technology to reveal the influence of critical risk factors on intraoperative blood transfusion volume, which provides an important reference for physicians to provide timely and effective interventions. It also enables personalized and precise intraoperative blood usage.

Sex Differences in Short- and Long-Term Survival after Acute Type A Aortic Dissection.

Background and Objectives: Acute type A aortic dissection (AAD) is a life-threatening disease. No differences between men and women have been made in the treatment of AAD so far and knowledge about sex differences regarding long-term outcomes is limited. Materials and Methods: Between 01/2004 and 12/2021, 874 patients were operated on for AAD, including 313 (35.8%) women and 561 (64.2%) men. Clinical and surgical records, including long-term follow-up information, were obtained and analyzed retrospectively. To account for differences in the outcome determined by different preoperative life expectancies, a subgroup analysis for a set of patients matched according to their remaining life expectancy was performed. Results: At the time of AAD, women were older than men (69.1 ± 13.0 vs. 61.8 ± 13.3 years, p < 0.001) and had a shorter remaining statistical life expectancy (18.6 ± 10.8 vs. 21.4 ± 10.4 years, p < 0.001). Significantly more DeBakey type II AAD was found in women (37.1% vs. 25.7%, p < 0.001). Comorbidities and preoperative status at the time of presentation were similar in women and men. More hemiarch procedures (63.3% vs. 52.0%, p < 0.001) and less arch replacements (8.6% vs. 16.6%, p < 0.001) were performed in women, resulting in shorter cross-clamp times for women (92 ± 39 vs. 102 ± 49 min, p < 0.001). The in-hospital mortality was similar in women and men (11.5% vs. 12.7%, p = 0.618). Long-term survival was significantly shorter in women compared to men (9.8 [8.1-11.5] vs. 15.1 [11.9-18.4] years, p = 0.011). A matched subgroup analysis revealed that when comparing groups with a similar remaining life expectancy, the long-term survival showed no significant differences between women and men (9.8 [7.9-11.6] vs. 12.4 [10.1-14.7] years, p = 0.487). Conclusions: There are sex differences in AAD, with DeBakey type II dissection being more frequent in women. The seemingly worse long-term outcome can mostly be attributed to the shorter remaining statistical life expectancy at the time of presentation.

Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs.

OBJECTIVE: The volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. METHODS: We used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. RESULTS: Among 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. CONCLUSIONS: The majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.

Intravenous Tranexamic Acid Reduces Post-Operative Bleeding and Blood Transfusion in Patients Undergoing Aortic Surgery: A PRISMA-Compliant Systematic Review and Meta-Analysis.

Background: Tranexamic acid (TXA), an antifibrinolytic agent, has been demonstrated to reduce blood loss and transfusion requirements in both cardiac and non-cardiac surgery. However, the evidence regarding the efficacy of intravenous TXA in aortic surgery has been seldomly analyzed. Therefore, the current study was performed to address this question. Methods: Searches of PubMed, EMBASE, OVID, Cochrane Library and CNKI were conducted comprehensively for randomized controlled trials (RCTs) comparing intravenous TXA versus no-TXA. Independently and in duplicate, we reviewed titles, abstracts and full-text articles, extracted data and evaluated bias risks. A random effect or fixed effect model was utilized to pool data. Results: The database search yielded 4 RCTs involving 273 patients. Meta-analysis revealed that, there was a significant reduction in bleeding volume within the first 4 hours post-operatively [(weighted mean difference (WMD) = -74.33; 95% confidence interval (CI): -133.55 to -15.11; p = 0.01)], and the first 24 hours post-operatively [(WMD = -228.91; 95% CI: -352.60 to -105.23; p = 0.0003)], post-operative red blood cell (RBC) transfusion volume [(WMD = -420.00; 95% CI: -523.86 to -316.14; p < 0.00001)], fresh frozen plasma (FFP) transfusion volume [(WMD = -360.35; 95% CI: -394.80 to -325.89; p < 0.00001)] and platelet concentrate (PC) transfusion volume [(WMD = -1.27; 95% CI: -1.47 to -1.07; p < 0.0001)] following intravenous TXA administration. In addition, intravenous TXA administration significantly decreased the incidence of postoperative complications (53/451 (8.2%) vs. 75/421 (13.9%); odds ratio (OR) = 0.47; 95% CI: 0.30 to 0.75; p = 0.001), according to this present meta-analysis. Conclusions: The current study preliminarily demonstrated that, TXA significantly reduced postoperative bleeding, blood transfusion requirements and postoperative complications among patients undergoing aortic surgery. More well-designed studies are warrant to confirm the efficacy and safety of intravenous TXA in patients undergoing aortic surgery.

Treating a Large Thoracoabdominal Aneurysm With Aberrant Right Subclavian Artery With a Physician-Modified Graft.

CLINICAL IMPACT: Large thoracoabdominal aortic aneurysms due to chronic aortic dissection in patients with connective tissue disorders such as Loeys-Dietz syndrome present a challenging scenario, particularly in cases of variant anatomy and when patients are not candidates for conventional open repair. We demonstrate how by combining and modifying off-the-shelf devices during a hybrid procedure, one can create an endovascular solution tailored to the patient's complex anatomy, making use of an aberrant right subclavian artery, and allow for good clinical outcomes.

Enlarging Paravisceral Aortic Aneurysm Treated With In Situ Laser Fenestration of Physician-Modified Stent Graft for Preservation of Accessory Renal Arteries.

PURPOSE: In situ laser fenestration (LISF) was performed as a bailout procedure to ensure renal perfusion during complex aortic aneurysm repair. CASE REPORT: A 69 year-old male patient with previous repair of abdominal aortic aneurysm who presented with increasing lower back pain and an enlarging, 6-cm, perivisceral aortic aneurysm that required urgent repair. Given potential complications and risks of redo open repair, we performed endovascular repair via deployment of a 5-vessel fenestrated physician modified stent graft (PMEG) with stent placement to the celiac, superior mesenteric, right renal, and 2 of the larger 3 left renal arteries. The renal artery planned for sacrifice was found intraoperatively to be perfusing a large portion of the kidney. Subsequently, LISF was used to cannulate and salvage perfusion to the third renal artery. Completion aortogram demonstrated patency of all renal visceral vessels with no vessel leak. Follow-up CT angiogram 1 year later demonstrated aortic graft with all visceral stents patent, no endoleak, and a reduction in residual aneurysm sac. CONCLUSION: Even with careful planning and design of a physician modified stent graft, in situ laser fenestration provides an option to successfully create additional stents intraoperatively in order to preserve perfusion to critical visceral organs. CLINICAL IMPACT: In situ laser fenestration will provide surgeons with a valuable intra-operative method to create additional stents when organ perfusion would otherwise be lost. As more surgeons develop this technical ability and more long-term outcomes are studied, this method has the possibility to not only be used for urgent and emergent cases but may one day be an acceptable variation to standard practice.

Association Between Device Type and Type IIIb Endoleaks Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: Endoleaks following thoracic endovascular aortic repair (TEVAR) can lead to the need for re-intervention and aortic rupture. Given the recent recall of a specific thoracic stent graft type due to concerns about type IIIb endoleak (T3bE), in which blood leaks through the stent graft fabric, the aim was to characterise patterns of T3bEs among available TEVAR devices. METHODS: Reports related to thoracic stent grafts in the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database between 2010 and 2020 were reviewed. Proportional reporting ratios (PRRs) and chi squared tests were used to assess for the presence of a signal of association between device type and T3bE. A PRR > 2 and chi squared value > 4 with three or more reports overall constituted a signal of association. The institutional database of patients undergoing TEVAR for thoracic aneurysms since 2002 was also queried for T3bE. RESULTS: There were 7 328 MAUDE reports available for analysis. When analysing T3bEs in the MAUDE database, the lowest PRR was 0.36 (95% confidence interval [CI] 0 - 1.03 in Gore CTAG, nine T3bE among 1 328 reports) and the highest was 2.07 (95% CI 1.72 - 2.42 in Medtronic Valiant, 64 T3bE among 2 520 reports). The T3bE chi squared value for Medtronic Valiant was 17.3. The relationship between Medtronic Valiant and T3bE was ascertainable by MAUDE data as early as 2013. Among 542 TEVARs for an aneurysm indication at Duke University Hospital since 2002, there were eight T3bEs - all in devices with sutured on graft material. CONCLUSION: The Medtronic Valiant device met criteria for association with type IIIb endoleaks in the FDA's MAUDE database and met those criteria as early as 2013. A possible relationship between woven graft fabric and T3bEs is supported by the observation that all types of T3bE that occurred among a large number of TEVARs at the institution followed placement of grafts with sutured on woven fabric.

Implementation of a direct-to-operating room aortic emergency transfer program: Expedited management of type A aortic dissection.

INTRODUCTION: Type A Aortic Dissection (TAAD) is a surgical emergency with a time-dependent rate of mortality. We hypothesized that a direct-to-operating room (DOR) transfer program for patients with TAAD would reduce time to intervention. METHODS: A DOR program was started at an urban tertiary care hospital in February 2020. We performed a retrospective study of adult patients undergoing treatment for TAAD before (n = 42) and after (n = 84) implementation of DOR. Expected mortality was calculated using the International Registry of Acute Aortic Dissection risk prediction model. RESULTS: Median time from acceptance of transfer from emergency physician to operating room arrival was 1.37 h (82 min) faster in DOR compared to pre-DOR (1.93 h vs 3.30 h, p < 0.001). Median time from arrival to operating room was 1.14 h (72 min) faster after DOR compared to pre-DOR (0.17 h vs 1.31 h, p < 0.001). In-hospital mortality was 16.2% in pre-DOR, with an observed-to-expected (O/E) ratio of 1.03 (p = 0.24) and 12.0% in the DOR group, with an O/E ratio of 0.59 (p < 0.001). CONCLUSION: Creation of a DOR program resulted in decreased time to intervention. This was associated with a decrease in observed-to-expected operative mortality. The transfer of patients with acute type A aortic dissection to centers with direct-to-OR programs may result in decreased time from diagnosis to surgery.

Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications.

Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs.

OBJECTIVE: Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. DESIGN: A retrospective cohort study. SETTING: In the operating room. PARTICIPANTS: Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. CONCLUSIONS: In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Comprehensive management of type A acute aortic dissection in the paediatric population with ACTA 2 mutation: case reports and literature review of paediatric aortic dissection.

Acute aortic dissection in the paediatric population is rare but lethal. We present two paediatric cases of type A acute aortic dissection that required emergent procedures and were later found to have genetic mutations. High index of suspicion, early clinical diagnosis, prompt treatment, the advantageous collaboration between the paediatric team and aortic surgeons, and familial genetic testing are paramount to achieve a good outcome.