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Background: Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention. Aims: The main scope of this review is to summarize the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD. Methods: A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies. Results: Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well‐established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left. Conclusion: This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD. [ABSTRACT FROM AUTHOR]

Background: Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD. Aims: The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD. Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD. Results: A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high‐risk features. Two clinical features representative of "high risk" are refractory pain and persistent hypertension. First‐line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the "high‐risk" UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population. Conclusion: Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short‐ and long‐term. [ABSTRACT FROM AUTHOR]

Background: Uncomplicated type B aortic dissection (un‐TBAD) has been managed conservatively with medical therapy to control the heart rate and blood pressure to limit disease progression, in addition to radiological follow‐up. However, several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) in un‐TBAD and suggested that TEVAR provides a survival benefit over medical therapy. Outcomes of TEVAR have also been linked with the timing of intervention. Aims: The scope of this review is to collate and summarize all the evidence in the literature on the mid‐ and long‐term outcomes of TEVAR in un‐TBAD, confirming its superiority. We also aimed to investigate the relationship between the timing of TEVAR intervention and results. Methods: We carried out a comprehensive literature search on multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on the mid‐ and long‐term outcomes of TEVAR in un‐TBAD, as well as its relationship with intervention timing. Results: TEVAR has proven to be a safe and effective tool in un‐TBAD, offering superior mid‐ and long‐term outcomes including all‐cause and aorta‐related mortality, aortic‐specific adverse events, aortic remodeling, and need for reintervention. Additionally, performing TEVAR during the subacute phase of dissection seems to yield optimal results. Conclusion: The evidence demonstrating a survival advantage in favor TEVAR over medical therapy in un‐TBAD means that with further research, particular trials and observational studies, TEVAR could become the gold‐standard treatment option for un‐TBAD patients. [ABSTRACT FROM AUTHOR]

Background: Uncomplicated Stanford Type B aortic dissection (un‐TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un‐TBAD with improved long‐term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. Aims: This review critically addresses current state‐of‐the‐art comparing TEVAR with OMT and corresponding clinical outcomes for un‐TBAD based on timing of intervention. Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. Results: TEVAR has proven to be a safe and effective treatment for un‐TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un‐TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. Conclusions: Further research is required into both short‐ and long‐term outcomes of TEVAR in addition to its optimal therapeutic window for un‐TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold‐standard intervention for un‐TBAD with definitive timeframe guidelines. [ABSTRACT FROM AUTHOR]

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work‐life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work‐life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons. [ABSTRACT FROM AUTHOR]

Background: Partial anomalous pulmonary venous connection (PAPVC) occurs when at least one pulmonary vein drains into the right atrium or its tributaries rather than the left atrium, most commonly connecting with the superior vena cava (SVC). The Warden procedure involves transecting the SVC proximal to the uppermost connection of the pulmonary vein followed by proximal SVC reattachment to the right atrial appendage. However, descending thoracic aortic homograft replacement for SVC translocation has recently been introduced as a modified technique. Aims: This commentary aims to discuss the recent study by Said et al. who reported their experiences with six PAPVC cases undergoing a modified Warden procedure using thoracic aortic homograft SVC translocation. Methods: A comprehensive literature search was performed using multiple electronic databases to collate the relevant research evidence. Results: The Warden procedure is associated with a 10% incidence of SVC obstruction with many requiring reintervention. Meanwhile, using the aortic homograft for SVC translocation, Said et al. observed no SVC obstructions. In addition, this modified technique does not require anticoagulation and has demonstrated an improvement in long‐term SVC patency. Nevertheless, it can be considered an expensive procedure. Moreover, since the thoracic aortic homograft utilized is biological tissue, only long‐term follow‐up will determine whether calcification and graft degeneration is an issue. Conclusion: It can be concluded that the modified Warden procedure is a safe and effective method to reconstruct the systemic venous drainage into the right atrium when a direct anastomosis under tension might be prone to re‐stenosis. [ABSTRACT FROM AUTHOR]

Background: The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients' quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimizing foreign valve tissue. AV Neo can either be performed using glutaraldehyde‐treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). Aims: This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes, and limitations of the Ozaki procedure, and compare this to the Batista procedure. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase, and Scopus to collate the relevant research evidence. Results: Although the Ozaki procedure can achieve favorable results whilst mainly avoiding the need for life‐long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde‐treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki's, including excellent survival, lower complications, and minimal need for reoperation as well as shorter operative times. Conclusion: AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure. [ABSTRACT FROM AUTHOR]

Background: Type A aortic dissection (TAAD) is a life‐threatening clinical emergency requiring timely surgical intervention. If untreated, 50% of TAAD die within the first 24 h, with mortality increasing by 1%–2% every passing hour within the first 48 h of presentation. Surgical repair of TAAD is a major procedure associated with relatively high mortality and morbidity postoperatively. Several inflammatory biomarker have been linked to aortic dissection (AD) as diagnostic and/or prognostic tools, one example is the monocyte count to high‐density lipoprotein ratio (MHR). Aims: This commentary aims to discuss the recent study by Savas et al. which investigated the use of MHR as a predictive biomarker for in‐hospital mortality following surgery for TAAD. Methods: We carried out a literature search on multiple electronic databases including PUBMED and Scopus to collate research evidence to assess the value of MHR as a prognostic biomarker in AD. Results: Savas et al. proved that MHR is an effective predictive biomarker for in‐hospital mortality following surgical repair of TAAD by demonstrating that MHR was independently associated with in‐hospital mortality in this subset of patients. Conclusion: Despite the advancement in surgical and perfusion techniques, surgical management of TAAD remains associated with relatively high risk of mortality and morbidity. Using prognostic biomarkers such as MHR can provide a means of reducing in‐hospital mortality by identifying those at risk. Yet, further research into this area is encouraged. [ABSTRACT FROM AUTHOR]

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

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

Background: The introduction of the single‐step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E‐Vita Open NEO hybrid prosthesis (HP) developed by CryoLife‐JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post‐anastomotic blood oozing through the E‐Vita Open NEO right after weaning from cardiopulmonary bypass. Aims: This commentary aims to discuss the recent study by Tan et al. which investigated E‐Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications. Methods: We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E‐Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid. Results: It is proven fact that the E‐Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E‐Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long‐standing favourable outcomes. Discussion: Tan et al. recently conducted an interesting study which proved that the E‐Vita NEO HP does excessively ooze blood and tackled the issue of pre‐emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E‐Vita Open NEO to overcome oozing a long‐term sustainable solution or is it merely a band aid? Conclusion: In the face of fierce commercial competition, the choice of design and material of the E‐Vita Open NEO HP would benefit from reconsideration. [ABSTRACT FROM AUTHOR]

Heart failure represents a dynamic clinical challenge with the continuous rise of a multi‐morbid and ageing population. Yet, the evolving nature of mechanical circulatory support offers a variety of means to manage candidates who might benefit from such interventions. This narrative review focuses on the role of the main mechanical circulatory support devices, such as ventricular assist device, extracorporeal membrane oxygenation, Impella and TandemHeart, in the physiological process of ventricular unloading and remodelling in heart failure, highlighting their characteristics, mechanism and clinical outcomes. The outcome measures described include physiological changes (i.e., stroke volume or preload and afterload), intracardiac pressure (i.e., end‐diastolic pressure) and extracardiac pressure (i.e., pulmonary capillary wedge pressure). Overall, all the above mechanical circulatory support strategies can facilitate the unloading of the ventricular failure through different mechanisms, which subsequently affects the ventricular remodelling process. These physiological changes start immediately after ventricular assist device implantation. The devices are indicated in different but overlapping populations and operate in distinctive ways; yet, they have evidenced performance to a favourable standard to improve cardiac function in heart failure, although this proved variable for different devices, and further high‐quality trials are vital to assess their clinical outcomes further. Both Impella and TandemHeart are indicated mainly in cardiogenic shock and high‐risk percutaneous coronary intervention patients; at the time the literature was evaluated, both devices were found to yield a significant improvement in haemodynamics but not in survival. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes. What is the topic of this review?This narrative review focuses on the role of the main mechanical circulatory support devices in the physiological process of ventricular unloading and remodelling in heart failure.What advances does it highlight?This narrative review presents a comprehensive overview of the main mechanical circulatory support devices in heart failure, highlighting their characteristics, mechanisms and clinical outcomes. These devices can facilitate the unloading of ventricular failure to varying extents and through different mechanisms, which subsequently affects the ventricular remodelling process. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes. [ABSTRACT FROM AUTHOR]

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

Background: There is emerging evidence to support pre‐emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre‐emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest‐risk patients that would benefit most from pre‐emptive TEVAR. Aim: This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients. Methods: A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients Results: At present, there are no clear clinical guidelines using risk‐stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at‐risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C‐reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well‐balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk‐stratified treatment protocols. Conclusion: There are a variety of risk profiling parameters that can be used to identify the high‐risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer‐term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk‐stratified selection protocols. [ABSTRACT FROM AUTHOR]

Background: Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5 cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. Aim: To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. Methods: A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. Results: FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. Conclusion: FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities. [ABSTRACT FROM AUTHOR]

The extent to which patients with an abdominal aortic aneurysm (AAA) should exercise remains unclear, given theoretical concerns over the perceived risk of blood pressure‐induced rupture, which is often catastrophic. This is especially pertinent during cardiopulmonary exercise testing, when patients are required to perform incremental exercise to symptom‐limited exhaustion for the determination of cardiorespiratory fitness. This multimodal metric is being used increasingly as a complementary diagnostic tool to inform risk stratification and subsequent management of patients undergoing AAA surgery. In this review, we bring together a multidisciplinary group of physiologists, exercise scientists, anaesthetists, radiologists and surgeons to challenge the enduring 'myth' that AAA patients should be fearful of and avoid rigorous exercise. On the contrary, by appraising fundamental vascular mechanobiological forces associated with exercise, in conjunction with 'methodological' recommendations for risk mitigation specific to this patient population, we highlight that the benefits conferred by cardiopulmonary exercise testing and exercise training across the continuum of intensity far outweigh the short‐term risks posed by potential AAA rupture. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR). METHODS This is a multicentre, retrospective, observational cohort study. We analysed data from patients treated with TEVAR between 22 June 2001 and 10 December 2022. Primary outcomes were postoperative overall organ ischaemic complications and early (≤30 days) survival. Secondary outcomes were long-term survival and freedom from aorta-related mortality. RESULTS A total of 255 patients were included in this study. We performed 233 (91.4%) isolated TEVARs, 14 (5.5%) fenestrated or branched TEVARs and 8 (3.1%) TEVARs in combination with normal infrarenal stent graft. Overall, 31 organ ischaemic complications were detected in 29 (11.4%) cases, out of which 8 (3.1%) complications were cerebrovascular, 8 (3.1%) spinal cord, 6 (2.3%) visceral, 4 (1.6%) renal, 2 (0.8%) peripheral and 3 (1.2%) myocardial. Binary logistic regression analysis identified grade III–IV aortic arch atheroma [odds ratio (OR): 6.6, P  =   0.001; 95% confidence interval: 2.9–14.9] and shaggy aorta (OR: 12.1, P  =   0.003; 95% confidence interval: 2.3–64.1) to be associated with the development of organ ischaemic complications. In patients with organ ischaemia, we observed higher early (≤30 days) mortality (20.7% vs 6.2%; OR: 3.6, P  =   0.016), prolonged hospitalization (P  =   0.001) and inferior estimated survival (log-rank, P  =   0.001). CONCLUSIONS Aortic arch atherosclerotic overload as well as the presence of shaggy aorta are predictors of organ ischaemic complications following TEVAR. They are neither uncommon nor negligible and are associated with perioperative mortality, prolonged hospitalization and a negative impact on long-term survival. [ABSTRACT FROM AUTHOR]

Post-FET thoracoabdominal stent-grafting therefore allows a safer alternative to extensive aortic repair in the high-risk patient population.2,4 Clamping of the stent-graft in the open thoracoabdominal approach following FET is not without concerning complications. Keywords: aortic aneurysm; aortic arch; aortic dissection; frozen elephant trunk; thoracoabdominal aortic aneurysm; vascular prosthesis EN aortic aneurysm aortic arch aortic dissection frozen elephant trunk thoracoabdominal aortic aneurysm vascular prosthesis 1473 1474 2 04/20/22 20220601 NES 220601 In the current era, thoracic aortic disease management is tailored to patients' associated comorbidities, risk profile, surgeon's skills, and expectations. [Extracted from the article]

Background: While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multicenter data from Europe documenting the neurological outcomes associated with RELAY™ Branched.Methods: Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centers across Europe was retrospectively analyzed with descriptive and distributive analysis. Follow-up data from 30 days and 6, 12, and 24 months postoperatively were included. Patient follow-up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS).Results: Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, six (4.1%) patients suffered DS, and eight (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis.Discussion: The data presented herein demonstrates that RELAY™ Branched is associated with favorable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair. [ABSTRACT FROM AUTHOR]

Background: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies. Methods: As part of routine preoperative patient contact, patients scheduled for major surgery were prospectively "eyeballed" (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either "frail" or "not frail" by ICE and "fit" or "unfit" from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET "cut‐off" metrics incorporating peak pulmonary oxygen uptake, V̇O2PEAK at the anaerobic threshold (V̇O2‐AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single‐center prospective National Health Service database. Data were analyzed using the Chi‐square automatic interaction detection decision tree method. Results: A total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m2. Patients were poorly conditioned with a V̇O2PEAK almost 20% lower than predicted for age, sex‐matched healthy controls with 35% exhibiting a V̇O2‐AT < 11 ml/kg/min. Disagreement existed between the subjective assessments of risk with ∼34% of patients classified as not frail on ICE were considered unfit by notes review (p <.0001). Furthermore, ∼35% of patients considered not frail on ICE and ∼31% of patients considered fit by notes review exhibited a V̇O2‐AT < 11 ml/kg/min, and of these, ∼28% and ∼19% were classified as intermediate to high risk. Conclusions: These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help us to improve perioperative risk assessment and better direct critical care provision in patients scheduled for "high‐stakes" surgery including open thoracoabdominal aortic aneurysm repair. [ABSTRACT FROM AUTHOR]

Background: The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un‐TBAD) remains controversial. There is a lack of consensus over whether pre‐emptive TEVAR should be carried out in patients with un‐TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un‐TBAD may prove beneficial relative to pharmacotherapy alone. Methods and materials: PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen (FL) expansion, and mortality. Papers were selected based on title and abstract. Results: Optimal medical therapy remains the mainstay treatment for patients with un‐TBAD, however, patients with un‐TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, FL thrombosis, and aortic branch involvement may potentiate progression from un‐TBAD to complicated TBAD. Short‐ and long‐term outcomes associated with TEVAR for TBAD remain promising. Conclusion: Pre‐emptive TEVAR may be beneficial in patients with un‐TBAD presenting with the above factors, however, further prospective research into the optimal timing for TEVAR in un‐TBAD is required. [ABSTRACT FROM AUTHOR]