Search

Objectives: The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices., Methods: In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article., Results: Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease., Conclusions: It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The optimal strategy for cerebral protection during repair of type A acute aortic dissection has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair., Methods: All patients in the International Registry of Acute Aortic Dissection Interventional Cohort database who underwent type A acute aortic dissection repair between 2010 and 2018 were identified. Data for operative temperature were available for 1962 patients subsequently divided into 2 groups according to lowest temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). We then propensity matched 362 pairs of patients and analyzed operative data and short-term outcomes., Results: The median lowest temperature was 25.0°C in the matched MHCA group as compared with 18.0°C in the DHCA group. For the entire cohort of 1962 patients, in-hospital mortality was 14.2% (278 deaths) but was not significantly different between DHCA and MHCA. The perioperative stroke rate was comparable between groups, before and after propensity matching. Circulatory arrest times were significantly longer in the MHCA cohort, regardless of matching. Use of antegrade or retrograde cerebral perfusion was similar in matched groups. There were no differences in 30-day survival or in other major postoperative morbidity between the 2 matched cohorts., Conclusions: A surgical strategy of MHCA + antegrade cerebral perfusion is at least as safe as DHCA during repair of acute type A aortic dissection., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Total aortic arch replacement remains a technically formidable procedure, particularly in patients with previous proximal aortic dissection repair. Our case discussion highlights a useful strategy for extracorporeal support and circulation management to facilitate total arch reconstruction in the reoperative setting, based on cannulation of the left axillary artery. Our preference is to use a left axillary artery approach to initiate cardiopulmonary bypass and to ultimately revascularize the left arm via an extra-anatomic graft. Our technique, as described, affords the option to initiate cardiopulmonary bypass before sternal re-entry, it reduces the risk of embolic complications and possible stroke, and it directly facilitates simple extra-anatomic debranching of the left subclavian artery, resulting in easier arch and great vessel reconstruction within the chest.

Background: Techniques for aortic surgery continue to evolve. A real-world snapshot of patients undergoing elective surgery for aneurysm in the modern era is helpful to assist in deciding the appropriate timing for intervention. We herein describe our experience with 100 consecutive patients who underwent primary elective surgery for aneurysm of the proximal thoracic aorta over a two-year period at a single institution., Methods: The majority of our patients were male, mean age 61.19 ± 13.33 years. Two patients had Marfan syndrome. Twenty-eight patients had bicuspid aortic valve. Thirty-four patients underwent aortic root replacement utilizing a composite valve/graft conduit; 23 had valve-sparing root replacements. The ascending aorta was replaced in 89 patients; 80 (89.9%) of these included a period of circulatory arrest at moderate hypothermia utilizing unilateral selective antegrade cerebral perfusion., Results: Thirty-day mortality was zero. Perioperative stroke occurred in 2 patients, both of whom completely recovered prior to discharge. No patients required re-exploration for bleeding. One patient developed a sternal wound infection. Fifteen patients required readmission to hospital within thirty days of discharge., Conclusion: Elective surgery for aneurysm of the proximal aorta is safe, reproducible, and is associated with outcomes that are superior to those seen in an acute aortic syndrome. It may be appropriate to offer surgery to younger patients with proximal aortic aneurysms at smaller diameters, even if their aortic dimensions do not yet meet traditional guidelines for surgical intervention.

Background: There is still significant disagreement among surgeons about the best method for arterial cannulation to institute cardiopulmonary bypass (CPB) in patients with acute type A aortic dissection (STAADs). This study aimed to provide support for central aortic cannulation as a viable and preferable option, as it reduces time to institute CPB, operative times, and decreases the complexity of the procedure., Methods: This study is a retrospective review of 34 patients who underwent STAAD repairs consecutively between October 2006 and January 2014. The sample was analyzed for method of cannulation, CPB time, cross-clamp time, circulatory arrest time, mortality, and complication rate. Statistical analysis was performed to compare a control group of patients who underwent nonaortic cannulation., Results: The most common method of cannulation was the distal aortic arch, which also produced the lowest relative mortality. The 30-day mortality was found to be 17.6%. Arrhythmia, acute renal injury, and failure to extubate within 48  hours were the most frequent complications, and cerebrovascular accidents occurred in three patients (8.8%). Statistically significant differences in bypass and cardiac arrest times favored aortic cannulation., Conclusions: This study supports the notion that central aortic cannulation is a viable option for CPB in STAAD repair, but further prospective, randomized trials are necessary for the procedure to replace peripheral cannulation techniques., (© 2014 Wiley Periodicals, Inc.)

An interesting case report detailing the management of an aorta that was inadvertently screwed during spinal fixation. The management and imaging encompass the use of computer tomography and intravascular ultrasound to determine the trajectory of the screw and the successful management of the patient.

This manuscript describes the initial experience of 15 patients undergoing aortic arch replacement using a modification of the trifurcate arch technique described by Spielvogel and coworkers [1]. This technique provides continuous antegrade cerebral perfusion and minimal myocardial ischemia with mild hypothermia., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The treatment of acute aortic pathologies continues to evolve with enhanced imaging capabilities. This case report highlights the rapid progression of penetrating atherosclerotic ulcer to pseudoaneurysm development and subsequent treatment with thoracic endovascular stent graft.

Blunt traumatic aortic injury is a highly fatal injury caused from rapid deceleration of the thorax. Most victims do not survive to obtain emergency medical care. Immediate open surgical repair had been the standard of care for decades, but more recent strategies and the emergence of thoracic aortic endografting have changed protocols for the treatment of this highly lethal lesion. This article reviews the current treatment of blunt thoracic aortic injury and the use of thoracic aortic stent grafting for this patient population., (Copyright 2009 Elsevier Inc. All rights reserved.)

The pathological variants of acute aortic syndromes include classic dissection, intramural hematomas, and penetrating atherosclerotic ulcers (PAUs). The subject of the appropriate management and treatment of PAUs continues to expand as this disease entity is increasingly identified. The application of thoracic endografting, or thoracic endovascular aortic repair (TEVAR), to treat these acute aortic pathologies is clearly evolving and the ultimate effectiveness and durability of thoracic endografting remains to be determined as clinical experience increases. The disease pathology of PAUs and the use of endovascular stent graft placement in PAU disease are closely examined in this manuscript.

Background: Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections., Methods: From January 1994 to April 2002, 163 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion to replace the aortic arch; HCA established after 3 minutes of electroencephalographic silence in neuromonitored patients (60%) or after 45 minutes of cooling in patients who were not neuromonitored (40%); reinforcement of the residual arch tissue with a Teflon felt "neo-media;" cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension or replacement with a biological or mechanical valved conduit. When HCA times were greater than 50 minutes, antegrade cerebral perfusion is used. Since Februay 1999, BioGlue has been used as an anastomotic adjunct in the repair of type A dissections., Results: Mean age was 62 +/- 14 years, with 68% men and 15% with previous cardiac surgery. Seven percent of patients presented with a preoperative neurologic deficit, and 3% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9.8%. Excluding the patients with preoperative strokes (7%) and those with postoperative stroke (3%), the in-hospital death rate was 6.6%. In 6 patients, prompt changes in circulatory management consisting of switching cannulation sites or cross-clamp release with direct temporary aortic arch fenestration occurred when there were sudden changes in electroencephalogram during cooling., Conclusions: A standardized approach to the treatment of acute type A dissections has improved outcomes. Our 55% mortality in patients with preoperative cerebral vascular accident (CVA) suggests that this group may be candidates for medical or delayed surgical treatment. Conversely, our 6.6% mortality rate for neurologically intact patients warrants aggressive and expeditious surgical intervention.