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Purpose: We aim to quantify multiaxial cardiac pulsatility-induced deformation of the thoracic aorta after ascending thoracic endovascular aortic repair (TEVAR) as a part of the GORE ARISE Early Feasibility Study., Materials and Methods: Fifteen patients (7 females and 8 males, age 73±9 years) with ascending TEVAR underwent computed tomography angiography with retrospective cardiac gating. Geometric modeling of the thoracic aorta was performed; geometric features including axial length, effective diameter, and centerline, inner surface, and outer surface curvatures were quantified for systole and diastole; and pulsatile deformations were calculated for the ascending aorta, arch, and descending aorta., Results: From diastole to systole, the ascending endograft exhibited straightening of the centerline (0.224±0.039 to 0.217±0.039 cm -1 , p<0.05) and outer surface (0.181±0.028 to 0.177±0.029 cm -1 , p<0.05) curvatures. No significant changes were observed for inner surface curvature, diameter, or axial length in the ascending endograft. The aortic arch did not exhibit any significant deformation in axial length, diameter, or curvature. The descending aorta exhibited small but significant expansion of effective diameter from 2.59±0.46 to 2.63±0.44 cm (p<0.05)., Conclusion: Compared with the native ascending aorta (from prior literature), ascending TEVAR damps axial and bending pulsatile deformations of the ascending aorta similar to how descending TEVAR damps descending aortic deformations, while diametric deformations are damped to a greater extent. Downstream diametric and bending pulsatility of the native descending aorta was muted compared with that in patients without ascending TEVAR (from prior literature). Deformation data from this study can be used to evaluate the mechanical durability of ascending aortic devices and inform physicians about the downstream effects of ascending TEVAR to help predict remodeling and guide future interventional strategies., Clinical Impact: This study quantified local deformations of both stented ascending and native descending aortas to reveal the biomechanical impact of ascending TEVAR on the entire thoracic aorta, and reported that the ascending TEVAR muted cardiac-induced deformation of the stented ascending aorta and native descending aorta. Understanding of in vivo deformations of the stented ascending aorta, aortic arch and descending aorta can inform physicians about the downstream effects of ascending TEVAR. Notable reduction of compliance may lead to cardiac remodeling and long-term systemic complications. This is the first report which included dedicated deformation data regarding ascending aortic endograft from clinical trial., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.-Y.K.S. has received research funding and/or consulting fees from Bentley InnoMed, Medtronic, Optimed Medical Instruments, Terumo Aortic, and W. L. Gore & Associates. M.C.N. has received salary from W. L. Gore & Associates. E.E.R. has received research funding and/or consulting fees from Cook, Artivion, Edwards Lifesciences, W.L. Gore & Associates, Medtronic, and Terumo Aortic. C.P.C. has received research funding and/or consulting fees from Abbott Laboratories, AneuMed, Arsenal Medical, Bentley InnoMed, Confluent Medical Technologies, Endospan, Medtronic, Optimed Medical Instruments, Qmedics, ReValve Solutions, Starlight Cardiovascular, Terumo Aortic, and W. L. Gore & Associates. J.B. and Y.D.Z. have nothing to disclose.

Our goal was to replace the previous composite graft with a bioprosthesis. The approach involved axillary artery and femoral vein cannulation and cardiopulmonary bypass with moderate hypothermia for re-entry of the chest and deep hypothermia with circulatory arrest to get control of and to clamp the aorta when entering the pseudoaneurysm. The myocardial protection strategy was general cooling and retrograde cardioplegia through direct coronary sinus cannulation and antegrade cardioplegia in the coronary ostia when possible. After the pseudoaneurysm was entered, the graft was divided in the middle, and the distal end was dissected out under circulatory arrest sufficiently to allow clamping and to resume systemic circulation. The graft was not dissected out beyond the previous anastomosis. Under another period of circulatory arrest, the distal graft was removed to the mid-arch, and a new graft was attached with a hemiarch anastomosis. Then the root was dissected out, and both coronary ostia were mobilized. The mechanical aortic valve and previous graft material were explanted. A new bioprosthetic valved conduit was used to replace the aortic root, and the coronary buttons were re-implanted directly in the new graft., (© The Author 2023. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The prognosis of patients undergoing emergency endovascular repair of ascending thoracic aortic aneurysm (ATAA) depends on defect location, with root disease bearing worse outcomes than proximal or distal aortopathy. We speculate that a spatial gradient in aneurysmal tissue mechanics through the length of the ascending thoracic aorta may fuel noted survival discrepancies. To this end, we performed planar biaxial testing on 153 root, proximal, and distal segments of ATAA samples collected from 80 patients receiving elective open surgical repair. Following data averaging via surface fitting-based interpolation of strain-controlled protocols, we combined in-vitro and in-vivo measurements of loads and geometry to resolve inflation-extension kinematics and evaluate mechanical metrics of stress, stiffness, and energy at consistent deformation levels. Representative (averaged) experimental data and simulated in-vivo conditions revealed significantly larger biaxial stiffness at the root compared to either proximal or distal tissues, which persisted as the entire aorta stiffened during aging. Advancing age further reduced biaxial stretch and energy storage, a measure of aortic function, across all ATAA segments. Importantly, age emerged as a stronger predictor of tissue mechanics in ATAA disease than either bicuspid aortic valve or connective tissue disorders. Besides strengthening the general understanding of aneurysmal disease, our findings provide specifications to customize the design of stent-grafts for the treatment of ATAA disease. Optimization of deployment and interaction of novel endovascular devices with the local native environment is expected to carry significant potential for improving clinical outcomes. STATEMENT OF SIGNIFICANCE: Elucidating the lengthwise regional mechanics of ascending thoracic aortic aneurysms (ATAAs) is critical for the design of endovascular devices tailored to the ascending aorta. Stent-grafts provide a less invasive alternative to support the long-term survival of ATAA patients ineligible for open surgical repair. In this study, we developed a numerical framework that combines semi-inverse constitutive and forward modeling with in-vitro and in-vivo data to extract mechanical descriptors of ATAA tissue behavior at physiologically meaningful deformation. Moving distally from the aortic root to the first ascending aortic branch, we observed a progressive decline in biaxial stiffness. Furthermore, we showed that aging leads to reduced aortic function and is a stronger predictor of mechanics than either valve morphology or underlying syndromic disorder., Competing Interests: Declaration of Competing Interest The Authors have nothing to declare., (Copyright © 2023 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival., Methods: From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years])., Results: After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology., Conclusions: FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to determine whether adding prophylactic aorta replacement increases the risk of a cardiac operation when cardiac rather than aortic disease is the primary indication for operation., Methods: Patients undergoing cardiac operations with aorta replacement (cardioaortic group), with or without circulatory arrest, were propensity matched to identify patients whose combined operation was not primarily indicated by aortic disease (n = 684). These patients were further propensity matched without accounting for thoracic-aortic measurements to patients undergoing cardiac operations without aorta replacement (cardiac-surgery only group), 647 pairs, for comparing outcomes., Results: Most (n = 431/503 [86%]) propensity-matched patients undergoing cardioaortic operations had ascending aorta dilatation with a maximum aortic diameter of less than 5.5 cm. There was no evidence of an incremental increase in risk of in-hospital stroke (cardioaortic, n = 9/1.4% vs cardiac only, n = 7/1.1%; P = .6) or mortality (cardioaortic, n = 6/0.93% vs cardiac only, n = 3/0.46%; P = .5). Unmatched patients undergoing concomitant aortic surgery had advanced aortic disease distal to the ascending aorta (arch, 3.8 ± 0.98 cm vs 3.2 ± 0.51 cm; descending, 4.4 ± 1.7 cm vs 3.2 ± 0.99 cm) as the primary indication for their operation and had a high occurrence of in-hospital stroke (6.5% vs 1.5%, P = .0007) and death (7% vs 1.2%, P = .0001)., Conclusions: Prophylactic aorta replacement can be safely performed during a cardioaortic operation, without added penalty, when aortic disease is less severe and not the primary indication for surgery. Risks after an aorta replacement combined with cardiac surgery can be substantial, however, when advanced aortic disease is the primary indication for operation. These distinctive risks should be taken into consideration at the time of surgical decision-making., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Kommerell diverticulum (KD) is an uncommon congenital vascular anomaly. This study assessed outcomes of open and endovascular repair of this disorder., Methods: Between 1997 and 2016, 152 adult patients presented with KD at Cleveland Clinic (Cleveland, OH), 87 had no intervention, and 65 underwent open repair (n = 55; 19 elephant trunk [ET] procedures [9 with aortic dissection], including 7 frozen ET, and completions with 5 thoracic endovascular aortic repairs, 2 open, and 5 lost to follow-up) or endovascular procedures (n = 10). Non-ET open KD repairs consisted of resection (n = 15), interposition graft (n = 16), patch (n = 4), or aortopexy (n = 1). Maximum KD diameter was 2.1 cm for nonsurgical patients and 3.2 cm for surgical patients. Among surgical patients, 51 of 65 had dysphagia or dyspnea. A total of 608 patient-years of follow-up were available., Results: For patients who underwent open and endovascular procedures, after multivariable adjustment, symptoms of dysphagia and hypertension predicted the likelihood of surgery (P < .05, all). There was no operative mortality. Complications included nondisabling stroke (n = 5; 8%), tracheostomy (n = 3; 4.6%), vocal cord paralysis (n = 2; 3%), and reoperation for bleeding (n = 3; 4.6%). During follow-up, 3 of 10 patients treated with hybrid or endovascular procedures required reinterventions for endoleaks. One patient had residual symptoms after aortopexy. Among nonsurgical patients, 2 patients refused surgery, and 1 died of aortic rupture, with a 4.7-cm descending aorta and a 3.4-cm KD. Seven additional patients died of nonaortic comorbidities. The remaining patients were asymptomatic, with an aortic diameter smaller than 4.5 cm., Conclusions: Open and endovascular approaches have a high success rate and low mortality risk. Selection of the specific type of intervention should be based on patient anatomy, additional needed procedures, and comorbid conditions., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bicuspid aortic valves (BAV) are associated with incompletely characterized aortopathy. Our objectives were to identify distinct patterns of aortopathy using machine-learning methods and characterize their association with valve morphology and patient characteristics., Methods: We analyzed preoperative 3-dimensional computed tomography reconstructions for 656 patients with BAV undergoing ascending aorta surgery between January 2002 and January 2014. Unsupervised partitioning around medoids was used to cluster aortic dimensions. Group differences were identified using polytomous random forest analysis., Results: Three distinct aneurysm phenotypes were identified: root (n = 83; 13%), with predominant dilatation at sinuses of Valsalva; ascending (n = 364; 55%), with supracoronary enlargement rarely extending past the brachiocephalic artery; and arch (n = 209; 32%), with aortic arch dilatation. The arch phenotype had the greatest association with right-noncoronary cusp fusion: 29%, versus 13% for ascending and 15% for root phenotypes (P < .0001). Severe valve regurgitation was most prevalent in root phenotype (57%), followed by ascending (34%) and arch phenotypes (25%; P < .0001). Aortic stenosis was most prevalent in arch phenotype (62%), followed by ascending (50%) and root phenotypes (28%; P < .0001). Patient age increased as the extent of aneurysm became more distal (root, 49 years; ascending, 53 years; arch, 57 years; P < .0001), and root phenotype was associated with greater male predominance compared with ascending and arch phenotypes (94%, 76%, and 70%, respectively; P < .0001). Phenotypes were visually recognizable with 94% accuracy., Conclusions: Three distinct phenotypes of bicuspid valve-associated aortopathy were identified using machine-learning methodology. Patient characteristics and valvular dysfunction vary by phenotype, suggesting that the location of aortic pathology may be related to the underlying pathophysiology of this disease., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Retrograde false lumen perfusion is a common mode of failure after stent grafting chronic aortic dissection. Open fenestration during the first-stage elephant trunk (ET) creates a landing zone for second-stage endovascular ET completion in patients with a false lumen aneurysm. Our objectives were to assess long-term safety and durability of this technique., Methods: From 2007 to 2014, 56 patients with thoracoabdominal dissection and aneurysm underwent stage 1 ET and open fenestration. Fifteen (26.8%) patients had DeBakey type III dissection, and 41 (73%) had type I, 38 (68%) with previous ascending repair. Mean maximum diameter was 5.8 ± 1 cm. Imaging follow-up was complete in all survivors., Results: Endovascular ET completion was performed in 49 patients (87.5%), urgently in 11 (22%). Operative mortality after the first stage was 1.8%. The ET in 8 patients was performed prophylactically. Complications after the first stage included transient ischemic attack in 1 patient (1.8%), subdural hemorrhage in 1 (1.8%), tracheostomy in 1 (1.8%), bleeding in 5 (8.9%), and paraplegia in 1 (1.8%). All 48 patients had false lumen thrombosis in the treated segment without endoleak or retrograde perfusion. The aneurysm sac shrunk in 67%, with a mean overall aortic diameter reduction of 1 ± 0.8 cm. Median follow-up was 33.8 months. Eight patients (16%) underwent 11 late reinterventions, comprising thoracic endovascular aortic repair extension in 4 patients (36%), thoracic endovascular aortic repair and false lumen embolization in 3 (27%), open thoracoabdominal aortic aneurysm completion repair in 2 (18%), and redo proximal repair for infection in 2 (18%). There were 6 late deaths., Conclusions: Open aortic fenestration to create a distal landing zone during stage 1 ET facilitates endovascular completion for chronic dissection with false lumen aneurysm. The technique is safe, effective, and durable. It promotes reverse aortic remodeling and eliminates retrograde false lumen flow., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Thoracic endovascular aortic repair (TEVAR) has undergone rapid evolution and is now applied to a range of aortic pathologies. Imaging plays a vital role in the pre- and postintervention assessment of TEVAR patients. Accurate characterization of pathology and evaluation for high-risk anatomic features are necessary in the planning phase, and careful assessment for graft stability, aortic lumen diameter, and presence of endoleak are paramount in the follow-up period. CTA is the imaging modality of choice for pre- and postintervention assessment, and MRA is an acceptable alternative depending on patient stability and graft composition. Lifelong imaging follow-up is necessary in TEVAR patients because endoleaks may develop at any time. The exact surveillance interval is unclear and may be procedure and patient specific. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Long-term data regarding the safety and durability of thoracic endovascular aortic repair (TEVAR) are limited. The study objective was to evaluate the long-term outcomes of TEVAR in high-risk patients with descending thoracic aortic pathology., Methods: High-risk patients were treated with thoracic endografts (2001-2011) under a prospective, physician-sponsored, investigational device exemption trial. Three-dimensional reconstructions and measurements were performed on computed tomography scans acquired before discharge, at 1, 6, and 12 months, and then yearly thereafter., Results: The study included 200 patients, of whom 171 were treated for thoracic aneurysm, 28 for chronic dissection, and 1 for aortobronchial fistula. Patients were monitored for an average of 4.8 ± 3.3 years, and 93 (46.5%) were monitored for >5 years. Operative mortality was 6.5%. Survival at 30 days and at 1, 5, and 9 years was 94.0%, 85.8%, 55.6%, and 31.4%, and freedom from aneurysm-related death was 94.0%, 92.4%, 91.7%, 91.7%, respectively. Sixty-one endoleaks occurred in 54 patients (28%). Sixty-seven reinterventions were performed in 50 patients. Overall freedom from reintervention at 30 days, 1, 5, and 9 years was 87.9%, 82.9%, 75.5%, and 64.0%, respectively. Forty-seven reinterventions (70%) were thoracic aneurysm-related, 35 (74%) of which were endovascular procedures. Thirty of these were to correct endoleaks at a median of 1.4 years (interquartile range, 0.2-5.0 years)., Conclusions: TEVAR is durable and associated with high long-term aneurysm-related survival. Long-term imaging follow-up remains critical to identify endoleaks or rare device durability issues, most of which can be monitored or managed with endovascular therapies., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We sought to study the impact of surgical intervention on long-term outcomes in bicuspid aortic valve (BAV) patients who develop aortic valvular complications and/or have a concomitant aortopathy., Methods: We studied 1890 consecutive patients with BAV (age 50 ± 14 years; 75% men), evaluated in the time period 2003 to 2007. Clinical and imaging data were recorded. The endpoint was a composite of death or type A aortic dissection., Results: The mean left ventricular ejection fraction was 55% ± 8%; 31% had New York Heart Association class ≥ III aortic regurgitation, and 17% had mean aortic valve (AV) gradient ≥30 mm Hg. Dilated (≥4 cm) aortic root and ascending aorta were observed in 35% and 42% of patients, respectively. At 8.1 ± 2 years, 918 (49%) patients underwent surgery (883 had AV replacement and/or repair (± combination procedures), 471 with ascending aortic grafting (30 had isolated aortic grafting), and 171 (9%) events (169 deaths and 2 dissections) occurred; 0.4% was the 30-day mortality). On multivariable Cox survival analysis, increasing age (hazard ratio [HR] 1.06, 95% confidence interval [CI] [1.05-1.07]), increasing aortic root size (HR 1.32, 95% CI [1.07-1.65]), decreasing LV ejection fraction (HR 1.04, 95% CI [1.03-1.05]), and hyperlipidemia (HR 1.51, 95% CI [1.20-1.89]) had higher associated events, and surgery related to BAV (time-dependent covariate) (HR 0.44, 95% CI [0.31-0.70]) was associated with significantly lower events (all P < .01). Addition of surgery to BAV risk score (a composite of age, ≥moderate-severe aortic stenosis or regurgitation) and aortic root size further improved risk stratification (the C-statistic increased from 0.65 to 0.73; P = .01)., Conclusions: Patients with BAV have a high prevalence of AV dysfunction and concomitant aortopathy. Undergoing surgery (AV replacement and/or repair ± AAR) was associated with a significantly lower incidence of death and/or dissection., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

In the current era of cardiac and aortic surgery lines between open and endovascular approaches are becoming blurred. Hybrid techniques emerged with the availability of endovascular devices and the idea that combining open operations with a stent graft might provide a treatment option to those patients deemed too high-risk for conventional surgery. As these procedures evolved, it became clear that they still carried significant risk especially for the "inoperable" or "high-risk" patients, but they also offered new options for treating complex pathologies involving multiple segments of the aorta. Hybrid techniques not only provide the potential for less invasive aortic repair, but must be considered as an important complementary treatment option for patients with aortic disease, allowing for a potentially more effective and complete repair. The objective of this article is to review the current options for hybrid arch repair and the indications for choosing the various techniques based on pathologic presentation.

Background: Improvements in care have prolonged survival of patients with connective tissue disorders (CTDs), but their entire native aorta remains at risk. Little data are available to guide treatment. Objectives were to characterize patients, describe repair methods, and assess outcomes., Methods: From 1996 to 2012, 527 patients with CTDs underwent cardiovascular operations. Beyond the root, arch and descending repair was performed in 121 patients (23%) for aneurysm (n = 17), acute complicated dissection (n= 5), or chronic dissection with aneurysmal degeneration (n = 99). CTD diagnoses included Marfan (n = 107), marfanoid (n = 7), Ehlers-Danlos (n = 4), and Loeys-Dietz (n = 3) syndromes. Eighty-seven (72%) had a previous ascending aorta repair, including 51 (57%) for type A dissection. Median interval to distal operation was 8.4 years. Index procedures for repair beyond the root were elephant trunk (ET) stage I (n = 63), open descending repair (n = 26), thoracoabdominal repair (n = 13), total arch replacement (n = 13), and stent-grafting (n = 6: frozen ET 3, thoracic endovascular aortic repair [TEVAR] 3). Median follow-up was 4.4 years., Results: Operative mortality was 2.5% (3 of 121). No paralysis occurred, but 3 patients (2.5%) had nonpermanent stroke, 4 (3.3%) required dialysis, 12 (10%) required tracheostomy, and 13 (11%) underwent reoperation for bleeding. During follow-up, 67 patients underwent 85 additional distal aortic procedures (58 open, 27 endovascular, 49 of which were stage II ET). By 10 years, probability of at least 1 reintervention was 61%. At 1, 5, and 10 years, estimated survival was 91%, 79%, and 62%, and event-free survival was 52%, 35%, and 24%, respectively., Conclusions: Most patients with CTDs who require operations beyond the aortic root have aortic dissection and require multiple reinterventions. Staged repair strategies, including open repair in combination with TEVAR, are feasible, and benefits outweigh risks. These patients require lifelong imaging surveillance., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury., Methods: From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury., Results: A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P = .2)., Conclusions: Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment., (Copyright © 2015. Published by Elsevier Inc.)

Objective: Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes., Methods: From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%])., Results: Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively., Conclusions: Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications., Competing Interests: Statement Authors have nothing to disclose with regard to commercial support., (Copyright © 2015. Published by Elsevier Inc.)

Objective: Large vessel vasculitides (LVV) are a group of autoimmune diseases characterized by injury to and anatomic modifications of large vessels, including the aorta and its branch vessels. Disease etiology is unknown. This study was undertaken to identify antigen targets within affected vessel walls in aortic root, ascending aorta, and aortic arch surgical specimens from patients with LVV, including giant cell arteritis, Takayasu arteritis, and isolated focal aortitis., Methods: Thoracic aortic aneurysm specimens and autologous blood were acquired from consenting patients who underwent aorta reconstruction procedures. Aorta proteins were extracted from both patients with LVV and age-, race-, and sex-matched disease controls with noninflammatory aneurysms. A total of 108 serum samples from patients with LVV, matched controls, and controls with antinuclear antibodies, different forms of vasculitis, or sepsis were tested., Results: Evaluation of 108 serum samples and 22 aortic tissue specimens showed that 78% of patients with LVV produced antibodies to 14-3-3 proteins in the aortic wall (93.7% specificity), whereas controls were less likely to do so (6.7% produced antibodies). LVV patient sera contained autoantibody sufficient to immunoprecipitate 14-3-3 protein(s) from aortic lysates. Three of 7 isoforms of 14-3-3 were found to be up-regulated in aorta specimens from patients with LVV, and 2 isoforms (ε and ζ) were found to be antigenic in LVV., Conclusion: This is the first study to use sterile, snap-frozen thoracic aorta biopsy specimens to identify autoantigens in LVV. Our findings indicate that 78% of patients with LVV have antibody reactivity to 14-3-3 protein(s). The precise role of these antibodies and 14-3-3 proteins in LVV pathogenesis deserves further study., (© 2015, American College of Rheumatology.)

Objectives: Standard treatment of ascending aortic pathology is open repair, but some patients are too high risk. Thoracic endovascular aortic repair (TEVAR) of the ascending aorta has been used as an alternative. Our objectives were to characterize patients, describe repair methods, and assess outcomes., Methods: From 2006 to 2014, 22 patients underwent supracoronary ascending TEVAR for acute Type A dissection (n = 9), intramural hematoma (n = 2), pseudoaneurysm (n = 9), chronic dissection (n = 2), or aorta-cardiac fistula (n = 2). Mean age was 71 ± 13 years and the maximum proximal aortic diameter was 6 ± 1 cm. Devices were delivered via a transfemoral (n = 10), transapical (n = 7), or axillary (n = 5) artery approach. The proximal landing zone was at the sinotubular junction in 14 patients, mid to distal ascending aorta in 3 patients, and surgical graft from previous ascending repair in 5 patients. More than 1 device was used in 15 patients. Imaging and engineering analysis was performed for all patients., Results: There were 3 hospital deaths (13.6%) (tamponade in 1 patient, bleed from left atrial fistula in another patient). One patient had partial occlusion of the left coronary artery requiring open conversion and died later from multiorgan failure. One patient required early open conversion for retained delivery system. There were 3 strokes, 2 myocardial infarctions, and 2 tracheostomies, but there was no new-onset renal failure. Median follow-up was 12 months. Six patients developed type 1 endoleak: 2 were treated endovascularly, 1 with open repair, 1 resolved, 1 refused treatment, and 1 is being watched. In 2 patients, initial TEVAR was performed as a bridge for ruptured high-risk dissection and were later converted to open repair. Reoperations also included removal of stent graft due to distal migration and repair of left ventricular pseudoaneurysm. There were 3 late deaths. Actual survival at 30 days, 1 year, and 5 years was 86%, 80%, and 75%, respectively., Conclusions: Ascending TEVAR is a feasible alternative to medical therapy for repair of acute and chronic ascending disease in high-risk patients. Development of devices dedicated to treat ascending aortic pathology is needed to improve outcomes., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) has been applied to increasingly complex aortic pathology, resulting in an increase in late complications. We characterized patients undergoing open repair after prior TEVAR including indications, operative techniques, and outcomes., Methods: Chart review and query of a prospectively collected database identified 50 patients who underwent thoracic aortic operation after prior TEVAR. Active follow-up was supplemented by Social Security information for vital status., Results: From July 2001 to January 2012 open arch (n = 25), descending (n = 6), thoracoabdominal (n = 17), or extra-anatomic bypass (n = 2) operations were performed after previous TEVAR (median interval from TEVAR to open surgical procedure: 13.9 months; interquartile range, 0.5 to 24 months). Indications for open operation included type 1 endoleaks (n = 19), retrograde aortic dissection (n = 9), chronic aortic dissection with persistent growth of the false lumen (n = 16), and graft infection (n = 6). Sixty percent had prior cardiovascular surgical procedures and 18% were done as emergencies. Circulatory support was required in 78% and hypothermic arrest in 48%. Hospital mortality occurred in 3 (6%) patients with no strokes and 1 patient with myocardial infarction; 5 (10%) patients required tracheostomy and 1 required dialysis. Survival was 67% at a median follow-up of 2.9 years., Conclusions: Conversion to open repair after thoracic stent-grafting may be indicated for type 1 endoleak, retrograde dissection, chronic aortic dissection with persistent false lumen growth, or graft infection. These salvage operations are complex but can be completed safely with good early outcomes and preservation of the stent-graft in most cases. Late outcomes are consistent with the chronic disease state of these patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic., Methods: High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research., Results: The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway., Conclusions: Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery.

Objective: Retrograde dissection is now recognized as an important complication after thoracic endovascular aortic repair (TEVAR), but its treatment is poorly understood. Our objectives were to investigate the risks, describe the repair methods, and assess the outcomes of this complication., Methods: From 2000 to 2012, 766 patients underwent TEVAR. Of these patients, 14 (1.8%), plus 1 who had undergone TEVAR elsewhere (n = 15), developed retrograde dissection after stent grafting. They had undergone TEVAR for distal aortic dissection in 7, intramural hematoma in 5, aneurysm in 2, and transection in 1. Their mean age was 65 ± 9 years. At the initial TEVAR, the left subclavian artery was covered in 9, the mean stent graft diameter was 34 ± 2 mm, and >1 device was used in 8 patients. The site of entry tear was at the greater curvature in 11 and lesser curvature in 4. One patient ruptured and died 12 days after TEVAR and never made it to the operating room. The other 14 underwent proximal aortic repair. The median interval between TEVAR and repair of retrograde dissection was 6 months; 3 patients presented within 1 month. The repair techniques included reverse frozen elephant trunk in 5, total arch repair in 4, ascending or hemiarch repair in 4, and ascending TEVAR in 1. Concomitant procedures included aortic valve repair in 4, replacement in 2, root remodeling in 1, and coronary bypass in 1., Results: No operative mortality occurred. One patient underwent reoperation for bleeding. Two required a tracheostomy for respiratory failure. However, no renal failure, stroke, or spinal injury occurred. At a median follow-up of 26 months, 4 aortic reoperations had occurred: 1 distal stent graft extension for type 1b endoleak, 2 hybrid thoracoabdominal completion repairs for growth of residual distal disease, and 1 emergency TEVAR for aortobronchial fistula. The latter patient died of septic complications, and 3 other late noncardiac deaths occurred., Conclusions: Retrograde ascending dissection can present as an early or a late complication after descending stent grafting because of aortic instability or disease progression and has usually been associated with descending dissection or intramural hematoma. It is a life-threatening complication that can be managed safely with early recognition and rapid delivery of open or hybrid repair., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: There are a variety of modified elephant-trunk methods, including use of endovascular stents. Our objectives were to classify these modifications, compare outcomes between the classic anastomotic site and these alternatives, and investigate time to second-stage elephant-trunk completion., Methods: From May 1992 to January 2011, 526 patients underwent a first-stage elephant-trunk procedure and were the subject of analysis., Results: Distal aortic anastomosis was located before the brachiocephalic artery in 6 patients (1.1%), between brachiocephalic and left common carotid artery (LCCA) in 1 (0.19%), between LCCA and left subclavian artery (LSCA) in 154 (29%), and beyond the LSCA (classic) in 365 (69%). Stroke occurred in 8% (n = 42) overall, 10% (n = 16) in the LCCA-LSCA group, and 6.8% (n = 25) in the classic group. Risk factors were older age and acute dissection. Thirty-day mortality was 7.6% (n = 40) and was similar for LCCA-LSCA (9.7%) and classic sites (6.3%; p = 0.7); risk factors included older age, smaller body surface area, and end-organ dysfunction. Likelihood of death before second-stage elephant trunk at 1, 4, and 8 years after operation was 16%, 22%, and 27%, respectively. The larger the distal aorta, the more likely was second-stage completion (p < 0.0001); when greater than 6 cm, 80% had second-stage completion., Conclusions: The elephant-trunk operation is safe for a broad population, including when anastomotic sites are other than beyond the LSCA. Without second-stage completion, patient mortality increases markedly after 4 years., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim of Study: Right-sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques., Methods: We retrospectively reviewed 17 patients undergoing right-sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach., Results: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In-hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months., Conclusion: The surgical treatment for right-sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention., (© 2012 Wiley Periodicals, Inc.)

Background: The frozen elephant trunk (FET) repair technique combines conventional arch repair with the patient under circulatory arrest with stent grafting and is increasingly being used to treat extensive thoracic aortic disease. This surgical approach is evolving, including its use for complications after thoracic aortic stent grafting - the so-called reversed frozen elephant trunk (RFET). We evaluated the safety and efficacy of FET and RFET operations in high-risk patients., Methods: Between July 2001 and December 2010, 31 patients underwent FET and 19 patients underwent RFET for extensive thoracic aortic disease. Causes included aneurysm (n=32), acute dissection (n=17), and rupture (n=1). Twenty-three cases (46%) were for urgent or emergency indications. Patient data and outcomes were collected through a prospectively maintained clinical database and 3-dimensional analysis of computed tomography (CT) scans. Outcomes were assessed using Kaplan-Meier methodology., Results: In-hospital mortality was 8% (n=4, including 1 emergency RFET procedure for aortic rupture and 2 urgent FET procedures for symptomatic degenerative aneurysm). Stroke occurred in 5 patients (10%) and spinal cord injury in 4 patients (8%). Mean hospital stay was 14.3 days (range 4 to 67 days). Five endoleaks were observed (4 type II, 1 type I) requiring 2 endovascular reinterventions. Mean follow-up was 17 months (range, 1 to 76 months) and actuarial survival was 87% at 2 years., Conclusions: Frozen elephant trunk repair is an effective surgical strategy for managing high-risk patients with extensive pathologic conditions of the thoracic aorta. The RFET approach is a feasible option for proximal aortic complications after previous descending stent grafting. Intermediate outcomes are reasonable for both approaches and further evaluation of these techniques is warranted., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Controversy surrounds the endovascular treatment of chronic dissection because of inconsistent remodeling of the aorta. The purpose of this study was to assess efficacy and safety of a novel technique for repairing aneurysmal change associated with chronic descending aortic dissection., Methods: From July 2007 to April 2011, 24 patients with descending aortic aneurysmal change, consequent to previously repaired ascending aortic dissection or medically treated descending dissection, underwent combined open first-stage elephant trunk (ET) insertion and fenestration of the descending aorta intimal flap. Second-stage ET endovascular completion was performed with the index operation in 4 patients and later in 20 patients (median, 62 days). Repair was elective in 14 patients and urgent in 10 patients. Concomitant procedures were aortic valve replacement in 3 patients and coronary revascularization in 3 patients, and 16 procedures were reoperations. Chart review and analysis of 3-dimensional computed tomography (CT) scans were performed. Imaging follow-up was complete in 89% of patients during a median of 18 months (interquartile range [IQR], 10 to 28 months)., Results: Technical success was achieved in all patients. Moderate reduction in aortic size occurred in most patients, with no retrograde false lumen flow. Late reintervention was required in 5 patients: endovascular for distal type I endoleak in 2 patients, type II endoleak in 1 patient, pseudoaneurysm of the abdominal aorta in 1 patient, and 1 open repair for aneurysm of the untreated distal segment in 1 patient. One patient died of pulmonary embolism on postoperative day 19 after 1-stage repair (4.0%) and 1 patient (4%) had a transient stroke, but there was no renal failure, respiratory failure, or permanent spinal cord injury. Median length of stay was 13 days (IQR, 8 to 16 days) after first-stage ET and 8 days (IQR, 5 to 12 days) after endovascular ET completion. One patient died during a mean of 23 ± 11 months of follow-up., Conclusions: Open distal landing zone fenestration during first-stage ET facilitates endovascular completion for aneurysm associated with chronic distal dissection. Early results suggest that this technique is efficacious in eliminating retrograde false lumen filling and promoting aortic size reduction and is safe for patients., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aortic pseudocoarctation is a congenital abnormality consisting of an elongated aortic arch with a kink at level of the isthmus. However, unlike coarctation, significant flow obstruction is not associated with pseudocoarctation, although there is an increased incidence other cardiovascular anomalies. This case demonstrates the use of multidetector CT as part of the clinical evaluation of a 49-year-old male with suspected aortic coarctation, leading to the final diagnosis of pseudocoarctation, as well as the incidental discovery of a crossed fused ectopic kidney., (© 2010 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic aortic disease involving the aortic arch presents a challenge to cardiovascular surgeons. The purpose of this study was to establish the safety and efficacy of antegrade delivery techniques of aortic stent grafting for the treatment of high-risk, complex thoracic aortic disease., Methods: From April 2007 to December 2009, 38 patients underwent stent graft repair of complex thoracic aortic diseases not otherwise amenable to standard retrograde delivery. Chart review, query of the Social Security Death Index, and three-dimensional analysis of computed tomography was performed. Indications were elective (n = 17), urgent (n = 11), or emergent (n = 10). Causes included coarctation (n = 1), acute aortic dissection (n = 4), traumatic transection (n = 2), and aneurysm or pseudoaneurysm (n = 31), of which 6 were ruptured. Sites of delivery included axillary (n = 4), ascending aorta (n = 18), and direct aortic placement (frozen elephant trunk, n = 16). Eleven were performed off-pump, 4 were performed on pump with a beating heart, 3 with cardiac arrest, and 20 under deep hypothermic circulatory arrest. Delivery was facilitated by transesophageal echocardiography alone (n = 14), or with fluoroscopy (n = 24). All devices used were commercially available (TAG, 18; Talent, 1; TX2, 19). Concomitant procedures were performed in 26 patients including 17 ascending repairs, 16 coronary artery bypass graftings, and 4 aortic valve replacements., Results: Technical success was achieved in 97% (37 of 38 patients). Hospital mortality was 10% (n = 4), and serious complications included stroke (n = 4), paraparesis (transient n = 3, persistent n = 1), renal failure (n = 4), and respiratory failure (n = 12). Mean length of hospital stay was 14.7 days (range, 4 to 36 days), and 6.7 days (range, 1 to 20 days) in the intensive care unit. Overall survival was 74% at median follow-up of 1.2 + or - 0.8 years. Ten endoleaks in 9 patients (8 type II, 2 type I) required 3 late reinterventions., Conclusions: Antegrade delivery of commercially available stent grafts to treat high-risk, complex thoracic aortic diseases is feasible with a high rate of technical success and good intermediate-term outcomes. Further evaluation of these alternative stent graft delivery techniques is warranted., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)