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Objectives: To investigate the optimal stent length and distal positioning of frozen elephant trunks (FETs) in patients with type A acute aortic dissection (TAAD)., Methods: Between October 2014 and April 2021, 191 patients (FET-150 group: 37 patients; stent length, 150 mm; 66.3 ± 12.6 years and FET-non-150 group: 154 patients; 60, 90, or 120 mm; 64.1 ± 12.5 years) underwent total arch repair with FETs for TAAD using the "zone 0 arch repair" strategy. In the FET-150 group, the proximal stent end was positioned at the innominate artery origin of the arch. In the FET-non-150 group, the distal stent end was to be positioned just proximal to the aortic valve level using transesophageal echocardiography. The proximal end of the non-stented FET part was sutured to an arch graft together with the aortic wall at 1 to 2 cm proximal to the innominate artery origin., Results: Distal stent ends were positioned at the thoracic vertebrae (Th) 4-5, 6-7, 8-9, and 10 levels in 0 (0%), 12 (32.4%), 25 (67.6%), and 0 (0%) patients, respectively, in the FET-150 group, and in 6 (3.9%), 98 (63.6%), 49 (31.8%), and 1 (0.7%), respectively, in the FET-non-150 group. No between-group difference in postoperative mortality was noted. The incidence of postoperative residual distal malperfusion and new-onset spinal cord ischemia in the FET-150 versus FET-non-150 groups were 2.7% versus 6.5% (P = .62) and 0% versus 1.9% (P = 1.00), respectively., Conclusions: FET positioning with the distal stent end at around Th 8 can reduce residual distal malperfusion when a FET with a 150-mm stent is deployed from the aortic zone 0 in patients with TAAD undergoing total arch repair., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the status of type A acute aortic dissection using the Tokyo Acute Aortic Super Network., Methods: Data of 6283 patients with acute aortic dissection between 2015 and 2019 were collected. Data of 3303 patients with type A acute aortic dissection were extracted for analysis., Results: Overall, 51.0% of patients were nondirect admissions. On arrival, 23.1% of patients were in shock, 10.0% in cardiopulmonary arrest, and 11.8% in deep coma or coma. Overall, 9.8% of patients were assessed as untreatable. Of 2979 treatable patients, 18.3% underwent medical treatment, whereas 80.7% underwent surgery (open [78.8%], endovascular [1.9%], and peripheral [1.1%] repair). The early mortality rate was 20.5%, including untreatable cases. Among treatable patients, in-hospital mortality rates were 8.6% for open repair, 10.7% for endovascular repair, and 25.3% for medical treatment. Advanced age, preoperative comorbidities, classical dissection, and medical treatment were risk factors for in-hospital mortality. Nondirect admission did not cause increased deaths. The mortality rates were high during the superacute phase following symptom onset., Conclusions: This study demonstrated current practices in the emergency care of type A acute aortic dissection via the Tokyo Acute Aortic Super Network system, specifically a high rate of untreatable or inoperable cases and favorable outcomes in patients undergoing surgical treatment. High mortality rates were observed during the super acute phase after symptom onset or hospital arrival., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires that editors and reviewers disclose conflicts of interest and decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

We investigated whether supra-aortic vessel (SAV)s dissection is a risk factor for neurological dysfunction (ND) after surgical repair for type A acute aortic dissection (TAAAD). A retrospective review was done in 178 patients with TAAAD undergoing aortic repair between 2015 and 2019, comparing those with SAV dissection to those without it. Preoperatively, 93 patients (54.4%) had SAV dissection. Postoperatively, ND occurred in 26 patients (14.6%), 17 of whom (65.4%) already had been present with preoperative ND. Patients with SAV dissection were more likely to have postoperative ND than those without it (21.5% vs 7.7%; p = 0.02). The severity of preoperative dissection-related stenosis in common carotid artery significantly related to postoperative ND (right; p =0.0071, left; p < 0.0001). Multivariable analysis showed dissection-related stenosis of > 75% in brachiocepharic and left common carotid arteries, and thrombosed false lumen in common carotid arteries were independent risk factors for postoperative ND. However, SAV dissection was not related to new onset of ND. Dissection with stenosis of > 75% in SAVs were significantly decreased after aortic repair and even after ascending aorta/hemiarch replacement. In conclusion, ND after surgical repair for TAAAD is closely related to SAV dissection, especially to stenosis of > 75% and thrombosed false lumen in common carotid arteries. Aortic repair significantly decreased SAV dissection and severity of stenosis., (© 2022. Springer Japan KK, part of Springer Nature.)

Objectives: Type A acute aortic dissection (TAAAD) complicated with cerebral malperfusion (CM) is a life-threatening condition associated with high mortality, poor outcomes, and the optimal surgical management remains controversial. The aim of this review was to report the current results of surgical interventions of these patients., Methods: A systematic review was performed using PubMed and MEDLINE search for cases underwent surgical repair for TAAAD with CM. Demographics, neurological symptom, the time from onset of symptoms to operation, operation data, mortality, neurological outcome, and follow-up were reviewed., Results: A total of 363 patients with mean age of 65.7 ± 13 years underwent surgical repair for TAAAD with CM were identified in 12 retrospective studies. In-hospital mortality was 20.1%. Mean duration of follow-up was 40.1 ± 37.6 months. The involved supra-aortic branch vessels were RCCA (n = 99), LCCA (n = 25), B-CCA (n = 52), CCA (n = 131), IA (n = 19), and LSA (n = 8). Time from onset of neurological symptoms to surgery was 13.3 h. Antegrade and/or retrograde cerebral perfusion were applied. Postoperatively, improved, unchanged and worsened neurological status was occurred in 54.3%, 27.1%, and 8.5%, respectively in 199 patients., Conclusion: The outcomes of surgical treatment of TAAAD complicated with CM indicate acceptable early mortality and morbidity. It is reasonable to perform lifesaving surgery on these patients. Early central surgical repair and reperfusion of brain may improve the outcomes., (© 2022. The Author(s).)

Objective: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection., Methods: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events., Results: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01)., Conclusions: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effects of seasonal and climatic changes on postoperative in-hospital mortality and length of stay (LOS) in patients with type A acute aortic dissection (AAD)., Methods: Patients undergoing implantation of the modified triple-branched stent graft to replace the descending aorta in addition to aortic root reconstruction for type A AAD in our hospital from January 2016 to December 2019 were included. Relevant data were retrospectively collected and analyzed., Results: A total of 404 patients were included in our analyses. The multivariate unconditional logistic regression analysis showed that patients admitted in autumn (OR 4.027, 95% CI 1.023-17.301, P = 0.039) or with coronary heart disease (OR 8.938, 95% CI 1.991-29.560, P = 0.049) were independently associated with an increased risk of postoperative in-hospital mortality. Furthermore, patients admitted in autumn (OR 5.956, 95% CI 2.719-7.921, P = 0.041) or with hypertension (OR 3.486, 95% CI 1.192-5.106, P = 0.035) were independently associated with an increased risk of longer LOS., Conclusion: Patients admitted in autumn or with coronary heart disease are at higher risk of in-hospital mortality following surgery for type A AAD. Also, patients admitted in autumn or with hypertension have a longer hospital LOS. In the autumn of the temperature transition, we may need to strengthen the management of medical quality after surgery for type A AAD., (© 2021. The Author(s).)

Background: Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion., Case Presentation: The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications., Conclusions: Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.

Background: Acute aortic dissection (AAD) is a rare, but a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A Acute aortic dissection (TAAAD) still remains high, and treatment for such patients remains controversial., Case Presentation: A new surgical approach which entails "stepwise external wrapping (SEW)" using a zero-porosity artificial graft was developed in extremely high-risk patients with TAAAD. Herein, we described its surgical details and showed two representative cases which was successfully done., Conclusions: Our SEW procedure is a feasible alternative to conventional graft replacement for TAAAD in extremely high-risk or aged patients, although the gold standard consists of surgical replacement of the dissected aorta. (129 words).

Objectives: It is unclear whether the hybrid debranching or total arch replacement (TAR) technique is preferential in treatment of acute Stanford type A aortic dissection (AAAD) among different age groups. The aim was to compare the clinical outcomes for the two therapeutic strategies., Design: Retrospective., Setting: University medical center, single institutional., Participants: Four hundred thirty-seven registered patients with AAAD who underwent aortic surgery from 2017 to 2019 were included in the analysis, and 309 met eligibility criteria for the study. Those excluded had an aortic landing zone 1 to 4, concomitant valve or coronary operations, staged thoracic endovascular aortic repair after TAR, and organ ischemia including renal and neurologic dysfunction., Interventions: Hybrid debranching or TAR surgery., Measurements and Main Results: Perioperative and mid-term (2 years) follow-up data were analyzed to evaluate outcomes between the 2 interventions. In the hybrid versus TAR groups, findings included hospital length of stay (days) of 22.3 ± 2.0 v 28.6 ± 5.0 (p < 0.001) for those ≥60 years and 18.6 ± 1.8 v 19.5 ± 2.8 (p = 0.061) for those <60 years; postoperative neurologic events in 5.2% v 16.7% (p = 0.038) of those ≥60 years and in 5.1% v 4.7% (p = 0.752) of those <60 years; renal insufficiency in 5.2% v 23.8% (p = 0.003) of those ≥60 years and 2.6% v 10.2% (p = 0.243) of those <60 years; midterm survival in 95.1% v 65.2% (p = 0.037) of those ≥60 years and 100% v 100% (p > 0.999) of those <60 years; and a reintervention rate of 5.2% v 0% (p < 0.05) in those ≥60 years and 7.7% v 0% (p < 0.05) in those <60 years., Conclusion: In the treatment of AAAD, patients older than 60 years undergoing hybrid debranching surgery had shorter hospital lengths of stay, lower rates of neurologic events and renal insufficiency, and a higher mid-term survival rate compared with the TAR procedure, whereas there was no statistical difference in hybrid debranching versus TAR in patients younger than age 60. Irrespective of reintervention, hybrid debranching can be a promising surgical option for patients with AAAD older than 60 years., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Few reports on the outcomes of patients treated for Stanford type A acute aortic intramural haematoma (TAAIMH) and retrograde thrombosed type A acute aortic dissection exist. This study aimed to evaluate their long-term results and predictors of adverse outcomes., Methods: We retrospectively analysed 40 patients with TAAIMH and retrograde thrombosed type A acute aortic dissection. All patients underwent urgent surgery on presentation of life-threatening complications. Before discharge, 18 patients underwent open aortic surgery, and 22 were treated with medical therapy alone. Clinical features of these patients and image appearances were reviewed, and the relationship with overall survival, aortic events, and aortic death was investigated., Results: The in-hospital mortality rate was 4.5% (1 patient) with medical therapy alone and 11.1% (2 patients) with surgical intervention. No patient with initial medical therapy required urgent surgery for life-threatening complications beyond 3 days of admission. The overall survival and aortic death-free survival rates at 1, 5 and 10 years were 85.0%, 72.5% and 59.8% and 90.0%, 81.6% and 77.1%, respectively. TAAIMH associated with penetrating aortic ulcer (PAU) was a risk factor of aortic events (P = 0.020) and significantly influenced aortic death-free survival (P = 0.003)., Conclusions: Urgent surgery for complicated TAAIMH and retrograde thrombosed type A acute aortic dissection patients and initial medical therapy for uncomplicated patients show favourable long-term survival rates. TAAIMH is frequently associated with PAU; PAU enlargement is common. Although PAU can remain stable for years, it is a strong predictor of poor prognosis. For optimal long-term results, surgical repair is recommended for TAAIMH associated with PAU., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Type A acute aortic dissection (TAAAD) sometimes presents with acute stroke-like symptoms. When intravenous tissue plasminogen activator (IV-tPA) therapy is considered for acute ischemic stroke, TAAAD must be excluded. Painless TAAAD presenting with acute stroke may be easily missed. Two cases of painless TAAAD presenting with acute stroke in which IV-tPA therapy was considered are reported. In these cases, cervical magnetic resonance angiography (MRA) was useful for detecting TAAAD, and IV-tPA therapy was canceled. The mottled high signal ("snowstorm") in the common carotid artery on cervical MRA is specific for TAAAD. We have thus named this phenomenon the "snowstorm sign" and believe it can help diagnose TAAAD., (Copyright © 2016 Elsevier Inc. All rights reserved.)