Search

Objective: To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections., Methods: Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention., Results: Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality., Conclusions: The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We aimed to determine whether non-A non-B aortic dissection (AD) differs in morphologic and haemodynamic properties from type B AD., Methods: We simulated and compared haemodynamics of patients with acute type B or acute non-A non-B AD by means of computational fluid dynamics. Wall pressure and wall shear stress (WSS) in both the true lumen (TL) and false lumen (FL) at early, mid- and late systole were evaluated. Morphology, WSS and the FL/TL wall pressure ratio were compared between groups., Results: Nineteen patients (type B, n = 7; non-A non-B, n = 12) were included. The median age (51 [46, 67] vs 53 [50, 63] years; P = 0.71) and a complicated course (14% vs 33%; P = 0.6) did not differ between the type B group and the non-A non-B group. However, the median entry tear width was increased in the non-A non-B group (9.7 [7.3, 12.7] vs 16.3 [11.9, 24.9] mm; P = 0.010). Streamlines showed, in patients with non-A non-B AD, blood from the TL flowed into the FL via the entry tear. Prevalence of a FL/TL wall pressure ratio >1.0 (type B versus non-A non-B) at early, mid- and late systole was 57% vs 83% (P = 0.31), 43% vs 83% (P = 0.13) and 57% vs 75% (P = 0.62), respectively. WSS did not differ between the groups., Conclusions: The increased FL/TL wall pressure ratio observed during systole in non-A non-B AD may beget a complicated presentation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture., Methods: Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed., Results: Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%)., Conclusions: Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: The aim of this study was to analyse outcomes of downstream thoracic endovascular aortic repair (TEVAR) following the frozen elephant trunk (FET) procedure., Methods: Sixty-six patients underwent downstream TEVAR following the FET procedure to treat thoracic aortic dissections (n = 42, 64%), aneurysms (n = 19, 29%) or penetrating aortic ulcers involving the aortic arch (n = 5, 8%). Patient and outcome characteristics were analysed., Results: Downstream TEVAR was performed 7 [interquartile range: 2-18] months after the FET procedure in 39 male (59%) and 27 female (41%) patients aged 68 [interquartile range: 56, 75] years, including 11 patients (17%) with a connective tissue disease. Before TEVAR, cerebrospinal fluid drainage was put in place in 61 patients (92%). Patients were treated with 1 stent graft (n = 28, 42%), 2 stent grafts (n = 37, 56%) or 3 stent grafts (n = 1, 2%). The femoral artery was accessed through surgical cut-down (n = 15, 23%) or percutaneously (n = 49, 74%). One patient (2%) developed a temporary spinal cord injury that resolved spontaneously. No case of permanent spinal cord injury, stroke or death was observed. After 12 [interquartile range: 2-23] months, 15 patients required an additional aortic reintervention (endovascular: n = 6; surgical: n = 9)., Conclusions: Downstream TEVAR following the FET procedure is associated with excellent clinical outcomes. We thus maintain that staging thoracic aortic repair-FET and secondary TEVAR-is a very successful and safe strategy. Certain patients might need a tertiary procedure to fix their entire aortic pathology; therefore, they will require long-term continuous follow-up, ideally in a dedicated aortic clinic., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique., Methods: Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each's cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke., Results: Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20-8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28-19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09-360.84; P = 0.044) as predictors for postoperative stroke., Conclusions: Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: To evaluate the safety and efficacy of recannulating the axillary artery in reoperative proximal thoracic aortic surgery., Methods: Between 2008 and 2020, we evaluated patients who underwent reoperative proximal thoracic aortic surgery. The patients were divided into 2 groups: (i) patients with no previous right axillary artery cannulation (primary cannulation group) and (ii) patients with a previous cannulated right axillary artery (recannulation group). We analysed the intraoperative data, cannulation-related complications, postoperative outcomes and compared the 2 groups (primary cannulation versus recannulation)., Results: The patient (n = 132) baseline characteristics did not differ significantly between the 2 groups. There was no statistically significant difference in regard to the duration of surgery, cardiopulmonary bypass, aortic cross-clamp and antegrade cerebral perfusion time nor in regard to the total number of patients with cannulation-related complications between the 2 groups [n = 8 (8.0%) vs n = 1 (3.1%), P = 0.34]. The incidence of iatrogenic axillary artery dissection, iatrogenic aortic dissection, iatrogenic aortic dissection leading to death, axillary artery thrombosis, need for surgical repair, brachial plexus injury rates, malperfusion, high perfusion resistance and hyperperfusion syndrome revealed no significant difference between the 2 groups (P > 0.05). There were 11 (11.0%) cases of stroke in the primary cannulation group and 1 (3.1%) in the recannulation group (P = 0.18)., Conclusions: Recannulation of the right axillary artery in reoperative proximal thoracic aortic surgery is not associated with worse clinical outcomes and can be safely and effectively performed, also representing a preventive and rescue measure. Previous cannulation of the axillary artery should not hinder the decision for recannulation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Acute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter changes during the dissection's acute and subacute phases. The aim of this study was to evaluate the change in aortic geometry within 30 days after the onset of a descending aortic dissection., Methods: Patients with acute type B and non-A non-B dissection who had at least 2 computed tomography angiography scans obtained within 30 days after the onset of dissection were evaluated. Exclusion criteria were a thrombosed false lumen, connective tissue disorders and endovascular or open aortic repair performed prior to the second computed tomography angiography., Results: Among 190 patients with acute aortic dissection, 42 patients met our inclusion criteria. Their aortic geometry was analysed according to the computed tomography angiography scans obtained between 0-3 (N = 35), 4-7 (N = 9) and 8-30 (N = 12) days after the dissection onset. The highest aortic diameter growth rate was observed in the first quartile of the thoracic aorta and measured 0.66 (0.06; 1.03), 0.29 (-0.01; 0.41) and 0.06 (-0.13; 0.26) mm/day at 0-3, 4-7 and 8-30 days after the dissection, respectively. Proximal entry location (P = 0.037) and entry located at the arch concavity (P = 0.008) were associated with a higher aortic diameter increase., Conclusions: Early rapid growth occurs during the first week after the descending aortic dissection-most intensely over the first 3 days, and this is associated with the location of the dissection's entry., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Our aim was to describe the outcomes of the latest treatment options of acute non-A non-B aortic dissection involving an entry tear in the aortic arch., Methods: Included were patients who presented between January 2001 and February 2020 with a non-A non-B aortic dissection involving the aortic arch but not the ascending aorta and with the most proximal entry tear located within the aortic arch between the innominate and left subclavian artery. Clinical data and operative details were retrieved from medical histories and surgical protocols. Preoperative, postoperative and follow-up computed tomography angiography scans were analysed., Results: We analysed a total of 39 patients [median age 62 (52; 67) years, men 76.9%] with non-A non-B arch entry aortic dissections type. They underwent 15 thoracic endovascular aortic repairs, 20 frozen elephant trunk implantations, 1 hybrid arch replacement, or 1 conventional arch replacement. Two patients were managed conservatively. Twelve (31%) patients underwent emergent intervention, 12 (31%) were treated invasively within 2 weeks. Another 2 (5%) and 9 (23%) patients were treated 2 and 4 weeks after dissection occurred, respectively. Six (15%) patients presented with an impending aortic rupture, while 19 (49%) had at least one malperfused organ. Four patients (27%) died after thoracic endovascular aortic repair; the 30-day mortality following frozen elephant trunk was 0%., Conclusions: Non-A non-B acute aortic dissection reveals a frequently complicated course requiring emergency intervention. The majority of patients required aortic arch repair within the first 2 weeks. Total arch replacement with the frozen elephant trunk technique seems to be low procedural mortality, and may become the treatment of choice in arch entry non-A non-B aortic dissection., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Detailed knowledge of aortic anatomy is necessary before new prostheses can be developed. Our aim was to provide a thorough analysis of aortic arch anatomy in patients who are potential candidates for arch repair. Patients' charts were screened between 2001 and 2019 for all those with a dissection or aneurysm involving aortic arch. Aortic diameters, segmental lengths, aortic arch type, tortuosity, diameters and length of supraaortic vessels were analyzed via computed tomography angiography. We included 558 patients who underwent thoracic aortic treatment for type A, B, non-A non-B dissection, or aortic arch aneurysm. Incidence of all three arch types was similar in patients with type A dissection. In type B dissection and arch aneurysm patients, arch type III was most commonly observed (47% and 52%, respectively). The left vertebral artery offspring from aortic arch was observed in 6.6%. The mid-ascending aorta and aortic arch were not dilated in type B and non-A non-B dissection patients. The innominate, left common carotid and left subclavian arteries median diameters were 16 (14; 18), 8 (7; 9) and 11 (10; 12) mm, respectively. The median innominate artery length was 37 (30; 44) mm. The median left subclavian artery length was 40 (34; 46) mm. Arch types are distributed differently among patients with various arch pathologies. Patients with aortic dissection type B and non-A non-B have a non-dilated ascending aorta and aortic arch. Aortic arch tortuosity, innominate and left subclavian artery lengths do not differ among aortic pathologies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The endovascular treatment of pathologies of the ascending aorta has not been incorporated into routine clinical practice. The aim of this article is to provide an overview of the endovascular treatment of pathologies of the ascending aorta, particularly type A aortic dissection. A thorough analysis and discussion of anatomical, physiological, clinical and technical challenges, and obstacles is performed. Conventional straight stent-grafts alone are not capable of fixing the entire complex underlying problem in the vast majority of patients with acute type A aortic dissection. An endovascular valve-carrying conduit consisting of a proximal transcatheter aortic valve connected to a covered stent-graft would be able to close a primary entry tear in the ascending aorta, ensure coronary perfusion, initiate true lumen expansion, treat malperfusion, treat aortic regurgitation, drain any pericardial effusion through a transapical approach, and possibly stabilize the distal aorta. Two thirds of all patients with acute aortic dissection are potential candidates for endovascular treatment, and the concept may help to significantly improve survival in patients with acute aortic dissection.

Objective: Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A., Methods: Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery., Results: Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21)., Conclusions: Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders., (Copyright © 2019. Published by Elsevier Inc.)

We report 3 cases of excessive oozing after aortic arch replacement using the frozen elephant trunk technique through the fabric of the branched Cryolife-Jotec Evita Open NEO hybrid prosthesis. After weaning from cardiopulmonary bypass, protamine administration as well as standard substitution of plasmatic and cellular coagulation adjusted to thrombelastometry, excessive oozing persisted leading to a complicated postoperative course in all 3 patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The goal of this study was to describe our 3-step approach to treat multisegmental thoraco-abdominal aortic disease due to aortic dissection and to present our initial clinical results., Methods: Nine patients with multisegmental thoraco-abdominal aortic pathology due to aortic dissection underwent our 3-step approach, which consisted of total aortic arch replacement via the frozen elephant trunk technique, thoracic endovascular aortic repair for distal extension down to the level of the thoraco-abdominal transition and, finally, open thoraco-abdominal aortic replacement for the remaining downstream aortic segments. We assessed their baseline and aortic characteristics, previous aortic procedures, intraoperative details, clinical outcomes and follow-up data., Results: The median age was 58 (42-66) years; 4 patients (44%) presented connective tissue disease. Eight patients (89%) had undergone previous aortic surgery for aortic dissection. In-hospital mortality was 0% (n = 0). None suffered symptomatic spinal cord injury or disabling stroke. During the follow-up period, 1 patient died of acute biliary septic shock 6 months after thoraco-abdominal aortic replacement., Conclusions: The 3-step approach to treat multisegmental thoraco-abdominal aortic pathology due to aortic dissection, which involves applying both open and endovascular techniques, is associated with an excellent clinical outcome and low perioperative risk. Distal shifting of the disease process through the thoracic endovascular aortic repair extension-and thereby necessitating limited open thoraco-abdominal aortic repair-seems to be the major factor enabling these favourable results., Irb Approval: IRB approval was obtained (No. 425/15) from the institutional review board of the University of Freiburg., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Our goal was to evaluate the use of the frozen elephant trunk (FET) technique for the treatment of penetrating aortic ulcers involving the aortic arch., Methods: Between January 2008 and January 2020, a total of 34 patients had the FET technique at 3 aortic centres. The indication for the FET technique was unsuitability for thoracic endovascular aortic repair due to the lack of a sufficient proximal landing zone even after supra-aortic rerouting (subclavian transposition, double transposition), ectasia of the ascending aorta/aortic arch (>40 mm) and/or a shaggy proximal thoracic aorta., Results: Additional cardiac procedures were performed in 14 patients (41%), and the beating heart technique was used in 7 patients (21%). Perioperative mortality was 18% (n = 6); 3 of these patients had a major stroke (9%). No case of spinal cord ischaemia was observed, and 2 patients (6%) developed a non-disabling stroke. After a median follow-up of 7 (first quartile: 1; third quartile 29) months, 2 patients (6%) died (1 of malignant disease and 1 of an unclear cause); 10 additional aortic interventions in all aortic segments (29%; endovascular: n = 8 [24%] and conventional surgical: n = 2 [6%]) were performed in 8 patients., Conclusions: The FET technique is a good treatment option for patients with penetrating aortic ulcers involving the aortic arch unsuitable for thoracic endovascular aortic repair. However, the high obliterative atherosclerotic load in these patients is accompanied by an un-neglectable risk of perioperative neurological injury. Concomitant cardiac surgical procedures are frequently needed. Patients commonly require secondary aortic procedures in all aortic segments, emphasizing the need for thorough primary conceptual planning and stringent follow-up., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The goal of this study was to evaluate outcomes of aortic arch replacement using the frozen elephant trunk (FET) technique after previous proximal and/or distal open or endovascular thoracic aortic repair., Methods: Sixty-three patients [median age: 63 (55-74) years; 65% men] were operated on for acute or chronic aortic dissection after previous proximal and/or distal open or endovascular thoracic aortic repair. Intraoperative details, clinical outcome and follow-up results were evaluated., Results: The median time between the index and the FET procedure was 81 (40-113) months. Fifty-eight (92%) patients had already undergone proximal aortic surgery; supracoronary ascending aortic replacement was the most frequent index procedure [n = 25 (40%)]. Distal aortic interventions had been done in 8 (13%) patients including endovascular thoracic aortic repair in 6 patients (10%). In-hospital mortality was 3% (n = 2). Postoperative strokes occurred in 5 patients (8%); of those, 1 stroke was dissection-related (2%). Subsequent aortic reinterventions after the FET procedure had to be done in 33% (n = 21)., Conclusions: Outcomes of aortic arch replacement using the FET technique after previous proximal and/or distal open or endovascular thoracic aortic repair are associated with low mortality and morbidity. Still, postoperative stroke remains an issue. After the successful accomplishments, the approach serves as an ideal platform for the secondary surgical or endovascular downstream aortic procedures, which are frequently needed., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To evaluate outcomes of patients with acute complicated or chronic Type B or non-A non-B aortic dissection who underwent the frozen elephant trunk (FET) technique., Methods: Between April 2013 and July 2019, 41 patients presenting with acute complicated (n = 29) or chronic (n = 12) descending thoracic aortic dissection were treated by the FET technique, which was the treatment of choice when supra-aortic vessel transposition would not suffice to create a satisfactory proximal landing zone for endovascular aortic repair, when a concomitant ascending or arch aneurysm was present, or in patients with connective tissue diseases., Results: One patient (2%) died intra-operatively secondary to an aortic rupture in dwnstream aortic segments. No post-operative deaths occurred. Four patients (10%) suffered a non-disabling posto-operative stroke and were discharged with no clinical symptoms (modified Rankin Scale [mRS] 0, n = 1), no significant disability (mRS 1, n = 2), or with slight disability (mRS 2, n = 1). No spinal cord ischaemia was observed. The primary entry tear was either surgically resected or excluded from circulation in all patients. During follow up, one patient (2%) died after two years (not aorta related) and 16 patients (39%) underwent an aortic re-intervention after 7.7 [interquartile range 0.7, 15.8] months (endovascular aortic repair: n = 14; open thoraco-abdominal aortic replacement: n = 1, hybrid approach: n = 1)., Conclusion: The FET technique is an effective treatment option for acute complicated and chronic Type B or non-A non-B aortic dissection in patients in whom primary endovascular aortic repair is non-feasible. While the post-operative outcome is acceptable with a relatively low incidence of non-disabling strokes, this study also underlines the considerable need for aortic re-interventions. Continuous follow up of all patients undergoing the FET procedure is essential., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms., Methods: In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison., Results: The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE., Conclusions: dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study sought to evaluate the incidence of and identify risk factors for distal stent graft-induced new entries (dSINEs) after the frozen elephant trunk (FET) procedure., Methods: Patient characteristics and radiographic and follow-up data on 126 patients treated for aortic dissections with the Thoraflex (Vascutek Ltd, Inchinnan, United Kingdom) FET device in 2 centers between November 2013 and December 2018 were evaluated. Stress-strain behavior and load-displacement curves of the Thoraflex and the E-Vita Open (Jotec Inc, Hechingen, Germany) FET prosthesis were evaluated by applying axial load to the most distal ring of the prostheses., Results: dSINEs were diagnosed in 16 patients (13%). There was no difference in the underlying disease, aortic features, or FET stent graft dimension between patients with and without dSINEs. No predictors for dSINE occurrence in patients treated with the Thoraflex device were identified. The risk for dSINE development was 14% (95% confidence interval [CI], 0% to 22%), 16% (95% CI, 0% to 24%), and 25% (95% CI, 0% to 45%) after 12, 24, and 36 months, respectively. When prostheses were loaded axially to 2-mm maximal displacement, the Thoraflex prosthesis exhibited strongly nonlinear behavior with maximal stiffness for minimal displacements, whereas the E-Vita prosthesis showed nearly constant stiffness. In addition, the Thoraflex prosthesis showed an increase in stiffness when confined., Conclusions: dSINEs may develop at any time after the FET procedure, and the risk for dSINE development is high. No clinical or patient-specific risk factors were identified in this study. The design of the Thoraflex graft with a stiff distal ring may be a potential reason for the occurrence of dSINEs., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal was to develop a scoring system to predict the 30-day mortality rate for patients undergoing surgery for acute type A aortic dissection on the basis of the German Registry for Acute Type A Aortic Dissection (GERAADA) data set and to provide a Web-based application for standard use., Methods: A total of 2537 patients enrolled in GERAADA who underwent surgery between 2006 and 2015 were analysed. Variable selection was performed using the R-package FAMoS. The robustness of the results was confirmed via the bootstrap procedure. The coefficients of the final model were used to calculate the risk score in a Web-based application., Results: Age [odds ratio (OR) 1.018, 95% confidence interval (CI) 1.009-1.026; P < 0.001; 5-year OR: 1.093], need for catecholamines at referral (OR 1.732, 95% CI 1.340-2.232; P < 0.001), preoperative resuscitation (OR 3.051, 95% CI 2.099-4.441; P < 0.001), need for intubation before surgery (OR 1.949, 95% CI 1.465-2.585; P < 0.001), preoperative hemiparesis (OR 1.442, 95% CI 0.996-2.065; P = 0.049), coronary malperfusion (OR 1.870, 95% CI 1.386-2.509; P < 0.001), visceral malperfusion (OR 1.748, 95% CI 1.198-2.530; P = 0.003), dissection extension to the descending aorta (OR 1.443, 95% CI 1.120-1.864; P = 0.005) and previous cardiac surgery (OR 1.772, 95% CI 1.048-2.903; P = 0.027) were independent predictors of the 30-day mortality rate. The Web application based on the final model can be found at https://www.dgthg.de/de/GERAADA&#95;Score., Conclusions: The GERAADA score is a simple, effective tool to predict the 30-day mortality rate for patients undergoing surgery for acute type A aortic dissection. We recommend the widespread use of this Web-based application for standard use., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Measuring transcranial motor evoked potentials (EPs) and somatosensory EPs is a well-established method to assess spinal cord function during thoracic endovascular aortic repair (TEVAR). Functional occlusion of one or both internal iliac arteries by large bore sheaths during TEVAR can cause unilateral intermittently EP loss., Methods: Between 2006 and 2016, 194 patients underwent TEVAR entailing EP monitoring. The ISIS IOM System (Inomed Medizintechnik GmbH, Emmendingen, Germany) was employed in all patients. EPs were recorded after inducing anesthesia, during the procedure, and before discontinuing anesthesia., Results: We observed a unilateral intermittently EP decrease or loss in 12 (6.2%) patients. Most events were ipsilateral (9 of 12). The underlying pathologies were descending aortic aneurysm in six patients and type B dissection in six patients. An evoked-potential decrease or loss was always associated with the insertion of large bore stent-graft-introducing sheaths. The median duration of the unilaterally EP decrease or loss was 16 (10; 31) minutes (range, 2-77 minutes) with baseline values re-established at the end of the procedure after sheath removal in all cases. No patient developed irreversible symptomatic spinal cord ischemia., Conclusion: A functional occlusion of internal iliac arteries via large bore TEVAR-introducing sheaths is associated with a unilateral intermittent decrease in or loss of EPs returning to baseline after sheath removal. This observation highlights the importance of the internal iliac arteries as one of the major spinal cord's blood supply territories, and may serve as a stimulus to reduce the duration of sheath indwelling to a minimum., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of this study was to determine geometric changes in the proximal and distal aortic landing zones after thoracic endovascular aortic repair (TEVAR) for acute descending aortic dissection., Methods: This was a retrospective analysis of clinical and radiological data. Included are patients who underwent TEVAR for acute descending aortic dissection between 2004 and 2018. Analysed are the proximal and distal landing zones' initial geometries and their change at follow up. Median follow up time was 2.3 (first quartile 0.9, third quartile 4.5) years., Results: One hundred and one patients were included (93 type B and 8 non-A non-B dissections, aged 65 (57, 74) years old, and 29% female). Dissection extended down to the abdominal aorta in 69% patients. The proximal landing zone was non-dissected in 92 patients. The diameters of non-dissected proximal landing zones increased by 3 (-1, 5; p < .001) mm at follow up. The distal landing zone was dissected in 84% of patients. The diameters of dissected distal landing zones had increased at follow up by 7 (3, 12) mm and 4 (1, 10; both p < .001) mm measured in true lumen and total aorta, respectively, observed one year after TEVAR. Stent grafts reached their nominal diameter at follow up in 22% and 17% of proximal and distal landing zones, respectively. There were seven proximal and 10 distal stent graft induced new entries at follow up. Aortic re-intervention was necessary in 23 patients entailing 19 TEVAR extensions and four open aortic repairs., Conclusion: The distal landing zone in patients undergoing TEVAR for descending aortic dissection is frequently dissected and is associated with the risk of d-SINE at follow up and the need for re-interventions after TEVAR - factors that emphasise the importance of long term follow up., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Our goal was to evaluate postoperative outcomes in patients with type A aortic dissection with preoperative neurological deficits independent of shock., Methods: Between 2002 and 2017, 150 of 1600 patients, operated on for aortic dissection type A in 3 centres, presented with preoperative new onset neurological deficits. Postoperative outcomes were classified using a modified Rankin Scale (mRS) as 'no to moderate disability' (mRS 0-3) or as 'poor clinical outcome' (mRS 4-6). Clinical and radiographic data were analysed., Results: Ninety-three patients (62%) had no to moderate disability and 57 (38%) had a poor clinical outcome. The in-hospital mortality rate was 18% (28 patients). Patients with poor clinical outcomes were significantly older (P = 0.01) and had a significantly higher incidence of hypertension (P = 0.04), history of stroke (P = 0.03) and common carotid artery occlusion (left common carotid artery: P = 0.01; right common carotid artery: P < 0.01). One-third of all patients developed haemodynamic instability (P = 0.27). Cardiopulmonary bypass (P < 0.01) and cross-clamp (P = 0.03) times were significantly longer in patients with poor clinical outcomes. Age (odds ratio 1.041; P = 0.02) and history of stroke (odds ratio 2.651; P = 0.03) were predictive of poor clinical outcome; coma was not. Haemorrhagic transformation occurred in 7 patients without any independent predictors., Conclusions: Most patients with preoperative neurological deficit have no to moderate disability postoperatively but commonly develop preoperative haemodynamic instability. This study suggests that an immediate surgical approach may be reasonable in patients with preoperative neurological deficit or coma., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Aortic dissection is complex. Imaging and treatment modalities are evolving, demanding a more differentiated but pragmatic dissection classification. Our goal was to provide a new practical classification system including Type of dissection, location of the tear of the primary Entry and Malperfusion (TEM)., Methods: We extended the Stanford dissection classification (A and B) by adding non-A non-B aortic dissection, the location of the primary entry tear (E) and malperfusion (M). A 0 was added if the primary entry tear was not visible; 1, if it was in the ascending aorta; 2, if it was in the arch; and 3, if it was in the descending aorta (E0, E1, E2, E3). We added 0 if malperfusion was absent; 1, if coronary arteries; 2, if supra-aortic vessels; and 3, if visceral/renal and/or a lower extremity was affected (M0, M1, M2, M3). Plus (+) was added if malperfusion was clinically present and minus (-) if it was a radiological finding., Results: The new classification system was analysed in 357 patients retrospectively; distribution was 59%, 31% and 10% for A, B and non-A non-B dissections. The in-hospital mortality rate was 16%, 5% and 8% (P = 0.01). Postoperative stroke occurred in 14%, 1% and 3% (P < 0.001). The in-hospital mortality rate was 22%, 14%, 40% and 0% in A E0, E1, E2 and E3 (P = 0.023), respectively. Two years after the onset of dissection, the lowest survival rate was observed in A, followed by non-A non-B and B (83 ± 3% vs 88 ± 6% vs 93 ± 3%; P = 0.019)., Conclusions: The new practical TEM aortic dissection classification system adds clarity regarding the extent of the disease process, enhances awareness of the disease mechanism, aids in decision-making regarding the extent of repair and helps in anticipating outcome., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The aim of this study was to evaluate clinical, aortic, and outcome characteristics of type A aortic dissection patients with bicuspid aortic valves (BAVs) and tricuspid aortic valves (TAVs)., Methods: Patient characteristics and radiographic, operative, and outcome data were evaluated and compared between 1068 TAV patients and 72 BAV patients operated on for type A aortic dissection in 2 centers. Predissection aortic diameters were calculated as previously reported for TAV patients., Results: BAV patients were significantly younger (P < .001) and had a lower incidence of cardiovascular risk factors. Although the clinical presentation was similar, the dissection affected the abdominal aorta significantly more often in TAV patients (P = .029). Aortic root replacements were performed significantly more often in BAV patients (P < .001). Postoperative outcome was similar between the 2 groups. BAV patients had a significantly larger maximum postdissection diameter (P < .001) and calculated predissection diameter (P < .001) compared with TAV patients. Predissection ascending aortic diameters were less than 5.5 cm in 96% of all TAV patients and less than 5.0 cm in 76% of all BAV patients., Conclusions: Acute type A aortic dissection in BAV patients is not associated with worse clinical or long-term outcome but significantly influences the proximal aortic repair. After modeling predissection aortic diameters, less than 5% of all TAV patients and possibly less than 25% of all BAV patients would meet the elective threshold for preventative replacement of the ascending aorta., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR)., Methods: Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate., Results: Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2-16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection-1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone., Conclusions: Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The aim of this study was to evaluate morphologic changes in dissected aortas after thoracic endovascular aortic repair (TEVAR) with the use of the Relay Nonbare stent graft stent graft by focusing on the geometric stent graft's performance in remodeling aortas., Methods: We conducted a retrospective three-dimensional computed tomography analysis preoperatively, postoperatively, and 6 months after TEVAR in patients with residual dissection after type A and those with acute and chronic type B dissections at two German centers., Results: Thirty-nine acute and 54 chronic aortic dissections were included. Median follow-up was 200 (interquartile range, 109-617) days. TEVAR induced aortic remodeling in both groups. Complete false lumen thrombosis along the stent graft (postoperative, 73%; follow-up, 84%; P < .0001) led to a decrease in aortic diameter at the middle stent graft level (preoperative, 45.9 mm [38.6-56.6] vs follow-up, 43.6 [37.4-52.4] mm; P = .009). True lumen expansion was observed in both groups and peaked in acute dissections in the distal landing zone (acute, +9.3 mm vs chronic, +5.8 mm; P < .0001). Migration was 2 (0-5) mm, and bird-beak and endoleak type IA rates were 20% and 4%, respectively. There was no retrograde type A dissection. Distal stent graft-induced new entry occurred in 15%; the major risk factor for incidence was the stent graft's wedge apposition angle (odds ratio, 1.365 [confidence interval, 1.115-1.671]; P = .003)., Conclusions: TEVAR with the use of the Relay NBS promotes aortic remodeling in acute and chronic dissections, entailing a low risk of migration, type IA endoleaks, and retrograde type A dissections. Wedge apposition was the predominant risk factor for distal stent graft-induced new entry., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to evaluate early- and mid-term outcome and aortic remodelling in patients undergoing implantation of 2 different frozen elephant trunk prostheses, either the Thoraflex™ hybrid (Vascutek, Inchinnan, UK) and the E-vita Open (Jotec Inc., Hechingen, Germany) for acute aortic dissection., Methods: All consecutive patients [n = 88; median age 59 (49-67) years; 69% male] undergoing surgery with a frozen elephant trunk prosthesis for acute aortic dissection from August 2005 until March 2018 were included in this study. The Thoraflex™ device was implanted in 55 patients and the E-vita Open graft in 33 patients., Results: Preoperative characteristics did not differ significantly between groups. There was also no statistically significant difference in postoperative outcome: in-hospital mortality (11% vs 12%; P > 0.99), stroke (18% vs 6%; P = 0.12) and spinal cord injury (6% vs 6%; P > 0.99). While there was no statistically significant difference in the occurrence of distal stent graft-induced new entries (16% vs 18%; P = 0.77), there was a significantly higher rate of secondary endovascular aortic interventions in the Thoraflex™ hybrid group (22% vs 0%; P = 0.003). There was a trend towards a higher rate of false lumen thrombosis at the level of the stent graft (74% vs 95%; P = 0.085) and was comparable at the thoraco-abdominal transition (53% vs 80%; P = 0.36) 1 year after implantation of the prostheses., Conclusions: In this comparison of 2 frozen elephant trunk prostheses, there is no evidence that different surgical techniques influence in-hospital outcome. At 1-year follow-up, patients who underwent implantation of the E-vita Open prosthesis showed a significantly reduced rate of secondary aortic interventions and a trend towards a higher rate of false lumen thrombosis which might be attributed to a longer coverage of the descending aorta due to a longer stent graft design and significantly more frequent implantation in zone 3., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Large aortic diameter is considered the most frequent cause of aortic dissection. However, this assumption relies on postdissection imaging of the aorta. We recently showed that acute dissection leads to a 23% increase in the descending aortic diameter. Our aim was to model the diameter of the aorta before the acute descending aortic dissection occurred., Methods: Between 2003 and 2017, a total of 190 patients developed acute descending aortic dissection. In total, 165 non-Marfan patients were included, whose computed tomography angiography scans were available and taken within 6 h after the occurrence of acute descending aortic dissection [67 (first quartile 58-third quartile 75) years, 69% males]. The maximum postdissection aortic diameter was measured at the level of the mid-descending aorta. Modelling was performed by dividing the postdissection aortic diameter by the factor 1.23., Results: The median modelled predissection descending diameter measured in the mid-descending aorta was 30.5 (27.3-35.4) mm. The median predissection descending diameter was higher in men (P = 0.021) and associated with age (P < 0.001) but not with body surface area. The modelled diameter of the predissected descending aorta revealed that 98.8% (163/165) of patients had an aortic diameter measuring <55 mm and 84.8% (140/165) <40 mm. In other words, 50% of these patients had a non-dilated descending aorta prior to dissection onset., Conclusions: Modelling indicated that more than 80% of patients who suffered an acute descending aortic dissection had a descending aorta <40 mm before dissection onset. Only 1% of them would have met the guideline criteria (aortic diameter ≥55 mm) for elective descending aortic repair. The role of an excessively large aortic diameter as a predictor of descending aortic dissection might be overrated., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To minimize the complications with thoracic endovascular aortic repair (TEVAR), a new stent graft with no bare ends was developed, namely the Relay non-bare stent (NBS). We hypothesized that the new features of the NBS graft would enable highly accurate deployment and fewer complications. The aim of this study was to analyse the quality of the Relay NBS with respect to its landing precision., Methods: Relying on computed tomography angiographs, we evaluated the distance between the stent graft and the target vessel in the proximal landing zone (before and after the intervention as well as the mid-term results). Seventy-eight patients with thoracic aortic pathologies were included. Median computed tomography angiograph follow-up was 16 months., Results: The stent graft was deployable ≤5 mm from the target vessel in 64 (82%) patients; in 14 (18%) of them, the distance to the target vessel was >5 mm. According to the last follow-up computed tomography angiograph, in 35 (55%) patients, the distance to the target vessel was ≤5 mm and in 29 (45%) patients, it was >5 mm. There was no endoleak type Ia immediately after TEVAR or during the follow-up period. A substantial bird beak phenomenon was observed in 3 (4%) and 7 (11%) patients immediately after TEVAR and during the follow-up period, respectively. One patient had a retrograde dissection type A., Conclusions: The Relay NBS graft can be deployed accurately in the aortic arch in most patients. Retrograde aortic dissection type A seldom occurs after TEVAR using the Relay NBS graft. The distance between the NBS graft and the intended target vessel increases during the follow-up period., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively., Conclusions: Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.

Objective: The study objective was to screen patients with acute type A aortic dissection for anatomic feasibility of ascending aortic endovascular treatment with a valve-carrying conduit., Methods: High-quality computed tomography scans of 167 patients were available for screening. Aortic dimensions were measured using multiplanar reconstruction in the plane perpendicular to the manually corrected aortic center line. The simulated stent-graft 10-mm-long landing zones were measured starting at the sinotubular junction (proximal landing zone) and ending at the brachiocephalic trunk (distal landing zone). Exclusion criterion was an entry within the aortic root or the landing zone., Results: In 113 patients (68%), the entry was in a coverable zone in the ascending aorta with sufficient proximal and distal landing zone or in more distal aortic segments. In these patients, the median distance between the proximal and distal landing zone was 89.1 (first quartile: 80.0 mm; third quartile: 101.2 mm) and the median diameter difference was 5.0 mm (2.0; 10.1) (12.3 [4.9; 23.0] %). The diameter difference was less than 2 mm in 32 patients (28%), between 6 mm and 10 mm in 20 patients (18%), between 10 mm and 14 mm in 11 patients (10%), and 14 mm or greater in 10 patients (9%)., Conclusions: Two thirds of all patients who present with type A dissections are potential candidates for treatment with endovascular valve-carrying conduits, but most patients would require tapered stent-grafts., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The risk of aortic dissection should be assessed based not only on the aortic diameter, but also on other biomechanical parameters that have an impact on the stress in the aortic wall. This study evaluates very rare clinical scenarios of patients with both pre- and post-dissection computed tomography (CT) images and evaluates whether an increased wall stress correlates with the localization of an intimal entry tear in Type A aortic dissection., Methods: CT-angiography images of 4 patients performed shortly prior to and after developing Type A aortic dissection were evaluated. The stress distribution in the pre-dissection aortas was evaluated using the finite elements method. Then, the areas of high stress in the pre-dissection aortas were compared to the localization of the intimal entry tears in the dissected vessels., Results: In all the patients, the pre-dissection areas of high wall stress correlated with the location of the intimal tears. The highest stress was not observed in the most dilated segments of the aorta but was predominantly found in the areas of an abrupt change in the geometry of the aorta., Conclusions: Wall stress can indicate the areas susceptible to the formation of an intimal tear and subsequent aortic dissection. Stress analysis may be a valuable tool to predict the risk of aortic dissection in patients with aortic dilatation.

Objectives: To evaluate early and mid-term clinical outcomes and to assess the potential of the frozen elephant trunk technique to induce remodelling of downstream aortic segments in acute and chronic thoracic aortic dissections., Methods: Over a 4-year period, 65 patients (48 men, aged 61 ± 12 years) underwent total aortic arch replacement using the frozen elephant trunk technique for acute (n = 31) and chronic (n = 34) thoracic aortic dissections at our institution. We assessed diameter changes at 3 levels: the L1 segment at the stent graft level; the L2 segment at the thoraco-abdominal transition level and the L3 segment at the coeliac trunk level. True-lumen (TL) and false-lumen (FL) diameter changes were assessed at each level., Results: Fifty-six percent of patients had already undergone previous aortic or cardiac surgery. In-hospital mortality was 6%. Symptomatic spinal cord injury was not observed in this series. During a mean follow-up of 12 ± 12 months, late death was observed in 6% of patients. Aortic reinterventions in downstream aortic segments were performed in 28% at a mean of 394 ± 385 days. TL expansion and FL shrinkage were measured in all segments and were observed at each level. This effect was the most pronounced at the level of the stent graft in patients with chronic aortic dissection, TL diameter increased from 15 ± 17 mm before surgery to 28 ± 2 mm (P = 0.001) after 2 years, and the FL diameter decreased from 40 ± 11 mm before surgery to 32 ± 17 mm (P = 0.026)., Conclusions: The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

Objectives: Thoracic endovascular aortic repair is the treatment of choice in complicated acute type B aortic dissection. How to infer predissection aortic diameter is not well understood. Our aim was to delineate changes in descending aortic geometry due to dissection., Methods: Five tertiary centres reviewed their acute aortic dissection type B databases containing 802 patients. All patients who had undergone computed tomography angiography less than 2 years before and immediately after aortic dissection onset were included. We compared the aortic geometry before and after the dissection onset., Results: Altogether 25 patients were included [median age 60 (first quartile 52, third quartile 72) years; 60% men]. In all except 1 patient, the maximum descending aortic diameter was less than 45 mm before aortic dissection onset. The largest increase in diameter induced by the dissection was observed in the proximal descending aorta 28.2 (25.1, 32.1) vs 34.6 (31.3, 39.1) mm (+6.4 mm; +23%; P < 0.001). The thoracic descending aortic length increased after the dissection onset [253.3 (229.3, 271.9) vs 261.3 (247.9, 285.4) mm; P = 0.003]. The predissection aortic diameter of the proximal thoracic descending aorta was 7.9 (5.2, 10.7) mm larger (P < 0.001) than the post-dissection area-derived true-lumen diameter and 2.5 (1.3, 6.1) mm larger than the maximum true-lumen diameter (P < 0.001)., Conclusions: Type B aortic dissection increases the diameter, length and volume of the descending thoracic aorta. The predissection aortic diameter most closely resembles the post-dissection maximum diameter of the true lumen.

Objectives: Our goal was to report our preliminary results in patients with acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair who were treated with the frozen elephant trunk (FET) technique., Methods: Within a 25-month period, 14 patients with acute complicated Type B aortic dissection underwent surgical repair using the FET technique. The reasons to perform the FET procedure were an ectatic ascending aorta/arch in 6 patients and the lack of an adequate landing zone in 8 patients., Results: No deaths were observed. A non-disabling stroke occurred in 2 patients. Symptomatic spinal cord injury was not observed. The closure of the primary entry tear was successfully achieved in all patients. In 3 patients, a secondary distal thoracic endovascular aortic repair extension was performed during the same hospital stay. The median follow-up period was 6 ± 5 months., Conclusions: The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To report a new technique for diameter correction in patients after thoracic endovascular aortic repair (TEVAR) with large stent-grafts using the Vascutek Siena 4-branch collared prosthesis (Vascutek Terumo, Inchinnan, Scotland, UK) in patients undergoing thoracoabdominal (TA) aortic replacement., Methods: Within a 24-month period, 39 patients underwent TA replacement at our center. Of these, 6 patients had undergone previous TEVAR with large stent-grafts (42 to 48 mm diameter). Indications for TEVAR were aneurysm formation in 3 patients and residual type B aortic dissection (status post repair of type A dissection) in 3 patients. In these patients, the Vascutek Siena 4-branch prosthesis was used in a reversed fashion, removing the elephant trunk portion and using the sewing collar for diameter correction at the anastomotic site., Results: No 30-day mortality and no stroke or symptomatic spinal cord ischemia was observed. Median diameter of the TEVAR graft at the anastomotic site was 44 mm. Median size of the Siena graft used was 26 mm. Diameter correction was successfully achieved in all patients by tailoring the sewing collar of the Siena 4-branch prosthesis to the individual need according to the diameter of the distal end of the stent-graft., Conclusions: Using the sewing collar of the Vascutek Siena 4-branch prosthesis for diameter correction in patients undergoing TA replacement after previous TEVAR with large stent-grafts adds a useful adjunct to the armamentarium of options in a growing patient population., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Our aim was to report outcome of patients with acute non-A non-B aortic dissection involving the aortic arch but not the ascending aorta., Methods: Dissection extension and entry location were analysed in patients with acute aortic dissection admitted between 2001 and 2016 at a tertiary centre. Non-A non-B dissection was classified as descending-entry type with entry distal to the left subclavian artery and dissection extending into the aortic arch, and arch-entry type with entry between the innominate and left subclavian arteries. We compared these 2 groups' clinical presentation, treatment and outcome., Results: Among 396 acute aortic dissection patients, 43 (median age 60 ± 12 years, 81% males) had non-A non-B dissection (descending-entry n = 21, arch-entry n = 22). The overwhelming majority of aortic segments were not dilated in all these patients. The 2 groups' cardiovascular risk profiles did not differ. Emergency open or endovascular aortic repair were necessary due to malperfusion or aortic rupture in 29% descending-entry and 36% arch-entry (in-hospital mortality was 1/6 and 3/8, respectively). Aortic repair within 2 weeks due to new organ malperfusion, rapid aortic growth, aortic rupture or persisting pain was performed in 43% descending-entry and 36% arch-entry patients (0% in-hospital mortality). All others (except for 1 diagnosed in 2014) required aortic repair for aneurysm at follow-up., Conclusions: Acute non-A non-B aortic dissection frequently requires emergency aortic repair due to organ malperfusion or aortic rupture. Most descending-entry and arch-entry non-A non-B dissection patients undergo aortic repair within 2 weeks after dissection onset., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To evaluate the fate of a dissected aortic arch after limited surgical repair of type A aortic dissection., Methods: Of the 271 patients operated for acute type A dissection between 2001 and 2015, 86 (age 57 ± 13 years, 74% men) with predischarge computed tomographic (CT) scans had a residual dissection in the arch. Aortic diameters, lengths, ellipticity and communications between lumina were assessed using predischarge and follow-up CT scans. The median CT scan follow-up was 31 months (first quartile 15, third quartile 52)., Results: The largest increase in the total aortic diameter at follow-up was 20 mm distal to the left subclavian artery (median +4.0 mm; first quartile +1.5, third quartile +9.2 mm; P  = 0.004), with an average growth rate of 1.5 mm/year (first quartile 0.6, third quartile 3.9 mm). The true lumen diameter was unchanged at follow-up. At least 1 communication between the true and the false lumina was observed in 80% of patients on the predischarge CT scan, and 70% had communications at the distal aorta-graft anastomosis. Accelerated increase in the diameter of the dissected aorta was associated with the number of communications between the lumina, communication at the distal anastomosis and false lumen perfusion (all, P  < 0.001)., Conclusions: Dissection of the residual aortic arch leads to aortic growth that may result in an aneurysm requiring treatment. The number of communications between the lumina, communication at the distal anastomosis and false lumen perfusion are associated with the accelerated aortic growth. Endovascular repair may be difficult due to the small true lumen and the presence of many communications between the lumina., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose of Review: Type B aortic dissection has largely been regarded as the nice dissection with regard to its natural course, especially when compared with type A aortic dissection. However, a more thorough look into the natural course of the disease has shown that a high number of patients with type B aortic dissection will experience complications and will require therapy, sooner or later., Recent Findings: Reasons and timepoints are different, being malperfusion, contained rupture and retrograde propagation of the disease into the aortic arch or into the ascending aorta in the early phase and being mainly aneurysmal formation in the chronic phase of the disease., Summary: This article provides the interested reader with detailed knowledge regarding the natural course of the disease and is meant as a companion to anticipate the right timepoint for therapy and finally as a guide to do the right things when advancing to treatment.

Objective: In patients with acute type A aortic dissection involving the innominate artery, it is unclear whether right axillary artery cannulation for arterial inflow is safe. We evaluated the surgical outcomes of patients with dissected innominate artery according to different arterial cannulation sites., Methods: From 2005 to 2014, of 416 patients with acute type A aortic dissection and preoperative computed tomography angiography in 2 centers, 186 (aged 63 ± 13 years; 43% were female; 95% with DeBakey type I) had dissected innominate artery (84%, 9%, and 7% involving its entire length or more or less than half of its length, respectively). Neurologic complications, in-hospital mortality, and survival were compared between patients with right axillary (N = 84) and non-right axillary (N = 102) cannulation sites. Median follow-up was 30 months (range, 0-130 months)., Results: In-hospital mortality was 9.5% and 10.8% (P = .97) for patients with right and non-right axillary cannulation, respectively. Seven patients (8.3%) with right axillary cannulation and 9 patients (8.8%; P = .89) with non-right axillary cannulation had a new-onset postoperative stroke. The axillary artery was cannulated (although dissected) in 8 patients. None of them had a new-onset stroke or died perioperatively. The innominate artery remodeling was observed on follow-up computed tomography in 12% of right axillary cases and 14% of non-right axillary cases (P = .82). Survival did not differ between right axillary and non-right axillary cases, and measured 92% ± 3% versus 87% ± 4% and 85% ± 5% versus 73% ± 9% at 1 and 5 years, respectively (log rank, P = .29)., Conclusions: The right axillary artery is safe to cannulate for arterial inflow in patients with type A aortic dissection with dissected innominate artery., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aortic cross-clamping may lead to iatrogenic tissue damage resulting in immediate or later aortic dissection or rupture., Methods: We report on a patient with an acute type B aortic dissection with mega-aortic syndrome whose aorta ruptured twice within 2 months., Results: The second aortic rupture occurred at the level of prior cross clamping. The pressure along the clamp jaws is distributed unequally. According to the law of the lever, the aortic area near the hinge is under more stress than the aortic area distal to the hinge. Unequal pressure distribution may injure the aorta., Conclusions: There is a need to evaluate pressure distribution along the various currently available aortic clamp jaws and to develop the perfect aortic clamp providing equal pressure distribution designed especially to clamp large aortas or those of patients with connective tissue disorders., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Aortic dissection DeBakey type I and II may require distal reinterventions after initial proximal repair. We evaluated outcomes following open versus endovascular approaches to distal aortic pathologies after surgery for acute dissection., Methods: One hundred and forty-one consecutive patients underwent 152 distal reinterventions after previous type I or II dissection repair [63 (first quartile, 55; third quartile, 72) years old; initially 86% DeBakey type I; 54% hemiarch, 39% isolated ascending, 7% total arch replacement] at two tertiary centres in the USA and Europe over the last 14 years. Among them, 56 and 85 required reintervention for the aortic arch and the descending aorta, respectively. The median follow-up was 2.1 (first quartile, 0.8; third quartile, 5.8) years (439 patient-years)., Results: The median time between acute aortic dissection repair and descending aortic reintervention was longer in the open group (2.7 (first quartile, 0.8; third quartile, 6.7) vs 0.6 (first quartile, 0.1; third quartile, 3.5) years, P < 0.01). There was one irreversible spinal ischaemia in the open and one stroke in the endovascular group. Two patients in the open and none in the endovascular group required re-exploration for bleeding. Two open and 4 endovascular patients required more than 1 distal reintervention (6 vs 8%, P = 1). Descending aortic open-repair patients experienced higher in-hospital mortality (23 vs 0%, P < 0.01) and lower survival at 1 and 5 years (74 ± 8% vs 96 ± 3%, 65 ± 9% vs 92 ± 5%, P < 0.01, respectively)., Conclusions: Endovascular intervention for descending aortic pathologies after DeBakey type I or II dissection surgical repair is associated with lower in-hospital mortality and better survival, and does not raise the likelihood of later reinterventions at the mid-term follow-up., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Technical variations of the David reimplantation valve-sparing aortic root replacement (V-SARR) procedure have been proposed to be advantageous in patients with connective tissue disease, such as the Marfan syndrome (MFS). We report results of a Marfan cohort treated exclusively with the non-modified David I procedure., Methods: Forty-eight Marfan patients (25 males, mean age 33 ± 12 years, range 15-62 years) underwent the original variant of the David V-SARR (David I) between 1997 and 2013. Forty-two operations (88%) were performed as elective procedures for aortic root aneurysms and six for acute dissections (12%). Seventeen had aortic regurgitation (AR) grades ≥2+ preoperatively, and 3 had AR >2+. No patients with severe AR (4+) were selected for V-SARR. Three full or hemi-arch replacements were performed. Patients who were operated on using a variation of the David I or David II procedure were excluded., Results: Mean prosthesis size was 28 ± 3 mm (18-30 mm). Mean clinical and echocardiographic follow-up (98% complete) was 3.8 ± 3.7 years with a cumulative follow-up of 178 patient-years. The early mortality rate was 2% (one hospital death). The survival rate was 98% (95% confidence 84-99%) at 4 years and 90% (57-98%) at 8 years with 5 patients at risk at 10 years. The rate of freedom from root or valve reoperation was 97% (79-99%) and 97% (79-99%) at 4 and 8 years, respectively. Only one patient required mechanical aortic valve replacement for progression of AR., Conclusions: Despite potential theoretical drawbacks of the David I V-SARR technique without neo-sinuses or a neo-sinotubular junction, it results in a favourable mid-term outcome in Marfan patients and compares well with reported results of different modifications of David V-SARR., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The aim of our study was to delineate the effect of aortic arch surgery extension on the outcomes in acute type A dissection extending beyond the ascending aorta., Methods: From 2001 to 2013, of 197 patients with type A dissection, 153 (78%) with dissection extending beyond the ascending aorta (age, 61 years; first quartile, 50; third quartile, 69; 67% men) were identified. Aortic repair involved isolated ascending replacement (n = 102), hemiarch (n = 37), and total arch replacement (n = 14). The median follow-up period was 4.9 years (first quartile, 2.5; third quartile, 7.6; 733 patient-years)., Results: In-hospital mortality was 9.8%, 21.6%, and 28.6% (P = .122) for patients with no, hemiarch, and total arch replacement. Age > 80 years (odds ratio [OR], 9.37; P = .006), malperfusion syndrome (OR, 4.74; P = .004), and total arch replacement (OR, 6.47; P = .016) were independent predictors of perioperative mortality. Freedom from distal reintervention was 93% ± 3%, 97% ± 3%, and 100% at 1 year and 89% ± 3%, 97% ± 3%, and 100% at 5 years for the no, hemiarch, and total arch replacement groups, respectively (log-rank, P = .440). Marfan syndrome (OR, 12.40; P = .038) and dissection of all aortic segments (OR, 10.68; P = .007) predicted distal aortic reintervention. In-hospital mortality for elective reintervention was 0%., Conclusions: Limiting the extent of surgery for type A aortic dissection to ascending aortic replacement was associated with low perioperative mortality. Thus, aortic arch repair can be deferred, because it can be performed electively with a lower mortality risk., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)