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Objective: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection., Methods: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. End points included technical success, clinical success, early (30-day) computed tomography angiography findings, early (30-day) mortality, adverse events, and aortic remodeling in patients with available computed tomography angiography follow-up and reintervention., Results: A total of 155 patients received a custom-made CP, of whom 32 patients (44% male, mean age 61 ± 9 years) were treated urgently and 123 patients (63% male, mean age 62 ± 11 years) electively. The primary CP rate was higher in the urgent group (28/32, 88%, in the urgent group vs 96/123, 78%, in the elective group, P = .051). The mean contrast volume was higher in the urgent group (157 ± 56 mL in the urgent group vs 130 ± 71 mL in the elective group, P = .017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 of 32 (78%) patients in the urgent group vs 113 and 123 (92%) in the elective group (P = .159). The early mortality rate was 13% (4 of 32 patients) in the urgent group vs 1% (1 of 123 patients) in the elective group (P = .120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related reinterventions were required in 6 of 32 (19%) patients in the urgent group vs 6 of 123 (5%) in the elective group (P = .094). Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, 18%, in the urgent group vs 63/114, 55%, in the elective group, P = .001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, 79%, in the urgent group vs 47/114, 41%, in the elective group, P = .000). An increase in thoracic aortic aneurysm sac occurred in 1 of 28 (4%) patients in the urgent group vs 4 of 114 (4%) patients in the elective group (P = .096)., Conclusions: The urgent use of the CP technique for distal FL occlusion in aortic dissection was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved a high rate of aortic remodeling., Competing Interests: Disclosures T.K. has intellectual property with Cook Medical; and receives royalties, research, travel and educational grant, speaking fees from and is a consultant and proctor for Cook Medical. S.H. is a consultant for Cook Medical, GE Healthcare, and Bentley. L.B. is a proctor and consultant for Cook Medical. S.T. is a consultant and speaker for WL Gore and Medtronic. T.L. is a proctor and consultant for Cook Canada. T.J. has travel grants, consultation fees, and proctorship fees from Cook Medical and Hammered (Polish representative of Cook Medical). J.S. is a speaker, proctor, and consultant for Cook Medical. N.T. is a proctor for Cook Medical and receives institutional grant from Cook Medical. G.P. is a proctor for Cook Medical. The remaining authors report no conflicts., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients., Methods: Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis., Results: Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p = .006) compared with B-EVAR., Conclusion: Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: To describe the implantation steps of the latest generation of candy-plug device (third CP generation [CP III]) and to illustrate its possible pitfalls by discussing a case in whom this device was employed to occlude the false lumen (FL) of a chronic type B aortic dissection., Technique: A 69 year-old male patient who underwent a frozen elephant trunk arch repair due to residual type A aortic dissection developed a FL aneurysmal degeneration limited to the descending thoracic aorta. Two thoracic stent-grafts were deployed into the true lumen up to the celiac trunk origin. Then, the FL was occluded with a self-occluding CP III device (Cook Medical, Bloomington, Indiana), placed at the same level as the distal thoracic stent-graft. The distal un-stented sleeve was pushed upward to allow immediate occlusion of its central lumen, avoiding interference with reno-visceral arteries arising from the FL. Both intraoperative transesophageal echocardiography and follow-up computed tomographic angiography scan demonstrated complete FL thrombosis., Conclusion: The introduction of CP III with its self-occluding mechanism helped to shorten and standardize the procedure. However, adjunctive steps may be needed to immediately obtain FL occlusion and avoid hampering the perfusion of vessels arising from the FL., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To describe the technical aspects and early results of a new endovascular fenestration method for false lumen occlusion in chronic aortic dissection: the Knickerbocker Technique., Methods: A retrospective observational study including all consecutively treated patients between November 1, 2012, through May 31, 2016, who underwent thoracic endovascular aortic repair with false lumen occlusion using the Knickerbocker Technique for thoracic false lumen aneurysm in chronic aortic dissection in a tertiary care center. Primary endpoints consisted of technical (correct deployment of the stent-graft) and clinical (false lumen occlusion) success. Secondary endpoints included overall survival and morbidity after 30 days. In 12 patients, follow-up computed tomography angiogram (CTA) was available and aortic remodeling was evaluated., Results: We identified 16 eligible patients (75% men, mean age: 69 years, range: 52-80 years). Technical success was 94%. Overall survival after 30 days was 100%; there was 1 aortic reintervention (additional false lumen embolization due to endoleak type 1a in 1 patient). Median total follow-up was 31.5 months (range: 3-66 months). Four (25%) of 16 patients died during follow-up, in 3 of those patients the cause of death is unknown, and 1 patient developed cardiac tamponade after being treated by fenestrated thoracic endovascular aortic repair. Imaging follow-up with CTA was available in 12 patients (median imaging follow-up: 27.5 months, range: 1-57 months). Nine (75%) of 12 patients showed thoracic aortic remodeling, and in 3 patients aneurysm size was stable. No patient showed aneurysm growth., Conclusion: The Knickerbocker Technique is a feasible endovascular fenestration method to achieve false lumen occlusion and aortic remodeling in chronic aortic dissection with low invasiveness.

Objective: To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry., Methods: A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres., Results: A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 - 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 - 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve., Conclusion: This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS)., Methods: A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken., Results: In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36-79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7-79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk., Conclusion: Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.

Connective tissue disease (CTD) syndromes involve the ascending, aortic arch, and thoracoabdominal aorta and are associated with higher risk of aortic aneurysm or dissection. Currently, vascular societies generally recommend open repair as the first option for aortic disease in patients with CTD. However, the implementation of endovascular techniques for patients with CTD with aortic pathologies seems to have increased in recent years, mainly in patients of high surgical risk or in urgent situations. Endovascular treatment of aortic arch pathologies in patients with CTD have been feasible in experienced centers; however, the evidence is scarce. Thoracic endovascular aneurysm repair in patients with CTD is more evident; in 15 studies, 304 patients with CTD were treated with thoracic endovascular aneurysm repair with high technical success rates (88% to 100%) and a low early mortality rate (1.6%). During the median follow-up, 33 patients died and 64 patients underwent a re-intervention. In 6 studies, 26 patients with CTD were treated with fenestrated/branched endovascular aneurysm repair for thoracoabdominal aortic aneurysm, with a technical success rate of 100%, without early mortality and morbidity. The endovascular approach to thoracoabdominal aortic aneurysm, especially in post-dissection patients, mandates adjunctive techniques to achieve false lumen thrombosis with various approaches; in our experience, the Candy-Plug technique has been proven to be technically feasible with good outcomes. Endovascular treatment of aortic pathologies in patients with CTD seems to be feasible and safe in high-risk and urgent patients. Re-intervention remains an issue. The constant development of endovascular techniques and devices may provide improved mortality and morbidity outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To study the outcome of endovascular treatment of aortic pathologies in patients with Marfan syndrome (MFS) at a single institution., Methods: Consecutive MFS patients who underwent endovascular repair or hybrid procedures for aortic pathologies from January 2010 to May 2020 were identified. Several endovascular and hybrid strategies have been used. Technical success, short- and mid-term survival, complications, and re-interventions were retrospectively analyzed., Results: During the study period, 24 patients with MFS (median age, 48 [13-78] years; 58% males) were treated. Indications for intervention were chronic aortic dissection with aneurysm degeneration in 16 patients (67%), acute type B aortic dissection in 4 patients (17%), aortic aneurysm without any dissection in 3 patients (13%), and aortic intramural hematoma in 1 patient (4%). Most patients were asymptomatic (83%), three (13%) were symptomatic and one (4%) had a contained rupture. The median aneurysm diameter was 56 (35-86) mm. Hybrid procedures were performed in 7 (29%) patients. Thoracic endovascular repair was performed in 12 (50%) patients, a fenestrated or branched endovascular aortic repair in 4 (17%) patients, and placement of an iliac artery stent-graft in 1 (4%) patient. Procedures were staged in 12 (50%) patients. Technical success was achieved in all patients. The median intensive care unit stay was 6 (range, 1-30) days, and the median hospital stay was 23 (range, 3-112) days. Early mortality was reported in 1 (4%) patient. Wound infection was seen in 7 (29%) patients and gastrointestinal complications in 3 (13%) patients. The median follow-up was 42 (range, 1-127) months. The cumulative survival rate was 87% at 24 months. The cumulative freedom from re-intervention was 77% at 12 months., Conclusions: Endovascular treatment of aortic pathologies in patients with MFS appears feasible with acceptable early and mid-term outcomes in terms of mortality and re-intervention rates. Endovascular therapy plays an increasing role in MFS patients with aortic pathology.

Purpose: The purpose of this study was to evaluate early and mid-term results of non-standard management of the supraaortic target vessels with the use of the inner branch arch endograft in a single high-volume center., Material and Methods: A single-center retrospective study including all patients undergoing implantation of an inner branch arch endograft from December 2012 to March 2021, who presented a non-standard management of the supraaortic target vessels (any bypass other than a left carotid-subclavian or landing in a dissected target vessel). Technical success, mortality, reinterventions, endoleak (EL), and aortic remodeling at follow-up were analyzed., Results: Twenty-four patients were included. In 17 (71%) cases, the non-standard management was related to innominate artery (IA) compromise (12 with IA dissection, 2 with short IA, 2 with short proximal aortic landing zone that required occlusion of IA, 1 with occluded IA after open arch repair). Two (8%) cases were related to an aberrant right subclavian artery (RSA), 1 patient (4%) due to the concomitant presence of a left vertebral artery (LVA) arising from the arch and an occluded left subclavian artery (LSA), and another patient presented with an occluded LSA distal to a dominant vertebral artery. Three (13%) cases were exclusively related to management in patients with genetic aortic syndromes. Twenty (83%) patients had a previous type A aortic dissection. Ten (42%) patients presented a thoracic or thoracoabdominal aortic aneurysm and 8 (33%) patients an arch aneurysm, 6 of them associated to false lumen (FL) perfusion. There were 2 (8%) perioperative minor strokes, and 1 patient with perioperative mortality. Seven patients presented an early type I endoleak, all resolved at follow-up. Seven patients required reinterventions during follow-up (7 reinterventions related to continuous false lumen perfusion, 3 related to Type Ia endoleak, 2 related to surgical bypass). All patients who presented with FL perfusion had complete FL thrombosis at follow-up. No patient presented aneurysm growth at follow-up., Conclusions: The use of the inner branch arch endograft with a non-standard management of the supraaortic target vessels is a possible option. Despite a high reintervention rate, regression or stability of the aneurysmal diameter was achieved in all the patients with follow-up.

Purpose: Endovascular repair of chronic thoracoabdominal aortic dissection with aneurysmal degeneration presents a therapeutic challenge when one or more visceral branches arise from the false lumen without an adjacent reentry. The chronic dissection flap can be thick and resistant to flap fenestration with standard techniques., Technique: The powered cheese wire technique facilitates cutting of a dissection flap using electrical current on a noninsulated through-and-through wire segment. The mid-shaft of the guidewire is denuded and kinked to form the "flying V" configuration. This solution is based on the BASILICA procedure, which uses electrosurgery to split aortic valve tissue lengthwise prior to transcatheter aortic valve replacement to prevent coronary artery obstruction. We demonstrate the technique in a case of branched endovascular aortic repair of a complex thoracoabdominal dissecting aneurysm in which a renal artery from the false lumen was catheterized by creating a powered cheese wire fenestration., Conclusion: The powered cheese wire technique is an effective approach to access false lumen originating branches during endovascular aortic repair of chronic aortic dissections.

Purpose: To report a single-center experience with the use of a custom-made Candy-Plug (CP) for distal false-lumen (FL) occlusion in subacute and chronic aortic dissection (AD)., Materials and Methods: A retrospective single-center analysis was conducted on consecutive patients with subacute and chronic AD who were treated with a custom-made CP for distal FL occlusion using 3 design generations (CP I to CP III) from October 2013 to September 2019., Results: A custom-made CP was used in 57 patients. Of these, 34 patients (29 males, mean age 62±10 years) were treated with a CP I vs 23 patients (16 males, mean age 59±17 years) with CP II/III. Technical success was achieved in 57 (100%) patients. Clinical success was achieved in 54 (95%) patients; 33 (97%) in CP I group vs 21 (91%) patients in CP II/III group, p=0.116. The mean hospital stay was 10±8 days (9±5 days in CP I group vs 13±9 days in CP II/III, p=0.102). The 30-day computed tomography angiography (CTA) confirmed successful CP placement at the intended level in all patients within both groups. Early complete FL occlusion was achieved in 50 (88%) patients; 30 (88%) patients in CP I group vs 20 (87%) in CP II/III group, p=0.894. Follow up CTA was available in 44 (77%) patients. Of these; 30/34 (88%) patients in CP I group with mean follow-up 29±17 months) vs. 14/23 (61%) patients with mean follow-up 14±5 months in CP II/III group. Thoracic aortic remodeling was achieved in 34/44 (77%) patients; 25/30 (83%) patients in CP I group vs 9/14 (64%) patients in CP II/III group, p=0.197. The aneurysm size remained stable in 9/44 (20%) patients; 5/30 (17%) patients in CP I group vs 4/14 (29%) patients in CP II/III group, p=0.741. The thoracic aneurysm increased size was seen in 1/44 (2%) patient. This patient was in CPII/III group., Conclusion: CP technique using custom-made devices is technically feasible with a low mortality and morbidity, and a high rate of aortic remodeling. Both, the original design (CP I) and newer designs with a self-closing central sleeve (CP II and CP III) showed similar excellent outcomes.

Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies' guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as "gray zone" issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.

Purpose: To report a single-center experience with thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection (cATBAD) comparing patients with vs without end-organ ischemia. Materials and Methods: Between November 2010 and December 2017, 64 patients (mean age 64.8±12.5 years; 49 men) underwent TEVAR for cATBAD. Patients were grouped into 2 cohorts: nonischemic (39, 61%) patients with unrelenting pain, early progressive aortic dilatation, uncontrolled hypertension, or rupture, and ischemic (25, 39%) patients with visceral, renal, lower extremity, or spinal cord hypoperfusion. Results: Mean time from diagnosis to treatment was 7.5 days (range 1-32) in the nonischemic group vs 2.3 days (range 1-14) days in the ischemic group (p=0.007). Fourteen (56%) of 25 ischemic cATBAD patients had stents implanted in the renovascular branch vessels, while 4 (16%) patients had stents implanted in the iliac arteries. When branch vessel cannulation failed, fenestrations were made in the intimal flap to improve perfusion of the involved branch (n=5). In the nonischemic group, 3 arteries were stented owing to atherosclerotic stenosis. Technical success was achieved in 62 (97%) of 64 patients; despite stenting, 2 patients had low renal artery perfusion on final angiography. There were no statistically significant differences in early or late outcomes between the nonischemic vs ischemic cATBAD patients. Six (9%) patients died within 30 days: 2 (5%) in the nonischemic group vs 4 (16%) in the ischemic group. Major complications (1 stroke, 2 cases of paraplegia, 1 retrograde type A dissection, and 1 case of bowel ischemia) occurred only in the nonischemic group. The mean follow-up was 28 months. Late endoleaks were observed in 3 (8%) nonischemic patients and 1 (4%) ischemic patient. Reinterventions were required in 7 (18%) nonischemic patients and 4 (16%) ischemic patients. Conclusion: TEVAR is an effective and safe method of treating cATBAD. Early intervention in ischemic cATBAD may have played a significant role in the lack of significant difference between ischemic and nonischemic cATBAD outcomes. Direct visceral reperfusion through branch vessel stenting during TEVAR may be crucial in achieving good outcomes in ischemic cATBAD.

Purpose: To present the early results of false lumen (FL) occlusion in chronic aortic dissection using the Candy-Plug generation II (CP II), which has a self-closing fabric channel that obviates the need for separate occlusion of its center. Materials and Methods: Fourteen consecutive patients (mean age 60±11 years; 10 men) with persistent FL backflow and aneurysm formation at the thoracic segment in chronic aortic dissection underwent thoracic endovascular aortic repair (TEVAR) with FL occlusion using the refined CP II. Primary endpoints were technical success (successful deployment) and clinical success (no FL backflow at the CP II level). Secondary endpoints included 30-day mortality and morbidity and aortic remodeling during follow-up. Results: Technical success was 100%. One patient required additional intraprocedural FL embolization at the CP II level due to persistent FL backflow on final angiography (clinical success 93%), though there was no flow through the CP II center. There were no intraprocedural complications. Immediate complete FL occlusion was achieved in 12 patients; the other 2 required reintervention. One had contrast enhancement in the distal FL proximal to the CP II and was treated with coil embolization. The other patient had persistent type I endoleak at the level of the left subclavian artery (LSA) and underwent left carotid-LSA bypass and proximal stent-graft extension. One patient died due to retrograde type A aortic dissection that was not related to CP II placement. Over a mean 8-month follow-up (range 3-12), 9 patients had computed tomography angiography; 8 patients had evidence of aortic remodeling, while 1 aneurysm sac was stable. Conclusion: The CP II reduces the number of procedural steps and offers good seal, with minimal morbidity and mortality and a high rate of aortic remodeling.

We report on our experience with a simplified elephant trunk (ET) procedure with a multi-branched prosthesis (Vascutek(®) Siena™ Collared Graft). It consists of a proximal portion (20 cm) with prefabricated side branches, a collar and a distal portion (30 cm). The collar, which can be trimmed into any desired diameter, constitutes the suture portion to the descending aorta. Radiopaque markers in the distal portion indicate the landing zone. Between January 2011 and June 2013, 20 consecutive patients (10 women; mean age, 66 ± 9.3 years) underwent ET procedure, including 6 re-do cases. Underlying aortic diseases were acute dissection (n = 6), chronic dissection (n = 4), aneurysm (n = 8) and PAU (n = 2). Mean preoperative diameter of the descending aorta was 49.1 ± 12.9 mm (range 74.7-29.7 mm). Concomitant procedures included ascending aortic replacement in 16 patients; root replacement in 2; AVR in 2, CABG in 3 and mitral repair in 1 patient. CPB time was 263 ± 94 min; mean duration of ACP was 65 ± 14 min. Two patients died on POD 8 and 78, respectively. Major adverse events included stroke (n = 1), resternotomy for bleeding (n = 2), renal failure requiring temporary dialysis (n = 1) and recurrent nerve paresis (n = 2). After a mean follow-up of 10 ± 8 months, all discharged patients were alive. Seven patients underwent stent-graft implantation of the descending aorta and one patient underwent open descending aortic replacement. The last generation of multi-branched arch prosthesis and especially the Vascutek(®) Siena™ Collared Graft make ET procedure a reasonable treatment option even in patients with acute aortic dissection.