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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: Our goal was to evaluate outcomes in all-comer patients undergoing open thoracoabdominal aortic replacement either unsuitable for or after failed endovascular aortic repair., Methods: Within a 4-year period, we analysed a consecutive series of 80 patients undergoing elective, urgent and emergency thoracoabdominal aortic replacement. Preoperative data, intraoperative data and outcomes were evaluated. Specific attention was given to technical refinements needed in patients after previous endovascular aortic repair., Results: Eighty patients underwent thoracoabdominal aortic replacement: 11.3% (n = 9) had connective tissue disorders. Twenty-six patients (32.5%) had previous endovascular aortic repair and 54 (67.5%) did not have previous endovascular repair. The mean age was 64.2 ± 12 years, and 70% (n = 56) were male. The mean EuroSCORE was 7.9 ± 2.6. Urgent or emergency operations were done in 22.5% (n = 18). Overall mortality was 20% (n = 16); symptomatic spinal cord injury occurred in 5% (n = 4). We did not observe differences in survival according to the presence or absence of previous endovascular aortic repair (P = 0.524). Multivariate regression analysis revealed the amount of packed red blood cell units (P = 0.009, confidence interval 1.028-1.215, odds ratio = 1.117) as a predictor of in-hospital death. Follow-up was 100% (37.9 ± 15.8 months); freedom from aortic-related reintervention was 96.3%., Conclusions: Despite an early attrition rate, survival after open thoracoabdominal aortic replacement is excellent, and freedom from aortic-related reintervention is high. Open surgery continues to remain an essential component in the treatment armamentarium of acute and chronic thoracoabdominal aortic pathology., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Our goal was to identify the inferior mesenteric artery diameter and number of patent lumbar arteries causing a significant type 2 endoleak to develop after infrarenal endovascular aneurysm repair., Material and Methods: Included were patients who underwent infrarenal endovascular aneurysm repair between April 2002 and January 2017. Patients with an aneurysm involving the iliac arteries were excluded. Significant type 2 endoleak was defined as a type 2 endoleak observed after infrarenal endovascular aneurysm repair and accompanied by abdominal aneurysm growth of at least 5 mm during that time., Results: A total of 277 patients were included. Mean follow-up was 38.9 (standard deviation 121.6) months. Immediately after infrarenal endovascular aneurysm repair, type 2 endoleaks occurred in 55 patients (20%), resolving spontaneously in 2 patients 6 months after infrarenal endovascular aneurysm repair. Thirty (10.8%) patients revealed a significant type 2 endoleak with aneurysm sack enlargement > 5 mm during follow-up, for which inferior mesenteric artery or lumbar artery coiling was performed. Mean time for coiling after primary infrarenal endovascular aneurysm repair was 25.4 (standard deviation 19.10) months. Twenty-three patients (8.3%) showed a non-significant type 2 endoleak during follow-up (no aneurysm sack enlargement). We found that the inferior mesenteric artery diameter and number of patent lumbar arteries were factors associated with a significant type 2 endoleak (odds ratio 1.755, P = 0.001; odds ratio 1.717, P < 0.001, respectively). Prior to endovascular aneurysm repair, the inferior mesenteric artery was patent in 212 (76.5%) patients; its median diameter measured 3 (0.5-3.8) mm. The median number of patent lumbar arteries was 3 (2-4). According to our receiver operating characteristic curve analysis, an inferior mesenteric artery diameter ≥3 mm (sensitivity 93.3%, specificity 65%) and ≥3 patent lumbar arteries (sensitivity 87.5%, specificity 43.6%) proved to be optimal cut-off values related to developing a significant type 2 endoleak. We therefore propose a composite score for the development of a significant type 2 endoleak [(inferior mesenteric artery diameter + patent lumbar arteries)/2]., Conclusions: Patients in whom the diameter of the inferior mesenteric artery is ≥ 3 mm and with ≥ 3 patent lumbar arteries carry a higher risk of developing significant type 2 endoleak after infrarenal endovascular aneurysm repair., (© 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: The aim of this study was to compare aortic diameters from admission computed tomography angiography (CTA) scans to postoperative aortic diameters in patients with traumatic aortic injury (TAI) and evaluate the influence of substantial blood loss on aortic diameter., Methods: The aortic databases of two tertiary university centers were retrospectively screened for patients with TAI between February 2002 and February 2019. Concomitant organ injuries, bone fractures, blood loss, and clinical outcomes were evaluated. Aortic diameters were measured in CTA upon admission and were compared with the CTA before discharge at three different aortic levels (mid-ascending, 5 cm distal to the end of the stent graft, and at the celiac trunk level)., Results: We identified 45 patients, aged 43 (first quartile; third quartile [26; 55]) years with a TAI treated by thoracic endovascular aortic repair. The most frequent cause of TAI was a car accident ( n  = 24). Concomitant injuries were seen in all but one patient. Bone and pelvic fractures were seen in 40 (89%) and 15 (33%) patients, respectively. Type III aortic injury was present in 25 patients (56%). Increase of aortic diameter after stabilization was +1.7 mm (-0.6 mm; 2.5 mm; p  = 0.004) at the mid-ascending aorta, +2.1 mm (0.2 mm; 3.8 mm; p  < 0.001) 5 cm distal to the stent graft, and +1.5 mm (0.5 mm; 3.2 mm; p  < 0.001) at the celiac trunk level., Conclusion: In patients with TAI, the aortic diameter is significantly reduced as compared with the aortic diameter at discharge. The reduction of aortic diameter might be caused by hemorrhagic shock and should be kept in mind for appropriate stent-graft sizing., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Objectives: To evaluate outcomes after thoracic endovascular aortic repair in young patients sustaining traumatic blunt aortic injury (BAI) using iliac extension stent-grafts because of small aortic diameters measuring <24 mm., Methods: Retrospective analysis regarding clinical presentation, trauma management, endovascular techniques and outcome of patients with a small descending aorta involving an iliac extension stent-graft to treat traumatic BAI., Results: Among 48 patients who suffered a BAI and underwent thoracic endovascular aortic repair, 7 received iliac extension stent-grafts. They were 27.4/[standard deviation (SD): -13.1] years old and 6 out of 7 were male. The iliac extension stent-graft was used as distal stent-graft, and a thoracic stent-graft was used in most patients as proximal extension. We achieved overall technical success in all patients during a procedure lasting 92.6 (SD: 54.9) min. One patient died 2 days after the endovascular procedure of hypoxic brain injury, and another died after 17 days of liver failure. That patient had also suffered a spinal cord injury following the procedure, as the stent-graft had been deployed in Ishimaru Zone 2, and the carotid to subclavian bypass had to be omitted because of his critical condition. Control computed tomographic angiographs was available in 6 patients after 7.7 (SD: 5.1) days and showed no endoleak. The surviving patients were discharged after 18.4 (SD: 13.4) days., Conclusions: Treating traumatic BAI using iliac extension stent-grafts in young patients with small aortic diameters is feasible. We observed no mortality caused by the BAI or related to endovascular therapy within this small patient cohort., (© 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.)

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.)

Objectives: Our goal was to evaluate the morphology of the aortic arch, focusing on the left subclavian artery (LSA), and to anticipate implications for single-branched endovascular aortic arch repair., Methods: We performed a morphological analysis of computed tomography angiography scans of 322 patients between January 2002 and December 2018. Arch type and distance between arch vessels on the convexity were evaluated. We defined 3 morphological types: U-type distance between the left common carotid artery (LCCA) and LSA offspring >10 mm; V-type distance between the LCCA and LSA offspring <10 mm and W-type isolated left vertebral artery offspring from the aortic arch., Results: Most patients presented a type III arch [50% (n = 161)]. The median distance from the brachiocephalic trunk offspring to the LCCA offspring measured 2.5 mm (2.0-3.0 mm) and that between the LCCA offspring and the LSA offspring was 6.5 mm (4.0-11.0 mm). We observed no significant difference based on the morphological type (V versus U versus W) in the brachiocephalic trunk-LCCA distance, but there were significant differences in the LCCA-LSA distance between types V and U (P < 0.001) and between types V and W (P < 0.001). Interestingly, we found no significant difference in the LCCA-LSA distance between types U and W. We noted a significant difference in the median diameter of the LSA according to U, V and W types: V type versus U type, 12.5 vs 13.5 mm (P = 0.033) as well as U type versus W type, 13.5 vs 10.5 mm (P < 0.001) and V type versus W type, 12.5 vs 10.5 mm (P < 0.002). The distances between the LSA offspring and left vertebral artery offspring between types U and V did not differ significantly., Conclusions: Our categorization of the U, V and W types of the LSA can help us anticipate shapes and distances and thereby function as an initial evaluation tool for predicting single branched endovascular aortic arch repair involving the LSA., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. 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.

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.)

Objectives: Endovascular aortic repair (EVAR) is a technically demanding procedure usually carried out by highly experienced surgeons. However, in this era of modern endovascular surgery with growing numbers of patients qualifying for the procedure, the need to enhance surgical training has emerged. Our aim was to compare the technical results of EVAR in patients operated on by trainees to that of those operated on by an endovascular expert., Methods: Between 2016 and 2018, a total of 119 patients diagnosed with an abdominal aorta disease requiring EVAR were admitted to our clinic. Overall, we included 96 patients who underwent preoperative and postoperative computed tomography angiography and EVAR performed either by an endovascular expert (N = 51) or a trainee (N = 45)., Results: We detected no difference in the baseline characteristics, indication for EVAR and preoperative anatomy between patients operated on by trainees and our endovascular expert. We noted the same incidence of endoleak type Ia occurrence (n = 2 vs n = 2, P = 1.00), reintervention rate (n = 0 vs n = 0, P = 1.00) and in-hospital mortality (n = 0 vs n = 1, P = 1.00) for operations done by trainees and the expert, respectively. There was no difference in X-ray doses or time between the 2 groups. Despite longer median operation times [112 (first quartile: 84; third quartile: 129) vs 89 (75-104) min; P = 0.03] and in-hospital stays [10 (8-13) vs 8 (7-10) days, P = 0.007] of the patients operated on by trainees, the overall clinical success of EVAR was satisfactory in both groups., Conclusions: An EVAR planned and performed by a trainee need not raise the cumulative risk of the procedure. Trainees who have undergone both mind and hand skills training can therefore carry out EVAR under the supervision of an experienced specialist as effectively and safely as experts do., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. 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: 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: Preclinical studies have suggested acute stiffening of the aorta following experimental thoracic endovascular aortic repair (TEVAR), resulting in acute elevated pulse pressure, hypertension and possibly heart failure. The aim of this study was to evaluate cardiac remodelling following TEVAR., Methods: From 2005 to 2018, 519 TEVAR procedures were performed at a single centre. Transthoracic echocardiography was performed pre- and post-TEVAR in 31 patients without previous replacement of the thoracic aorta. Patient characteristics, drug information, radiographic and follow-up data were evaluated. Aortic details were measured in multiplanar reconstruction., Results: Transthoracic echocardiography was performed 2 ± 2 years after TEVAR. At this time, patients received significantly more antihypertensive drugs compared to the pre-TEVAR intake (beta-blocker therapy: P = 0.037; calcium channel blocker: P = 0.022). Compared to pre-TEVAR, there was a significant reduction in the left ventricular ejection fraction (P = 0.008) and tricuspid annular plane systolic excursion (P = 0.013) post-TEVAR. A significant increase in the left ventricular mass was not detected in this study (P = 0.95). The mean distance of 163 ± 66 mm of the descending aorta was covered., Conclusions: This study suggests negative cardiac remodelling with a decrease in the left and right ventricular function following TEVAR despite an increase in oral antihypertensive medication. The impact of stiffer endovascular grafts compared with the native aortic wall should be considered by endovascular specialists and manufacturers., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The aim of this study was to evaluate the volume of air released from Relay Pro NBS thoracic stent grafts using different de-airing methods. The gas volume was measured in an in vitro experimental setting. Stent grafts were de-aired via (i) standard saline flushing (40 ml), (ii) increased volume saline flushing (120 ml), (iii) carbon dioxide followed by 40 ml saline flushing and (iv) de-airing with 40 ml of saline in an ultrasound bath. The volume of gas released was measured separately while introducing the folded stent graft in the delivery device into the simulated aorta (step 1) and while deploying it outside the delivery device (step 2). Median air volumes released during steps 1 and 2 after flushing with 40 ml of saline were 0.09 (1st-3rd quartile 0.06-0.21) and 0.14 (0.11-0.15) ml, respectively. The volume of air released during step 2 was significantly less [0.09 (0.08-0.10) ml] after de-airing with 120 ml saline (P = 0.049). Neither de-airing with carbon dioxide nor in an ultrasonic bath led to a reduction in the volume of gas released during step 2. Air remaining after de-airing with a standard 40 ml of saline was released partially during stent graft introduction into the aorta and partially during final deployment. The most effective method of reducing air volume was de-airing with increased saline volume., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. 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.)

Background:  To assess risks and benefits of a standardized strategy to prevent symptomatic spinal cord ischemia (SSCI) after thoracic endovascular repair (TEVAR) using routine cerebrospinal fluid (CSF) catheter placement and evoked potential (EP) monitoring., Methods:  One hundred and ninety-five patients underwent 223 SSCI low-risk TEVAR procedures between 1998 and 2014. CSF catheter was used to measure CSF pressure and drain CSF if necessary throughout the procedure and up to 24 hours thereafter. EPs were used to monitor spinal cord integrity throughout the procedure., Results:  Underlying pathologies included descending thoracic aortic aneurysm in 115 (52%), type B aortic dissection in 85 (38%), traumatic aortic rupture in 16 (7%), and others in 7 (3%) patients. CSF catheter was inserted before TEVAR in 116 procedures (52%). Active CSF draining was required in 29 patients (25%). The CSF catheter caused no major and 11 (10%) minor complications. EP were monitored during 88 (40%) procedures. We observed a reduction in the amplitude, prolonged latencies, or complete signal loss in nine procedures. There were no EP monitoring-related complications. SSCI incidence was higher in patients without CSF drainage (0.8% vs 4.7%, p  = 0.031)., Conclusion:  Use of CSF drainage is associated with a significant lower incidence of SSCI after SSCI low-risk TEVAR than nonuse, whereas the complication rate associated with CSF drainage insertion or removal is very low. Routine EP monitoring is a useful tool to detect immediate arterial inflow obstruction to the spinal cord. The combination of these two methods serves as a safe and reliable standardized strategy in reducing the incidence of SSCI to a minimum., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

The number of patients undergoing surgery on the thoracic and thoraco-abdominal aorta has been steadily increasing over the past decade. This document aims to give guidance to authors reporting on results in aortic surgery by clarifying definitions of aortic pathologies, open and endovascular techniques and by listing clinical parameters that should be provided for full presentation of patients' clinical profile and in particular, their outcome. The aim is to help find a common language in the treatment of aortic disease and to contribute to a better understanding of this patient population., (© 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: Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome., Methods: Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions., Results: Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting., Conclusions: Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation., Methods: Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016., Results: In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) ( p  = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p  = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p  = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p  = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients ( p  = 0.45)., Conclusion: Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut-down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Thoracic endovascular aortic repair technology focuses on accurately deploying the stent graft in the proximal landing zone in the proximal to distal direction. The aim of this in vitro study was to evaluate the accuracy of stent graft deployment in the distal landing zone., Methods: It was hypothesised that a reverse implantation mechanism (in a distal to proximal deployment direction, when the operator starts to open the endoprosthesis from distal to proximal), might enhance landing accuracy in the distal LZ. The aim was to investigate this hypothesis by implanting stent grafts into the 3D printed aortas with the currently available deployment mechanism. Based on two human patients' computed tomography angiography scans, two aortas were 3D printed at 1:1 scale: "straight" and "crooked" aortas with distal aortic tortuosity of 1.006 and 1.078, respectively. They were used in order to test three endoprostheses (E-vita THORACIC 3G, Relay Plus, Valiant Captivia) 10 times by implanting them in three ways: proximal landing in the aneurysm, proximal landing in another stent graft, reverse implantation (via simulated antegrade access). The aim was to land just above the target vessel's upper edge. The distance to the target vessel and wedge apposition were assessed under a direct view using caliper., Results: The distance to the target vessel was 3 mm (IQR 0; 8) if the stent graft landed proximally in aneurysm, 2 mm (IQR 0; 5) if it landed proximally in another stent graft, and 0 mm (IQR 0; 0) when reverse implantation was applied. The distance to the target vessel measuring 5 mm or occurred in 45%, 30%, and 0%, respectively. Overall the median wedge apposition after stent graft implantation was 0 mm (IQR 0; 0) in the "straight" versus 18 mm (IQR 15; 20) in the "crooked" aorta (p < .001)., Conclusions: Reverse stent graft deployment is associated with more accurate landing in the distal landing zone. Distal aortic tortuosity constitutes an important impediment to covering the distal LZ's entire circumference with a stent graft., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to define how the proximal landing zone changes geometrically after endovascular abdominal aortic aneurysm repair (EVAR) with the Anaconda (Vascutek, Inchinnan, United Kingdom) stent graft., Methods: Among 230 patients who underwent Anaconda stent graft implantation between 2005 and 2014, we included 126 with adequate computed tomography (CT) image quality and follow-up. CT analysis entailed the geometric changes in the main body, proximal rings, and proximal landing zone. The median CT follow-up was 2.0 years (345.8 patients-years)., Results: The proximal portion of the main body ring system flattened within the first year after EVAR, resulting in an up to 30° increase in the upper ring's angle in 40% patients and up to 40° increase in 24% patients. One year after EVAR, the upper ring angle increase slowed down. Aortic diameter measured at the level of the upper and lower ring expanded by 2 to 4 mm within 1 year, but remained unchanged afterward. The main body migrated continuously down toward the aortic bifurcation, attaining an average 6-mm increase in the distance between the superior mesenteric artery and main body within 4 years. Freedom from endoleak type IA was 95 ± 2% and 93 ± 3% after 1 and 4 years, respectively., Conclusions: The Anaconda main body ring system in its proximal portion flattens within the first year after EVAR, leading to an increase of 2 to 4 mm in the proximal landing zone's aortic diameter. The main body migrates slowly but continuously down toward the aortic bifurcation., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to investigate the accuracy of stent graft deployment in the distal landing zone (LZ) during thoracic endovascular aortic repair (TEVAR). Currently, TEVAR focuses on accurate stent graft deployment in the proximal LZ. Data on landing in the distal LZ are lacking., Methods: Of 195 TEVAR patients (2005-16) with a non-dissected aortic pathology, 59 [median age 73 years (first quartile 68; third quartile 77), 20 women] patients had a distal LZ shorter than 40 mm. In all, the aim was to deploy the stent graft just above the target vessel (coeliac trunk, mesenteric superior or renal artery). Patients were divided into the accurate landing (n = 10) and inaccurate landing (IAL, n = 49) groups according to the distance to the target vessel ≤ 5 mm or > 5 mm after TEVAR, target vessel coverage and the need for a second stent graft in the distal LZ. We assessed the distal LZ, stent graft distance to the target vessel, apposition, migration and endoleak Ib on computed tomography. Median follow-up period was 23 months (5; 48)., Results: Distal LZ anatomy did not differ between groups. Overall stent graft distance to the target vessel was 10.0 mm (6.5 mm; 16.0 mm). Three patients required a second stent graft in the distal LZ, and in 3 others, the target vessel was accidentally covered. In patients of the accurate landing group primary endoleak Ib occurred less frequently than those in the IAL group (0% vs 33%; P = 0.049). Three (30%) accurate landing and 19 (39%) IAL patients (P = 0.73) presented with substantial stent graft wedge apposition., Conclusions: Accurate stent graft implantation in the distal LZ with the currently available deployment mechanism is often challenging. An inaccurate landing is associated with a higher incidence of endoleak Ib.

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.)

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.

There is a growing number of devices used for thoracic endovascular aortic repair (TEVAR). The designs of stent grafts and their delivery systems differ substantially. The success of TEVAR is based on the correct use of stent graft delivery systems, the identification and understanding of radiopaque markers, and the stent graft's accurate placement. In this brief communication, we introduce the TEVAR App-a novel guide for thoracic endovascular aortic repair. It is a tool that provides key information that is quick to access and easy to understand on the thoracic aortic stent grafts currently available. It includes instructions for use, animations demonstrating the stent grafts' deployment, troubleshooting information, size tables, the locations of radiopaque markers, stent graft and delivery system photos, chest X-rays, and information on magnetic resonance safety and compatibility. Furthermore, it contains the TEVAR Calculator, which assists one in planning stent graft size according to individual aortic dimensions and oversizing factors. The TEVAR App is cost-free, and its development has not been supported financially by any industry. It is a non-profit project that aims to educate and help physicians performing TEVARs., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. 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.)

This manuscript describes the mechanisms behind aorto-oesophageal fistulation (AOF) and aortobronchial/pulmonary (ABPF) fistulation after TEVAR, reports the therapeutical approaches and defines recommendations how to prevent these complications in the future.

Objectives: To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR)., Methods: International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres)., Results: Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33)., Conclusions: The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.

Introduction: Patients with acute aortic dissection type A (AADA) with aortic arch and supra-aortic vessel involvement have a higher postoperative stroke prevalence and risk of later aortic arch aneurysm development., Case Report: We report a case of AADA with involvement of supraaortic arteries, complicated by cerebral malperfusion. The ascending aorta was replaced using bilateral antegrade cerebral perfusion through side-grafts attached to both carotid arteries, which were subsequently used as aorto-bi-carotid bypass. One year later, the diameter of aortic arch increased to 5 cm. The endovascular treatment of aortic arch was easily performed since debranching was already almost complete., Conclusions: Immediate bilateral carotid artery inflow and subsequent aorto-bi-carotid bypass is a safe way to prevent cerebral malperfusion in the setting of complicated AADA.A potential benefit of this technique is almost complete debranching that facilitates an endovascular arch replacement.

Objectives: To investigate mid-term outcome in patients undergoing thoracic endovascular aortic repair (TEVAR) for non-dissected aortic pathology with favourable and unfavourable landing zone and aortic anatomy., Methods: Between 2000 and 2011, TEVAR was performed in 208 patients with descending thoracic aortic disease. Of 105 patients with non-dissected thoracic aortic pathology, 69 presented with unfavourable anatomy as defined by short length (<15 mm), large diameter (>42 mm), angulation of >60° of the proximal or distal landing zone or extreme aortic tortuosity. The endpoints perioperative mortality, 1-year survival, endoleak occurrence and incidence of secondary intervention were compared with the remaining 36 patients with favourable anatomy., Results: Median follow-up was 18 months. TEVAR was performed emergently in 24 of 69 (35%) patients with unfavourable anatomy and in 11 of 36 (31%) of those with favourable anatomy (P = 0.68). No patients underwent conversion to open surgery, no periinterventional rupture was observed. Perioperative mortality did not differ between cohorts (1/69 vs 1/36, P = 0.78). Postoperative permanent spinal cord ischaemia occurred in patients with unfavourable anatomy only (2/69 vs 0/36, P = 0.78). Early endoleak and secondary intervention were more frequent in patients with unfavourable anatomy (19/69 vs 7/36 and 13/69 vs 1/36), but not statistically significant (P = 0.5 and P = 0.13, respectively). One-year aorta-related survival rates were similar in both groups (66/69 vs 33/36, P = 0.45)., Conclusions: Mid-term outcome after TEVAR does not differ between patients with favourable and unfavourable landing zone anatomy in terms of aorta-related survival. However, the more frequent need for secondary intervention warrants a more rigorous follow-up after TEVAR in patients with unfavourable anatomy.

Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR)., Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database., Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90)., Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.