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In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.

Interferon-gamma (IFN-γ) is a cytokine involved in the pathogenesis of Takayasu’s arteritis (TAK). However, the source of IFN-γ in TAK patients is not fully clear. We aimed to investigate the source of IFN-γ in TAK. 60 TAK patients and 35 health controls were enrolled. The lymphocyte subsets of peripheral blood were detected by flow cytometry, cytokines were detected by Bio-plex. The correlation among lymphocyte subsets, cytokines and disease activity indexes was analyzed by person correlation. The level of serum IFN-γ in TAK patients was significantly increased (P +IFN-γ+ cells in peripheral blood CD3+ cells was significantly higher in TAK patients than that of healthy control group (P = 0.002). A higher proportion of CD3+CD8+IFN-γ+ cells/CD3+IFN-γ+ cells (40.23 ± 11.98% vs 35.12 ± 11.51%, P = 0.049), and a significantly lower CD3+CD4+IFN-γ+/ CD3+CD8+IFN-γ+ ratio (1.34 ± 0.62% vs 1.80 ± 1.33%, P = 0.027) were showed in the TAK group than that of control group. The CD3+CD8+IFN-γ+/CD3+IFN-γ+ ratio was positively correlated with CD3+IFN-γ+cells/ CD3+cells ratio (r = 0.430, P = 0.001), serum IFN-γ level (r = 0.318, P = 0.040) and IL-17 level (r = 0.326, P = 0.031). It was negatively correlated with CD3+CD4+IFN-γ+/CD3+IFN-γ+ ratio (r = − 0.845, P +CD8 + T cells is an important source of serum IFN-γ in TAK patients.

Background Aortic arch surgery and obesity are both related to the risk of acute kidney injury. Our hypothesis was that the risk of postoperative acute kidney injury increases as body mass index increases in patients undergoing urgent aortic total arch replacement surgery for acute DeBakey Type I aortic dissection. Methods We conducted a retrospective cohort study in Beijing Anzhen Hospital from December 2015 to April 2017. All patients receiving urgent aortic total arch replacement surgery with a frozen elephant trunk implant for acute DeBakey Type I aortic dissection were included. Body mass index was calculated based on height and weight. Acute kidney injury was diagnosed based on the Kidney Disease Improving Global Outcomes standards. Results We included 115 consecutive patients in this study. A total of 53.0% (n = 61) of patients had acute kidney injury. The mean age was 47.8 ± 10.7 years, and 25.2% were women. Mean body mass index was 26.2 ± 3.9 kg/m2. The results of a univariate analysis showed that BMI, eGFR, CPB time, operative time, intraoperative blood loss, intraoperative amount of PRBCs, and respiratory failure were significantly correlated with AKI. In-hospital mortality was obviously increased in the acute kidney injury group (13.1% vs 1.9%; P = 0.025). Multivariate logistic regression showed that body mass index was associated with postoperative acute kidney injury after adjusting for other confounding factors (odds ratio = 1.16; 95% confidence interval: 1.02–1.33; P = 0.0288). The risk of postoperative AKI in the BMI ≥ 24 kg/m2 group was increased by 2.35 times (OR = 3.35, 95% CI: 1.15–9.74; p = 0.0263). Conclusions Body mass index was an independent predictor of acute kidney injury after urgent aortic total arch replacement surgery with a frozen elephant trunk implant.

Objective To screen several immune-related long non-coding RNAs (lncRNAs) and construct a prognostic model for papillary renal cell carcinoma (pRCC). Methods Transcriptome-sequencing data of pRCC was downloaded and a prognostic model was constructed. Time-dependent receiver operating characteristic (ROC) curve was plotted and the area under curve (AUC) was calculated. We conducted quantitative reverse transcription polymerase chain reaction (RT-PCR) to verify the model. The gene set enrichment analysis (GSEA) was used to show the connection of our model with immune pathways. Result We identified four lncRNAs to constructed the model. The model was significantly associated with the survival time and survival state. The expression-levels of the four lncRNAs were measured and the prognosis of high-risk patients was significantly worse. The two immune-gene sets had an active performance in the high-risk patients. Conclusion We constructed a prognostic model in pRCC which provided more reference for treatment.

Background Cardiac reoperation has always been a difficult problem in clinical practice. Because of the difficulty of operation, the incidence of complications and mortality rate is high. Secondary aortic surgery, especially the reoperation involving arch, has higher risk and is more difficult for patients with renal failure. Sun's operation (total arch replacement + stent elephant nose) has achieved good results in the treatment of diseases involving aortic arch, and occupies an important position in the treatment of patients with secondary arch lesions after cardiac surgery. Methods A total of 395 patients with a history of cardiac surgery were recorded in our center from January 1, 2009 to December 31, 2017, among whom 118 (30.1%) patients underwent aortic reoperation via the original incision using Sun's aortic procedure owing to postoperative great vessel disease. We analyzed the clinical data and survival time, and used Cox regression to analyze the risk factors for 30-day mortality as well as long term mortality. Results The interval between the last operation and the present operation was 0.08–19 years. Sixteen patients died within 30 days after operation and the average mortality rate was 13.6%. During the follow-up period, 28 patients died, with the mortality rate of 23.7%. As of December 31, 2017, the longest survival time was 9.36 years, and the survival time of 70 patients was more than 3.05 years. The main risk factor associated with the 30-day survival was cardiopulmonary bypass (CPB) time. The longer the CPB time was, the greater the risk of death was. The main risk factors associated with the long-term survival were CPB time and 24-h bleeding volume. The longer the CPB time was, the more the 24-h bleeding volume was, the higher long-term mortality rate was. Conclusion The second Sun's operation, as a surgical treatment after cardiac surgery, showed a high survival rate, with long survival time and good curative effect. CPB is the main risk factor for the 30-day survival state after operation, and CPB time and 24-h bleeding volume are the main risk factors for the long-term survival state after operation.

Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk.Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient.There were no in-hospital deaths. Fourteen patients required mechanical ventilation for24 h and one for48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up.The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P.01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = -0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.

Background: The aim of this study was to analyse the differences in renal function among various types of renal artery involvement in acute Debakey Type I aortic dissection. Methods: From January 2016 to January 2018, 304 consecutive patients with acute Debakey type I aortic dissection with renal artery involvement were included. According to computed tomography angiography (CTA) findings, renal artery involvement on one side can be classified into four types: type A, in which a large intimal tear is near the renal artery orifice; type B, the orifice of the renal artery originates entirely from the false lumen; type C, the orifice of the renal artery originates entirely from the true lumen; and type D, a renal artery dissection is observed. All patients underwent aortic repair. Results: The average age was 46.98±10.64 years. The types of bilateral renal artery involvement were as follows: AB type, four patients (1.32%); AC type, 38 patients (12.50%); AD type, three patients (0.99%); BB type, 13 patients (4.28%); BC type, 140 patients (46.05%); BD type, four patients (1.32%); CC type, 76 patients (25.00%); and CD type, 26 patients (8.55%). One-way ANOVA showed that there was no significant difference in serum creatinine (P = .57) and creatinine clearance rate (P = .08) between the groups. A statistically significant difference in age, gender, body mass index, hypertension history and aortic dissection onset time also was not observed (P > .05). The overall incidence of KDIGO acute kidney injury (AKI) was 49.67%. There was no significant difference in AKI incidence between different types of renal artery involvement after aortic surgery (P = .39). For patients needing renal replacement therapy, CTA showed that enhancement of renal cortex in the arterial phase was low and the boundary between the cortex and medulla was unclear in bilateral kidneys. Conclusion: The types of renal artery involvement did not affect renal function in the acute phase.

Background The etiology of Takayasu arteritis (TA) is unknown; however, a possible relationship between streptococcal infection and TA has been proposed. This study aimed to identify the clinical features and cardiac valvular involvement in untreated TA patients with an elevated antistreptolysin O (ASO) titer. Methods In this retrospective study, the clinical characteristics and features of valvular involvement were compared in TA patients with or without an elevated ASO titer. Results Of the 74 untreated TA patients, 13 patients were found have elevated ASO titers (17.6%). Mitral insufficiency was the most common in patients with elevated ASO (69.2%, 9/13), followed by aortic valve insufficiency (46.2%, 5/13) and tricuspid insufficiency (46.2%, 5/13), which were no significantly different than that in normal ASO group. The proportions of moderate to severe mitral (30.8% vs 1.6%, p = 0.000) and tricuspid valve (15.4% vs 1.64%, p = 0.023) insufficiency in the ASO positive group were significantly higher than those in the ASO negative group. The odds of mitral regurgitation in patients with elevated ASO titers were 3.9 times higher than those in the group with normal ASO titers (p = 0.053, OR = 3.929, 95% confidence interval [CI]: 0.983–15.694). Furthermore, the risk of moderate to severe mitral insufficiency in patients with elevated ASO titers was 41.6 times higher than that in patients with normal ASO titers (p = 0.002, OR = 41.600, 95% CI: 3.867–447.559). Conclusions An increase in ASO titer is related to valvular involvement in TA and is closely linked to mitral insufficiency.

Objective: To develop and validate ubiquitination-related molecular subtypes and a novel prognostic index using ubiquitination-related genes (URGs) for patients with bladder cancer (BCa).Materials and Methods: We downloaded the clinical data and transcriptome data of BCa from TCGA and GEO database. Consensus clustering analysis was conducted to identify ubiquitination-related molecular subtypes for BCa. Besides, we performed univariate and multivariate Cox regression analysis to develop a novel prognostic URGs-related index for BCa. We conducted internal and external verification in TCGA cohort and GEO cohort, respectively. Furthermore, the associations of ubiquitination-related molecular subtypes and prognostic index with tumor immune environment were also investigated.Results: A total of four ubiquitination-related molecular subtypes of BCa were finally identified. These four molecular subtypes had significantly different clinical characteristics, prognosis, PD-L1 expression level and tumor microenvironment. Besides, we developed a novel prognostic index using six URGs (including HLA-A, TMEM129, UBE2D1, UBE2N, UBE2T and USP5). The difference in OS between high and low-risk group was statistically significant in training cohort, testing cohort, and validating cohort. The area under ROC curve (AUC) for OS prediction was 0.736, 0.723, and 0.683 in training cohort, testing cohort, and validating cohort, respectively. Multivariate survival analysis showed that this index was an independent predictor for OS. This prognostic index was especially suitable for subtype 1 and 3, older, male, high grade, AJCC stage III-IV, stage N0, stage T3-4 BCa patients.Conclusions: This study identified a total of four ubiquitination-related molecular subtypes with significantly different tumor microenvironment, prognosis, clinical characteristics and PD-L1 expression level. Besides, a novel ubiquitination-related prognostic index for BCa patients was developed and successfully verified, which performed well in predicting prognosis of BCa.

Background Although obstructive sleep apnoea (OSA) is prevalent among patients with aortic dissection, its prognostic impact is not yet determined in patients undergoing major vascular surgery. We aimed to investigate the association of OSA with hypoxaemia and with prolonged intensive care unit (ICU) stay after type A aortic dissection (TAAD) repair. Methods This retrospective study continuously enrolled 83 patients who underwent TAAD repair from January 1 to December 31, 2018. OSA was diagnosed by sleep test and defined as an apnoea hypopnea index (AHI) of ≥ 15/h, while an AHI of > 30/h was defined severe OSA. Hypoxaemia was defined as an oxygenation index (OI) of 72 h. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of postoperative OI for prolonged ICU stay. Multivariate logistic regression was performed to assess the association of OSA with hypoxaemia and prolonged ICU stay. Results A total of 41 (49.4%) patients were diagnosed with OSA using the sleep test. Hypoxaemia occurred postoperatively in 56 patients (67.5%). Postoperatively hypoxaemia developed mostly in patients with OSA (52.4% vs. 83.0%, p = 0.003), and particularly in those with severe OSA (52.4% vs. 90.5%, p = 0.003). The postoperative OI could fairly predict a prolonged ICU stay (area under the receiver-operating characteristic curve, 0.72; 95% confidence intervals [CI] 0.60–0.84; p = 0.002). Severe OSA was associated with both postoperative hypoxaemia (odds ratio [OR] 6.65; 95% CI 1.56–46.26, p = 0.008) and prolonged ICU stay (OR 5.58; 95% CI 1.54–20.24, p = 0.009). Conclusions OSA was common in patients with TAAD. Severe OSA was associated with postoperative hypoxaemia and prolonged ICU stay following TAAD repair.

Summary: Objective: The aim of our study was to assess how much renal malperfusion increases the risk of early and late mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair. Methods: This study included 218 patients with ATAAD undergoing surgical repair using the total arch replacement and frozen elephant trunk technique. Mean age was 47.8 ± 10.7 years and 170 were male (78.0%). Based on clinical symptoms and computed tomographic angiography (CTA) findings, 48 patients were diagnosed with preoperative renal malperfusion (22.0%). Clinical data were compared between two groups. The impact of renal malperfusion on operative and late mortality were evaluated with Cox regression. Results: Patients with renal malperfusion experienced significantly higher incidences of persistent postoperative acute kidney injury (AKI; 10/48, 20.8% vs 7/170, 4.1%; p

Background To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. Methods Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04 ± 13.67 years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass. Results No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80 ± 23.58 to 127.0 ± 6.86 mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80 ± 8.73 to 11.47 ± 2.12 mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75–64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0–1), which was a significant reduction compared with preoperative drugs (2, IQR 1–3). Conclusions Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

BACKGROUND The aim of this study was to estimate the long-term efficacy of total aortic arch replacement combined with the frozen elephant trunk (TAR+FET) technique for aortic disease following a prior cardiac surgery procedure. MATERIAL AND METHODS We performed TAR+FET for 118 patients for major vessel disease following a prior cardiac procedure with median sternotomy incision. All patients were divided into 5 groups: in group A, the prior major procedure was aortic valve replacement (AVR); in group B, the prior major procedure was isolated ascending aorta replacement; in group C, the prior major procedure was aortic root replacement; in group D, the prior major procedure was aortic arch replacement or intervention; and in group E, the prior major procedure was 'other' cardiac operative procedure. The long-term follow-up visit results were estimated using the Kaplan-Meier method. RESULTS The 30-day mortality rate after the operation was 13.6% (16/118) - 2 died in group A, 1 in group B, 8 in group C, 4 in group D, and 1 in group E. Follow-up visits were completed in 99% of patients. The mean follow-up time was 47.6±36.3 months and 12 patients had died by follow-up, so the total long-term survival rate was 76.3%. One-year survival rates of the 5 groups were 85% (group A), 93.8% (group B), 82.3% (group C), 50% (group D), and 50% (group E), respectively. Five-year survival rates of the 5 groups were 85%, 93.8%, 80.6%, 50%, and 50%, respectively. CONCLUSIONS The TAR+FET technique is feasible and efficacious for aortic reoperation in patients who previously underwent cardiac surgery since the short-term mortality in patients with recurrent aortic arch disease after cardiac surgery is not high.

Background Thoracic aortic surgery and cardiopulmonary bypass are both associated with development of postoperative acute kidney injury. In this study, we undertook to investigate the relationship between cardiopulmonary bypass time and postoperative acute kidney injury in patients undergoing thoracic aortic surgery for acute DeBakey Type I aortic dissection. Methods All patients receiving thoracic aortic surgery for acute DeBakey Type I aortic dissection in Beijing Anzhen hospital from December 2015 to April 2017 were included. Cardiopulmonary bypass time was recorded during surgery. Acute kidney injury was defined based on the Kidney Disease Improving Global Outcomes criteria. A total of 115 consecutive patients were eventually analyzed. Results The overall incidence of acute kidney injury was 53.0% (n = 61). The average age was 47.8 ± 10.7 years; 74.8% were male. Mean cardiopulmonary bypass time was 211 ± 56 min. In-hospital mortality was 7.8%. Multivariate logistic regression revealed that cardiopulmonary bypass time was independently associated with the occurrence of postoperative acute kidney injury after adjust confounding factors (odds ratio = 1.171; 95% confidence interval: 1.002–1.368; P = 0.047). Conclusions Cardiopulmonary bypass time is independently associated with an increased hazard of acute kidney injury after thoracic aortic surgery for acute DeBakey Type I aortic dissection. Further understanding of the mechanism of this association is crucial to the design of preventative strategies. Electronic supplementary material The online version of this article (10.1186/s13019-019-0907-x) contains supplementary material, which is available to authorized users.

OBJECTIVES To study the perioperative outcomes and long-term survival rates in patients undergoing thoracic endovascular aortic repair (TEVAR) for uncomplicated type B dissection. METHODS A total of 751 patients with uncomplicated type B dissection who underwent TEVAR at our centre between May 2001 and December 2013 were retrospectively reviewed. The mean age of all patients (619 males and 132 females) was 52.8 ± 10.9 years. The follow-up period ranged from 1 to 170 months (median 70 months). RESULTS Five patients died during the perioperative period (mortality rate 0.7%). Four patients (0.5%) developed retrograde type A dissection. Two patients (0.3%) developed paraplegia and 1 patient developed incomplete paralysis (0.1%). There were no postoperative cerebral infarctions. The 5- and 10-year survival rates were 96.5% [95% confidence interval (CI) 95.0–98.0%] and 83.0% (95% CI 77.9–88.4%), respectively. The 5- and 10-year reintervention rates were 4.6% (95% CI 3.0–6.2%) and 7.9% (95% CI 5.3–10.5%), respectively. CONCLUSIONS Although the application of TEVAR for patients with uncomplicated dissection is still under debate, many patients who have undergone TEVAR have benefitted substantially from the treatment. Our data showed that TEVAR had low mortality and complication rates both in the short- and long-term follow-up periods. TEVAR may be considered as a first choice for patients with uncomplicated type B dissection.

Following hospital discharge, patients with type A acute aortic dissection (TA-AAD) may present an increase in mortality risk. However, little is known about specific biomarkers associated with post-discharge survival, and there is a paucity of prognostic markers associated with TA-AAD. Here, we identify nine candidate proteins specific for patietns with TA-AAD in a cross-sectional dataset by unbiased protein screening and in-depth bioinformatic analyses. In addition, we explore their association with short-term and long-term mortality in a derivation cohort of patients with TA-AAD, including an internal (n = 300) and external (n = 236) dataset. An elevated osteoprotegerin (OPG)/tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) ratio was the strongest predictor of overall, 30-day, post-30-day mortality in both datasets and was confirmed to be a strong predictor of mortality in an independent validation cohort (n = 400). Based on OPG/TRAIL ratio-guided risk stratification, patients at high risk (>33) had a higher 1-year mortality (55.6% vs. 4.3%; 68.2% vs. 2.6%) than patients at low risk (, Despite many therapeutic improvements, mortality risk in patients with type A acute aortic dissection remains high. Here the authors construct a biomarker-guided risk stratification tool to predict death, which could potentially contribute to treatment decision-making and improvement of the prognosis.

Expression of kinesin family member 18B (KIF18B), an ATPase with key roles in cell division, is deregulated in many cancers, but its involvement in prostate cancer (PCa) is unclear. Here, we investigated the expression and function of KIF18B in human PCa specimens and cell lines using bioinformatics analyses, immunohistochemical and immunofluorescence microscopy, and RT-qPCR and western blot analyses. KIF18B was overexpressed in PCa specimens compared with paracancerous tissues and was associated with poorer disease-free survival. In vitro, KIF18B knockdown in PCa cell lines promoted cell proliferation, migration, and invasion, and inhibited cell apoptosis, while KIF18B overexpression had the opposite effects. In a mouse xenograft model, KIF18B overexpression accelerated and promoted the growth of PCa tumors. Bioinformatics analysis of control and KIF18B-overexpressing PCa cells showed that genes involved in the PI3K–AKT–mTOR signaling pathway were significantly enriched among the differentially expressed genes. Consistent with this observation, we found that KIF18B overexpression activates the PI3K–AKT–mTOR signaling pathway in PCa cells both in vitro and in vivo. Collectively, our results suggest that KIF18B plays a crucial role in PCa via activation of the PI3K–AKT–mTOR signaling pathway, and raise the possibility that KIF18B could have utility as a novel biomarker for PCa.

To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR).From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT).The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p0.001), PC transfusion (OR, 1.28; p0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p0.001) were independent risk factors.Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.

OBJECTIVES: We seek to report our management protocol and early outcomes of acute type A aortic dissection (ATAAD) repair during the early phase of coronavirus disease 2019 (COVID-19). METHODS: From January 23 to April 30, 2020, we performed ATAAD repair for 33 patients, including three with pregnancy-related TAADs. Confirmation of COVID-19 depended on the results of two nucleic acid tests and pulmonary computed tomography scan. Based on testing results and hemodynamic stability, patients were triaged to an isolated intensive care unit or negative pressure operating room for emergency surgery. RESULTS: Mean age 50.2 ± 13.3 years and 20 were male (60.1%) and 8 patients were febrile (>37.3°C; 24.2%) and 17 were lymphopenic (51.5%). No patient was excluded from COVID-19 infection preoperatively. Extensive aortic repair with total arch replacement (TAR) was performed in 24 (72.7%), and limited proximal repair in 9 patients (27.3%). Cardiopulmonary bypass and cross-clamp times averaged 177 ± 34 and 88 ± 20 min for TAR, and 150 ± 30 and 83 ± 18 min for hemiarch, respectively. The mean operation time was 410 ± 68.3 min. Operative mortality was 6.1% (2/33). Complications included reintubation in four (12.1%), acute kidney failure in two (6.1%), and cerebral infarction in one (3.0%). No paraplegia nor re-exploration for bleeding occurred. COVID-19 was excluded in 100% eventually. No nosocomial infection occurred. Nor did any patient/surgical staff develop fever or test positive during the study period. CONCLUSIONS: The results of this study show that our management protocol based on testing results and hemodynamic stability in patients with ATAAD during the COVID-19 pandemic was effective and achieved favorable early surgical outcomes.

Objectives Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF. Methods From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision. Results In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up. Conclusions ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

BACKGROUND Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using the frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation. METHODS The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2±10.5 years and 426 were male (82.2%). The mean time from symptomatic onset to surgery was 4.8±3.7 days. Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass (CPB), cross-clamp and selective antegrade cerebral perfusion were 201±50, 112±34, and 26±10 minutes, respectively. RESULTS Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), re-exploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0±4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, and anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P

Background In this study we sought to verify the existence of primary cardiac impairment in patients with Marfan syndrome (MFS) undergoing a Bentall procedure and to explore its clinical significance. Methods Between October 2010 and April 2019, 164 patients with MFS and 748 patients without MFS with aortic root aneurysms underwent a Bentall procedure. Clinical characteristics and perioperative cardiac structure and function between both groups were compared after propensity score matching. Multivariate regression analysis was performed to identify factors that influenced the postoperative left ventricular ejection fraction and any adverse cardiogenic events. The midterm survival between these 2 groups were compared. Results After propensity score matching both groups had similar preoperative baseline characteristics. The MFS patients presented a higher preoperative New York Heart Association classification, larger left ventricular size, and poorer postoperative cardiac function compared with non-MFS patients. In our multivariate regression analysis MFS was associated with a lower postoperative left ventricular ejection fraction. Furthermore MFS was an independent risk factor for adverse postoperative cardiogenic events during patients’ hospital stay (odds ratio, 6.243; 95% confidence interval, 1.71-22.75; P = .006). There was no difference in midterm survival between the 2 groups (P = .772). Conclusions Clinical manifestations observed in MFS patients supported the existence of primary cardiac impairment. Because of a higher rate of postoperative cardiogenic adverse events in MFS patients, the potential impact of primary cardiac impairment in MFS should be carefully considered in cardiovascular surgery.

Background Hybrid repair of complicated acute type B aortic dissection (ATBAD) with aortic arch involvement is associated with a high rate of endoleak, stroke, and retrograde aortic dissection. Optimal management of this lesion remains uncertain. In this hybrid repair era, surgical results of ATBAD with distal aortic arch involvement using a frozen elephant trunk procedure with transposition of the left subclavian artery (LSCA) to left common carotid artery (LCCA) is reported. Methods From April 2011 to April 2016, 53 patients with complicated ATBAD with distal aortic arch involvement underwent a frozen elephant trunk procedure with LSCA-LCCA transposition. Preoperative organ malperfusion included renal ischemia in 10 subjects, renal infarction in 2, lower limb ischemia in 6, and visceral ischemia in 5. Results There was no inhospital death. Continuous renal replacement therapy was required in 1 patient. Permanent neurologic injury was observed in 1 patient and temporary neurologic dysfunction in 1 patient. Ischemia of the lower limb and viscera was ameliorated after frozen elephant trunk implantation. During follow-up, thoracoabdominal aortic replacement was required in 1 patient, and the Wheat procedure in 1 other patient. The patency rate of the anastomotic site between the LSCA and LCCA was 100%, and shrinkage of the descending aorta occurred in 90.4% of patients (47 of 52) as demonstrated by computed tomography. Conclusions Open repair of ATBAD with distal aortic arch involvement using the frozen elephant trunk procedure with LSCA-LCCA transposition obtained satisfactory outcomes. Avoidance of complications using hybrid repair, good postoperative recovery, and a low prevalence of late reintervention were achieved. The satisfactory results favored this technique for this lesion in this hybrid repair era.

Background Prolonged mechanical ventilation (PMV) after surgical repair of acute type A aortic dissection (ATAAD) is associated with increased risk for mortality and morbidity. Objective(s) The goal of this study was to evaluate the influence of PMV on early and late outcomes and to identify the risk factors for PMV after ATAAD repair. Design, Setting, and Participants This study was a retrospective analysis of prospectively collected data, which resulted from a prior clinical trial. Clinical outcomes were analyzed in 121 patients with ATAAD (mean age 46.6 ± 10.4 years; 93 men), who underwent total arch replacement and frozen elephant trunk at a mean of 3.6 days from onset. Multivariate analysis was used to identify risk factors for PMV after surgery. Main Outcome Measures The primary endpoint of this study was the occurrence of PMV following ATAAD surgery. The second endpoints were risk factors for PMV, in-hospital mortality and one-year survival. Results PMV was needed in 35 patients (28.9%). The PMV group had a longer ventilation time and length of ICU stay (129 ± 79 and 167 ± 119 hours vs. 19 ± 10 and 32 ± 23 hours, respectively, P < 0.001). Post-operative mortality was 6.6% (8/121), including 6 (17.2%) in the PMV and 2 (2.3%) in the non-PMV groups (P = 0.003). PMV was associated with increased in-hospital mortality (OR, 6.4; 95% CI, 1.1-36.0; P, 0.036). Follow-up was complete in 88.6% (98/113) of patients at a mean of 26 months (1-39). Survival at 1 year was significantly lower in the PMV group compared with the non-PMV group (77.1% vs. 95.3%, P = 0.002). Risk factors for PMV were the level of serum lactate (mmol/L) at the end of surgery (odds ratio, OR 1.189; 95% confidence interval CI 1.026-1.377; P = 0.021) and a lower preoperative platelet count (109/L) (OR 0.918; 95% CI 0.847-0.994; P = 0.034). Conclusion In this study, the occurrence of PMV was 28.9% in patients with ATAAD. A lower preoperative platelet count and a higher serum lactate level after ATAAD surgery were risk factors for PMV. Identification of risk factors may be helpful for preventing PMV and improving outcomes after surgical repair of ATAAD.

Acute aortic dissection (AAD) is an emergent vascular disease. Currently, its diagnosis depends on clinical and radiological investigations but lacking of serum biomarkers. In this study, we aimed to identify potential serum biomarkers for AAD using label-free proteomics approach. A total of 90 serum samples were collected from three groups: patients with acute aortic dissection (AAD, n=30), patients with acute myocardial infarction (AMI, n=30), and healthy controls (n=30), and the first four samples from each group were selected for label-free proteomics analysis. Using label-free approach, a total of 22 differentially expressed proteins were identified in the serum samples of the AAD group, of which 15 were upregulated and 7 were downregulated as compared to the AMI and healthy control groups. The most prominent increased protein was vinculin, which was selected to validate in total samples. The level of vinculin was significantly elevated in AAD patients (15.8 ng/ml, IQR: 9.3-19.9 ng/ml) than that in AMI patients (8.6 ng/ml, IQR:5.3-11.4 ng/ml) and healthy volunteers (5.3 ng/ml, IQR:2.8-7.6 ng/ml), P<0.0001. Furthermore, the concentration of vinculin both increased in type A and B dissection. At the early stage of AAD, vinculin maintained a high level to 48 hours compared with that of AMI. Our study demonstrated that vinculin may play a role in the early diagnosis of AAD.

Objective Prediction of acute renal failure (ARF) and paraplegia after thoracoabdominal aortic aneurysm repair (TAAAR) is helpful for decision-making during the postoperative phase. To find a more efficient method for making a prediction, we performed tests on the efficacy of different machine learning predicting models. Methods Perioperative TAAAR data were retrospectively collected from Beijing Anzhen Hospital and Shanghai DeltaHealth Hospital. Operations were conducted under normothermia using a four-branched graft. Four commonly used machine learning classification models (ie, logistic regression, linear and Gaussian kernel support vector machine, and random forest) were chosen to predict ARF and paraplegia separately. The efficacy of the models was validated by five-fold cross-validation. Results From 2009 to 2017, 212 TAAARs were performed. ARF was identified in 27 patients, and paraplegia was found in 18 patients. Five-fold cross-validation showed that among the four classification models, random forest was the most precise model for predicting ARF, with an average area under the curve (AUC) of 0.89 ± 0.08. Linear support vector machine was the most precise model for predicting paraplegia, with an average AUC of 0.89 ± 0.18. The prediction program has been uploaded to GitHub for open access. Conclusion Machine learning models can precisely predict ARF and paraplegia during early stages after surgery. This program allows cardiac surgeons to address complications earlier and may help improve the clinical outcomes of TAAAR.

OBJECTIVES Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience. METHODS From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15–40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft. RESULTS ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011–1.348; P = 0.034). CONCLUSIONS The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.

Background: Acute aorta dissection (AD) is a fatal emergency, however, studies addressing the clinical characteristics, management, and outcome of acute AD in young adult patients aged under 45 yea...

Background Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during aortic arch surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. Methods From January 2009 to January 2016, 1691 patients who underwent aortic arch surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. Results The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P for interaction 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). Conclusions This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.

High body mass index (BMI) is associated with increased incident atrial fibrillation (AF) and mortality rate. In patients presenting with nonvalvular AF (NVAF), the prognostic relevance of BMI remains unclear.In this prospective observational study, a total of 1759 patients with NVAF (69.9±12.9 years old, 47.9% male) were divided into three clinical settings according to estimated stroke risks (CHADSDuring a mean follow-up of 1 year representing 1974 patient-years at risk, 256 patients died, 142 suffered from thromboembolism and 17 developed major bleeding. Multivariate adjusted Cox analysis indicated that a BMI of 24.0-27.9 kg/mA paradoxical BMI-all-cause mortality risk association was observed in Chinese patients with NVAF, and this association was pronounced among patients at high stroke risk rather than in those at low stroke risk.

OBJECTIVES: An aberrant right subclavian artery (ARSA) is one of most common congenital anomalies, but the coexistence of type B dissection and an ARSA is extremely rare. Repair of type B dissection poses a technical challenge due to an ARSA. We retrospectively reviewed our experience of surgical treatment of a complicated type B dissection with an ARSA. METHODS: From August 2010 to March 2014, 7 patients with chronic type B dissection with an ARSA underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass in our centre. The mean age was 45 ± 7 (range, 32–54) years. Total arch replacement was performed in 2 patients. Revascularization of the ARSAwas done in 5 of 7 patients. RESULTS: There were no in-hospital deaths. The mean time of mechanical ventilation and stay in the intensive care unit was 22 ± 11 and 53 ± 11 h, respectively. Neurological deficit, visceral ischaemia or injury to the spinal cord was not observed. Right upper-limb ischaemia was not observed in patients without ARRA revascularization during follow-up. CONCLUSIONS: In patients not undergoing descending aortic replacement, the stented elephant trunk method is our preferred procedure for this anomaly via a median sternotomy. Repair of type B dissection and revascularization of the ARSA were achieved in a single stage using this technique. Satisfactory surgical results and follow-up outcomes were obtained. There was no right upper-limb ischaemia or neurological deficit in patients without ARSA revascularization, but revascularization of the ARSA is recommended for this vessel anomaly.

Background Aortic arch surgery for patients with acute aortic dissection is frequently complicated by excessive bleeding and transfusion of allogeneic blood products. However, the physiopathology of acute aortic dissection and surgery-induced coagulopathy has never been precisely studied. The aim of the present study is to describe the changes of the perioperative hemostatic system in patients with acute aortic dissection undergoing aortic arch surgery. Methods Sixty-two patients undergoing emergent aortic arch surgery for Stanford type A acute aortic dissection were enrolled in this study from January 2013 to September 2014. The hemostatic system was evaluated using standard laboratory tests, plasma fibrinogen levels, and thromboelastogragh at 5 time points: anesthesia induction (T0), lowest nasopharyngeal temperature (T1), protamine reversal (T2), 4 h after surgery (T3), and on the first postoperative day (T4). Results The study results revealed that clotting factors had a tendency to be consumed in the preoperative period. Surgery and hypothermia resulted in a progressive reduction in clotting factors, platelet counts, and function, as well as fibrinogen concentration and function. After hemostatic therapy, although platelet counts were constantly low, clotting factors and platelet function returned to nearly preoperative levels. In contrast, fibrinogen concentration and function were still significantly lower than preoperative levels. Conclusions The results of this prospective analysis showed that acute aortic dissection itself activated the hemostatic system even before surgery. After hemostatic therapy, fibrin formation was more impaired than platelet function. In this setting, we proposed that hemostatic therapy should focus on rapid and sufficient supplementation of fibrinogen. Thus, we recommend further increases in fibrinogen concentration to improve coagulopathy in patients with acute aortic dissection.

This study sought to evaluate the long-term impact of frozen elephant trunk (FET) on the distal aorta of patients with Marfan syndrome (MFS) who had type I dissection confined to the thoracic aorta (above the diaphragmatic hiatus).Between 2003 and 2016, 42 patients with MFS (Ghent or revised Ghent criteria) (age 33.3 ± 8.9 years; 27 men; 64.3%) sustaining type I dissection above the diaphragmatic hiatus involving the aortic arch (22 acute; 52.4%) underwent total arch replacement and FET. Dissection extended distally to the mid-descending aorta in 32 (76%) and to above the diaphragmatic hiatus in 10 (24%) patients. Operative mortality was 4.8% (2 of 42). Follow-up was 100% at 6.3 ± 3.0 years.Maximal aortic sizes at the mid-descending aorta, diaphragmatic hiatus, renal arteries, and largest segment of abdominal aorta were 22.8, 21.1, 19.1, and 19.9 mm preoperatively and 23.1, 22.0, 19.8, and 22.4 mm on the latest computed tomographic angiography. Dilation and complete remodeling of the distal aorta occurred in 10.0% (4 of 40) and 90% (36 of 40) of patients, respectively. One late death occurred, and 3 distal reoperations were performed. Preoperative abdominal aortic maximal aortic size was predictive of distal dilatation (mm) (hazard ratio, 1.78; P = .021) and reoperation (≥25 mm vs25 mm) (hazard ratio, 12.88; P = .037). At 10 years, freedom from dilation, reoperation, and death were 69.8%, 78.1%, and 90.0%, respectively. At 8 years, the rates of death, reoperation, and reoperation-free survival were 10%, 11%, and 79%, respectively.The FET technique has a positive remodeling impact on type I dissection confined to the thoracic aorta in patients with MFS. This study adds evidence supporting the safety and durability of this extended approach for type I aortic dissection in MFS.

Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme.Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients.Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively.Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.

Objective The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of aortic arch surgery based on the 7-year clinical experience of a single center. Methods We analyzed the data of 1708 patients who underwent aortic arch surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes. Results Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24°C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24°C. Conclusions The study showed that the largest reported cohort of patients undergoing aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24°C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.

Purpose Platelets are crucial components of the coagulation processes, and low admission platelet count (PLC) is associated with adverse clinical outcomes in patients with Stanford type A acute aortic dissection (AAD). Methods A total of 130 consecutive patients undergoing Stanford type A AAD surgery in Beijing Anzhen Hospital were enrolled between January 2013 and July 2014. Preoperative clinical and laboratory data from patients were collected. Multiple regression analyses were used to determine the independent factors of low admission platelets. Results Adjusted multiple regression analysis showed that age (β: -1.069, 95% confidence interval [CI]: -2.109, -0.029), sex (β: -29.973, 95% CI: -56.512, -3.433), tissue factor pathway inhibitor (TFPI; β: 0.197, 95% CI: 0.039, 0.354), fibrinogen degradation product (FDP) (β: -0.476, 95% CI: -0.879, -0.074), and attack time (β: 11.125, 95% CI: 7.963, 14.287) were significantly associated with admission PLC. Admission PLC increased with attack time up to the 3 days (β: 16.2, 95% CI: 12.1, 20.2). Conclusions We found that increasing age, male patients, patients with lower serum levels of TFPI and higher serum levels of FDP, and patients with a shorter attack time were significantly associated with lower PLC at admission. Moreover, the turning point of attack time is 3 days after the onset of dissection.

Summary: Objective: To compare the outcomes of the en bloc and branched graft techniques for supra-aortic vessel reconstruction in total arch replacement (TAR) for acute type A aortic dissection (ATAAD). Methods: In 53 ATAAD patients with intact supra-aortic arch vessels undergoing TAR, the arch vessels were reconstructed using the branched graft technique in 35 patients and en bloc technique in 18, i.e. reimplantation of the innominate artery and the left carotid artery (LCA) and transposition of left subclavian artery to LCA. The early and mid-term outcomes were compared between two groups. Results: The selective antegrade cerebral perfusion time in en bloc group was significantly longer (33 ± 10 vs 24 ± 7 min, p = 0.001). Operative mortality was 5.7% (3/53), including 1 and 2 in the en bloc and branched graft groups, respectively (5.6% vs 5.7%, p = 0.981). Stroke occurred in 1 patient. No spinal cord injury occurred. At mean 4.3 ± 1.6 years, clinical and CT follow-up were complete in 100% and 86% (43/50). No cerebrovascular accidents or upper extremity claudication occurred. There were 4 deaths and 1 reintervention in follow-up. Survival was 88.6% and 88.9% at 3 months, and 83.3% and 88.6% at 6 months, 3 and 5 years in the en bloc and branched graft groups, respectively (p = 0.597). The arch vessels were patent in 100% (43/43) without stenosis or aneurysm. Conclusions: The modified en bloc technique could achieve comparable early and mid-term outcomes to the branched graft technique in patients undergoing TAR for ATAAD. This approach may be an alternative technique for ATAAD patients with intact supra-aortic arch vessels. Keywords: Aortic dissection, Aortic arch, Surgery, Total arch replacement, Vascular prosthesis/frozen elephant trunk

Background Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients. Methods Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD. Results Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7 ± 2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINE recurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8 years compared with medical therapy (88.3% vs 63.5%, p = 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p = 0.037) and chronic phase (hazard ratio, 1.725; p = 0.049). Conclusions In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.

The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test.The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test).PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.

Complete or partial supra-aortic debranching, after thoracic endovascular aortic repair, is appealing treatment for complicated acute type B dissection (ABAD) with aortic arch involvement (AAI) because of reduced surgical trauma. However, unsatisfactory outcomes have been reported. We retrospectively reviewed our experience of left subclavian artery (LSCA) transposition with stented elephant trunk (SET) implantation for complicated ABAD with distal AAI.From April 2011 to December 2014, 19 patients (all men; mean age: 44 years) who had complicated ABAD and distal AAI underwent LSCA transposition with SET implantation via a median sternotomy under hypothermic cardiopulmonary bypass with selective cerebral perfusion. Preoperative renal dysfunction was observed in 3 patients, visceral ischemia in 2 patients, and lower-limb ischemia in 1 patient.No in-hospital deaths occurred. Seventeen patients required mechanical ventilation for24 hours, and 2 cases for48 hours. The mean time of mechanical ventilation and duration of stay in the intensive care unit was 18 ± 6 hours and 44 ± 16 hours, respectively. Ischemia of the viscera and lower limbs after surgery was ameliorated. Continuous renal replacement therapy was not required in 3 patients who had preoperative renal dysfunction. Complete thrombosis of the false lumen at the distal end of the SET was observed in 17 of 18 (94.4%) patients during follow-up.This method preserves autologous brachiocephalic vessels, excludes the false lumen, promotes thrombosis and remodeling of the distal aorta, and repairs proximal aortic lesions simultaneously. Satisfactory surgical outcomes and follow-up results were achieved using LSCA transposition with SET implantation.

Background A combined endovascular and debranching hybrid procedure was performed for descending aortic pathologies involving the distal aortic arch. We reviewed our results of this procedure to summarize clinical experiences. Methods From April 2009 to April 2013, 36 patients (21 males and 15 females) underwent the hybrid operation. Hospital stay and complications were closely monitored after operation. Follow-up CT scan was performed at postoperative 3 months and 12 months. Results The hospital stay ranged from 7 to 25 (15.1 ± 5.0) days. The mean age at operation was 67.6 ± 4.8 years (range: 60–79 years). In-hospital mortality and stroke rates were 2.8% (1/36) and 2.8% (1/36). At a mean follow-up of 22 months (4–52 months), the mortality was 0% (0/35). All remaining 35 patients returned to normal life. During the follow-up period, one patient required secondary endovascular reintervention for a type 1 distal endovascular leak. Conclusion Hybrid repair for descending aortic pathologies involving the distal arch proves to be effective and safe at midterm follow-up with acceptable surgical risks and satisfactory results.

OBJECTIVES: The presence of an isolated left vertebral artery (ILVA) remains a challenging issue for thoracic endovascular aortic repair (TEVAR) of type B dissection if the proximal landing zones are inadequate. We retrospectively reviewed our experience of the surgical management of complicated type B dissection with an ILVA using the stented elephant trunk technique. METHODS: Between February 2009 and May 2013, 7 patients with complicated type B dissection (acute = 2 and chronic = 5) underwent the stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All the patients were males with a median age of 53 ± 6 (range 42–59) years. Preoperative lower limb ischaemia was observed in 1 patient, renal dysfunction in 1 patient and visceral ischaemia in 1 patient. RESULTS: There were no in-hospital deaths. The median ventilator support time was 16 ± 3 (range 11–20) h. Ischaemia of the lower limb and viscera was ameliorated after surgical stent-graft implantation. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurological deficits were observed in any patients prior to hospital discharge. One patient underwent TEVAR due to distal aortic dilatation within the mean follow-up period, which was 44 ± 19 months. CONCLUSION: Repair of complicated type B dissection with an ILVA using the stented elephant trunk technique was associated with satisfactory surgical results in patients with inadequate proximal fixation zones. This technique is an alternative to TEVAR for complicated type B dissection with inadequate proximal landing zones.

Objective Various techniques have been introduced to treat acute type A dissection during aortic arch reconstruction. We retrospectively reviewed our experience of total arch replacement, with implantation of a stented elephant trunk, using preservation of autologous brachiocephalic vessels in patients with acute type A dissection. Methods Between August 2011 and April 2013, 20 patients (16 men, 4 women; mean age, 45 ± 10 years, range, 24-62 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation, using preservation of autologous brachiocephalic vessels under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. Results No in-hospital deaths occurred. A transient neurologic deficit occurred in 1 patient, who ultimately required tracheotomy. Reoperation was indicated in 1 patient for bleeding. All patients survived and were discharged. During the mean follow-up period of 26 ± 7 months, 1 patient underwent thoracoabdominal aortic replacement, and 1 patient was lost to follow up. The patency of the anastomotic site between the left subclavian artery and the left common carotid artery was confirmed on computed tomography scanning. Conclusions This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results. This technique is an alternative approach for suitable patients with acute type A dissection. However, outcomes are preliminary, and long-term follow up is required.

To analyze the clinical outcome of corticosteroid and/or immunosuppressive treatment preoperatively in patients with Takayasu's arteritis.Forty-six patients with Takayasu's arteritis who received cardiovascular surgery between January 2010 and December 2015 in Beijing Anzhen Hospital were enrolled in this study. Their clinical characteristics, preoperative drug therapy, surgical treatment, and pathological examination results were retrospectively analyzed for the effect of drugs on outcome of the surgery.All 8 patients with active disease prior to surgery had postoperative complications including one death due to stubborn perivalvular regurgitation induced heart failure during the perioperative period. Among 38 patients without active disease prior to surgery, only 4 patients (10.5%) had postoperative complications. Thirty-four patients showed symptomatic relief in the perioperative period, of whom 23 patients treated with corticosteroid and/or immunosuppressive agents preoperatively.The surgery can effectively improve the symptoms of patients with Takayasu's arteritis. Active disease of Takayasu's arteritis markedly increased risk for postoperative complication and resulted in poor outcome of the surgery. Treatment with corticosteroid and/or immunosuppressive agents before surgery can effectively control the patient's condition, improve the rate of remission, and effectively reduce the incidence of postoperative complications.

Background Acute ischemic pancreatitis secondary to aortic dissection is very rare with an unclarified mechanism. We retrospectively reviewed 6 such cases in our center and present their outcomes herein. Methods Between February 2009 and April 2017, 6 patients (male = 2 and female = 4; mean age, 58 ± 8 years [range, 47–70 years]) with acute aortic dissection associated with pancreatitis were admitted to our center. There were 3 type A and 3 type B dissections. One patient developed renal dysfunction and visceral organ ischemia, and 1 developed renal failure and ischemia of the lower extremity. Five patients had a history of hypertension, and 1 had diabetes mellitus. Results After aggressive medical treatment, 5 patients survived the acute phase of aortic dissection and acute ischemic pancreatitis. Surgery was required in 4 patients and thoracic endovascular aortic repair in 1 patient. There were no severe postoperative complications, and all 5 were discharged. One patient with acute type B dissection refused treatment and died from multiple organ failure. No complications or deaths occurred in the postoperative follow-up period. Conclusions Acute ischemic pancreatitis after aortic dissection is a very unusual complication. The potential for this concomitant diagnosis should always be considered during the diagnostic stages. There is no clear consensus regarding the management of aortic dissection associated with acute pancreatitis.

Background Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. Methods Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51 ± 14 (range 20–69) years. Results There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33 ± 21 months, one patient died. Conclusions Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.

Background Type Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent-graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. Methods From July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. Results All cases of type Ia endoleak (100%) were repaired successfully. There were no in-hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow-up. During follow-up, there were 3 deaths. Conclusions Acceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion.

EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation.Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation.The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 10⁹/L (p0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75).EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation.