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Type A aortic dissection (TAAD) has been associated with thoracic endovascular aortic repair (TEVAR) for aortic conditions: dissection and aneurysm. Our purpose was to study a subset of patients who had an initial TEVAR for type B aortic dissection, followed by a TAAD, which was treated by open ascending aortic repair. Over a 6-year period, 171 consecutive patients underwent open ascending aortic repair for TAAD, of whom 21 (12%) had a previous cardiovascular procedure, 17 of which were endovascular. A total of 9 (5.2%) of 171 patients with TAAD had a previous TEVAR for a type B. The mean interval from TEVAR to open ascending aortic repair for TAAD was 4.6 years, with only 1 occurring within a month. Only 1 patient had abnormal aortic media by histology. In 5 of the 9 patients, the entry tear was in the proximal ascending aorta, remote from the endograft, which suggests that a TAAD late after TEVAR for type B represents a new spontaneous event., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Extended reality includes both virtual and augmented realities. In virtual reality objects are rendered in an artificial environment where the user can move and interact with a head mounted display. In augmented reality virtual objects are superimposed to real environment enriching it via a head mounted display. In human medicine these technologies have been already used for educational surgical purposes, but remain relatively unknown in veterinary medicine. We report a case of a 1-year-old, female, French bulldog presented for exercise intolerance and dyspnea. Echocardiography showed signs of left ventricular enlargement with reduced fractional shortening and turbulent flow distal to the pulmonary artery bifurcation. Computed tomography revealed a complex vascular network comprising the descending aorta and left pulmonary artery resembling a patent ductus arteriosus. Virtual reality was used for the surgical planning and a left thoracotomy was performed to close the abnormal vessel at the level of the entrance in the left pulmonary artery with augmented reality assistance. No complications were reported during or after the surgery and the dog completely recovered. Echocardiographic findings 3 days, 1 month and 18 months after the surgery demonstrated absence of residual flow and improving ventricular dimensions. To our knowledge this report documents the first use of extended reality for the visualization, planning and execution of the surgical correction of a complex vascular defect in veterinary medicine., Competing Interests: Declarations. Ethics approval: Ethical review and approval were waived for this study because, being a case report derived from clinical practice, all medical procedures were performed after obtaining written consent from the owner. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: Complicated type B Aortic dissection is a severe aortic pathology that requires treatment through thoracic endovascular aortic repair (TEVAR). During TEVAR a stentgraft is deployed in the aortic lumen in order to restore blood flow. Due to the complicated pathology including an entry, a resulting dissection wall with potentially several re-entries, replicating this structure artificially has proven to be challenging thus far., Methods: We developed a 3d printed, patient-specific and perfused aortic dissection phantom with a flexible dissection flap and all major branching vessels. The model was segmented from CTA images and fabricated out of a flexible material to mimic aortic wall tissue. It was placed in a pulsatile hemodynamic flow loop. Hemodynamics were investigated through pressure and flow measurements and doppler ultrasound imaging. Surgeons performed a TEVAR intervention including stentgraft deployment under fluoroscopic guidance., Results: The flexible aortic dissection phantom was successfully incorporated in the hemodynamic flow loop, a systolic pressure of 112 mmHg and physiological flow of 4.05 L per minute was reached. Flow velocities were higher in true lumen with a up to 35.7 cm/s compared to the false lumen with a maximum of 13.3 cm/s, chaotic flow patterns were observed on main entry and reentry sights. A TEVAR procedure was successfully performed under fluoroscopy. The position of the stentgraft was confirmed using CTA imaging., Conclusions: This perfused in-vitro phantom allows for detailed investigation of the complex inner hemodynamics of aortic dissections on a patient-specific level and enables the simulation of TEVAR procedures in a real endovascular operating environment. Therefore, it could provide a dynamic platform for future surgical training and research., Competing Interests: Declarations. Conflict of interest: The authors have no relevant financial or non-financial interests to disclose. Ethical approval: Patient consent and ethical approval was obtained from the Ethics Committee of the Faculty of Medicine of Ruprecht-Karls-University Heidelberg, Germany (S-158/2015). Informed consent: Informed consent was obtained from all individual participants included in the study., (© 2024. The Author(s).)

Purpose: We aim to quantify multiaxial cardiac pulsatility-induced deformation of the thoracic aorta after ascending thoracic endovascular aortic repair (TEVAR) as a part of the GORE ARISE Early Feasibility Study., Materials and Methods: Fifteen patients (7 females and 8 males, age 73±9 years) with ascending TEVAR underwent computed tomography angiography with retrospective cardiac gating. Geometric modeling of the thoracic aorta was performed; geometric features including axial length, effective diameter, and centerline, inner surface, and outer surface curvatures were quantified for systole and diastole; and pulsatile deformations were calculated for the ascending aorta, arch, and descending aorta., Results: From diastole to systole, the ascending endograft exhibited straightening of the centerline (0.224±0.039 to 0.217±0.039 cm -1 , p<0.05) and outer surface (0.181±0.028 to 0.177±0.029 cm -1 , p<0.05) curvatures. No significant changes were observed for inner surface curvature, diameter, or axial length in the ascending endograft. The aortic arch did not exhibit any significant deformation in axial length, diameter, or curvature. The descending aorta exhibited small but significant expansion of effective diameter from 2.59±0.46 to 2.63±0.44 cm (p<0.05)., Conclusion: Compared with the native ascending aorta (from prior literature), ascending TEVAR damps axial and bending pulsatile deformations of the ascending aorta similar to how descending TEVAR damps descending aortic deformations, while diametric deformations are damped to a greater extent. Downstream diametric and bending pulsatility of the native descending aorta was muted compared with that in patients without ascending TEVAR (from prior literature). Deformation data from this study can be used to evaluate the mechanical durability of ascending aortic devices and inform physicians about the downstream effects of ascending TEVAR to help predict remodeling and guide future interventional strategies., Clinical Impact: This study quantified local deformations of both stented ascending and native descending aortas to reveal the biomechanical impact of ascending TEVAR on the entire thoracic aorta, and reported that the ascending TEVAR muted cardiac-induced deformation of the stented ascending aorta and native descending aorta. Understanding of in vivo deformations of the stented ascending aorta, aortic arch and descending aorta can inform physicians about the downstream effects of ascending TEVAR. Notable reduction of compliance may lead to cardiac remodeling and long-term systemic complications. This is the first report which included dedicated deformation data regarding ascending aortic endograft from clinical trial., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.-Y.K.S. has received research funding and/or consulting fees from Bentley InnoMed, Medtronic, Optimed Medical Instruments, Terumo Aortic, and W. L. Gore & Associates. M.C.N. has received salary from W. L. Gore & Associates. E.E.R. has received research funding and/or consulting fees from Cook, Artivion, Edwards Lifesciences, W.L. Gore & Associates, Medtronic, and Terumo Aortic. C.P.C. has received research funding and/or consulting fees from Abbott Laboratories, AneuMed, Arsenal Medical, Bentley InnoMed, Confluent Medical Technologies, Endospan, Medtronic, Optimed Medical Instruments, Qmedics, ReValve Solutions, Starlight Cardiovascular, Terumo Aortic, and W. L. Gore & Associates. J.B. and Y.D.Z. have nothing to disclose.

Objective: Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which uses downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection., Methods: A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with computed tomography scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum of 3 months of follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed., Results: The analysis identified predictors of favorable aortic remodeling, including age >60 years, a larger downstream aorta stent graft, a smaller abdominal aorta (<450 mm 2 ), and oral angiotensin II receptor blocker administration. Over a median 47.5 months of follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not differ significantly (89.2% vs 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs 8.1%)., Conclusions: The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and angiotensin II receptor blocker therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the transaxillary branch-to-branch-to-branch carotid catheterization technique (tranaxillary 3BRA-CCE IT) for cannulation of all supra-aortic vessels using only 1 femoral and 1 axillary access during triple-branch arch repair., Technique: After deployment of the triple-branch arch device, catheterization and bridging of the innominate artery (IA) should be performed through a right axillary access (cutdown or percutaneous). Then, the retrograde left subclavian (LSA) branch should be catheterized (if not preloaded) from a percutaneous femoral access, and a 12×90Fr sheath should be advanced to the outside of the endograft. Subsequently, catheterization of the left common carotid artery (LCCA) antegrade branch should be performed, followed by snaring of a wire in the ascending aorta which was inserted through the axillary access, creating a branch-to-branch-to-branch through-and-through guidewire. Over the axillary access, a 12×45Fr sheath should be inserted into the IA branch and looped in the ascending aorta using a push-and-pull technique so that it faces the LCCA branch, allowing for stable catheterization of the LCCA. The retrograde LSA branch should then be bridged following the standard fashion., Conclusions: This series of 5 patients demonstrates that triple-branch arch repair can be performed with the transaxillary 3BRA-CCE IT, allowing catheterization of the supra-aortic vessels without manipulation of the carotid arteries., Clinical Impact: The transaxillary 3BRA-CCE IT allows catheterization and bridging of all supra-aortic vessels in triple-branch arch repair through only 2 vascular access points, the femoral artery and the right axillary artery. This technique avoids carotid surgical cutdown and manipulation during these procedures, reducing the risk of access site complications, including bleeding and reintervention, reintubation, cranial nerve lesions, increased operating time, and so on, and has the potential to change the current vascular access standard used during triple-branch arch repair., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The objective of this research is to analyze the hemodynamic differences in five configurations of left subclavian artery (LSA) stent grafts after LSA endovascular reconstruction in thoracic endovascular aortic repair (TEVAR). For numerical simulation, one three-dimensional thoracic aortic geometry model with an LSA stent graft retrograde curved orientation was reconstructed from post-TEVAR computed tomography angiography (CTA) images, and four potential LSA graft configurations were modified and reconstructed: three straight (0, 2, and 10 mm aortic extension) and one anterograde configuration. The blood perfusion of the LSA, flow field, and hemodynamic wall parameters were analyzed. The vortex evolution process was visualized by the Liutex method which enables accurate extraction of the pure rigid rotational motion of fluid and is highly suitable for identifying the vortex structure of blood flow near the vessel wall. The average flow in the retrograde configuration decreased by 11.2% compared to that in the basic configuration. When the LSA stent graft extends in the aortic lumen, flow separation is observed, and vortex structures begin to form at the proximal inferior arterial geometry and the wall of the extension in late systole. A greater extension length and inflow angle upstream resulted in a greater oscillatory shear index (OSI) and relative residence time (RRT) on the nearby wall of the posterior flow field of the extension. Shorter intra-aortic extension length (<10 mm) and smaller LSA stent graft inflow angle (<120 deg) may be recommended in TEVAR, considering LSA perfusion and minimized flow field disturbance., (Copyright © 2025 by ASME.)

Background: Thromboelastometry plays a key role in many transfusion algorithms. ROTEM® Sigma is the fully automated successor of ROTEM® Delta. Compatibility with current ROTEM® Delta-based algorithms remains uncertain. This study compares ROTEM® Delta with ROTEM® Sigma in patients undergoing thoracic aortic surgery., Methods: Three ROTEM® measurements in duplicate (one Delta and one Sigma) per patient were performed during aortic surgery. The primary outcome was the percentage of patients who would have received a different haemostatic intervention after protamine reversal based on the institutional ROTEM®-guided transfusion algorithm ('deviation'). A 10% deviation was deemed acceptable. Secondary outcomes were differences in numerical values assessed by Passing-Bablok regressions, Bland-Altman plots, and correlations with conventional coagulation tests., Results: Of 111 patients, 102 had matched post-protamine ROTEM® measurements. There were 43 algorithm deviations. Most deviations (29) were attributable to conflicting advice on CT EXTEM-based plasma or prothrombin complex concentrate (PCC) administration; in 25 patients, Delta results advised the administration of plasma or PCC, whereas Sigma did not, and vice versa in four patients. Deviations on additional protamine, fibrinogen concentrate, or platelet administration were acceptable. All numerical ROTEM® variables examined passed the criteria for equivalence, except for A10 FIBTEM at baseline and A10 EXTEM in heparinised and post-protamine samples, which would not have led to clinical consequences. Correlations with conventional coagulation tests were similar or better for Sigma compared with Delta., Conclusions: ROTEM® Sigma can be used with existing ROTEM-guided transfusion algorithms in cardiothoracic surgery except for the advice for administration of plasma or PCC., Clinical Trial Registration: Netherlands trial register NL8273., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging., Methods: All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density., Results: After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years., Conclusions: Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period., Competing Interests: Conflict of Interest Statement H.T. reported consultant for Artivion and speaker with Terumo. M.C. reported consulting fees from Artivion and Terumo. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The predissection aortic diameter is the best reference for determining the size of the frozen elephant trunk in aortic dissection. We aimed to develop a new prediction method to estimate the predissection diameter of proximal descending aorta. Furthermore, we evaluated the accuracy of the estimated predissection proximal descending aortic diameters calculated using 3 prediction methods., Methods: A total of 39 patients with acute type A aortic dissection who underwent predissection computed tomography were included in derivation sets. We measured the aortic dimensions at 3 levels of the proximal descending aorta: 5, 10, and 15 cm from zone 2. We developed a new prediction method-postdissection aortic diameter divided by 1.13 (AoD New factor )-and estimated the predissection aortic diameter using the new and previously proposed methods by Rylski (AoD Rylski ) and Yamauchi (Equation Yamauchi ). Furthermore, we validated the new prediction method using a validation dataset with 24 patients., Results: The rate of bias ≤2 mm was significantly greater with Equation Yamauchi and AoD New factor than with AoD Rylski in the derivation group at each level of the proximal descending aorta (P < .001). In the validation group, the rate of bias ≤2 mm was significantly greater with Equation Yamauchi and AoD New factor than with AoD Rylski at 10 cm and 15 cm from zone 2 (10 cm: P = .014, 15 cm: P < .001)., Conclusions: These results suggest that the new prediction method can be used as a simple and accurate estimation method for the predissection aortic diameter at the proximal descending aorta., Competing Interests: Conflict of Interest Statement S.N. reported consulting fees from Cook Medical Japan, Medtronic Japan Co, Ltd, Medico's Hirata Inc, Japan Lifeline, and Terumo Corp. A.Y. reported consulting fees from Japan Lifeline. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study compares the long-term outcomes of patients after repair of transposition of the great arteries (TGA) with and without aortic arch obstruction (AAO)., Methods: This is a single-institution, retrospective study between October 2004 and February 2023. Patients who underwent arterial switch operation and aortic arch repair (ASO-AAR group) with patch augmentation were compared with those without AAO (ASO group). The primary end point was survival; freedom from reintervention was a secondary end point., Results: We identified 176 patients, 31 in the ASO-AAR group and 145 in the ASO group. The median follow-up period was 10.3 years. There were no differences between the ASO-AAR group and the ASO group in early deaths (3.2% vs 0.7%) and late deaths (3.2% vs 2.8%), or 15-year survival rates (92.6% vs 96.2%). Surgical and catheter-based reinterventions were higher in the ASO-AAR group, involving the pulmonary arteries (41.9% vs 4.8%, P < .001), aortic arch (16.1% vs 0.7%, P < .001), and residual ventricular septal defects (11.4% vs 0%, P = .05). The ASO-AAR group showed a higher prevalence of double-outlet right ventricle TGA-type (61.3% vs 4.1%, P < .001) and a lower aortopulmonary index (0.67 vs 1.01, P < .001)., Conclusions: Patients undergoing surgical repair of TGA and AAO achieved excellent survival rates, comparable to patients with simple transposition. A higher rate of surgical and catheter-based reinterventions was observed in patients with arch obstruction and/or a low aortopulmonary index. AAR with patch augmentation proved to be an effective surgical technique with a low incidence of aortic reinterventions., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Published by Elsevier Inc.)

Background: This study aimed to evaluate the efficacy and safety of Pro-Glide, a suture-mediated vascular closure device, regarding technical success and complications in patients who had undergone aortic intervention and had previous groin intervention (PGI)., Methods: One hundred and thirty-five patients who underwent percutaneous thoracic endovascular aortic repair via the femoral artery and were closed with the Pro-Glide device were analyzed retrospectively. PGI was defined as a history of open surgical access to the femoral artery or wide sheath (>18 F) placement due to endovascular or valvular intervention. The patients were divided into two groups 38 cases with PGI and 97 cases without PGI., Results: The overall success rate of closure of the femoral artery with Pro-Glide was not statistically significant between the two groups (93.8% vs 92.1%, p = .711). Sheath sizes were compared between the groups and PGI (+) group had significantly higher sheath sizes compared to PGI (-) group (24.3 ± 1.1 F vs 23.8 ± 1.0 F, p = .011). Three patients in the PGI (+) group and six patients in the PGI (-) group experienced technical failure of the percutaneous femoral approach. Femoral complications were seen after the procedures in four patients in the PGI (+) group and four in the PGI (-) group. The PGI (+) group had a higher complication rate when compared to the PGI (-) group; however, this was not statistically significant ( p = .181)., Conclusion: The present study was conducted on a significantly larger sample compared to previous studies and the findings suggest that the Pro-Glide vascular closure device is a safe option for patients with a history of PGI and may not be considered as a contraindication., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: During infant aortic arch reconstruction, traditional electroencephalography (EEG) provides only qualitative data limiting neuromonitoring efficacy. Interhemispheric differences in the alpha:delta ratio (ADR) and suppression ratio (SR) measured using quantitative EEG generate numerical trends that may suggest cerebral ischemia. We hypothesized that the ADR and SR during cardiopulmonary bypass (CPB) would correlate with hemodynamics, and that ADR and SR interhemispheric differences would precede neurological injury from infants requiring aortic arch reconstruction., Methods: During aortic arch reconstruction, bilateral hemispheric ADRs and SRs were recorded every five minutes in conjunction with mean arterial pressure, temperature, CPB flow, and cerebral oximetry. Data were grouped into the cooling, antegrade cerebral perfusion (ACP), and rewarming periods of CPB. Correlation analysis determined relationships between the ADR, SR, and hemodynamic data. The cumulative interhemispheric ADR and SR differences were calculated during CPB. Neurological injury was defined as clinical/subclinical seizure or stroke., Results: Among 79 infants, the ADRs decreased significantly during rewarming, whereas SRs were significantly greatest during ACP. There was a direct correlation between the ADR and cerebral oximetry (R 2  = 0.734; P < 0.001) and an inverse correlation between the SR and temperature (R 2  = 0.882; P < 0.001). Eight infants developed neurological injury that was more often preceded by an interhemispheric ADR difference >0.1 (50% vs 7.8%; P = 0.01) or SR difference >18% (41.7% vs 4.8%; P = 0.008)., Conclusions: The ADR and SR correlate with cerebral oximetry and temperature, respectively, and significant interhemispheric differences often preceded neurological injury, suggesting the importance of quantitative EEG monitoring during infant aortic arch reconstruction., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: We sought to examine the relative importance of surgical lesion complexity versus the presence of genetic/syndromic/extracardiac anomalies (GSAs) in determining survival, morbidity or need for reinterventions following repair for aortic arch hypoplasia., Methods: A single-centre, retrospective cohort study of infants undergoing biventricular aortic arch repair via sternotomy from 2010 to 2021 was conducted. Survival analysis was performed using Kaplan-Meier methods, with additional Bayesian survival modelling for subgroups. Composite morbidity comprised respiratory, renal, neurologic, or sepsis-related complications., Results: Of 83 included infants, n = 13/83 (15.7%) had complex repairs; 27/83 (32.5%) were GSA+. Operative mortality was significantly higher in GSA+ versus GSA- patients (18.5% vs. 1.8%; p = 0.01), though not for complex versus non-complex repairs. Overall 10-year Kaplan-Meier survival was 86.7%. Bayesian modelling suggested equivalent post-discharge attrition in non-complex/GSA+ and complex/GSA- patients, with the poorest outcomes in complex/GSA+ patients; non-complex/GSA- patients had 100% survival. GSA+ patients exhibited higher composite morbidity (44.4% vs. 7.1% in GSA- p < 0.001), with their mode of death seemingly related to a high incidence of respiratory and neurological morbidity, notably in Dandy-Walker syndrome. The 10-year freedom from arch reinterventions was 87.7%; neither complexity, GSA status, nor post-repair peak arch velocity predicted the need for arch reinterventions., Conclusions: Whilst anatomic complexity may have been somewhat neutralised as a risk factor for operative mortality, in contrast to GSA+ status, there is further post-discharge attrition attributable to complexity or GSA+ status, with additive risk effects. Morbidity directly related to certain syndromes underlies some of this risk. Non-anatomic substrates represent a persistent limitation to outcomes of surgical aortic arch repair in infants.

Background: Late hypertension (HTN) after coarctation of the aorta (CoA) repair contributes to higher morbidity and mortality. An association between transverse aortic arch (TAA) hypoplasia and HTN has been found, but its relationship with surgical strategy is unclear. We studied the association between late HTN and initial surgical strategy pertaining to the TAA., Methods: We retrospectively reviewed patients who underwent surgical repair of CoA during infancy with at least 10 years of follow-up, excluding those with atypical coarctation, major associated heart defects, and residual isthmic narrowing. TAA diameter z-score immediately postrepair was measured as a marker of surgical strategy. Systemic HTN at latest follow-up was assessed using standard criteria., Results: A total of 130 patients underwent surgical repair of CoA (76% via thoracotomy, 24% via sternotomy) with resection and end-to-end anastomosis (62%), extended end-to-end anastomosis (30%), subclavian flap (5%), or arch repair with patch (4%), at a median age of 14 days (interquartile range [IQR], 7-62 days). The median postrepair TAA diameter z-score was -2.04 (IQR, -2.69 to 1.24). At a mean follow-up of 17.3 years, 43 of the 130 patients (33%) developed HTN. After controlling for age at repair, sex, and presence of a genetic syndrome, HTN was not associated with immediate postrepair TAA diameter z-score (P = .41), type of surgical incision (P = .99), or type of surgical repair (P = .66)., Conclusions: In patients undergoing surgical repair of CoA during infancy, late HTN was not associated with immediate postrepair TAA size or surgical strategy pertaining to the TAA. These results suggest that factors other than surgical strategy, such as differential growth of the TAA during childhood, may be important., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It has long been held that the safe duration of hypothermic circulatory arrest (HCA) is at least 25 to 30 minutes. However, this belief is based primarily on clinical outcomes research and has not been systematically investigated using more sensitive brain imaging and neurocognitive assessments., Methods: This exploratory substudy of the randomized Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest (GOT ICE) trial, which compared outcomes for deep vs moderate hypothermia during aortic arch surgery, investigated the frequency of neurocognitive and structural and functional magnetic resonance imaging (MRI) deficits with HCA of short (<20 minutes) duration. Neurocognitive deficit was defined as ≥1 SD decline in ≥1 of 5 cognitive domains on neurocognitive testing., Results: Of 228 GOT ICE participants with complete 4-week cognitive data, 74.6% (n = 170 of 228) had HCA durations <20 minutes, including 59 patients randomized to deep hypothermia (<20.0 °C), 55 patients randomized to low-moderate (20.1-24.0 °C) hypothermia, and 56 randomized to high-moderate (24.1-28.0 °C) hypothermia. Of these participants, cognitive deficit was detected 4 weeks postoperatively in ∼40% of patients in all 3 groups (deep hypothermia, 22 of 59 [37.3%]; low-moderate hypothermia, 23 of 55 [41.8%]; and high-moderate hypothermia, 24 of 56 [42.9%]). Furthermore, in a subset of patients with complete MRI data (n = 43), baseline to 4-week postoperative right frontal lobe functional connectivity change was inversely associated with HCA duration (range, 8-17 minutes; P for familywise error rate < .01)., Conclusions: Even short durations of HCA result in cognitive deficits in ∼40% of patients, independent of systemic hypothermia temperature. HCA duration was inversely associated with frontal lobe functional MRI connectivity, a finding suggesting that this brain region may be preferentially sensitive to HCA. Surgeons should be aware that even short durations of HCA may not provide complete neuroprotection after aortic arch surgery., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2025 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The main purpose of this trial is to assess the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery., Methods: This is a prospective, single-center, randomized controlled study. A total of 170 eligible patients will be recruited from The Fourth Affiliated Hospital, Zhejiang University School of Medicine in China and randomized on a 1:1 basis either to the group A (extracorporeal fenestration) or the group B (in situ fenestration). The primary outcome will be the all-cause mortality (30 days). The secondary outcomes will include incidence of secondary intervention (30 days, 6 months, 1 year), incidence of endoleak (30 days, 6 months, 1 year), incidence of major adverse events (MAE) (i.e., immediate procedural success and complications) (30 days, 6 months, 1 year), immediate technical success rate, and all-cause mortality (6 months, 1 year)., Discussion: Suppose extracorporeal fenestration non-inferior to in situ fenestration in patients with aortic disease involving the left subclavian artery. This trial aims to demonstrate the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery, which is expected to provide a reference for Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations., Trial Registration: ClinicalTrials.gov NCT06256757. Registered on February 5, 2024. https://clinicaltrials.gov/study/NCT06256757 ., Competing Interests: Declarations. Ethics approval and consent to participate {24}: The study has been approved by the Ethical Committee of The Fourth Affiliated Hospital Zhejiang University School of Medicine (Approval No: K2024031). Consent for publication {32}: Not applicable. Competing interests {28}: The authors declare that they have no competing interests., (© 2025. The Author(s).)

A patient in his early adolescence, who was treated for T5-T6 tubercular spondylodiscitis with an un-instrumented decompression, presented at 36 months post-index surgery, for post-laminectomy instability and kyphosis, after completing his requisite antitubercular treatment. He underwent thoracic posterior instrumented kyphosis correction and anterior reconstruction, with a T5-T6 partial corpectomy and corpectomy spacer placement, through a posterior midline incision. On the second postoperative day, he started complaining of pain on the left side of his chest, abdomen and left shoulder. On contrast-enhanced CT evaluation, one of the pedicle screws was found to be impinging on the aortic wall, with contrast opacification in the left hemithorax. After resuscitation, he underwent a minimally invasive endovascular procedure (thoracic endovascular aortic repair, TEVAR), circumventing the need for a complex and morbid open thoracic repair in an adolescent. Post-TEVAR, the pedicle screw realignment was done. The patient has now returned to full daily activities and a normal schooling., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: The aim of this study was to investigate whether the hybrid technique yields superior outcomes in comparison with the total arch replacement combined with frozen elephant trunk (TAR + FET) for acute aortic dissection (AAD) involving the aortic arch., Methods: This retrospective cohort study using propensity-score matching included patients with AAD involving the aortic arch admitted to Nanjing First Hospital and Shanghai General Hospital from January 2015 to June 2020. The in-hospital and mid-term outcomes were compared between patients who received hybrid treatment (n = 136) and those who received TAR + FET (n = 415). Study end points included in-hospital mortality and morbidity, and mid-term rates of death from all causes, stroke, and aortic re-intervention., Results: A total of 121 pairs were formed after matching. In-hospital mortality did not differ between hybrid versus TAR + FET groups (5.8% vs. 7.9%, P = .860). Up to 6 years, patients treated with TAR + FET were associated with reduced rate of aortic re-intervention (HR 0.21, 95% CI 0.05-0.97; P = .023). There was no difference in death from all causes and stroke., Conclusions: Hybrid technique and TAR + FET showed comparable mid-term survival. Hybrid technique showed higher rate of aortic re-intervention and should therefore be applied with great caution in patients with AAD involving the aortic arch., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University (protocol code KY20220425-05), and the Ethics Committee of Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (protocol code 2018KY241) and conducted in accordance with the Declaration of Helsinki. Due to the retrospective study design, the written informed consent was waived by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University and the Ethics Committee of Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine. The data in the research was de-identified to protect patients’ privacy. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Blunt traumatic aortic injury (TAI) is a critical condition and a leading cause of mortality in trauma patients, often resulting from high-speed accidents. Thoracic endovascular aortic repair (TEVAR) has developed into the preferred therapeutic approach due to its minimally invasive nature and promising outcomes. This study evaluates the safety and efficacy of TEVAR for managing TAI over a 10-year period at a Level-1 trauma center., Methods: A retrospective analysis was conducted on 19 patients with acute TAI treated with TEVAR between 2012 and 2022 at the University Hospital Zurich. Data were collected from digital records and analyzed according to the Fillinger TEVAR reporting framework. Outcomes included technical success, perioperative complications, and long-term graft durability., Results: The cohort had a mean age of 39 years and included patients with severe polytrauma. Technical success was achieved in 95% of cases, with no intraoperative deaths or need for open surgical conversion. Perioperative complications were minimal, and the reintervention rate was 5.3%. This study evaluates 10 years of clinical experience managing TAI with TEVAR. Long-term follow-up, with a median duration of 29 months, revealed no graft-related complications or secondary interventions. Imaging confirmed sustained graft integrity, and clinical outcomes were favorable., Conclusion: TEVAR is a reliable and effective treatment for traumatic aortic injuries, offering excellent technical success rates and minimal perioperative and long-term complications. This study highlights TEVAR's advantages in managing polytrauma patients and its role as a minimally invasive alternative to open surgery. Additionally, the findings emphasize the need for comprehensive long-term follow-up protocols. Future research should aim to address challenges related to device durability and the integration of advanced imaging techniques to further enhance patient outcomes and broaden the applicability of TEVAR in trauma care., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

This study aims to assess the outcomes of therapeutic options for aortic arch pathologies by comparing thoracic endovascular aortic repair (TEVAR) with open arch replacement (OAR) using woven polyester grafts from a mechanical and biomechanical perspective, with emphasis on ex vivo perfused human thoracic aortas reproducing heart rate and stroke volume conditions. Eleven non-diseased thoracic aortas from human cadavers were divided into TEVAR (n=5) and OAR (n=6) and tested using a custom-built mock circulation loop. Pressure, diameter, and stroke volume were monitored during perfusion before and after the intervention. Samples undergoing TEVAR showed a higher ascending systolic pressure post-intervention than OAR (TEVAR: 137±9mmHg vs OAR: 126±6mmHg, p=0.017). After the intervention, a significant discrepancy in the mean pressure differences between the ascending and descending aorta ΔP was observed (TEVAR: 9±3mmHg vs OAR: 1±2mmHg, p=0.004). Input impedance at zero frequency, approximating Windkessel resistance, was higher for TEVAR than for OAR (TEVAR: 1.78±0.04 vs OAR: 1.66±0.03mmHgs/ml, p=0.004). A correlation was found between the resistance and the negative peak of the time-normalized wave intensity analysis (Kendall's coefficient τ=-0.35 and p=0.023). Another correlation was observed between resistance and ΔP (τ=0.51, p=0.001). Looking at the replication of heart rate and stroke volume over the course of the study, the observed differences can largely be attributed to the type of intervention. The results suggest that TEVAR has adverse effects compared to OAR, particularly with regard to left ventricular afterload. Clinicians should consider the possibility of increased afterload and altered wave dynamics when deciding on TEVAR, particularly in patients with pre-existing impaired cardiovascular conditions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The author is an Editor-in-Chief for Biomechanics and Modeling in Mechanobiology and was not involved in the editorial review or the decision to publish this article., (Published by Elsevier Inc.)

BACKGROUND Acute intramural hematoma (IMH) of the ascending thoracic aorta and aortic arch is a life-threatening condition, particularly in elderly patients with comorbidities, due to its risk of progression and rupture. Unlike aortic dissection, IMH lacks an intimal tear, influencing both clinical presentation and treatment strategy. This report describes a 74-year-old hypertensive woman with type A IMH and a penetrating atherosclerotic ulcer (PAU), managed with a hybrid surgical approach that combines external Dacron wrapping of the ascending aorta and endovascular stenting of the aortic arch with in-situ fenestration of the supra-aortic arteries. CASE REPORT A 74-year-old woman with a history of hypertension, insulin-dependent diabetes, chronic kidney disease, coronary artery disease, and extracardiac arteriopathy presented with chest pain and was diagnosed with type A IMH. Cardiac assessment showed a moderate left ventricular ejection fraction (45%) and New York Heart Association class III functional status, indicating high surgical risk (EuroSCORE II: 11.66). A hybrid approach was chosen, involving Dacron wrapping of the ascending aorta to reduce its diameter, followed by endovascular stent grafting of the aortic arch with in-situ fenestration to preserve supra-aortic branch blood flow. The patient recovered without complications, and 5-month follow-up imaging confirmed stable stent position, PAU exclusion, and preserved branch patency. CONCLUSIONS This case illustrates the feasibility and safety of combining off-pump external wrapping of the ascending aorta with endovascular stent grafting using in-situ fenestration, offering a promising, less-invasive alternative for high-risk patients with favorable short-term outcomes.

One of the most common congenital cardiac anomalies is coarctation of the aorta (CoA) It accounts for 4%-6% of all congenital heart defects. A CoA case surviving into adulthood may result in hypertension, weak femoral pulse, limb and bowel ischaemia and heart failure. A man in his early 20s presented with severe lower limb and abdominal pain with long-standing hypertension, refractory to antihypertensives. Difference in upper and lower limb blood pressures, weak peripheral pulses and radiofemoral delay were noted. Angiogram showed adult CoA with total occlusion of the proximal aortic segment. The patient underwent left axillary artery to descending thoracic aorta bypass grafting, had a normal recovery and was put on life-long antihypertensives. An untreated case of CoA surviving into adulthood will result in complications. Any individual with unknown aetiology of hypertension and ischaemic symptoms must be screened for CoA., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Interventional occlusion of Patent ductus arteriosus (PDA) is generally efficacious and complications such as delayed occluder displacement are infrequent. Herein, we report a case of 24-year-old female with a history of unsuccessful PDA closures, who subsequently experienced delayed occluder displacement into the left main pulmonary artery. Despite numerous unsuccessful catheter-based interventions, thoracic endovascular aortic repair (TEVAR) was successfully executed. This procedure effectively resolved the PDA without any postprocedural complications. This case highlights the efficacy and safety of TEVAR as a viable alternative for managing complex PDA cases involving occluder displacement., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: none declared. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Delayed stent grafting for blunt thoracic aortic injuries (BTAIs) is current standard of care. However, given the heterogeneity of pseudoaneurysm presentations, it is currently unclear which severe BTAIs require more urgent intervention. We hypothesize that a Traumatic Aortic Disruption Index (TADI) calculation based on sagittal computed tomography angiography imaging measurements would correlate with urgency of stent grafting., Methods: All patients at a level-1 trauma center with BTAIs over a 12-year period were identified. A TADI score was then calculated using the length of pseudoaneurysm (L), maximum width of pseudoaneurysm (W), and normal adjacent aortic diameter (NA). Patient presentation, injury characteristics, timing of stent grafting, and outcomes were then evaluated., Results: Forty-two patients were diagnosed with BTAIs. Mean age was 37.6 years, with a median injury severity score (ISS) of 29. Overall mortality was 11.9%. TADI scores ranged from 3.6 to 158.6. Compared to patients with a TADI <28, patients with TADI >28 had similar median ISS scores (34 vs. 29, P = 0.16), and rates of both traumatic brain injury (TBI; 33.3% vs. 42.0%, P = 0.53) and nonaortic hemorrhage control procedures (44.4% vs. 33.3%, P = 0.3). TADI >28 patients had a lower initial mean systolic BP (98.5 vs. 121.9, P = 0.003), more severe hypotension (lowest systolic 77.0 vs. 91.2, P = 0.034), lower initial Glasgow Coma Scale (6 vs. 13, P = 0.039), higher mean admission lactate (4.6 vs. 3.3, P = 0.036), and higher overall mortality (23.8% vs. 0%, P = 0.048). Patients with TADI >28 received stent grafting at significantly shorter median time intervals from injury identification (median 4 hrs vs. 14 hrs, P = 0.001). Overall causes of mortality were aortic hemorrhage related (n = 3, 60%) and TBI (n = 2, 40%)., Conclusions: This simple-to-calculate index is independently correlated with mortality and urgency of stent grafting in blunt trauma patients with similar ISS. Patients with TADI scores >28 were more likely to undergo urgent stent grafting, thereby suggesting a trend in practice patterns with higher scores representing injuries that should be considered for expedited operative management. The TADI score should be validated in a larger sample of blunt trauma patients as an injury prioritization tool in the multisystem injured patient., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Unrecognized intraoperative cerebral ischemia during neonatal aortic arch reconstruction may precede neurologic injury. Electroencephalogram (EEG) alpha:delta ratio (A:D) changes predict cerebral ischemia; however, if A:D differences can identify ischemia during neonatal antegrade cerebral perfusion (ACP) and aortic arch reconstruction is unknown. We hypothesized that A:D changes would precede neurologic injury. Methods: Simultaneous EEG derived left versus right: hemispheric and anterior cerebral A:Ds were retrospectively measured at baseline and every 5 min during arterial cannulation, cooling, ACP, and the rewarming phases of the operation. A paired left versus right A:D difference >25% was considered significant for ischemia, and the duration of a significant and continuous A:D difference was quantified in minutes. Neonates were divided into two groups: (1) new neurologic injury (stroke or seizure) and (2) no known neurologic injury. Results: From 72 neonates, there were no significant differences in the baseline A:Ds. Seven neonates (9.7%) developed a new neurologic injury (seizure = 3, stroke = 2, seizure and stroke = 2). Male gender and longer ACP times were significantly associated with neurologic injury. In neonates with a neurologic injury, the duration of a significant and continuous A:D difference was longer within the hemispheric and anterior regions. Multivariable analysis demonstrated that a significant and continuous anterior A:D difference (odds ratio: 1.345, 95% CI 1.058-1.712; P  = .01) was independently associated with neurologic injury. Conclusions: A longer continuous anterior A:D difference > 25% was independently associated with neurologic injury. Intraoperative EEG monitoring could be considered during neonatal arch reconstruction., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Kommerell's diverticulum (KD) is associated with a high incidence of right-sided aortic arch (RAA). Hybrid thoracic endovascular aortic repair (TEVAR) is an effective and less invasive alternative to open repair. However, the long-term results regarding KD diameter regression or symptom improvement remain inadequately described., Methods: Nine patients underwent TEVAR for KD associated with RAA between January 2016 and September 2023 at our university hospital and affiliated institutions. A hybrid procedure was performed to exclude KD by blocking the proximal blood flow with TEVAR and distal blood flow with embolization of the aberrant subclavian artery. Simultaneously, extra-anatomical bypass surgery was performed to revascularize the covered supraarch vessels., Results: The patients' mean age was 65.2 years, and 6 patients were men. Two patients presented with dysphagia, whereas the rest were asymptomatic. The mean diameter and distance to the opposite aortic wall (OAW) of KD were 32.1 mm and 56.2 mm, respectively. For revascularization of the covered supraarch vessels, 6 and 2 patients underwent total debranching with sternotomy and extra-thoracic bypass (bilateral common carotid artery-axial artery bypass), respectively. The 30-day and in-hospital mortality rates were 0%, with no instances of cerebral infarction or spinal cord ischemia. The mean follow-up period was 3.2 years. The survival and avoidance rates of aortic events were 100% at 1 and 3 years. Follow-up computed tomography scans showed no endoleaks; however, 1 (11.1%) type 2 endoleak from the aberrant left subclavian artery occurred 1 week postoperatively, necessitating additional coiling. Seven patients were followed up for more than 1 year, with 5 experiencing reductions of more than 3 mm in KD diameter, distance to the OAW, or both., Conclusions: Although further follow-up and investigations are needed, TEVAR may be a safe and effective surgical treatment for KD associated with RAA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch)., Methods: Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender)., Results: Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found., Conclusions: Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important., Competing Interests: Conflict of Interest Statement Dr Preventza is a consultant for Terumo Aortic, W.L. Gore & Associates, Abiomed, and Intressa. Dr Chatterjee has served on advisory boards for Edwards Lifesciences, La Jolla Pharmaceutical, Baxter Pharmaceuticals, and Eagle Pharmaceuticals. Dr Moon serves on the advisory boards of Medtronic and Edwards Lifesciences. Dr Coselli serves as principal investigator for, consults for, and receives royalties and a departmental educational grant from Terumo Aortic; consults and participates in clinical trials for Medtronic Inc, and W.L. Gore & Associates; and participates in clinical trials for Abbott Laboratories, CytoSorbents, Edwards Lifesciences, and Artivion. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study compared the outcomes of primary and staged surgery for interrupted aortic arch (IAA) with biventricular circulation., Methods: A search of our surgical database identified 181 patients with biventricular anatomy who underwent surgical repair of IAA between 1982 and 2022. The patients were divided according to whether they underwent surgery in 1982 to 2001 or 2002 to 2022 and were categorized according to their anomalies into a simple group and a complex group. Repair was 1-stage in 130 patients (71.8%) and 2-stage in 51 (28.2%)., Results: There were 6 early deaths (3.3%) and 9 (5.0%) late deaths. The 20-year actuarial survival rate was 91.7%. The 20-year survival rate was 94.7% in the simple group and 82.9% in the complex group (P = .007); the respective rates were 91.7% and 96.8% in 1982 to 2001 (P = .63) and 68.4% and 90.1% in 2002 to 2022 (P = .012). Multivariate analysis identified a complex anomaly and surgery performed in 1982 to 2001 to be risk factors for mortality. Aortic arch reintervention was required in 26 patients (balloon dilation, n = 15; surgical, n = 11). The 15-year freedom from reintervention rate improved from 67.8% in 1982 to 2001 to 89.8% in 2002 to 2022 (P = .041). Multivariate analysis identified type of surgical approach and emergent surgery to be risk factors for reintervention on the aortic arch., Conclusions: The results of IAA surgery have improved in recent years, especially for complex cases. Development of surgical techniques and individualized treatment strategies could reduce postoperative mortality and morbidity. However, follow-up for recurrence of aortic arch obstruction is necessary., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The GORE® TAG® Thoracic Branch Endoprosthesis is the only currently Food and Drug Administration-approved branched device for the treatment of thoracic aortic pathology requiring landing in Zone 2 in the United States. While the aneurysm cohort disabling stroke rate in the pivotal trial has previously been reported, a more complete and granular description has not yet been published. This is a descriptive series detailing the neurologic sequelae from the pivotal trial, out to 12 months., Methods: All the patients underwent modified Rankin Scale assessment at screening, discharge, and 1-, 6-, and 12-month intervals. A disabling stroke was defined as occurring within 30 days of the index procedure, combined with a modified Rankin Scale ≥2 with an increase from baseline of at least 1 grade. Descriptive statistics with important associations with aortic pathology, landing in native aorta versus Dacron graft, and intraoperative ballooning were noted. Further granularity with regard to the distribution and type of stroke are also reported, where available., Results: A total of 238 patients were included in the pivotal trial. The treated aortic pathologies were aneurysm (n = 84), dissection (n = 132), traumatic transection (n = 9), and other isolated lesions (n = 13). Through 12 months, the overall stroke rate was 5.9%, with the highest rate of stroke in the aneurysm cohort (aneurysm-8.3%, dissection-4.6%, traumatic transection-0%, other-7.7%). The frequencies of disabling strokes through 12 months were aneurysm-4.3%, dissection-2.3%, and other lesion-7.7%. Forty percent of strokes (n = 6) occurred within 30 days and included both hemorrhagic (n = 3) as well as ischemic (n = 3) events. The distribution of strokes within 30 days included left carotid (n = 1), posterior circulation (n = 2), as well as unknown (n = 3). The strokes occurring after 30 days were primarily ischemic (6/8), and included left carotid (n = 2), right carotid (n = 1), posterior circulation (n = 1), posterior circulation and right carotid (n = 1), posterior circulation and left and right carotid (n = 1), and unknown location (n = 1). The majority of patients suffering from stroke had aortic component landing in the native aortic arch, as well as ballooning of the aortic component (10/14)., Conclusions: The Thoracic Branch Endoprosthesis is associated with comparable 30-day stroke rates to a similar series of patients undergoing Zone 2 landing after debranching procedures. Stroke rates were highest in aneurysm pathology patients, with no strokes in the traumatic transection cohort. Perioperative strokes were hemorrhagic and ischemic, whereas those occurring after the perioperative period were primarily ischemic in nature. The distribution of stroke covered multiple territories, suggesting an embolic etiology. These data better define the neurologic risks associated with placement of this branched technology in the aortic arch., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To investigate the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) for infectious aortic diseases., Materials and Methods: Patients who underwent TEVAR for infectious aortic diseases including infected thoracic aortic aneurysm, aortobronchial fistula (ABF), and aortoenteric fistula from December 2011 to October 2022 at 4 institutions were retrospectively studied. The primary outcome of the study was overall survival, whereas the secondary outcome was comprehensive adverse events. Comprehensive adverse events were defined as a combination of deaths, aortic events, and infectious adverse events., Results: A total of 28 patients were included in the analysis, with 13 patients having infected thoracic aortic aneurysms, 12 ABFs, and 3 aortoenteric fistulae. Seven patients (25%) underwent additional procedures (abscess drainage, 6 cases; total esophagectomy, 1 case). The mean follow-up period was 30.0 months (SD ± 33.9). The 1-year and 5-year survival rates were 85.7% and 67.9%, respectively. The 1-year and 5-year aorta-related complication-free survival rates were 64.3% and 42.9%, respectively. On univariate analysis, the presence of an ABF was associated with a higher risk of comprehensive adverse events (odds ratio = 11; P = .038)., Conclusions: TEVAR might be a promising treatment for infectious thoracic aortic diseases. Among the infectious pathologies, ABF was considered ominous in terms of late outcomes., (Copyright © 2024. Published by Elsevier Inc.)

Objective: The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters., Methods: In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre- and post-operative computed tomography angiograms., Results: Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [13.3, 15.3] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [3.8, 5.2] vs. 1.2 mm [0.3, 3.1]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m 2 [28.7, 36.2] vs. 25.7 kg/m 2 [23.8, 29.2]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively., Conclusion: The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The mortality and morbidity of emergency total aortic arch replacement (TAAR) for acute type A aortic dissection (ATAAD) is high, which is partly due to the excessively activated systemic inflammatory response. Methylprednisolone, an anti-inflammatory agent, might suppress the systemic inflammatory response and lead to improved outcomes. However, the protective effects of methylprednisolone on TAAR for ATAAD were not clarified. The usage and dosage varied in different centers across the world., Methods and Results: The Medal trial is a prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate whether 500 mg methylprednisolone IV before cardiopulmonary bypass could reduce the incidence of postoperative major organ injury, compared to placebo. Adult patients with the diagnosis with ATAAD, awaiting emergency total aortic arch replacement with hypothermic circulatory arrest and selective cerebral perfusion will be included in the trial. A total of 340 eligible subjects from 9 large cardiovascular centers will be randomized in a 1:1 ratio to receive 500 mg methylprednislone or placebo before cardiopulmonary bypass. The primary outcome is postoperative major adverse outcome [defined as all-cause death or postoperative neurological deficit or KDIGO II -III acute kidney injury or respiratory syndrome (tracheal intubation> 72 hours, tracheostomy or re-intubation) until postoperative day 30 or patient discharge]. The study has received approval from the local Ethics Committees of the 9 participating centers, and enrolled its first subject in June 24, 2022. As of September 5, 2024, 323 subjects have been enrolled. Results of the Medal trial will be published once data collection and analysis have been completed., Conclusions: The Medal trial will determine the effectiveness of 500 mg methylprednisolone on the outcomes of patients with ATAAD undergoing TAAR., Registration: URL https://www.chictr.org.cn/searchprojEN.html (Chinese Clinical Trial Registry). Unique identifier: ChiCTR2200059286., Competing Interests: Conflict of interest None reported., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized owing to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR., Methods: We identified patients in the Vascular Quality Initiative undergoing TEVAR isolated to zones 0 to 5 from 2010 to 2023 for nontraumatic pathologies. After determining the incidence of postoperative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined preoperative and intraoperative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression models were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other nonrespiratory postoperative complications in a separate model., Results: Of 10,708 patients, 8.3% had any RAE (pneumonia only, 2.1%; reintubation only, 4.8%; both, 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication, 46% vs no respiratory complication, 35%; P < .001), and be symptomatic (58% vs 48%; P < .001). Developing RAEs after TEVAR was associated with male sex (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], 1.01-1.41; P = .037), obesity (aRR, 1.31; 95% CI, 1.07-1.61; P = .009), morbid obesity (aRR, 1.68; 95% CI, 1.20-2.32; P = .002), renal dysfunction (aRR, estimated glomerular filtration rate 30-45, 1.45; 95% CI, 1.15-1.82; P = .002; estimated glomerular filtration rate <30/hemodialysis, 1.7; 95% CI, 1.37-2.11; P < .001), anemia (aRR, 1.31; 95% CI, 1.09-1.58; P = .003), aortic diameter >65 mm (aRR, 1.54; 95% CI, 1.25-1.89; P < .001), proximal disease in the aortic arch (aRR, 1.23; 95% CI, 1.03-1.48; P = .025) or ascending aorta (aRR, 1.61; 95% CI, 1.19-2.14; P = .002), acute aortic dissection (aRR, 2.13; 95% CI, 1.72-2.63; P < .001), ruptured presentation (aRR, 3.07; 95% CI, 2.43-3.87; P < .001), same-day surgical thoracic branch treatment (aRR, 1.51; 95% CI, 1.25-1.82; P < .001), chronic obstructive pulmonary disease on home oxygen (aRR, 1.58; 95% CI, 1.08-2.25; P = .014), limited self-care or bed-bound status (aRR, 2.12; 95% CI, 1.45-3.03; P < .001), and intraoperative transfusion (aRR, 1.88; 95% CI, 1.47-2.40; P < .001). Patients who developed postoperative RAEs had higher 30-day mortality (27% vs 4%; P < .001) and 5-year mortality than patients without respiratory complications (46% vs 20%; P < .001). After adjusting for preoperative and postoperative variables, the 5-year mortality was higher in patients who developed any postoperative RAE (adjusted hazard ratio [aHR], 1.8; 95% CI, 1.6, 2.1; P < .001), postoperative pneumonia only (aHR, 1.4; 95% CI, 1.0, 1.8; P = .046), reintubation only (aHR, 2.2; 95% CI, 1.8, 2.6; P < .001) or both (aHR, 1.5; 95% CI, 1.1, 2.0; P = .008)., Conclusions: RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, chronic obstructive pulmonary disease on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intraoperative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other postoperative complications. Considering these factors in assessing the risks and benefits of TEVAR procedures, along with implementing customized postoperative care, can potentially improve clinical outcomes., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Circulatory arrest is the main method used in surgical interventions for prosthetics of the proximal aorta. However, recently, facts have been discovered that prove the benefits of avoiding circulatory arrest during planned and emergency surgical interventions. We present a clinical case of planned prosthetics of the ascending section and the aortic arch with a Intergard Woven 28 mm multibranch prosthesis without circulatory arrest in conditions of mild hypothermia. The patient was extubated 5 hours after the operation, and was discharged home in satisfactory condition on the 7th day. The rejection of circulatory arrest made it possible to reduce the duration of surgery, the duration of hospitalization and complications associated with hypoperfusion of organs and tissues that occur during cooling of patients.

Objectives: Aortic arch appearances can be associated with worse cardiac function and chronic hypertension late after coarctation of the aorta (CoA) repair, even without residual obstruction. Statistical shape modeling (SSM) has identified specific 3D arch shapes linked to poorer cardiovascular outcomes. We sought a mechanistic explanation. Methods: From 53 asymptomatic patients late after CoA repair with no residual obstruction (age: 22.3 ± 5.6 years; 12-38 years after operation), eight aortic arch shapes associated with the four best and four worst cardiovascular parameters were obtained from 3D SSM. Four favorable shapes were affiliated with left ventricular (LV) ejection fraction +2 standard deviation (SD) values from the mean, and indexed LV end diastolic volume/indexed LV mass/resting systolic blood pressure that were -2SD. Four unfavorable shapes were defined by the reverse. Computational Fluid Dynamics modeling was carried out to assess differences in pressure gradient across the aortic arch and viscous energy loss (VEL) between favorable and unfavorable aortic arches. Results: In all aortic arches, the pressure gradients were clinically insignificant (<8 mm Hg). However, in the four unfavorable aortic arches, VEL were uniformly higher than those in the favorable shapes (VEL difference: 15%-32%). There was increased turbulence and more complex propagation of VEL along with the unfavorable aortic arches. Conclusions: This study reveals the variable flow dynamics that underpin the association of aortic arch shapes with worse cardiovascular outcomes late after successful CoA repair. Higher VEL persists in the unfavorable aortic arch shapes. Further understanding of the mechanism of viscous energy loss in cardiovascular maladaptation may afford mitigating strategies to monitor and modify this unrelenting liability., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Blunt thoracic aortic injuries (BTAIs) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated., Methods: All patients with Grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multicenter registry from 2015 to 2022 were categorized dependent on timing of repair (early repair [ER] < 24 hours, late repair > 24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality., Results: Two hundred and twenty two Grade 2 and 3 BTAI treated by TEVAR were analyzed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale, age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. Thirty-day in-hospital mortality occurred in 14 patients (6%), 2 of which were aortic-related. Thirty-day mortality was associated with a higher baseline incidence of coronary artery disease/peripheral vascular disease/previous cardiac revascularization; lower systolic blood pressure, Glasgow Coma Scale, hemoglobin, platelet count, and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower hemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (P < 0.05), although time to TEVAR was not., Conclusions: In selected patients, delay in performance of TEVAR for Grade 2 and 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) was expanded in 2017 to include more granular detail on thoracic aortic surgeries. We describe the first validated risk model in thoracic aortic surgery from the STS ACSD., Methods: The study population consisted of patients undergoing nonemergent isolated ascending aortic aneurysm repair by open or clamped distal anastomoses, including those requiring aortic root or valve replacement. Model outcomes included operative mortality, 30-day major morbidity (cardiac reoperation, deep sternal wound infection, stroke, prolonged ventilation, renal failure), and a composite of both. To select the predictors, univariate associations and clinical face validity of models were examined. Models were evaluated by their ability to distinguish between patients with and without specific outcomes (discrimination) and their predictive accuracy (calibration)., Results: Between 2017 and 2021, 24,051 eligible patients underwent ascending aortic aneurysm surgery at 905 hospitals. Procedures included 8913 aortic root replacements, 2135 valve-sparing root replacements, 7545 ascending aortic replacements with aortic valve replacement, and 5458 ascending aortic replacements. Circulatory arrest was performed in 7316 (30.4%) cases. Operative mortality was 1.9%, and 12.2% of patients experienced major morbidity including 2.4% incidence of stroke. The adjusted C statistics for the model were 0.74, 0.67, and 0.67 for mortality, morbidity, and the composite, respectively. Previous stroke and circulatory arrest were associated with new stroke. Genetic aortopathy was associated with less mortality., Conclusions: A new STS ACSD risk model to predict mortality and morbidity after ascending aneurysm surgery has been developed, and predictors of better and worse outcomes have been identified., Competing Interests: Disclosures Nimesh Desai reports a relationship with W. L. Gore & Associates Inc that includes: consulting or advisory; with Terumo Medical Corp that includes: consulting or advisory; with Artivion, Inc that includes: consulting or advisory; with Edwards Lifesciences Corporation that includes: consulting or advisory; and with Baxter International Inc that includes: consulting or advisory. Hiroo Takayama reports a relationship with Edwards Lifesciences which includes consulting and advisory and W.L. Gore which includes consulting and advisory. Eric Roselli reports a relationship with Artivion, Inc that includes: consulting or advisory and a licensing agreement; with Cook Medical Inc that includes: consulting or advisory; with Edwards Lifesciences Corporation that includes: consulting or advisory; with W. L. Gore & Associates Inc that includes: consulting or advisory; with Medtronic that includes: consulting or advisory; with JenaValve Technology Inc that includes: speaking and lecture fees; with LifeNet Inc that includes: speaking and lecture fees; and with Terumo Aortic that includes: speaking and lecture fees. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To evaluate the outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD))., Methods: This retrospective observational study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. All cases of NANB AAD (B 1-2 D) treated at our institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodeling were analyzed., Results: Among 519 cases of acute aortic syndrome, n = 22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n = 16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly 2 days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7 (31.8%) needed emergent operation for risks of impending aortic rupture or retrograde aortic dissection extension, and 4 (26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of false lumen thrombosis (100% vs 55.5%, P = 0.033), and a significant positive aortic remodeling in zone 3 (P < 0.001) and 4 (P = 0.038) were reported in operated versus medically managed patients., Conclusions: The best treatment for NANB is not established. We advocate for medical stabilization with an operative approach that favors open surgery in the acute post dissection period, promotes aortic remodeling, and carries acceptable risk in centers where FET is performed routinely., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Since the mid-1900s, techniques in the repair of aortic arch and thoracoabdominal aortic pathologies have drastically evolved. Open aortic surgical repair was once the sole option for both simple and complex aneurysmal degeneration. Today, a number of minimally invasive and hybrid approaches are now available to assist both the surgeon and patient in tackling this challenging problem., Areas Covered: In this review, we discuss the most current techniques in the repair of these complex pathologies as well as new advances. These include aortic arch and abdominal aortic debranching with endovascular repair, branched stent graft repair, parallel grafting techniques, fenestration techniques, and a hybrid approach to the aforementioned. In addition, we discuss comparative outcomes of these techniques spanning disciplines of both cardiac and vascular surgery., Expert Opinion: The most vital part of the treatment of complex aortic aneurysms is the tailoring of the treatment plan to each patient's unique anatomic and physiologic attributes.

Objectives: Anomalous aortic origin of a coronary artery is a rare congenital lesion in which a coronary artery arises from an anomalous location within the aorta. Anomalous aortic origin of a coronary artery has been associated with myocardial ischemia and it is considered the second most common cause of sudden cardiac arrest in young athletes. When surgical repair is indicated, surgical unroofing is the most commonly employed technique. Our objective is to describe the outcomes of our surgically treated patients., Methods: We present a series of 16 adult patients who underwent surgical repair of anomalous aortic origin of a coronary artery. Patients were treated in three different institutions by the same surgeon. Surgical unroofing of the anomalous coronary artery was the surgical technique chosen in the majority of the patients. Follow-up was performed., Results: Unroofing of an intramural anomalous coronary artery was the procedure performed in 11 patients. Three patients underwent neo-ostium creation; one patient underwent a David procedure with coronary reimplantation; and one patient was treated with coronary bypass grafting due to severe coronary atheromatous lesions. There were no perioperative deaths, and no major postoperative complications. Follow-up period was 73.8 months, the survival rate was 100%, and there were neither ischemia or heart failure reports., Conclusions: The surgical repair of anomalous aortic origin of a coronary artery by coronary unroofing or neo-ostium creation has demonstrated excellent early and late outcomes. Late survival was excellent. The follow-up period revealed no significant morbidity or complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses., Methods: After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24)., Results: The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1 min in the Zone 2 group and 52.9 ± 12.8 min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality., Conclusions: Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy., Competing Interests: Declarations. Conflict of interest: None declared. Ethical approval: This study was approved by the Ethics Committee of Nerima Hikarigaoka Hospital, 20190219-2., (© 2024. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

The retroaortic innominate vein variant usually courses asymptomatically. However, when associated with coarctation of the aorta and hypoplastic aortic arch, modifications in the surgical technique to correct the aorta should be done to avoid compression of the vein. The ascending sliding arch aortoplasty, which allows the vein to be brought anterior to the aorta, can be a good alternative, as shown in these two cases., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis., Methods: This is a single-center retrospective cohort study. Patients who received TEVAR for BTAI at our institution from October 2016 to September 2023 were divided into 2 categories depending on the injury severity score (ISS) (≤ 25 vs. > 25) and when the TEVAR was performed for BTAI (within 24 h vs. after 24 h), respectively. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography. Patients treated with open repair and non-operative management were excluded. After propensity-score matching for various factors, outcomes during hospitalization and follow-up were compared. These factors included demographics, comorbidities, concomitant injuries, cause and location of aortic injury, Glasgow coma scale score, society for vascular surgery grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission. The comparison was conducted using SPSS 26 software. Continuous variables were presented as either the mean ± standard deviation or median (Q 1 , Q 3 ), and were compared using either the t-test or the Mann-Whitney U test. Categorical variables were expressed as n (%), and comparisons were made between the 2 groups using the χ 2 test or Fisher's exact test. Statistical significance was defined as a 2-sided p < 0.05., Results: In total, 110 patients were involved in the study, with 65 (59.1%) patients having ISS scores > 25 and 32 (29.1%) receiving immediate TEVAR. The perioperative overall mortality rate in the group with ISS > 25 was significantly higher than that in the group with ISS ≤ 25 (11 (16.9%) vs. 2 (4.4%), p < 0.001). Upon admission, the elective group exhibited a notably higher Glasgow coma scale score (median (Q 1 , Q 3 )) compared to the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039), while the creatinine concentration (median (Q 1 , Q 3 )) at admission was significantly higher in the immediate group (90.5 (63.8, 144.0) vs. 71.5 (58.3, 80.8), p = 0.012). The final sample included 52 matched patients. Complications occurred significantly less frequently in the elective group compared to the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Single-factor analysis of variance showed that complications in hospitalized patients were significantly associated with immediate TEVAR as the sole independent risk factor (odds ratio: 9.000, 95% confidence interval: 2.266-35.752, p = 0.002)., Conclusion: In this propensity-score matched analysis of patients undergoing TEVAR for BTAI, elective TEVAR was significantly associated with a lower risk of complication rates. In this study using propensity-score matching, patients who underwent elective TEVAR for BTAI had lower complication rates than immediate TEVAR., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024. Published by Elsevier B.V.)

We present simultaneous aortic valve reimplantation, replacement of aortic arch, right common carotid artery and proximal parts of the right subclavian and left common carotid arteries in a patient with type I aortic dissection. Involvement of supra-aortic arteries is the main predictor of cerebral malperfusion and mortality in acute aortic dissection. Optimal surgical intervention in such patients is still unclear. Moreover, patients with acute ascending aortic dissection rarely undergo valve-sparing surgery, since such interventions require much time and prolong myocardial ischemia.

A variety of surgical approaches exist to treat aortic coarctation in neonates and infants. Our institutional approach is designed to match the surgical approach to the individual anatomy of the patient. The objective of this study is to evaluate operative characteristics and outcomes of all neonates and infants who underwent surgical repair of coarctation of the aorta or hypoplastic aortic arch at University of Florida from 2006 to 2021, inclusive, either in isolation or with concomitant repair of atrial septal defect (ASD) and/or ventricular septal defect (VSD). A retrospective review was performed of 132 patients aged 0-1 year who underwent surgical repair of aortic coarctation or hypoplastic aortic arch between 2006 and 2021, inclusive, either in isolation or with concomitant repair of ASD and/or VSD. Patients were divided into two groups based on the surgical approach: Group 1 = Median Sternotomy and Group 2 = Left Lateral Thoracotomy. Continuous variables are presented as median (minimum-maximum); categorical variables are presented as N (%). The most common operative technique in Group 1 was end-to-side reconstruction with ligation of the aortic isthmus. The most common operative technique in Group 2 was extended end-to-end repair. Operative Mortality was one patient (1/132 = 0.76%). Transcatheter intervention for recurrent coarctation was performed in seven patients (7/132 = 5.3%). Surgical re-intervention for recurrent coarctation was performed in three patients (3/132 = 2.3%). From these data, one can conclude that a strategy of matching the surgical approach to the anatomy of neonates and infants who underwent surgical repair of aortic coarctation or hypoplastic aortic arch, either in isolation or with concomitant repair of ASD and/or VSD, is associated with less than 1% Operative Mortality and less than 3% recurrent coarctation requiring reoperation., Competing Interests: Declarations. Conflict of Interest: None. Ethical standards: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Decision making during aortic arch surgery regarding cannulation strategy and nadir temperature are important in reducing risk, and there is a need to determine the best individualized strategy in a data-driven fashion. Using machine learning (ML), we modeled the risk of death or stroke in elective aortic arch surgery based on patient characteristics and intraoperative decisions., Methods: The study cohort comprised 1323 patients from 9 institutions who underwent an elective aortic arch procedure between 2002 and 2021. A total of 69 variables were used in developing a logistic regression and XGBoost ML model trained for binary classification of mortality and stroke. Shapely additive explanations (SHAP) values were studied to determine the importance of intraoperative decisions., Results: During the study period, 3.9% of patients died and 5.4% experienced stroke. XGBoost (area under the curve [AUC], 0.77 for death, 0.87 for stroke) demonstrated better discrimination than logistic regression (AUC, 0.65 for death, 0.75 for stroke). From SHAP analysis, intraoperative decisions are 3 of the top 20 predictors of death and 6 of the top 20 predictors of stroke. Predictor weights are patient-specific and reflect the patient's preoperative characteristics and other intraoperative decisions. Patient-level simulation also demonstrates the variable contribution of each decision in the context of the other choices that are made., Conclusions: Using ML, we can more accurately identify patients at risk of death and stroke, as well as the strategy that better reduces the risk of adverse events compared to traditional prediction models. Operative decisions made may be tailored based on a patient's specific characteristics, allowing for maximized, personalized benefit., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To correlate intraoperative near-infrared spectroscopy (NIRS) values with neurologic outcomes in patients undergoing total aortic arch replacement using the frozen elephant trunk (FET) technique., Design: Retrospective, single-center registry study using a two-way repeated-measures analysis of variance., Setting: Between November 2013 and December 2023, 427 patients were treated for acute and chronic aortic pathologies using the FET procedure., Participants: A total of 166 patients with complete NIRS data at all predefined time points were included and retrospectively divided into two groups: patients diagnosed by experienced radiologists and clinicians with stroke and without stroke after FET., Measurements: Bilateral NIRS values were recorded continuously and at seven critical time points in each patient, and correlations were made between left- and right-sided NIRS values and stroke., Main Results: A total of 23 patients (13.9%) were diagnosed with stroke. There was a significantly higher in-hospital mortality in patients with stroke (21.7%) compared with patients without stroke (7.7%, p = 0.037). Left-sided regional cerebral oxygenation did not show significant difference in patients with versus without stroke (p = 0.550). Differences were detected in right-sided regional cerebral oxygenation trends (p < 0.001) and interhemisphere NIRS at specified time points (p = 0.009). The interaction, time × stroke, however, did not show significant results in any analysis (p > 0.05)., Conclusion: NIRS is a reliable tool to monitor intraoperative frontal lobe cerebral oxygen saturation. However, its use to predict postoperative stroke remains limited. Further refinements are needed to develop the technique into a prediction tool., Competing Interests: Declaration of competing interest This work was funded by the Berta-Ottenstein-Programme for Advanced Clinician Scientists, Faculty of Medicine, University of Freiburg. M. Czerny is a consultant to Terumo Aortic, Medtronic, Endospan, and NEOS; is a shareholder of Ascense Medical and TEVAR Ltd; and received speaking honoraria from Cryolife-Jotec and Bentley. M. Kreibich has received speaking honoraria from Terumo Aortic. There are no other conflicts of interest to declare., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)