Search Results (42)

Background/Objectives: The frozen elephant trunk (FET) technique is a cornerstone procedure for complex thoracic aortic pathologies. This single-center retrospective study evaluates early and midterm outcomes of total arch replacement (TAR) using three generations of the E-vita Open hybrid prosthesis over 11 years. Methods: From January 2013 to June 2024, 51 patients underwent TAR with the FET technique using the E-vita Open prostheses. Exclusion criteria were isolated ascending or descending aortic replacement, partial arch replacement, TAR without FET, and use of other stent grafts. We analyzed outcomes including in-hospital mortality, survival, stroke, spinal cord injury, and renal complications across three prosthesis generations. Results: The cohort included 52.9% males, with a mean age of 61.5 ± 10.51 years. FET as reoperation was performed in 52.9% patients. In-hospital mortality was 7.8% and, unexpectedly, only occurred with the newest E-vita Open Neo (23.5%), despite this being the latest generation. Overall survival was 72.5% at one year, 60.8% at two years, and 54.9% at three years. Stroke occurred in 17.6% with marked variation by pathology: 0% in dissection, 31.6% in aneurysm, and 13.6% in combined disease. Spinal cord injury occurred in 7.8%. Re-operation was a significant risk factor for complications and was strongly associated with renal complications (85.7% of dialysis patients) but not mortality. Secondary endovascular procedures were required in 49% of patients. Conclusions: The FET technique with E-vita Open prostheses demonstrates acceptable outcomes in high-risk patients with complex aortic pathologies. While perioperative morbidity is significant, particularly in reoperative cases, it varies significantly by underlying pathology and prosthesis generation, with unexpected trends suggesting that technological advancement does not automatically translate into improved outcomes. Despite this, the procedure enables comprehensive management of extensive aortic disease through a staged approach. Full article

Background: Advances in stent grafts and endovascular techniques have expanded the indications for thoracic endovascular aortic repair (TEVAR) to include arch lesions. In situ needle fenestration (ISNF) has emerged as a promising technique for revascularizing supra-aortic branches. The aim of this study is to evaluate the safety and efficacy of triple in situ needle fenestration during TEVAR for aortic arch pathologies in a single-center experience. Materials and Methods: A retrospective analysis was conducted on fifteen patients who underwent in situ triple fenestration TEVAR between June 2023 and March 2024. The median age of the patients was 51,33 years (±19.69) and twelve of the patients were male. All procedures were performed under general anesthesia in a hybrid operating room. Ethical approval was obtained from the institutional review board, and informed consent was received from all participants. Results: Primary technical success was achieved in all cases (15/15, 100%). The mean operation time was 197.33 min (range: 126–302). Two patients experienced a minor hematoma at the access site. Mortality was observed in one patient (6.66%) during the 30-day follow-up period. The total hospital stay averaged 7 ± 3.36 days. One patient had a transient ischemic attack, but there were no incidents of stroke or spinal cord ischemia. No procedure-related endoleak was observed during the intervention; however, eight patients required reintervention in the descending aorta. Conclusions: ISNF may be an effective and feasible method for revascularizing arch vessels, with low rates of early mortality and stroke when performed by experienced practitioners. However, larger multicenter studies with longer follow-up are needed to confirm the durability and long-term outcomes of this technique. Full article

Advancements in endovascular stent graft design have enabled the treatment of distal aortic arch pathologies. However, the length of the proximal landing zone remains a limitation, especially with vascular anomalies like an aberrant right subclavian artery (ARSA) posing additional challenges. A 78-year-old patient underwent computed tomography angiography (CTA), which revealed progressive enlargement of a distal aortic arch aneurysm located beyond an ARSA that coursed between the esophagus and trachea. Following evaluation by the multidisciplinary Aortic Team, a hybrid procedure was planned. A right carotid-to-ARSA bypass was performed and a Castor single-branched stent graft (CSBSG) was deployed in the aortic arch with its side branch directed into the left subclavian artery (LSA), thereby covering the origin of the ARSA. To prevent a type II endoleak, plug embolization of the ARSA origin was subsequently performed. CSBSG is a feasible treatment for distal aortic arch aneurysms, even in the presence of vascular anomalies such as ARSA. Full article

Background: Carotid web (CaW) usually presents as a shelf-like intimal flap at the beginning of the internal carotid artery. It has been proven that CaW is associated with ischemic stroke, particularly in young patients without other risk factors. This case report aimed to describe the carotid web that causes ischemic stroke due to embolic complications. Moreover, both pathologies were successfully treated with endovascular techniques in the presented case study. Methods: A 59-year-old male presented to the neurological department with motor aphasia, right-sided weakness, and hypoesthesia. Computer tomography (CT) of the head and computed tomography angiography (CTA) of the aortic arch and intracranial arteries were performed. Due to the unknown onset of the presented stroke symptoms, diagnostics were extended to magnetic resonance (MR), and based on this, the patient qualified for immediate mechanical thrombectomy (according to the DAWN trial protocol). Intraoperative digital subtraction angiography (DSA) revealed embolism material in the left middle cerebral artery (segment M1). The artery was recanalized via aspiration thrombectomy using the Penumbra system, and complete restoration of flow was obtained (according to the TICI scale). In addition, DSA revealed the presence of CaW changes in the left internal carotid artery (LICA). In the control CT scanning, an acute ischemic area in the left temporal lobe was found. After the treatment, the patient demonstrated complete neurological improvement from his initial presentation. He qualified for carotid artery stenting of the LICA, which was postponed to a later period due to the presence of an area of infarction. The angioplasty with stenting was performed 6 months later, and a carotid antiembolic “mesh” stent (Roadsaver, Terumo) was implanted into the LICA across the carotid web. Conclusions: CaW should be considered in the case of stroke resulting from unknown causes. The presented case study demonstrated that both carotid web and ischemic stroke pathologies can be effectively treated with emerging endovascular techniques. Full article

Background/Objectives: The frozen elephant trunk (FET) technique was introduced as a possible single-stage procedure for treating aortic arch pathologies. However, up to a third of patients are reported to need subsequent completion (extension). This retrospective analysis aimed to evaluate the impact of early (within 30 days; EC group) versus late (>30 days; LC group) endovascular completion with thoracic endovascular aortic repair (TEVAR) in patients treated with FET. Methods: A single-center, retrospective analysis of all consecutive patients for the period between June 2017 and December 2023 who underwent FET and received endovascular extension was conducted. Indications for endovascular extension were aneurysms of the descending aorta, aneurysmal progress, endoleak, malperfusion, distal stent-induced new entry (dSINE), and aortic rupture. Results: A total of 37 of 232 FET patients received endovascular extension (15.9%). Average age at the time of TEVAR was 63.3 ± 10.3 years. There was an increase in the maximum total aortic diameter post-FET from 40.8 ± 9 mm to 45.1 ± 14 mm prior to TEVAR. Only 14 patients (37.8%) had the desired complete occlusion of the false lumen or aneurysm prior to extension; 23 (62.2%) still had relevant perfusion of the false lumen or aneurysm. The EC and LC groups were defined by time between FET and TEVAR: a mean of 4.8 ± 5.2 days in the EC group and 18.4 ± 18 months in the LC group. The EC group had markedly more complex procedures, reflected in intensive care (10.7 ± 6.9 vs. 0.1 ± 0.3 days, p < 0.001) and hospitalization (22.4 ± 14.0 vs. 8.1 ± 5.6 days, p = 0.003) durations. There was one early death due to multiorgan failure in the EC group and there were none in the LC group. There were no major cardiac events in either group. In the EC group, seven patients (50%) suffered from postoperative respiratory failure and four (28.6%) developed acute kidney failure requiring dialysis. Only one patient in the LC group (4.3%) experienced complications. During follow-up, another three patients (21.4%) of the EC group died, but none of the LC group did. Post-extension aortic remodeling was similar in both groups, with complete occlusion achieved in 27 cases (72%) during early follow-up and increased to 90.6% after a mean of 22.0 ± 23.4 months. Conclusions: Following aortic arch repair using FET, there is still a need for second-stage repair in 16% of patients. Endovascular completion post-FET is safe and feasible with a technical success rate of 100%, but early completion is associated with greater morbidity and mortality. TEVAR extension surgery may be better delayed, if possible, until after recovery from the hybrid arch repair. Full article

Background: Penetrating aortic ulcer (PAU) is an acute aortic syndrome characterized by a high rupture risk. There are several PAU-treatment procedures indicated for the management of this pathology associated with different effects on vessel morphology and hemodynamics. A deep evaluation of the different types of treatment may be helpful in decision making. Computational Fluid Dynamics (CFD) is a powerful tool for detailed inspection of cardiovascular diseases. The aim of this work was to implement a comparative analysis based on CFD evaluation of the effects of two type of PAU treatments. Methods: Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery (LSA) branched aortic endograft (SBSG) and a hybrid approach including TEVAR and carotid-LSA bypass were considered. Aortic anatomical models were created from computed tomography (CT) images acquired before and after PAU treatment with SBSG for three patients. Starting from these models, a new aortic geometry corresponding to the outcome of the hybrid strategy was generated. Morphological analysis and CFD simulations were carried out for all aortic models to evaluate LSA outflow for the same predefined boundary conditions. Results: Reductions in LSA diameter were found between aortic models before and after the SBSG (18.2%, 20.8%, and 12.4% for CASE 1, CASE 2, and CASE 3, respectively). The flow rate at LSA changed between pre-configuration and aortic configuration after the PAU treatments: an averaged decrement of 1.08% and 7.5% was found for SBSG and the hybrid approach, respectively. The larger increase in pressure drop between the aortic arch and the LSA extremity was shown in the hybrid approach for all cases. Conclusions: CFD simulations suggest that SBSG preserves LSA perfusion more than a hybrid strategy and has less impact on thoracic aorta hemodynamics. Full article

Objectives: Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergent surgical intervention. Numerous surgical approaches exist for ATAAD, and controversy remains regarding the optimal arch interventions for ATAAD patients. Aortic Arch Interventions: Approaches to ATAAD repair include hemiarch repair or extended arch repairs, including the hemiarch with a hybrid stent implantation, such as the AMDS hybrid Prosthesis, total arch replacement (TAR), and the use of an elephant trunk and frozen elephant trunk. While indications for each procedure exist, such as entry tears in the arch, arch aneurysms, and head vessel communications for TAR and malperfusion and a reduced risk of distal anastomotic new entry tears in Debakey I aortic dissection for the AMDS and frozen elephant trunks, the optimal intervention depends on numerous factors. Surgeon and center experience, resource availability, patient risk, and anatomy all contribute to the decision-making process. TAR has improved in safety over the years and has been demonstrated to be comparable to the hemiarch repair in terms of safety in many settings. TAR may also prevent adverse remodeling and can effectively treat more distal diseases, the presence of arch tears, arch aneurysms, and branch vessel involvement or malperfusion. Conclusions: Numerous surgical approaches exist to manage ATAAD, allowing for the surgeon to tailor the repair to the individual patient and pathology. TAR allows for single or staged repair of extensive pathologies and can address distal entry tears, the aneurysmal arch, and head vessel pathologies. In cases with malperfusion, an AMDS can be used in many cases. The management strategy for ATAAD should always involve performing the best surgery for the patient, although in cases where a total arch is indicated but cannot be performed safely by a non-aortic surgeon, the safest approach may be to perform a hemiarch initially and to plan for an elective arch reoperation in the case it is required following close surveillance. Full article

Objective: This study aimed to examine contemporary results of the frozen elephant trunk (FET) procedure in an all-comers patient cohort. Methods: Between January 2017 and May 2024, a total of 132 consecutive patients with either aortic aneurysm (n = 32), acute aortic dissection (n = 32), or chronic aortic dissection (n = 68) underwent total aortic arch replacement employing the FET technique. In-hospital data were collected prospectively and included preoperative characteristics, intraoperative data, and follow-up results. Results: The median cardiopulmonary bypass time, cardiac ischemia time, and selective antegrade cerebral perfusion time were 180 (161–205), 89 (70–113), and 45 (38–54) min, respectively. Total 30-day mortality rate was 7.6% (n = 10). The rate of major postoperative neurological complications was 6.8% (n = 9) for perioperative stroke and 2.3% (n = 3) for permanent spinal cord injury. Five patients (3.8%) required hemofiltration at the time of discharge due to postoperative kidney injury. Rates of subsequent endovascular and open aortic repair following primary FET were 40.9% (n = 54) and 3.8% (n = 5), respectively. The median time to reintervention was 86 (30–439) days. The median follow-up time was 25 (8–52) months, and overall survival rates at 1, 2, and 3 years were 89%, 89%, and 87%, respectively. Conclusions: Our data are consistent with current reports, indicating that the FET technique is a valuable adjunct in treating extensive aortic arch pathologies. The procedure provides an increasingly safe and effective option for complete aortic arch replacement, even in patients requiring a redo procedure. Full article

Background: The frozen elephant trunk method combines the implantation of a Dacron prosthesis with a self-expanding stent graft, which allows for complex repairs of the aortic arch and thoracic aorta in one procedure. Despite the advantages of hybrid treatment for aortic arch aneurysms, in Poland, only a few such surgeries are performed annually compared to in Western countries. The aim of this study was to demonstrate the 8-year outcomes of treatment at the center where the Aortic Team operates, which is one of the centers in Poland with the most extensive experience in hybrid FET treatment. Methods: Patients who underwent frozen elephant trunk surgery for chronic and acute pathologies of the aortic arch and thoracic aorta between March 2016 and March 2024 were comprehensively analyzed retrospectively. Frozen elephant trunk procedures were performed under three consecutive clinical conditions: acute aortic dissection, chronic aortic dissection and redo surgery. Results: A total of 40 patients (median age: 60 years (53–66), 67.5% male) were admitted to our hospital and underwent an FET procedure. The median Euroscore II was 25.9% and the 30-day mortality was 7.5%. The 1-year and 5-year mortalities were the same, equal to 15%, with mortality cases observed only in the first and second groups of consecutive patients during the first two months of follow-up. Spinal cord injury was observed in 2.5% of patients. Conclusions: The FET technique can be successfully used to treat aortic aneurysms with optimal results and low complication rates. The surgery length, including the cardiopulmonary bypass and aortic cross-clamp times, decreased significantly with increasing experience. Full article

The advent of endovascular aortic surgery has led to the rise of novel techniques and devices in treating pathologies of the aorta. While endovascular surgery has been well established in the descending thoracic and abdominal aorta, the endovascular treatment of the aortic arch represents a new and exciting territory for aortic surgeons. This article will discuss the different aortic diseases amenable to endovascular treatment, currently available aortic arch stent grafts and their limitations, and the future of endovascular aortic arch therapies. Full article

The treatment of complex aortic pathologies requires specialized techniques and tailored approaches due to each patient’s unique anatomical and clinical challenges. The European Association for Cardiothoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) new guidelines identify the aorta as the body’s 24th organ and reiterate that multidisciplinary aortic teams are recommended for shared decision-making to determine optimal treatment strategies. Patients treated for conditions such as aneurysms, dissections, intramural hematomas, or penetrating aortic ulcers may develop complex forms over time, necessitating careful follow-up and timely corrective actions. Endovascular solutions can be favorable for older patients with complex anatomies and multiple comorbidities. However, when endovascular treatment is not feasible, hybrid treatments or open surgery must be considered if the patient’s condition allows it. The risk–benefit ratio of each procedure must be carefully evaluated; choosing the best intervention or deciding not to intervene becomes a critical and challenging decision. At our Cardiac Surgery Center in Verona, a multidisciplinary team with over 20 years of experience in treating complex aortic arch pathologies extensively discussed different cases of complex aortic pathologies treated with endovascular, hybrid, or surgical approaches, emphasizing the importance of considering both anatomical and patient-specific characteristics. The decisions and treatments were often challenging, and unanimity was not always achieved, reflecting the complexity of finding the best solutions. Full article

Objectives: There are several endovascular treatment options to treat aortic arch and thoracic aortic pathologies with custom-made or surgeon-modified aortic stent grafts. This study seeks to assess endovascular treatment methods for aortic arch and thoracic aortic pathologies with no acceptable proximal landing zone for standard thoracic endovascular aortic repair (TEVAR), comparing different treatment methods and evaluating technical success, intraoperative parameters and short-term outcomes. Methods: All patients undergoing elective or emergency endovascular treatment of aortic arch and thoracic aortic pathologies, with no acceptable landing zone for standard TEVAR, between 1 January 2010 and 31 March 2024, at the University Hospital Düsseldorf, Germany were included. An acceptable landing zone was defined as a minimum of 2 cm for sufficient sealing. All patients were not suitable for open surgery. Patients were categorized by an endovascular treatment method for a comprehensive comparison of pre-, intra- and postoperative variables. IBM SPSS29 was used for data analysis. Results: The patient cohort comprised 21 patients, predominantly males (81%), with an average age of 70.9 ± 9 years with no acceptable proximal landing zone for standard TEVAR procedure. The most treated aortic pathologies were penetrating aortic ulcers and chronic post-dissection aneurysms. Patients were sub-grouped according to the applied procedure as follows: five patients with chimney thoracic endovascular aortic repair (chTEVAR), seven patients with in situ fenestrated thoracic endovascular aortic repair (isfTEVAR), six patients with custom-made fenestrated thoracic endovascular aortic repair (cmfTEVAR) and three patients with custom-made branched thoracic endovascular aortic repair (cmbTEVAR). Emergency procedures involved two patients. There were significant differences in the total procedure and fluoroscopy time, as well as in contrast agent usage among the treatment groups. cmfTEVAR had the shortest total procedure time, while chTEVAR exhibited the highest contrast agent usage. The overall mortality rate among all procedures was 9.5% (two patients) and 4.7% for elective procedures, respectively. Deaths were associated with either retrograde type A dissection or stent graft infection. Both patients were treated with chTEVAR. There was one minor and one major stroke; these patients were treated with isfTEVAR. No endoleak occurred during any procedure. The reintervention rate for chTEVAR was 20% and 0% for all other procedures during the in-hospital stay. The patients who were treated with cmfTEVAR had no complications, the shortest operating and fluoroscopy time, and less contrast agent was needed in comparison with other treatment methods. Conclusions: Complex endovascular procedures of the aortic arch with custom-made or surgeon-modified aortic stent grafts offer a safe solution, with acceptable complication rates for patients who are not suitable for open aortic arch repair. In terms of procedure-related parameters and complication rates, a custom-made fenestrated TEVAR is potentially advantageous compared to the other endovascular techniques. Full article

In the context of thoracic endovascular aortic repair (TEVAR), the reconstruction of the left subclavian artery (LSA) has emerged as a crucial component in establishing a sufficient proximal landing zone. However, the technical difficulty of these procedures raises the possibility of endoleaks and neurological consequences. Single-branched stent grafts offer good anchoring and LSA flow for these patients. This study evaluates the feasibility of utilizing novel single-branched stent grafts in the treatment of distal aortic arch disease, identifying good results in the short and medium term. From September 2019 to March 2023, TEVAR and revascularized LSA were performed on ten patients at the Ospedale del Cuore—FTGM in Massa, Italy, using Castor single-branched thoracic aortic stent grafts (Microport Medical, Shanghai, China). The authors’ first findings demonstrated that, after an average follow-up of one year, the Castor branching aortic stent graft system was safe and achieving an appropriate proximal landing zone and maintaining sufficient LSA perfusion was possible. With regard to the endovascular treatment of distal aortic arch diseases, this product offers a compelling substitute for surgery. For the purpose of assessing the long-term effectiveness of this approach, the follow-up period should be extended. Full article

Background: Our aim was to investigate outcomes and long-term survival in male and female patients after frozen elephant trunk (FET) total arch replacement. Methods: Between March 2013 and January 2023, 362 patients underwent aortic arch replacement via the FET technique. We compared patient characteristics and intra- and postoperative data between male and female patients. Results: Male patients were significantly younger (p = 0.012) but revealed a higher incidence of coronary artery disease (p = 0.008) and preoperative dialysis (p = 0.017). More male patients presented with type A aortic dissections (p = 0.042) while more female patients had aortic aneurysms (p = 0.025). The aortic root was replaced in significantly more male patients (p = 0.013), resulting in significantly longer cardiopulmonary bypass duration (p < 0.001) and operative times (p < 0.001). There were no statistically significant differences in postoperative outcome parameters including in-hospital mortality (p = 0.346). However, new in-stent thrombus formation was significantly more frequent in female patients (p = 0.002). Age in years (odds ratio (OR): 1.026, p = 0.049), an acute pathology (OR: 1.941, p = 0.031) and preoperative dialyses (OR: 3.499, p = 0.010) were predictive for long-term mortality in our Cox regression model, sex (p = 0.466) was not. There was no statistical difference in overall survival (log rank: p = 0.425). Conclusions: Female patients are older but reveal fewer cardiovascular risk factors; aneurysms are more common in female than male patients. As female patients undergo concomitant surgical procedures less often, their operative times are shorter. While survival and outcomes were similar, female patients suffered from postoperative new in-stent thrombus formation significantly more often. Full article

Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders. Methods: In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. Results: The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11–1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59–0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74–9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. Conclusions: This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients. Full article