Search Results (80)

Background: Acute Stanford Type A aortic dissection (ATAAD) often requires total arch replacement (TAR) with frozen elephant trunk (FET) to address entry tears and support aortic remodeling. In select cases, AMDS may provide a simpler option. The present meta-analysis aims to compare surgical outcomes between these two approaches. Methods: A comprehensive search in the Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases was performed until February 2025. We included studies that reported the outcomes of patients with ATAAD undergoing TAR with AMDS or FET. To enable a meaningful comparison, we only included FET studies where patients met the same inclusion criteria as those with the AMDS. Results: Thirty-eight articles met our inclusion criteria, with a total of 319 patients in the AMDS group and 4129 in the FET group. Patients undergoing an AMDS procedure experienced significantly higher bleeding requiring surgery (21.2% vs. 6.4%, p < 0.001) and a higher hospital mortality (14.5% vs. 10.0%, p = 0.037) compared to FET. The individual patient data of 1411 patients were constructed. Overall survival at 1 and 3 years was 81.9% ± 3.3% vs. 88.8% ± 0.9% and 81.9% ± 3.3% vs. 85.2% ± 1.0% between AMDS and FET, respectively. A flexible parametric survival model demonstrated a significant mortality drawback for AMDS compared to FET up to 31 days, beyond which the difference was no longer evident. Conclusions: The comparison between AMDS and FET for ATAAD treatment remains debated, with FET favored for its lower mortality and stronger long-term evidence. AMDS, as a newer technique, shows promise but lacks sufficient data to confirm its safety and efficacy. Full article

Background: Non-adjustable patient characteristics such as diabetes mellitus may influence surgical decision-making and outcome after acute type A aortic dissection (ATAAD). The aim of this study was to compare the degree of aortic wall atherosclerosis and surgical solutions in patients with diabetes mellitus versus those without during ATAAD. Methods: Altogether, 123 consecutive patients undergoing surgery for ATAAD at Tampere University Heart Hospital were evaluated. The ascending aortic wall resected in surgery was processed for histopathological analysis of atherosclerosis, inflammation, and medial layer degeneration. Patients with and without diabetes mellitus were compared during a mean 4.7-year follow-up. Results: There were 11 patients with diabetes mellitus and 112 without. The mean age for all patients was 63.6 years (standard deviation [SD] 13.3). Altogether, 48 patients had a conduit aortic prosthesis replacing the aortic root together with the ascending aorta, including only one patient with diabetes (p = 0.049). Nine patients received a frozen elephant trunk prosthesis to treat the aortic arch together with the ascending aorta. The severity of ascending aorta atherosclerosis was more prominent in patients with diabetes mellitus as compared to patients without (0.8 [0.4] vs. 0.3 [0.5], p = 0.009, respectively). During follow-up, 8 and 78 patients with and without diabetes died, respectively (logarithmic rank p = 0.187). Conclusions: Histopathology of the ascending aorta during ATAAD reveals distinctive severity of aortic wall atherosclerosis in patients with diabetes mellitus versus those without. The degree of atherosclerosis assessed postoperatively is associated with the extent of surgical procedure in many patients and may guide follow-up protocol. Full article

Objectives: Several conditions associated with type A aortic dissection may require preoperative invasive mechanical ventilation (IMV). The current literature lacks data on this subset of patients’ prevalence and postoperative outcomes. This study aims to investigate this unexplored issue in a multicenter European registry. Methods: Data from 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD) were the subject of this analysis. Bootstrapped Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was performed for variable selection to identify key predictors of hospital death. In the second step, a multilevel multivariable logistic regression (MMLR) was carried out, given the clustered structure of the data. Results: A total of 346 (9.3%) out of 3735 patients required preoperative IMV. Compared to the non-IMV patients, patients requiring IMV had a significantly higher rate of organ malperfusion (52% vs. 35%, p < 0.001) and a higher proportion of tears in the aortic root (p = 0.048). The in-hospital mortality rate among IMV patients was 38% vs. 15% in non-IMV patients (p < 0.001), without a difference in post-discharge survival (p = 0.84). At the MMLR, patients who required IMV had 135% higher odds of in-hospital death compared to the remaining patients. IMV yielded the second highest odds in the prediction model for in-hospital mortality (OR 2.13, CI 1.60 to 2.85, p < 0.001). Among IMV patients, the extension of surgery to the aortic arch was significantly associated with increased in-hospital mortality (p < 0.001, OR 2.98). In multivariable analysis, preoperative IMV was independently associated with increased odds of in-hospital mortality. Conclusions: The need for invasive mechanical ventilation before surgical repair for type A aortic dissection is not infrequent. In this subpopulation, the in-hospital mortality rate was twofold compared to patients who did not require IMV. The awareness of the preoperative risk profile and outcomes of this subset of patients should urge surgeons to tailor the surgical strategy more appropriately to improve the immediate postoperative results. Full article

Background/Objectives: After years of work in the field of aortic arch surgery, the technique has evolved, making this procedure relatively safe, with lasting results. Due to the increasing long-term survival and overall aging of the patient population, more patients require aortic arch reoperation. In the present study, the safety of aortic arch reoperations was analyzed in the long term, focusing on risk factors for mortality. Methods: Between 1999 and 2023, 108 patients were included in our study who underwent reoperation on aortic arch after prior operation on the aorta, the aortic valve, or a combination of both. The exclusion criteria were being aged under 18 years and transcatheter aortic valve implantation as a previous intervention. The principal outcome was the incidence of mortality, and additional outcomes of interest included cardiac re-reoperation, bleeding, a new aortic type B dissection, infective endocarditis, readmission due to a cardiac cause, coronary intervention and neurovascular complications, pacemaker implantation, and temporary mechanical circulatory support. Results: The mean age was 56 ± 14 years, and 75% (81/108) of patients were male. In our study, we found age (p ≤ 0.01) and history of coronary artery disease (p = 0.01) to be preoperative risk factors for adverse outcomes. The mean time between the index operation and reoperation was 6.84 years (1.61–14.94). Indications for reoperation included dilatation (HR = 0.49, p = 0.05), rupture or false aneurysm (HR = 2.08, p= 0.08), dissection (HR = 1.41, p = 0.30), and endocarditis (HR = 1.49, p = 0.41). A main risk factor was the need for a salvage reoperation (p ≤ 0.01). Also, a longer operation (p = 0.04), cardiopulmonary bypass (p ≤ 0.01), and ventilation time (p ≤ 0.01), bleeding complications (p ≤ 0.01), and requiring temporary mechanical circulatory support (p = 0.04) were linked to higher mortality. The overall survival was 82% after 1 year, 73% after 5 years, and 56% after 10 years. In the multivariate Cox regression analysis, age (HR = 1.04, p ≤ 0.01), the need for a salvage operation (HR = 5.38, p = 0.01), a prolonged ventilation time (HR = 1.08, p = 0.04), and bleeding complications (HR = 3.76, p = 0.03) were associated with higher mortality. In the ROC analysis, an age over 57.5 years was associated with significantly lower overall survival (p ≤ 0.01). Conclusions: Aortic arch reoperations can be performed with acceptable long-term outcomes, but perioperative factors significantly influence early mortality. Salvage operations, bleeding complications, and prolonged ventilation were strong predictors of adverse outcomes. Older age, particularly >57.5 years, was independently associated with increased mortality risk. Full article

Introduction: Among aortic diseases in children, congenital defects such as coarctation of the aorta (CoA), interrupted aortic arch (IAA), hypoplastic aortic arch (HAA), and hypoplastic left heart syndrome (HLHS) predominate. Tissue patches are applied in pediatric cardiovascular surgery for the repair of congenital aortic defects as a filling material to replenish missing tissue or as a substitute material for the complete reconstruction of the vascular wall along the course of the vessel. This retrospective single-center study aimed to present the safety and feasibility of extracellular matrix (ECM) biological scaffolds in pediatric aortic surgery. Patients and methods: There were 26 patients (17 newborns and nine children), who underwent surgical procedures in the Department of Pediatric Cardiac Surgery (Poznań, Poland) between 2023 and 2024. The patients’ population was divided into two subgroups according to the hemodynamic nature of the primary diagnosis of the congenital heart defect and the performed pediatric cardiovascular surgery. The first group included 18 (72%) patients after aortic arch repair for interrupted aortic arch and/or hypoplastic aortic arch, while the second group included seven (28%) patients after aortopulmonary anastomosis. In the first group, patches were used to reconstruct the aortic arch by forming an artificial arch with three separate patches sewn together, primarily addressing the hypoplastic or interrupted segments. In the second group, patches were applied to augment the anastomosis site between the pulmonary trunk and the aortic arch, specifically at the connection points in procedures, such as the Damus–Kaye–Stansel or Norwood procedures. The analysis was based on data acquired from the national cardiac surgery registry. Results: The overall mortality in the presented group was 15%. All procedures were performed using median sternotomy with a cardiopulmonary bypass. The cardiopulmonary bypass (CPB) and aortic cross-clamp (AoX) median times were 144 (107–176) and 53 (33–79) min, respectively. There were two (8%) cases performed in deep hypothermic circulatory arrest (DHCA). The median postoperative stay in the intensive care unit (ICU) was 284 (208–542) h. The median mechanical ventilation time was 226 (103–344) h, including 31% requiring prolonged mechanical ventilation support. Postoperative acute kidney failure requiring hemodiafiltration (HDF) was noticed in 12% of cases. Follow-up data, collected via routine transthoracic echocardiography (TTE) and clinical assessments over a median of 418 (242.3–596.3) days, showed no evidence of patch-related complications such as restenosis, aneurysmal dilation, or calcification in surviving patients. One patient required reintervention on the same day due to a significantly narrow ascending aorta, unrelated to patch failure. No histological data from explanted patches were available, as no patches were removed during the study period. The median (Q1–Q3) hospitalization time was 21 (16–43) days. Conclusions: ProxiCor^® biological patches derived from the extracellular matrix can be safely used in pediatric patients with congenital aortic arch disease. Long-term follow-up is necessary to confirm the durability and growth potential of these patches, particularly regarding their resistance to calcification and dilation. Full article

Objective: Over the last ten years, aortic surgery has transitioned from a high-risk procedure to a well-established operation, offering favorable outcomes and survival when performed by experienced hands. Advances in surgical techniques and evolving technologies allow treatment of older and more complex patients with reoperations. However, outcome data are limited. This study aims to identify risk factors for adverse outcomes after reoperation on the aortic root. Methods: This retrospective study included patients who received aortic root reoperation from 1999 to 2023 in a high-volume center, with a history of previous surgery on the thoracic aorta or aortic valve. Patients under the age of 18 or those with transcatheter aortic valve implantation as an index procedure were excluded. Results: A total of 192 patients were analyzed. Mean age was 57 ± 13 years, and 77.6% were men. The main procedure was Bentall (88.5%). An elective operation was performed in 54.7% of the patients. The mean time between the index operation and reoperation was 8.61 (3.01–16.05) years. Mortality at 30 days was 13%. Survival rates at one, five, and ten years were 84%, 81%, and 71%, respectively. Female gender, non-elective surgery, concomitant procedures, and combined procedures on the aortic root and arch were associated with worse survival. In the Cox regression, age (HR = 3.98, p < 0.01), EuroSCORE II (HR = 1.46, p < 0.01), concomitant procedures at reoperation (HR = 2.53, p = 0.01), prolonged cardiopulmonary bypass time (HR = 1.01, p < 0.01), bleeding complications (HR = 6.11, p < 0.01), and need for temporary mechanical circulatory support (HR = 4.86, p = 0.01) were significantly associated with a higher mortality. Analysis of the receiver operating characteristic curve revealed that age > 60 years at reoperation is a strong predictor for poor outcomes (AUC = 0.712, p < 0.01). Conclusions: Mortality following aortic root reoperation is primarily driven by baseline patient risk and perioperative complications. Reduced survival was observed in patients over 60 years of age, females, those having non-elective surgery, combined root and arch operations, and procedures with additional concomitant operations. Bleeding events, the use of temporary mechanical circulatory support, and concomitant interventions at reoperation emerged as independent predictors of mortality. Full article

Perioperative management of patients undergoing surgeries of the aortic arch is challenging. This cohort of patients has a high risk of poor neurological outcomes both as a consequence of the disease process as well as the methods employed during surgical management. Many strategies have been put forward to ameliorate these complications; however, maintaining cerebral and spinal cord perfusion and reducing metabolic oxygen demand is the core principle of these strategies. Moderate hypothermia and selective ante-grade perfusion are the most promising methods that provide the best conditions for the competing requirements of both the brain and spinal cord. Intraoperative and postoperative monitoring is essential for early detection and intervention in delayed spinal cord ischaemia and stroke. In this article we aim to discuss the current methods of neuroprotection and spinal cord protection in aortic arch surgery and stenting. 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

Objectives: Perfusion strategy is crucial for the outcome of neonatal aortic arch surgery. This study investigates Whole-Body Perfusion to potentially improve postoperative outcomes for neonates, addressing a significant gap in current research. Methods: Retrospective analysis was conducted for neonates receiving aortic arch reconstruction in our institution: 33 patients were treated with Antegrade Cerebral Perfusion (ACP, 2014–2017) and 61 patients with Whole-Body Perfusion (WBP, 2017–2022). After strict Propensity Score Matching, 20 patients were analyzed in each group. WBP consists of ACP and Lower Body Perfusion (LBP), achieved through a femoral arterial sheath. Results: Patients with WBP had a shorter time on Cardiopulmonary Bypass (86.65 ± 25.47 vs. 172.95 ± 60.12 min) and Cross-Clamp time (46.70 ± 18.48 vs. 91.30 ± 40.10 min) (p ≤ 0.001). Lactate at the time of reperfusion and after 24 h was lower in the WBP group (1.73 ± 0.63 vs. 4.29 ± 1.61, p < 0.001; 1.45 ± 0.57 vs. 2.09 ± 0.96 mmol/L, p = 0.026). Patients with WBP needed significantly fewer intraoperative transfusions of Red Blood Cells, Fresh Frozen Plasma and Platelets (p ≤ 0.001). WBP patients had a shorter time on ventilator (5.15 ± 4.05 vs. 10.00 ± 8.72 days, p = 0.01) and a higher urine output after 24 h (200.85 ± 100.87 vs. 118.10 ± 82.33 mL, p = 0.002). Conclusions: Patients treated with WBP received significantly fewer intraoperative transfusions and had a shorter time on extracorporeal circulation and ventilator. Furthermore, there was a trend for reduced multiorgan dysfunction. Full article

Background and Objective: Effective cerebral perfusion monitoring is essential in aortic arch surgery, particularly when employing the Kazui technique under moderate hypothermia. Near-infrared spectroscopy (NIRS) provides real-time regional oxygen saturation (rSO₂) measurements, while the continuous monitoring of venous drainage flow and oxygen extraction ratio (ERiO₂) delivers additional insights into cerebral oxygenation and metabolic balance. This study investigates the correlation between NIRS-derived rSO₂, venous drainage flow, and ERiO₂ during selective antegrade cerebral perfusion (SACP) to better understand their interplay and clinical significance. Materials and Methods: This retrospective study analyzed data from 10 patients undergoing aortic arch surgery with the Kazui technique, including 4 patients with type I A dissections and 6 with aortic arch aneurysms. Bilateral NIRS (Masimo system) was used to measure rSO₂, while venous drainage flow and ERiO₂ were continuously monitored using the Landing system. Intraoperative parameters such as cardiopulmonary bypass (CPB) time, cooling and rewarming duration, venous return flow, and perfusion delivery rates were collected and analyzed. The correlations between rSO₂, venous drainage flow, and ERiO₂ were statistically evaluated. Results: The mean CPB time was 182 ± 15 min, with a mean cross-clamp time of 98 ± 12 min. Cooling to 20 °C was achieved in 29 ± 3 min, followed by a controlled rewarming phase of 10 ± 1.5 min. The venous return flow averaged 570 ± 25 mL/min, while the perfusion delivery rates exceeded 600 ± 30 mL/min. Bilateral NIRS monitoring revealed stable rSO2 values averaging 65 ± 5%, while ERiO2 averaged 28 ± 4%. A strong correlation (r = 0.91, p < 0.01) was observed between rSO₂ and ERiO₂, with venous drainage flow playing a critical role in maintaining this relationship. Conclusions: This study demonstrates a robust correlation between NIRS-derived rSO₂, continuous venous drainage flow, and ERiO₂ during SACP in aortic arch surgery. 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

Endovascular stent graft repair was developed to minimize the invasiveness of open surgery for thoracic and abdominal aortic diseases. This approach involves covering the diseased segment with a stented artificial graft. However, in thoracic endovascular aortic repair (TEVAR) for aortic arch diseases, special consideration is needed to preserve the aortic arch vessels. Standard stent grafts often require additional procedures, such as bypass surgery, to reconstruct the arch vessels. The semi-custom-made Najuta fenestrated stent graft was developed to address this issue. It is a three-dimensional patient-specific stent graft with fenestrations that allow for the preservation of the arch vessels. This study discusses the unique features of the Najuta stent graft and the techniques for its deployment, and it provides an analysis of treatment outcomes based on the current literature. Full article

Non-A non-B aortic dissection remains a complex and controversial topic in cardiovascular management, eliciting varied approaches among cardiologists and surgeons. Due to the limited evidence surrounding this condition, existing guidelines are limited in the complexity of their recommendations. While most patients are initially managed medically, invasive treatment becomes necessary in a large proportion of patients. When surgery is considered, the most utilized techniques include the frozen elephant trunk procedure and endovascular repair strategies targeting the arch and descending thoracic aorta. This narrative review aims to synthesize current knowledge and clinical experiences, highlighting the challenges and evolving practices related to non-A non-B dissection management. 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