Search Results (508)

Significant progress has been achieved in the treatment of acute aortic dissection over the past 90 years, following the first surgical intervention. This review pays tribute to the dedication of pioneers and innovators who developed advanced medical devices and therapeutic strategies to address this challenging condition. While navigating uncertainties in treatment optimization, the primary focus of the therapeutic strategies has been to save lives by increasing survival rates during the acute phase and to prevent aorta-related lethal events and late-stage thoracoabdominal aortic replacements. From a neutral standpoint, this review traces over 90 years of progress in treating acute aortic dissection. We hope that as many patients as possible will receive treatment rationally, without over- or under-treatment. Full article

Aortic valve diseases affect a significant percentage of the population, and with the extension of survival expectancy, they are expected to increase furthermore. Surgical treatment of aortic valve diseases mainly includes valve replacement and, rarely, its repair. The technology of both surgical and transcatheter valves is evolving, and new prosthetic valves with improved characteristics are available, e.g., longer lifespan, faster implantation, better hemodynamic performance with better effective orifice area, suitable for small aortic annuli, etc. Minimally invasive surgical techniques are constantly evolving and spreading. New access sites are used for transcatheter valve implantation. The Heart Team determines the most appropriate intervention for each patient based on their anatomical and clinical profiles, aiming to optimize long-term outcomes. Full article

Thoracic endovascular aortic repair (TEVAR) for cardiovascular diseases often encounters complications that are closely linked to the mechanical properties of stent-grafts. Both the design and material properties influence device performance, but the specific impacts of material properties remain underexplored and poorly understood. This study aims to fill this gap by systematically investigating how material science can modulate stent-graft mechanics. Four types of bare nitinol stents combined with expanded polytetrafluoroethylene (e-PTFE) or polyethylene terephthalate (PET) grafts were modeled via finite element analysis, creating eight stent-graft configurations. Key mechanical properties—flexibility, crimpability, and fatigue performance—were evaluated to dissect material effects. The results revealed that nitinol’s properties significantly influenced all performance metrics, while PET grafts notably enhanced flexibility and fatigue life. No significant differences in equivalent stress were found between PET and e-PTFE grafts, and both had minimal impacts on radial force. This work underscores the potential of material science-driven optimization to enhance stent-graft performance for improved clinical outcomes. Full article

Background/Objective: Sarcopenia is a predictor of poor surgical outcomes in older adults. The Psoas Muscle Index (PMI), calculated from routine preoperative CT scans, has been proposed as an imaging-based marker of physiological reserve, but its diagnostic utility in vascular surgery remains unclear. We aimed to assess the predictive value of PMI for early complications following elective abdominal aortic aneurysm (AAA) repair in two European centers. Methods: We retrospectively analyzed 245 patients who underwent open or endovascular AAA repair between 2018 and 2022 in Poland and The Netherlands. PMI was measured at the level of third lumbar vertebrae (L3) level, normalized to height, and stratified into center-specific tertiles. Early complications were compared across tertiles, procedures, and centers. Multivariate logistic regression was used to adjust for age, comorbidities, and procedure type. Results: Low PMI was significantly associated with early complications in EVAR patients at the Polish center (p = 0.004). No associations were found in open repair or at the Dutch center. Mean PMI values did not differ significantly between centers. Conclusions: PMI may serve as a context-dependent imaging biomarker for early risk stratification following AAA repair, particularly in endovascular cases. Its predictive value is influenced by institutional and procedural factors, highlighting the need for prospective validation and standardization before clinical adoption. Full article

Background/Objectives: There are no reports about the nationwide trends in abdominal aortic aneurysm (AAA) repair and mortality rates. This study aims to evaluate the trend in AAA treatment and related mortality, including ruptured AAAs (rAAAs) and intact AAAs (iAAAs) over the last 13 years. Methods: This serial, cross-sectional study investigated the time trends in patients who were treated for an AAA and underwent an aneurysm repair between 2010 and 2022. Data from the Health Insurance Review and Assessment Service (HIRA) and Statistics Korea were used. A linear-by-linear association and Poisson regression analysis were performed to determine the changes in the treatment of AAAs and related mortality. Results: The number of patients with an rAAA increased from 462 in 2010 to 770 in 2022 (relative risk, RR 1.57; p < 0.0001). The number of patients with an iAAA increased from 3685 to 12,399 in the same period (RR 3.16; p < 0.0001). Endovascular aneurysm repair (EVAR) has been more commonly performed since 2011. During the study period, EVAR increased from 406 to 1161 (RR 2.68; p < 0.0001). Although the annual mortality rates after iAAA treatment decreased from 1.4% to 0.7% (mean mortality rate, 1.1%), the mortality rates after rAAA treatment were similar, ranging from 34.6% to 34.2%, during the study period (mean mortality rate, 35.2%). Conclusions: During the last 13 years, the annual number of patients with rAAAs and iAAAs has increased. Since 2011, EVAR has been more commonly performed. The annual iAAA-related mortality rate decreased along with the increasing trend in EVAR. However, the annual rAAA-related mortality rate did not change. Full article

Background/Objective: Bridging stent optimal choice in fenestrated and branched endovascular aortic repair (f/bEVAR) is under investigation. This systematic review and meta-analysis studied the outcomes of the BeGraft peripheral and peripheral PLUS as bridging stents in f/bEVAR. Methods: The methodology was pre-registered to the PROSPERO (CRD420251007695). Following the PRISMA guidelines and PICO model, the PubMed, Cochrane and Embase databases were searched for observational studies and randomized control trials, in English, from 2015 to 2025, reporting on f/bEVAR patients using the second-generation BeGraft peripheral or the BeGraft peripheral PLUS balloon expandable covered stent (BECS; Bentley InnoMed, Hechingen, Germany) for bridging. The ROBINS-I assessed the risk of bias and GRADE the quality of evidence. Target vessel technical success, occlusion/stenosis, endoleak Ic/IIIc, reintervention and instability during follow-up were primary outcomes, assessed using proportional meta-analysis. Results: Among 1266 studies, eight were included (1986 target vessels; 1791 bridged via BeGraft); all retrospective, except one. The ROBINS-I showed that seven were at serious risk of bias. According to GRADE, the quality of evidence was “very low” for primary outcomes. Target vessel technical success was 99% (95% CI 98–100%; I² = 12%). The mean follow-up was 20.2 months. Target-vessel instability was 3% (95% CI 2–5%; I² = 44%), occlusion/stenosis was 1% (95% CI 1–4%; I² = 8%) and endoleak Ic/IIIc was 1% (95% CI 0–3%; I² = 0%). The estimated target-vessel reintervention was 2% (95% CI 2–4%; I² = 12%). Celiac trunk, superior mesenteric and renal artery instability were 1% (95% CI 0–16%; I² = 0%;), 1% (95% CI 0–5%; I² = 14%) and 4% (95% CI 2–7%; I² = 40%), respectively. Conclusions: The BeGraft peripheral and peripheral PLUS BECS performed with high technical success and low instability when used for bridging in f/bEVAR. Cautious interpretation is required due to the very low quality of evidence. Full article

Background: Fenestrated stentgrafting has become a first-line treatment for juxtarenal aneurysms, and the incorporation of all renovisceral vessels with fenestrations has become common to increase the proximal sealing zone. This increases the complexity of the repair compared to using fewer fenestrations, and stenting of the celiac artery (CA), in particular, can be technically challenging. Objective: This study evaluates the mid-term outcomes of leaving the celiac artery unstented during quadruple fenestrated stentgrafting for complex aortic aneurysms. Additionally, it explores the clinical and anatomical factors that influence the decision to not stent the celiac artery. Methods: A retrospective review was conducted of patients with complex aortic aneurysms who underwent elective fenestrated endovascular aneurysm repair (FEVAR) between 2018 and 2023. Custom Cook Zenith grafts were used, and all patients underwent preoperative computed tomography angiography (CTA) as well as follow-up CTA to assess the celiac artery. This study evaluated celiac artery anatomic factors, such as proximal and distal diameter; presence of stenosis (<50% or >50%) and patency; length of any CA stenosis; CA takeoff angulation, CA tortuosity, early CA division; calcification; and presence of CA aneurysm or ectasia anatomical abnormalities. Recorded outcomes of CA instability included any stent stenosis, target vessel occlusion, reintervention, or endoleak (types 1C and 3). Results: A total of 101 patients underwent FEVAR, with 72 receiving a stent in the celiac artery and 29 not receiving it. Rates of technical success (96.5% vs. 100%), intervention times (256 min vs. 237 min), and lengths of hospital stay (5.1 vs. 4.7 days) were similar between unstented vs. stented groups. At one year, no significant difference in celiac artery instability was noted (17.2 vs. 5.5%; p = 0.06). Risk factors for CA occlusion on univariate analysis included a steep takeoff angle (≥140°), length of stenosis >6.5 mm, proximal diameter ≤6.5 mm, preoperative stenosis ≥50%, and celiac artery tortuosity. Conclusions: Anatomical features of the CA impact the ability to achieve routine CA stenting during FEVAR. Selectively not stenting the celiac artery during FEVAR might simplify the procedure without compromising patient safety and mid-term outcomes. Full article

Contemporary evaluation and surgical approaches in congenital aortic valve disease have yielded limited success. The ability to evaluate and understand detailed flow characteristics surrounding surgical repair may be beneficial. This study explores the feasibility and utility of echocardiographic-based blood speckle imaging (BSI) in assessing pre- and post-operative flow characteristics in those with non-stenotic congenital aortic root disease undergoing aortic valve repair or valve-sparing root replacement (VSRR) surgery. Transesophageal echocardiogram was performed during the pre-operative and post-operative assessment surrounding aortic surgery for ten patients with non-stenotic congenital aortic root disease. BSI, utilizing block-matching algorithms, enabled detailed visualization and quantification of flow parameters from the echocardiographic data. Post-operative BSI unveiled enhanced hemodynamic patterns, characterized by quantified changes suggestive of the absence of stenosis and no more than trivial regurgitation. Rectification of an asymmetric jet and the reversal of flow on the posterior aspect of the ascending aorta resulted in a reduced oscillatory shear index ($OSI$) of $0.0543\pm 0.0207$ (pre-op) vs. $0.0275\pm 0.0159$ (post-op) and $p=0.0044$, increased peak wall shear stress of $1.9423\pm 0.6974$ (pre-op) vs. $3.6956\pm 1.4934$ (post-op) and $p=0.0035$, and increased time-averaged wall shear stress of $0.6885\pm 0.8004$ (pre-op) vs. $0.8312\pm 0.303$ (post-op) and $p=0.23$. This correction potentially attenuates cellular alterations within the endothelium. This study demonstrates that children and young adults with non-stenotic congenital aortic root disease undergoing valve-preserving operations experience significant improvements in flow dynamics within the left ventricular outflow tract and aortic root, accompanied by a reduction in $OSI$. These hemodynamic enhancements extend beyond the conventional echocardiographic assessments, offering immediate and valuable insights into the efficacy of surgical interventions. Full article

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome. Full article

The natural history of focal non-infected lesions of the abdominal aorta (fl-AA) remains unclear and largely depends on their aetiology. These lesions often involve a focal “tear” or partial disruption of the arterial wall. Penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) are examples of focal tears in the aortic wall that can either progress to dilatation (saccular aneurysm) or fail to fully propagate through the medial layers, potentially leading to aortic dissection. These conditions typically exhibit a morphology consistent with eccentric saccular aneurysms. The management of focal non-infected pathologies of the abdominal aorta remains a subject of debate. Unlike fusiform abdominal aortic aneurysms, the inconsistent definitions and limited information regarding the natural history of saccular aneurysms (sa-AAAs) have prevented the establishment of universally accepted practice guidelines for their management. As emphasized in the latest 2024 ESVS guidelines, the focal nature of these diseases makes them ideal candidates for endovascular repair (class of evidence IIa—level C). Moreover, the Society for Vascular Surgery just referred to aneurysm diameter as an indication for treatment suggesting using a smaller diameter compared to fusiform aneurysms. Consequently, the management of saccular aneurysms is likely heterogeneous amongst different centres and different operators. Endovascular repair using tube stent grafts offers benefits like reduced recovery times but carries risks of migration and endoleak due to graft rigidity. These complications can influence long-term success. In this context, the use of endovascular bifurcated grafts may provide a more effective solution for treating these focal aortic pathologies. It is essential to achieve optimal sealing regions through anatomical studies of aortic morphology. Additionally, understanding the anatomical characteristics of focal lesions in challenging necks or para-visceral locations is indeed crucial in device choice. Off-the-shelf devices are favoured for their time and cost efficiency, but new endovascular technologies like fenestrated endovascular aneurysm repair (FEVAR) and custom-made devices enhance treatment success and patient safety. These innovations provide stent grafts in various lengths and diameters, accommodating different aortic anatomies and reducing the risk of type III endoleaks. Although complicated PAUs and focal saccular aneurysms rarely arise in the para-visceral aorta, the consequences of rupture in this segment might be extremely severe. Experience borrowed from complex abdominal and thoracoabdominal aneurysm repair demonstrates that fenestrated and branched devices can be deployed safely when anatomical criteria are respected. Elective patients derive the greatest benefit from a fenestrated graft, while urgent cases can be treated confidently with off-the-shelf multibranch systems, reserving other types of repairs for emergent or bail-out cases. While early outcomes of these interventions are promising, it is crucial to acknowledge that limited aortic coverage can still impede effective symptom relief and lead to complications such as aneurysm expansion or rupture. Therefore, further long-term studies are essential to consolidate the technical results and evaluate the durability of various graft options. Full article

Background: Obstructive sleep apnea (OSA) is a prevalent but frequently underdiagnosed comorbidity in patients undergoing cardiac surgery, including coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair or replacement (MVR). This systematic review and meta-analytic synthesis investigates the relationship between OSA and postoperative morbidity and mortality, with particular attention to the predictive utility of established screening instruments. Methods: A systematic search of the PubMed database was conducted (April 2025), identifying 724 articles published in the last ten years. Seventeen primary studies met the inclusion criteria for qualitative synthesis, and four additional studies were included in the meta-analyses. Outcomes assessed included atrial fibrillation, major adverse cardiac and cerebrovascular events (MACCE), acute kidney injury (AKI), respiratory complications, pneumonia, hospital length of stay (LOS), and mortality. Risk of bias was assessed qualitatively based on study design and reporting limitations. This review was registered in the PROSPERO database under registration number CRD420251049574. Results: Meta-analyses demonstrated significantly elevated odds of atrial fibrillation (OR = 2.44, 95% CI: 1.46–4.07), major adverse cardiac and cerebrovascular events (OR = 2.06, 95% CI: 1.61–2.63), acute kidney injury (OR = 2.24, 95% CI: 1.67–3.01), and respiratory complications (OR = 1.15, 95% CI: 1.05–1.25) among patients with OSA. Additionally, OSA was associated with a significantly prolonged hospital length of stay (standardized mean difference [SMD] = 0.62, 95% CI: 0.46–0.78) and a marginal increase in pneumonia risk (OR = 1.07, 95% CI: 1.00–1.15). Evidence regarding stroke, intensive care unit (ICU) stay, and mortality was inconsistent or underpowered. Conclusions: Across core outcomes, findings were consistent across multiple studies involving a large patient population. Obstructive sleep apnea is a clinically consequential risk factor in cardiac surgery, associated with increased perioperative complications and prolonged hospitalization. These findings support the integration of routine OSA screening into preoperative risk assessment protocols. Further prospective, multicenter trials are warranted to assess the efficacy of perioperative management strategies, including continuous positive airway pressure (CPAP) therapy, in improving surgical outcomes. Full article

Background: Aortic valve infective endocarditis (IE) complicated by an aortic root abscess is a challenging problem that leads to increased morbidity and mortality. Aortic root repair or replacement are two potential treatment options. We aimed to compare patients undergoing aortic root repair or replacement with short- and mid-term outcomes. Methods: Consecutive patients with active aortic valve IE complicated by aortic root abscess undergoing cardiac surgery from January 2012 to January 2022 were included. Patients receiving aortic root repair were compared to patients undergoing aortic root replacement. Endpoints included overall mortality, incidence of recurrent IE and re-intervention during a two-year follow-up period. Inverse propensity weighting was employed to adjust for confounders. Results: Seventy-three patients with aortic valve IE with root abscess underwent surgical therapy. Fifty-six patients received aortic root repair and seventeen patients underwent aortic root replacement. Patients undergoing root replacement had significantly higher surgical risk (EuroSCORE II: 9 versus 19, p = 0.02) and extended disease (circumferential annular abscess: 9% versus 41%, p < 0.01). Inverse propensity weighted analysis revealed no relationship between surgical strategy and outcome. Weighted regression analysis revealed EuroSCORE II and disease extension as significant predictors of 30-day and 2-year mortality. Conclusions: In patients with aortic valve IE with root abscess, root repair is mostly performed in lower-risk patients with limited disease extension. Short- and mid-term mortality, recurrent endocarditis and reintervention were comparable between surgical strategies during follow-up. Surgical risk and disease extension, rather than surgical strategy, seem to be significant predictors of short- and mid-term mortality. 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

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Background: Previous studies reported a protective effect of type 2 diabetes on the progression of aortic aneurysms. We aimed to investigate whether this paradoxical phenomenon remained in patients with diabetes undergoing repair of ruptured aortic aneurysms. Methods: Data from the US Nationwide Readmission Database from 2016 to 2019 were analyzed. Patients admitted for surgical repair of ruptured abdominal or thoracic aortic aneurysms were included. Patients discharged alive were followed for 30 days. The co-primary outcomes were in-hospital and 30-day mortality. Results: A total of 9858 patients hospitalized for surgical repair of ruptured abdominal or thoracic aortic aneurysm were included, of whom 16.4% had diabetes. A lower adjusted risk of in-hospital mortality in abdominal and thoracic aneurysms was observed in diabetes patients (aOR = 0.76 [0.67–0.87], 0.61 [0.46–0.810], respectively). However, atrial fibrillation and acute renal failure were more likely to occur in the presence of diabetes (aOR = 1.25 [1.11–1.42]; 1.17 [1.05–1.32], respectively). Within 30 days, diabetes was not associated with a difference in the incidence of mortality or readmission (aHR = 1.47 [95% CI 0.98–2.22]; 1.15 [95% CI 0.99–1.34], respectively). Cardiovascular system-related pathologies were the most prevalent etiologies in all readmitted patients. Infections were more likely to occur in the diabetes group (16.0% vs. 11.0%, respectively, p = 0.042). Conclusions: The paradoxical effect of diabetes is also observed in ruptured aneurysms treated surgically, as type 2 diabetes patients have a lower in-hospital mortality. However, this protective effect does not extend to 30-day readmission or survival. Full article