Single-stage total aortic replacement in a young patient with chronic type A aortic dissection, Marfan and mega-aorta syndromes.

Single-stage total aortic replacement represents a comprehensive approach for patients at high risk of aorta-related complications between procedures. It not only avoids staged surgical treatment but also facilitates quicker rehabilitation. Opting for a radical surgery in such cases can yield superior outcomes compared with a staged approach, making it particularly suitable for young patients with aorta-related risk factors. Moreover, a single-stage aorta repair reduces the likelihood of subsequent aortic interventions.

Thoracoscopic Clipping of Intercostal Artery for Treatment of Type II Endoleak Following Frozen Elephant Trunk Procedure: Case Report.

A 38-year-old man with history of Crawford extent I thoracoabdominal aneurysm and chronic type B1,10 aortic dissection underwent a hybrid repair using the frozen elephant trunk technique. The patient was followed up annually, and type II endoleak of the descending thoracic aorta was diagnosed, leading to negative aortic remodeling. The endoleak was managed by performing intercostal artery clipping using minimally invasive thoracoscopic technique under transesophageal echocardiography control. The computed tomography scan showed no endoleak and complete false-lumen thrombosis with positive remodeling in the distal aortic segments.

Update in Carotid Disease.

This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?

Preoperative assessment of the technical complexity of minimally invasive aortic root repair.

BACKGROUND: The aim of this study was to assess predictors of technical complexity of minimally invasive aortic root repairs (MIARR) performed through J-shaped mini-sternotomies in patients with aortic root aneurysm. METHODS: This study included 49 patients with aortic root aneurysm who underwent MIARR via an upper median J-shaped mini-sternotomy between January 2017 and April 2020. Preoperative high-resolution computed tomographic images synchronised with electrocardiography were mandatory for inclusion. Predictors of technical complexity were identified, and a scoring system was created. The correlation between technical complexity and intraoperative/postoperative parameters was explored. RESULTS: There was a significant association between technical complexity and increased procedure time (Spearmen's ρ=-0.45, P=0.001), blood loss (Spearmen's ρ=-0.384, P=0.006), cardiopulmonary bypass time (Spearmen's ρ=-0.301, P=0.035), and postoperative bleeding (Spearmen's ρ=-0.265, P=0.066). The anatomical aorta-sternal relationship (distance of >22.1 mm in the axial plane between the midline of the sternotomy plane and the left coronary), distance between the sternal notch and the aortic valve annulus (>14.5 cm in the sagittal plane), distance between the skin and the left coronary artery (>9.53 cm in the axial plane), obesity (Body Mass Index >30), and-diameter at the brachiocephalic trunk level (>37 mm), were strongly associated with procedural complexity. Overall test accuracy was 75.5%, sensitivity was 73.1%, and specificity 78.3%. Finally, we created an online calculator that surgeons can use to determine the probability of a technically difficult of MIARR based on these factors. CONCLUSIONS: This novel scoring system can be used to assess the technical complexity of minimally invasive aortic root repairs and to aid in preoperative planning.

Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension.

OBJECTIVE: Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH). MATERIALS AND METHODS: The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% (n = 289) - classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% (n = 472) - eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% (n = 109) - the formation of a new bifurcation; Group 4: 7.4% (n = 117) - autoarterial reconstruction; Group 5: 37.4% (n = 590) - glomus-saving CEE (1 technique - according to A.N. Kazantsev; two technicians - according to R.A. Vinogradov; three technicians - according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° - 5.7% (n = 89); 2° - 64.2% (n = 1013); and 3° - 30.1% (n = 475). RESULTS: In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (group 1: 1.03% (n = 3); group 2: 3.6% (n = 17); group 3: 3.67% (n = 4); group 4: 2.56% (n = 3); group 5: 0.5% (n = 3); p = 0.10). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. CONCLUSION: Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.

A new dissection-specific hybrid stent graft for patients with DeBakey type I aortic dissection.

OBJECTIVES: We present our first experience of using a new dissection-specific hybrid stent graft (SG) (the 'Soft Elephant Trunk') in the frozen elephant trunk technique, in patients with non-acute DeBakey type I aortic dissection. METHODS: Between September 2016 and February 2021, patients with non-acute DeBakey type I aortic dissection underwent the frozen elephant trunk procedure at our centre using 3 SG types: group Z used stiff, distal Z-shaped nitinol SGs (E-Vita, Medtronic); group R used a stiff, ring-shaped nitinol SG (Thoraflex); and group S used a soft, distal dissection-specific SG. Predictors of distal SG-induced new entry were analysed. End points were hospital- and midterm-follow-up results. RESULTS: The study comprised 109 patients with 46 (42.2%), 22 (20.2%) and 41 (37.6%) patients in groups Z, R and S, respectively. No significant differences were found in early outcomes. Freedom from distal SG-induced new entry was comparable in groups Z, R and S (68.9% vs 92.9% vs 100%, log-rank = 0.14). There was no significant difference in follow-up between the groups. Four-year survival rates were 80.44%, 71.59% and 95.06% in groups Z, R and S, respectively. On multivariable analysis, the presence of connective tissue disorders [hazard ratio (HR) = 5.62, P = 0.11] and SG diameter (HR = 1.37, P = 0.034) were strong predictors of distal SG-induced new entry. CONCLUSIONS: Dissection-specific hybrid SG with a soft distal end is effective in patients with non-acute DeBakey type I aortic dissection. Compared to non-soft distal SGs, this can reduce the incidence of distal complications. Long-term outcomes are necessary to determine the potential advantages and disadvantages of the new prosthesis.

Single-stage total aortic replacement in patients with mega-aortic syndrome.

BACKGROUND: Staged total aortic replacement (TAR) is standard for patients with mega-aortic syndrome (MAS) and severe comorbidities, but a single-stage approach may be better for younger and fit patients. This report described the mid-term results of this approach. METHODS: We conducted a retrospective medical chart review of all MAS patients in our center between May 2016 and December 2020 to analyze outcomes of single-stage TAR. Primary endpoints were mortality and major adverse postoperative events; secondary endpoints included aortic re-intervention, all complications, and survival. RESULTS: Of 47 MAS patients, 13 (27.7%) received single-stage TAR from valve to bifurcation through thoracophrenolumbotomy using circulatory arrest, antegrade cerebral and visceral perfusion. Mean age was 40.1±6.5 years. In-hospital mortality was 15.4%; two patients died on postoperative day (POD) 14 due to fatal stroke and POD 85 due to prosthesis infection. Mean intensive care stay was 7 (15) day, mean hospital stay was 27.5±16.2 day. Stroke occurred in two patients with "shaggy" aortas (one fatal, one transient); paraplegia in one; temporary acute renal failure in two (15.4%), and respiratory failure in 4 (30.8%). There was no aortic re-intervention or further mortality during follow-up. CONCLUSIONS: Total aortic replacement from valve to bifurcation is a safe approach for younger and fit patients with MAS and provides acceptable midterm outcomes in an experienced center. Thoracoabdominal incision at fourth intercostal space with retroperitoneal approach of abdominal aorta provides satisfactory exposure for the thoracic aorta and TAA and minimizes surgical trauma in comparison with a combination of two surgical incision.

Follow-up outcomes after the frozen elephant trunk technique in chronic type B dissection.

OBJECTIVES: Our goal was to present our experience with a hybrid approach to the frozen elephant trunk (FET) technique for the treatment of patients with chronic type B aortic dissection. METHODS: Between January 2013 and July 2019, 86 patients underwent the FET procedure at our centre. In 20 patients, the indication was chronic type B aortic dissection with a concomitant proximal aortic lesion. We evaluated the sites of proximal and distal entries, luminal communication and originating visceral branches in the computed tomography scan data. Primary end points were hospital deaths, complications and follow-up survival. Secondary end points included reintervention, thrombosis of the false lumen and aortic remodelling. RESULTS: There were no deaths, neurological complications or paraplegia during hospitalization; however, a few patients (10%) had temporary acute renal failure or required secondary aortic reintervention during the follow-up period. We performed thoracic endovascular aortic repair with stable aortic remodelling during follow-up. The follow-up survival rate was 92.3%, and 87.5% of cases did not require aortic reintervention. CONCLUSIONS: The FET technique is an effective method for treating chronic Stanford type B aortic dissection in patients at high risk of retrograde type A aortic dissection, concomitant disease of the proximal aorta and unsuitable anatomy for thoracic endovascular aortic repair, which allows for single-stage radical correction. Compared with thoracic endovascular aortic repair, the FET technique excludes the risk of type Ia endoleak, retrograde type A aortic dissection and possible stent graft migration. This technique provides comparable midterm follow-up outcomes and freedom from reintervention.