Downstream thoracic endovascular aortic repair following zone 2, 100-mm stent graft frozen elephant trunk implantation.

OBJECTIVES: The aim of this study was to analyse outcomes of downstream thoracic endovascular aortic repair (TEVAR) following the frozen elephant trunk (FET) procedure. METHODS: Sixty-six patients underwent downstream TEVAR following the FET procedure to treat thoracic aortic dissections (n = 42, 64%), aneurysms (n = 19, 29%) or penetrating aortic ulcers involving the aortic arch (n = 5, 8%). Patient and outcome characteristics were analysed. RESULTS: Downstream TEVAR was performed 7 [interquartile range: 2-18] months after the FET procedure in 39 male (59%) and 27 female (41%) patients aged 68 [interquartile range: 56, 75] years, including 11 patients (17%) with a connective tissue disease. Before TEVAR, cerebrospinal fluid drainage was put in place in 61 patients (92%). Patients were treated with 1 stent graft (n = 28, 42%), 2 stent grafts (n = 37, 56%) or 3 stent grafts (n = 1, 2%). The femoral artery was accessed through surgical cut-down (n = 15, 23%) or percutaneously (n = 49, 74%). One patient (2%) developed a temporary spinal cord injury that resolved spontaneously. No case of permanent spinal cord injury, stroke or death was observed. After 12 [interquartile range: 2-23] months, 15 patients required an additional aortic reintervention (endovascular: n = 6; surgical: n = 9). CONCLUSIONS: Downstream TEVAR following the FET procedure is associated with excellent clinical outcomes. We thus maintain that staging thoracic aortic repair-FET and secondary TEVAR-is a very successful and safe strategy. Certain patients might need a tertiary procedure to fix their entire aortic pathology; therefore, they will require long-term continuous follow-up, ideally in a dedicated aortic clinic.

Treatment of infectious aortic disease with bovine pericardial tube grafts.

OBJECTIVES: Our aim was to evaluate the mid-term outcomes of bovine pericardial tube graft repair for infectious aortic disease in any aortic segment. METHODS: Between May 2015 and July 2020, 45 patients were treated for infectious aortic disease of the native (n = 9) aorta or after (endo-)graft (n = 36) implantation with bovine pericardial tube grafts. Clinical, infectious details, outcomes and follow-up data were evaluated. RESULTS: All aortic segments underwent pericardial tube graft or bifurcational replacement: the aortic root (n = 12, 27%), ascending aorta (n = 18, 40%), aortic arch (n = 7, 16%), descending aorta (n = 5, 11%), thoraco-abdominal aorta (n = 6, 13%) and abdominal aorta (n = 18, 40%) including the iliac arteries (n = 14, 31%). Organ fistulation (n = 15, 33%) was the most common underlying pathology. Seven patients (16%) expired in-hospital secondary to ongoing sepsis (n = 5, 11%), respiratory failure (n = 1, 2%) and unknown cause (n = 1, 2%). A fungal infection was predictive for in-hospital mortality (P = 0.026, odds ratio: 19.470). After a median follow-up of 11 [first quartile: 2, third quartile 26] months, 9 additional patients (20%) expired and 1 patient developed a postoperative spondylodiscitis at the level of the aortic tube graft. Hence, freedom from proven aortic graft re-infection was 98%. CONCLUSIONS: Orthotopic aortic reconstruction using bovine pericardial tube grafts to treat infectious aortic disease is possible in any aortic segment. Organ fistulation is a frequently observed disease mechanism requiring concomitant treatment. Granted, the early attrition rate is substantial, but after the initial period, both survival and freedom from re-infection appear encouraging.

The Frozen Elephant Trunk Technique for the Treatment of Type B and Type Non-A Non-B Aortic Dissection.

OBJECTIVE: To evaluate outcomes of patients with acute complicated or chronic Type B or non-A non-B aortic dissection who underwent the frozen elephant trunk (FET) technique. METHODS: Between April 2013 and July 2019, 41 patients presenting with acute complicated (n = 29) or chronic (n = 12) descending thoracic aortic dissection were treated by the FET technique, which was the treatment of choice when supra-aortic vessel transposition would not suffice to create a satisfactory proximal landing zone for endovascular aortic repair, when a concomitant ascending or arch aneurysm was present, or in patients with connective tissue diseases. RESULTS: One patient (2%) died intra-operatively secondary to an aortic rupture in dwnstream aortic segments. No post-operative deaths occurred. Four patients (10%) suffered a non-disabling posto-operative stroke and were discharged with no clinical symptoms (modified Rankin Scale [mRS] 0, n = 1), no significant disability (mRS 1, n = 2), or with slight disability (mRS 2, n = 1). No spinal cord ischaemia was observed. The primary entry tear was either surgically resected or excluded from circulation in all patients. During follow up, one patient (2%) died after two years (not aorta related) and 16 patients (39%) underwent an aortic re-intervention after 7.7 [interquartile range 0.7, 15.8] months (endovascular aortic repair: n = 14; open thoraco-abdominal aortic replacement: n = 1, hybrid approach: n = 1). CONCLUSION: The FET technique is an effective treatment option for acute complicated and chronic Type B or non-A non-B aortic dissection in patients in whom primary endovascular aortic repair is non-feasible. While the post-operative outcome is acceptable with a relatively low incidence of non-disabling strokes, this study also underlines the considerable need for aortic re-interventions. Continuous follow up of all patients undergoing the FET procedure is essential.

Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC.

BACKGROUND: The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. METHODS: In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. RESULTS: The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. CONCLUSIONS: dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.

Distal Stent Graft-Induced New Entries After the Frozen Elephant Trunk Procedure.

BACKGROUND: This study sought to evaluate the incidence of and identify risk factors for distal stent graft-induced new entries (dSINEs) after the frozen elephant trunk (FET) procedure. METHODS: Patient characteristics and radiographic and follow-up data on 126 patients treated for aortic dissections with the Thoraflex (Vascutek Ltd, Inchinnan, United Kingdom) FET device in 2 centers between November 2013 and December 2018 were evaluated. Stress-strain behavior and load-displacement curves of the Thoraflex and the E-Vita Open (Jotec Inc, Hechingen, Germany) FET prosthesis were evaluated by applying axial load to the most distal ring of the prostheses. RESULTS: dSINEs were diagnosed in 16 patients (13%). There was no difference in the underlying disease, aortic features, or FET stent graft dimension between patients with and without dSINEs. No predictors for dSINE occurrence in patients treated with the Thoraflex device were identified. The risk for dSINE development was 14% (95% confidence interval [CI], 0% to 22%), 16% (95% CI, 0% to 24%), and 25% (95% CI, 0% to 45%) after 12, 24, and 36 months, respectively. When prostheses were loaded axially to 2-mm maximal displacement, the Thoraflex prosthesis exhibited strongly nonlinear behavior with maximal stiffness for minimal displacements, whereas the E-Vita prosthesis showed nearly constant stiffness. In addition, the Thoraflex prosthesis showed an increase in stiffness when confined. CONCLUSIONS: dSINEs may develop at any time after the FET procedure, and the risk for dSINE development is high. No clinical or patient-specific risk factors were identified in this study. The design of the Thoraflex graft with a stiff distal ring may be a potential reason for the occurrence of dSINEs.

Impact of Intermittent Functional Internal Iliac Artery Occlusion on Spinal Cord Blood Supply during TEVAR.

BACKGROUND: Measuring transcranial motor evoked potentials (EPs) and somatosensory EPs is a well-established method to assess spinal cord function during thoracic endovascular aortic repair (TEVAR). Functional occlusion of one or both internal iliac arteries by large bore sheaths during TEVAR can cause unilateral intermittently EP loss. METHODS: Between 2006 and 2016, 194 patients underwent TEVAR entailing EP monitoring. The ISIS IOM System (Inomed Medizintechnik GmbH, Emmendingen, Germany) was employed in all patients. EPs were recorded after inducing anesthesia, during the procedure, and before discontinuing anesthesia. RESULTS: We observed a unilateral intermittently EP decrease or loss in 12 (6.2%) patients. Most events were ipsilateral (9 of 12). The underlying pathologies were descending aortic aneurysm in six patients and type B dissection in six patients. An evoked-potential decrease or loss was always associated with the insertion of large bore stent-graft-introducing sheaths. The median duration of the unilaterally EP decrease or loss was 16 (10; 31) minutes (range, 2-77 minutes) with baseline values re-established at the end of the procedure after sheath removal in all cases. No patient developed irreversible symptomatic spinal cord ischemia. CONCLUSION: A functional occlusion of internal iliac arteries via large bore TEVAR-introducing sheaths is associated with a unilateral intermittent decrease in or loss of EPs returning to baseline after sheath removal. This observation highlights the importance of the internal iliac arteries as one of the major spinal cord's blood supply territories, and may serve as a stimulus to reduce the duration of sheath indwelling to a minimum.

Evaluation of myocardial injury, the need for vasopressors and inotropic support in beating-heart aortic arch surgery.

BACKGROUND: In contrast to the standard cardioplegic cardiac arrest (CA), some centers prefer the beating-heart technique using selective normothermic myocardial perfusion (SMP) during aortic arch repair. The aim of this study was to evaluate myocardial injury and the need for inotropic and vasopressor support in patients undergoing total aortic arch replacement using SMP or CA during arch repair. METHODS: Total arch replacement was performed in 127 patients (65 years [IQR: 56-73 years] years) between March 2013 and May 2018 via the frozen elephant trunk technique. Of those, 25 patients were operated on with selective myocardial perfusion. Blood samples and catecholamine doses were evaluated. We compared the SMP group's and CA group's outcomes. RESULTS: The two groups' risk factors, underlying aortic pathologies, and surgical details were similar. The SMP group's intraoperative norepinephrine application rates were significantly lower than the CA group's (P=0.030), as were their postoperative norepinephrine application rates (norepinephrine: P=0.007). Postoperative cardiac enzymes tended to be lower in the SMP group; the difference in creatine-kinase MB reached statistical significance after 14 hours (P=0.024). Intensive care unit stay was significantly shorter in the SMP group (P=0.041), and in-hospital mortality was comparable (4% in the SMP and 11% in the CA group; P=0.46). CONCLUSIONS: By applying selective normothermic myocardial perfusion, beating-heart aortic arch surgery has the potential to reduce the need for perioperative inotropes, and it might reduce myocardial injury. This approach is a potentially useful adjunct to our armamentarium, particularly in patients with preexisting myocardial damage or in conjunction of arch repair together with other cardiac procedures.

Decreased biventricular function following thoracic endovascular aortic repair.

OBJECTIVES: Preclinical studies have suggested acute stiffening of the aorta following experimental thoracic endovascular aortic repair (TEVAR), resulting in acute elevated pulse pressure, hypertension and possibly heart failure. The aim of this study was to evaluate cardiac remodelling following TEVAR. METHODS: From 2005 to 2018, 519 TEVAR procedures were performed at a single centre. Transthoracic echocardiography was performed pre- and post-TEVAR in 31 patients without previous replacement of the thoracic aorta. Patient characteristics, drug information, radiographic and follow-up data were evaluated. Aortic details were measured in multiplanar reconstruction. RESULTS: Transthoracic echocardiography was performed 2 ± 2 years after TEVAR. At this time, patients received significantly more antihypertensive drugs compared to the pre-TEVAR intake (beta-blocker therapy: P = 0.037; calcium channel blocker: P = 0.022). Compared to pre-TEVAR, there was a significant reduction in the left ventricular ejection fraction (P = 0.008) and tricuspid annular plane systolic excursion (P = 0.013) post-TEVAR. A significant increase in the left ventricular mass was not detected in this study (P = 0.95). The mean distance of 163 ± 66 mm of the descending aorta was covered. CONCLUSIONS: This study suggests negative cardiac remodelling with a decrease in the left and right ventricular function following TEVAR despite an increase in oral antihypertensive medication. The impact of stiffer endovascular grafts compared with the native aortic wall should be considered by endovascular specialists and manufacturers.

Late surgical conversions after abdominal endovascular aortic repair: underlying mechanisms, clinical results and strategies for prevention.

OBJECTIVES: Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR). METHODS: Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate. RESULTS: Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2-16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection-1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone. CONCLUSIONS: Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum.

Local and Lower Limb Complications during and after Femoral Cannulation for Extracorporeal Life Support.

OBJECTIVE: The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation. METHODS: Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016. RESULTS: In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) (p = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients (p = 0.45). CONCLUSION: Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut-down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled.

Endovascular aortic arch repair using a double-branched approach.

The last 15 years have overwhelmed the surgical community with a range of approaches in treating pathologies involving the aortic arch of which some are here to stay. The ones to stay are-in the authors' opinion-refined classical surgical approaches such as the frozen elephant trunk technique, near-orthotopic combined vascular and endovascular approaches such as subclavian to carotid transposition/bypass and double transposition, and finally, near-orthotopic advanced endovascular solutions such as the double-endovascular repair using fenestrated and/or branched solutions which will be the main focus of this article.

Endovascular treatment of acute Type A aortic dissection-the Endo Bentall approach.

Outcome after classical surgical repair of acute Type A aortic dissection has steadily improved over the years and several modifications in cannulation and perfusion added to this achievement. However, subgroups remain where results of classical surgical repair still have room for improvement, particularly patients with severe preoperative malperfusion as well as elderly patients with a limited physiological reserve. So far, only small case series or case reports have been published on the endovascular treatment of dissected ascending aortas. However, a tube alone is not sufficient to fix the entire complex underlying problem in the vast majority of patients with acute Type A aortic dissection. In addition, these published reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule. The concept of an endovascular valve-carrying conduit may significantly increase the number of patients suitable for endovascular therapy and it may soon be common practice.

Surgical Treatment of Native and Prosthetic Aortic Infection With Xenopericardial Tube Grafts.

BACKGROUND: The study sought to report our results of surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts from the ascending aorta to beyond the bifurcation. METHODS: Within a 28-month period, 20 patients were treated with a bovine self-made pericardial tube graft to replace infected vascular grafts (after conventional surgical aortic replacement or endovascular stent graft implantation) or to treat a contaminated surgical site. An integrated standardized therapeutic concept was applied in all patients, consisting of complete removal of the infected prosthetic material, extensive debridement, and orthotopic vascular reconstruction with self-made tube grafts constructed from a bovine pericardial patch. RESULTS: Four patients died perioperatively (20%) due to sepsis, pulmonary failure, or sudden circulatory arrest. The mean follow-up was 18 months (first quartile 2, third quartile 17 months). Interval computed tomography scans revealed 100% freedom from proven aortic reinfection, but reinfection cannot be ruled out in 4 patients who died of unknown causes during follow-up or because of ongoing sepsis. Three patients required aortic reintervention for a suture-line aneurysm, for graft occlusion, and for the development of a neoaortointestinal fistulation, respectively. CONCLUSIONS: Patients with infectious aortic disease present in a frail state and the initial and the late mortality is substantial. Yet, surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts shows promising short-term results with regard to durability and freedom from reinfection in any aortic segment. Further studies are needed to learn of the long-term behavior of these grafts.

Identification of experimental bladder sensitivity among dysmenorrhea sufferers.

BACKGROUND: Dysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction. OBJECTIVE: We sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome. STUDY DESIGN: We compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures. RESULTS: Women with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0-100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R2 = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R2 = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain. CONCLUSION: Women experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.

Chronic type B "residual" after type A: what I would do?

"The major goal of surgery for acute type A aortic dissection is to have an alive patient." This motto still remains the most important directive. However, also depending onto the extent of the underlying pathology and consecutively depending onto the extent of primary surgery, there is and will be need for additional classical surgical or interventional treatment sooner or later during follow-up in a substantial number of patients having had surgery for acute type A aortic dissection. This article shall guide the interested reader through the underlying mechanisms as well as treatment options in patients with chronic type B "residual" after type A repair and shall finally suggest preventive strategies to reduce the occurrence of this pathology to a minimum.

True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation.

OBJECTIVES: To evaluate early and mid-term clinical outcomes and to assess the potential of the frozen elephant trunk technique to induce remodelling of downstream aortic segments in acute and chronic thoracic aortic dissections. METHODS: Over a 4-year period, 65 patients (48 men, aged 61 ± 12 years) underwent total aortic arch replacement using the frozen elephant trunk technique for acute (n = 31) and chronic (n = 34) thoracic aortic dissections at our institution. We assessed diameter changes at 3 levels: the L1 segment at the stent graft level; the L2 segment at the thoraco-abdominal transition level and the L3 segment at the coeliac trunk level. True-lumen (TL) and false-lumen (FL) diameter changes were assessed at each level. RESULTS: Fifty-six percent of patients had already undergone previous aortic or cardiac surgery. In-hospital mortality was 6%. Symptomatic spinal cord injury was not observed in this series. During a mean follow-up of 12 ± 12 months, late death was observed in 6% of patients. Aortic reinterventions in downstream aortic segments were performed in 28% at a mean of 394 ± 385 days. TL expansion and FL shrinkage were measured in all segments and were observed at each level. This effect was the most pronounced at the level of the stent graft in patients with chronic aortic dissection, TL diameter increased from 15 ± 17 mm before surgery to 28 ± 2 mm (P = 0.001) after 2 years, and the FL diameter decreased from 40 ± 11 mm before surgery to 32 ± 17 mm (P = 0.026). CONCLUSIONS: The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery.

OBJECTIVES: Our goal was to assess the results after orthotopic branched endovascular aortic arch repair using a new double-branch endoprosthesis in patients with thoracic aortic disease affecting the aortic arch who cannot undergo classical surgery. METHODS: Within a 4-year period, 15 patients with thoracic aortic disease affecting the aortic arch were treated with the Bolton Relay plus double-branch endoprosthesis (Bolton Medical, Sunrise, FL, USA). We assessed clinical outcome, occurrence of endoleaks and the need for secondary interventions. The median logistic EuroSCORE I level was 13.6 (4.2; 22.8). RESULTS: The in-hospital mortality rate was 6.7%. A disabling stroke was observed in 1 (6.7%) patient, whereas non-disabling strokes occurred in 2 (13.3%) patients. Type I and III endoleaks occurred in 6.7%. The median follow-up period was 263 (1st quartile 84; 2nd quartile 564) days. Four patients died during the follow-up period. Aortic-related survival was 100%. CONCLUSIONS: Orthotopic branched endovascular aortic arch repair using the Bolton Relay Plus double-branch endoprosthesis is a safe and feasible technique enriching the armamentarium to treat patients with thoracic aortic disease who cannot undergo classical surgery. Aortic-related survival is excellent, and the occurrence of disabling stroke and endoleaks warranting treatment is low. Further studies are needed to assess the long-term durability of this new method.

Aortic Replacement After TEVAR-Diameter Correction With Modified Use of the Siena Prosthesis.

BACKGROUND: To report a new technique for diameter correction in patients after thoracic endovascular aortic repair (TEVAR) with large stent-grafts using the Vascutek Siena 4-branch collared prosthesis (Vascutek Terumo, Inchinnan, Scotland, UK) in patients undergoing thoracoabdominal (TA) aortic replacement. METHODS: Within a 24-month period, 39 patients underwent TA replacement at our center. Of these, 6 patients had undergone previous TEVAR with large stent-grafts (42 to 48 mm diameter). Indications for TEVAR were aneurysm formation in 3 patients and residual type B aortic dissection (status post repair of type A dissection) in 3 patients. In these patients, the Vascutek Siena 4-branch prosthesis was used in a reversed fashion, removing the elephant trunk portion and using the sewing collar for diameter correction at the anastomotic site. RESULTS: No 30-day mortality and no stroke or symptomatic spinal cord ischemia was observed. Median diameter of the TEVAR graft at the anastomotic site was 44 mm. Median size of the Siena graft used was 26 mm. Diameter correction was successfully achieved in all patients by tailoring the sewing collar of the Siena 4-branch prosthesis to the individual need according to the diameter of the distal end of the stent-graft. CONCLUSIONS: Using the sewing collar of the Vascutek Siena 4-branch prosthesis for diameter correction in patients undergoing TA replacement after previous TEVAR with large stent-grafts adds a useful adjunct to the armamentarium of options in a growing patient population.

The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection.

OBJECTIVES: Our goal was to report our preliminary results in patients with acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair who were treated with the frozen elephant trunk (FET) technique. METHODS: Within a 25-month period, 14 patients with acute complicated Type B aortic dissection underwent surgical repair using the FET technique. The reasons to perform the FET procedure were an ectatic ascending aorta/arch in 6 patients and the lack of an adequate landing zone in 8 patients. RESULTS: No deaths were observed. A non-disabling stroke occurred in 2 patients. Symptomatic spinal cord injury was not observed. The closure of the primary entry tear was successfully achieved in all patients. In 3 patients, a secondary distal thoracic endovascular aortic repair extension was performed during the same hospital stay. The median follow-up period was 6 ± 5 months. CONCLUSIONS: The FET technique is an attractive method for the repair of acute complicated Type B aortic dissection without a suitable landing zone for primary thoracic endovascular aortic repair. It should be considered as an alternative in patients who are at high risk for retrograde Type A aortic dissection, in patients with an unfavourable anatomy or in patients with connective tissue disease.

Inaccurate aortic stent graft deployment in the distal landing zone: incidence, reasons and consequences.

OBJECTIVES: The aim of this study was to investigate the accuracy of stent graft deployment in the distal landing zone (LZ) during thoracic endovascular aortic repair (TEVAR). Currently, TEVAR focuses on accurate stent graft deployment in the proximal LZ. Data on landing in the distal LZ are lacking. METHODS: Of 195 TEVAR patients (2005-16) with a non-dissected aortic pathology, 59 [median age 73 years (first quartile 68; third quartile 77), 20 women] patients had a distal LZ shorter than 40 mm. In all, the aim was to deploy the stent graft just above the target vessel (coeliac trunk, mesenteric superior or renal artery). Patients were divided into the accurate landing (n = 10) and inaccurate landing (IAL, n = 49) groups according to the distance to the target vessel ≤ 5 mm or > 5 mm after TEVAR, target vessel coverage and the need for a second stent graft in the distal LZ. We assessed the distal LZ, stent graft distance to the target vessel, apposition, migration and endoleak Ib on computed tomography. Median follow-up period was 23 months (5; 48). RESULTS: Distal LZ anatomy did not differ between groups. Overall stent graft distance to the target vessel was 10.0 mm (6.5 mm; 16.0 mm). Three patients required a second stent graft in the distal LZ, and in 3 others, the target vessel was accidentally covered. In patients of the accurate landing group primary endoleak Ib occurred less frequently than those in the IAL group (0% vs 33%; P = 0.049). Three (30%) accurate landing and 19 (39%) IAL patients (P = 0.73) presented with substantial stent graft wedge apposition. CONCLUSIONS: Accurate stent graft implantation in the distal LZ with the currently available deployment mechanism is often challenging. An inaccurate landing is associated with a higher incidence of endoleak Ib.