Three-Dimensional-Evaluation of Aortic Changes after Frozen Elephant Trunk (FET) in Zone 0 vs. Zone 2 in Acute Type A Aortic Dissection.

Introduction: The management of aortic dissection has evolved significantly over the decades, with the frozen elephant trunk (FET) procedure emerging as a key technique for treating complex aortic pathologies. Recent practices involve deploying the FET prosthesis more proximally in the aorta (Zone 0) to reduce complications, leading to questions about its impact on long-term aortic remodeling compared to traditional Zone 2 deployment. Methods: This retrospective analysis utilized 3D segmentation software to assess the volumetric changes in aortic remodeling after acute Type A aortic dissections, comparing FET stent graft deployment in Zone 0 and Zone 2. The study included 27 patients operated on between 2020 and 2022, with volumetric measurements taken from postoperative and 6-month follow-up CT scans. Statistical analyses were performed to evaluate the differences in the aortic true lumen (TL) and the perfused false lumen (PFL) between the two groups. Results: Both Zone 0 and Zone 2 deployments resulted in significant true lumen (TL) increases (Z0 p = 0.001, Z2 p < 0.001) and perfused false lumen (PFL) decreases (Z0 p = 0.02, Z2 p = 0.04), with no significant differences in volumetric changes between the groups (p = 0.7 post op and p = 0.9 after 6 months). The distal anastomosis in Zone 0 did not compromise the aortic remodeling outcomes and was associated with reduced distal ischemia and cerebral perfusion times (p = 0.041). The angle measurements in Zone 0 did not show any significant changes after the 6-month control (p = 0.2). However, in Zone 2, a significant change was detected. (p = 0.022). The part comparison analyses did not indicate significant differences in aortic deviation between the groups (p = 0.62), suggesting comparable effectiveness in aortic remodeling. Conclusions: Performing the distal anastomosis more proximally in Zone 0 offers technical advantages without compromising the effectiveness of aortic remodeling compared to the traditional Zone 2 deployment. This finding supports the continued recommendation of Zone 0 deployment in the management of acute Type A aortic dissections, with ongoing studies being needed to confirm the long-term outcomes and survival benefits.

Sex Differences in Short- and Long-Term Survival after Acute Type A Aortic Dissection.

Background and Objectives: Acute type A aortic dissection (AAD) is a life-threatening disease. No differences between men and women have been made in the treatment of AAD so far and knowledge about sex differences regarding long-term outcomes is limited. Materials and Methods: Between 01/2004 and 12/2021, 874 patients were operated on for AAD, including 313 (35.8%) women and 561 (64.2%) men. Clinical and surgical records, including long-term follow-up information, were obtained and analyzed retrospectively. To account for differences in the outcome determined by different preoperative life expectancies, a subgroup analysis for a set of patients matched according to their remaining life expectancy was performed. Results: At the time of AAD, women were older than men (69.1 ± 13.0 vs. 61.8 ± 13.3 years, p < 0.001) and had a shorter remaining statistical life expectancy (18.6 ± 10.8 vs. 21.4 ± 10.4 years, p < 0.001). Significantly more DeBakey type II AAD was found in women (37.1% vs. 25.7%, p < 0.001). Comorbidities and preoperative status at the time of presentation were similar in women and men. More hemiarch procedures (63.3% vs. 52.0%, p < 0.001) and less arch replacements (8.6% vs. 16.6%, p < 0.001) were performed in women, resulting in shorter cross-clamp times for women (92 ± 39 vs. 102 ± 49 min, p < 0.001). The in-hospital mortality was similar in women and men (11.5% vs. 12.7%, p = 0.618). Long-term survival was significantly shorter in women compared to men (9.8 [8.1-11.5] vs. 15.1 [11.9-18.4] years, p = 0.011). A matched subgroup analysis revealed that when comparing groups with a similar remaining life expectancy, the long-term survival showed no significant differences between women and men (9.8 [7.9-11.6] vs. 12.4 [10.1-14.7] years, p = 0.487). Conclusions: There are sex differences in AAD, with DeBakey type II dissection being more frequent in women. The seemingly worse long-term outcome can mostly be attributed to the shorter remaining statistical life expectancy at the time of presentation.

Island remodelling in acute and chronic aortic dissection treated with frozen elephant trunk.

OBJECTIVES: The island technique for reimplantation of supra-aortic vessels in frozen elephant surgery is commonly used but might be questioned for dissected vessels. This study analyses the remodelling of reimplanted supra-aortic vessels after FET in acute and chronic aortic dissection (CAD). METHODS: Between June 2017 and April 2021, 133 patients were operated for acute and CAD using the frozen elephant technique. The island technique for reimplantation of the supra-aortic vessels was used in 94/133 patients. In 68 acute and 21 chronic patients, the total vessel lumen (VL), true lumen, false lumen (FL) and perfused FL area were measured in the innominate, right common carotid and left common carotid artery. Relative luminal changes were compared. RESULTS: In acute aortic dissection, 80% innominate, 40% right carotid and 59% left carotid arteries were dissected preoperatively, but postoperatively FL was only patent in 29%, 12% and 10% (P < 0.001). FL disappearance resulted in >20% total VL reduction in innominate, right carotid and left carotid artery (P < 0.01). In CAD, only 38% innominate, 14% right carotid and 43% left carotid arteries were dissected preoperatively, but postoperatively FL was patent in 19% (ns), 10% (ns) and 5% (P = 0.009). CONCLUSION: Vascular remodelling is frequently found after the island technique. In acute aortic dissection, the island technique frequently initiates FL disappearance associated with VL decrease. Continuously dissected head vessels show positive remodelling with true lumen increase without VL increase. FL disappearance is frequently found in CAD.

Risk Factors for High Blood Product Use in Patients with Stanford Type A Dissection.

BACKGROUND: Intraoperative and postoperative bleeding associated with allogeneic blood transfusion and reoperation is still a common and feared complication in patients undergoing surgery due to acute Type A Aortic Dissection (aTAAD). The aim of our study was to identify risk factors for higher transfusion rates. METHODS: In this retrospective single center study we evaluated pre -, intra-, and postoperative data of 121 patients with aTAAD. Depending on the median of received packed red blood cells (PRBCs), patients were divided into Group A (<8 PRBC, n = 53) and Group B (≥8 PRBC n = 68). Statistical analyses (descriptive statistics, univariable and multivariable logistic regression) were performed using SPSS software 25.0. Statistical significance was assumed at p-value <0.05. RESULTS: A total of 120 patients received a blood product during their perioperative course. Among others we identified age, hemorrhagic pericardial effusion, and dual antiplatelet therapy as preoperative risk factors, low rectal temperature as intraoperative risk factor and low body temperature, positive fluid balance, high lactate level and beginning development of acute renal failure as postoperative risk factors. CONCLUSION: Our study identifies several factors which predict a higher likelihood of bleeding and consecutive blood transfusion. Knowledge of these factors could influence the therapy to reduce transfusion requirements and lead to a targeted and more efficient use of coagulation products.

Endovascular repair of ascending aortic diseases with custom-made endografts.

OBJECTIVES: The aim of this article is to report the mid-term results of ascending thoracic endovascular aortic repair using a custom-made device (CMD). METHODS: This was a retrospective study performed at tertiary centres. Nine patients considered unfit for open surgery received elective total endovascular repair of the ascending aorta with a Relay® (Terumo Aortic, Sunrise; FL, USA) CMD: pseudoaneurysn (n = 5), localized dissection (n =3) and contained rupture (n = 1). RESULTS: Primary clinical success was achieved in all patients with no major complications and no early conversion to open surgery. All patients were discharged home and independent: median length of stay was 7 days (interquartile range, 6-18). No patient was lost to follow-up at a median 26 months (interquartile range, 12-36). Three patients died 2, 6 and 24 months after intervention; 1 was aorta related (late aorto-atrial fistula due to infection that required open surgery). At the last follow-up available, no endoleaks, migrations, fractures or ruptures were observed in the remaining 6 patients. CONCLUSIONS: Ascending thoracic endovascular aortic repair with Terumo Aortic CMDs was technically feasible, effective and safe in very selected lesions. CMDs showed good ascending aorta conformability with different configurations and diameters, and satisfactory mid-term durability as shown by both structural integrity and aortic lesion exclusion.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions.

OBJECTIVES: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures. METHODS: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared. RESULTS: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02). CONCLUSIONS: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

Retrograde autologous priming in surgery of thoracic aortic aneurysm.

OBJECTIVES: Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). METHODS: A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value <0.05. RESULTS: Lower blood product requirements were observed for the RAP group regarding the transfusion of intraoperative RBC (0.87 ± 1.33 vs 1.97 ± 2.43, P = 0.013), postoperative RBC (0.57 ± 1.4 vs 1.32 ± 1.82, P = 0.002) and postoperative fresh frozen plasma (0.52 ± 1.63 vs 1.48 ± 3.32, P = 0.036). The postoperative drainage loss showed significantly lower measurements for the RAP group after 6 h (295.9 ± 342.6 vs 490.6 ± 414.4 ml, P ≤ 0.001), 12 h (450.1 ± 415.5 vs 652.1 ± 463.9 ml, P < 0.001) and 24 h (693.1 ± 483.9 vs 866.4 ± 508.4 ml, P = 0.004). CONCLUSIONS: RAP is a safe and easy method to reduce RBC transfusion in TAA surgery without any adverse effects on the clinical outcome. We were also able to show beneficial effects on fresh frozen plasma requirements and postoperative chest drainage volume. Furthermore, improved microcirculation can be suspected. In consequence, we have implemented RAP as a clinical standard during thoracic aortic surgery.

Retrograde Stanford type A dissection caused by a multilayer stent graft in a patient with chronic type B dissection.

A patient with progressive chronic type B dissection and contraindication for open surgery underwent thoracic endovascular aortic repair using a Cardiatis Multilayer Flow Modulator®. Two weeks after the intervention, the patient experienced a ruptured retrograde type A aortic dissection caused by the stent's uncovered proximal ends.

Dilatation of Vascular Prostheses in Ascending Aortic Position: A Long-Term Follow-Up Computed Tomography Study with Comparison of Different Measurement Methods.

BACKGROUND: The aim of this study was to evaluate long-term dilatation of Hemashield Gold and Hemashield Platinum vascular prostheses in ascending aortic position using different measurement methods to obtain precise results. METHODS: Between 1999 and 2007, 73 patients with Stanford type A dissection received ascending aortic replacement with Hemashield Gold and Hemashield Platinum prostheses. Measurements were performed using multiplanar reconstruction mode of electrocardiogram (ECG)-gated, multislice spiral computed tomography (MSCT) in strictly orthogonal cross-sectional planes. Different methods of measurement were compared and maximum dilatation was estimated for different time spans. RESULTS: Diameters calculated from the measured circumference showed a significant (p = 0.037) but clinically not relevant difference (0.1 mm) to the mean between the largest and the shortest cross-sectional diameter of the prosthesis. Dilatation after 24.2 ± 10.2 months was 8.5 ± 4.5%. Long-term dilatation after 91.8 ± 34 months amounted to 11.8 ± 4.2%. CONCLUSION: Based on ECG-gated MSCT images, the presented methods of measurement provided reliable results. Long-term analysis shows low dilatation rates for Hemashield prostheses, which therefore can be considered as safe from this point of view. Nevertheless, a maximal dilatation of 20% could be relevant in valve sparing root replacement. It remains unclear if a dilatation like this contributes to the formation of suture aneurysms.

Paradoxical Embolus Stuck in a Patent Foramen Ovale.

In-hospital mortality rate of an embolus in transit is as high as 44.7%. In some cases, a paradoxical embolus can get stuck in a patent foramen ovale. Because of the high mortality rate, this condition should be considered as an emergency case. Echocardiography has been established as the gold standard method for the diagnosis. A negative echocardiography, however, does not rule out an embolus in transit. To rule out pulmonary embolisms, a computed tomography scan of the chest should also be performed. A cardiothoracic surgeon should be consulted immediately upon diagnosis of an embolus in transit. There is no medical consensus for the treatment of the above mentioned condition, however, surgical treatment appears to be the best approach in patients who are surgical candidates.

Endovascular and Operative Treatment of the Aortic Arch in a High-Risk Marfan Patient.

In this case, we describe a combined endovascular and operative management for aortic arch repair in a 57-year-old Marfan patient with complex aortic arch geometry previously treated with several open surgeries for acute type A dissection. The patient, who was presented to our department with dorsal pain, deemed to be at high operative risk for another open aortic surgery due to massive aortic calcification. It is an unusual method of placing a custom-made stent-graft system in the false aortic lumen with operative and endovascular treatment of the supra-aortic vessels.

Long-Term Outcome and Quality of Life in Aortic Type A Dissection Survivors.

BACKGROUND: Aortic dissection is a severe and sophisticated disease that is often linked with a number of possible complications. Our study concerns with long-term outcome and quality of life (QoL) in acute aortic dissection type A (AADA) survivors. METHODS: From January 1999 until December 2006, 120 consecutive patients with AADA received an emergency operation. Of the total number of patients, 84 were males (70.0%) and 36 females (30.0%), mean aged 59.8 ± 12 years with a mean follow-up (FU) of 99.2 ± 6 months. RESULTS: Overall mortality was 39.1% during the observational period with a maximum of 156 months. SF-36 observation showed a significant decay in both Physical Component Summary (PCS) and Mental Component Summary (MCS) in FUII (PCS = 38.4) versus FUI (PCS = 43.4, p = 0.013). CONCLUSION: With ongoing postoperative time, patients did not recover but instead have got worse in terms of QoL. The decrease in MCP and linked subscores is an underestimated factor in QoL and long-term outcome after AADA. This is especially true in younger patients, which are judged to compensate better than older patients.

Activation of Endocannabinoid System Is Associated with Persistent Inflammation in Human Aortic Aneurysm.

Human aortic aneurysms have been associated with inflammation and vascular remodeling. Since the endocannabinoid system modulates inflammation and tissue remodeling, we investigated its components in human aortic aneurysms. We obtained anterior aortic wall samples from patients undergoing elective surgery for aortic aneurysm or coronary artery disease as controls. Histological and molecular analysis (RT-qPCR) was performed, and endocannabinoid concentration was determined using LC-MRM. Patient characteristics were comparable between the groups except for a higher incidence of arterial hypertension and diabetes in the control group. mRNA level of cannabinoid receptors was significantly higher in aneurysms than in controls. Concentration of the endocannabinoid 2-arachidonoylglycerol was significantly higher, while the second endocannabinoid anandamide and its metabolite arachidonic acid and palmitoylethanolamide were significantly lower in aneurysms. Histology revealed persistent infiltration of newly recruited leukocytes and significantly higher mononuclear cell density in adventitia of the aneurysms. Proinflammatory environment in aneurysms was shown by significant upregulation of M-CSF and PPARγ but associated with downregulation of chemokines. We found comparable collagen-stained area between the groups, significantly decreased mRNA level of CTGF, osteopontin-1, and MMP-2, and increased TIMP-4 expression in aneurysms. Our data provides evidence for endocannabinoid system activation in human aortic aneurysms, associated with persistent low-level inflammation and vascular remodeling.

Implantation of a total abdominal mesh plastic ending up in multiple, lethal right heart injuries.

We present the case of a 62-year old patient who had an elective surgery to implant a total abdominal plastic mesh due to massive herniation after prior lower body gun shots and deep wound infections. Twenty-four hours after the operation, the patient's condition deteriorated, ST-deviation occurred and the Troponin I test was positive. On admission, the patient needed moderate catecholamine therapy and echocardiography showed a pericardial effusion (>3 cm). Puncture of the effusion was impossible due to the plastic mesh and the patient was transferred to the operating room. A subxiphoidal pericardial incision was performed and 800 ml of fresh blood was drained. Despite this, the patient's condition worsened. A full sternotomy was performed, and intrathoracal cardiopulmonary resuscitation started. During examination of the pericardium and the heart, multiple plastic parts from the mesh fixation system were observed transdiaphragmally and were found to have penetrated the diaphragmal part of the right ventricle. In spite of maximum drug, respiratory and surgical therapy, a sufficient heart ejection fraction could not be achieved. Upon interdisciplinary consent, therapy was stopped after 60 min.

Retrograde Autologous Priming as a Safe and Easy Method to Reduce Hemodilution and Transfusion Requirements during Cardiac Surgery.

BACKGROUND: During the last decades many efforts have been made to reduce transfusion requirements and adverse clinical effects during cardiopulmonary bypass (CPB). The minimal extracorporeal circulation (MECC) system and the technique of retrograde autologous priming (RAP) of a conventional CPB circuit have been associated with decreased hemodilution. Our study aimed to compare conventional CPB (cCPB), RAP, and the ROCsafe MECC (Terumo Europe N.V., Leuven, Belgium) system in elective coronary artery bypass patients. PATIENTS AND METHODS: Data were retrospectively collected on three cohorts of 30 adult CPB patients. Patients were operated using cCPB, RAP, and the ROCsafe MECC system. RESULTS: The three groups were comparable in demographic data. The priming volume in the ROCsafe and RAP group was significantly less compared with the conventional priming group (p <0.05). The mean time of extracorporeal circulation and aortic cross-clamp time (p <0.05) were significantly shorter in the ROCsafe group. The levels of hemoglobin (Hb) and hematocrit (Hct) during CPB and postoperatively showed significant differences between the three groups (p < 0.05) and resulted in significantly higher blood transfusion requirements (p < 0.05). Lactate, serum creatinine, troponin, and creatine kinase-myocardial band (CK-MB) levels did not differ significantly among the three groups (p >0.05). There was also no statistically significant difference in ventilation time, intensive care unit (ICU) stay, overall hospital stay, and postoperative complications (p >0.05). CONCLUSION: In conclusion, RAP is compared with cCPB and MECC a safe and low-cost technique in reducing the priming volume of the CPB system, causes less hemodilution, and reduces the need for intra- and postoperative blood transfusion.

Surgical treatment and thoracic endovascular aortic repair in type A aortic dissection in a pregnant patient with Marfan syndrome.

We report an acute aortic dissection type Stanford A extending down to both iliac arteries affecting a 32-year-old woman suspected to have Marfan syndrome during week 37 of pregnancy. In a multidisciplinary approach, and emergency Cesarean section was performed followed by an abdominal hysterectomy and a valve-sparing aortic root replacement using a reimplantation technique. The aorta was replaced up to the hemi arch. Because of the high suspicion of visceral ischemia as confirmed ex juvantibus, an endovascular stent graft was implanted. Molecular testing revealed a frameshift mutation and confirmed the diagnosis of Marfan syndrome. Both the patient and her healthy child underwent an uneventful recovery.

A migrated aortic stent graft causing erosive spondylopathy.

We report about a patient presenting with back pain 4 months after an uneventful endovascular implantation of an aortic stent graft. Computed tomography scan revealed a migration of the stent with consecutive endoleakage, kink formation, and movement of the stent toward the spine, which caused destruction of the aortic wall as well as vertebral necrosis. Explantation of the stent and replacement of the native aorta relieved the patient of his symptoms.