Two-Stage Open Ascending Aorta Replacement Followed by Total Aortic Arch Repair Using a Double-Fenestrated Physician-Modified Endograft for Patients with an Aortic Arch Aneurysm and an Aneurysmal Ascending Aorta.

BackgroundConcave supra-arch triple branched stent-graft system (CS system) offers a new option for treating aortic arch pathologies. However, the efficacy of the innovative device still lacks objective evaluations. Patient-specific CS system design and treatment strategies remain unknown. This study aims to assess the effectiveness and to inform the patient-specific CS system design by evaluating the hemodynamic effects of key parameters.MethodsSimulations were conducted via pre- and post-operative computed tomography angiography datasets from five first-in-man study cases. Parametric studies on the CS system were developed by virtually adjusting concave degree (angle α) in scenarios with patient-specific aortic diameter. Boundary conditions were obtained through three-element Windkessel model. Quantitative and qualitative hemodynamic analyses were conducted via flow rate, pressure, time-averaged wall shear stress (TAWSS)-based parameters and energy loss.ResultsCS system insertion effectively maintained supra-aortic trunks (SATs) blood flow, without significantly affecting ascending aortic (AA) pressure and hemodynamic environments, regardless of postoperative normotensive (120/80 mmHg) or hypertensive (180/140 mmHg) states. Larger concave angles improved SATs perfusion by approximately 1–2%, with hemodynamic variations becoming notably more pronounced when α increased beyond 150°. Specifically, increases in SATs flow were 0.6–0.7% from 120° to 150°, compared with 1.8–2.0% from 150° to 180°, while flow to the left subclavian artery decreased by ~0.45% and ~0.75% over the same ranges. AA pressure changes remained small, with CS implantation increasing systolic pressure by only ~1.2%. Larger aortic diameters or smaller diameter differences between AA and descending aorta (DA) further reduced postoperative AA pressure by approximately 0.1–2%. Notably, patients with smaller aortic diameters exhibited substantially larger hemodynamic changes: for example, TAWSS in the thoracic aorta increased by up to ~40% when D1 =30 mm, compared with only ~10% when D1 =48 mm.ConclusionsCS system shows improved hemodynamic features in treating aortic arch aneurysm and can maintain stability under both normotensive and hypertensive postoperative blood pressure conditions. Larger concave angle can improve surgical convenience, but may also increase the risk of pressure elevation. For patients with small aortic diameters, reducing the concave degree may help to optimize the hemodynamic environment. The findings presented herein provide objective evaluation for assessing CS system outcomes and patient-specific clinical decision making.

Contemporary Outcomes of Thoracic Endovascular Aortic Repair in Patients with Syndromic Genetic Aortopathy: A Multi-Centre National Study.

Medical and surgical comorbidities may present prohibitive risk for open surgical reconstruction of aortic arch pathology. Also, complex anatomy may preclude use of company-manufactured devices available in repair of aneurysmal aortic arch pathology. We sought to describe early experience with physician-modified endografts for management of aortic arch pathology. This was an institutional review board (IRB)-approved retrospective review of prospectively collected data among patients undergoing total endovascular aortic arch repair with a physician-modified endograft (PMEG) in conjunction with cardiothoracic surgery which was performed at a single institution between December 2020 and August 2024. Primary outcomes were technical success, stroke, and target vessel instability. Secondary outcomes included 30-day mortality, spinal cord ischemia, and reinterventions. Nine patients underwent total endovascular repair of the aortic arch with proximal seal in zone 0, with 67% presenting needing urgent or emergent repairs. Repairs were completed using 3 retrograde branches in 3 patients (33%), 3 inner branches in one patient (11%), back-table fenestrations in 3 patients (33%), and laser in situ fenestration in one patient (11%), and the remaining repair was completed with a combination of back-table fenestration and laser in situ fenestration (11%). Technical success was achieved in 8 patients (89%), while access vessel rupture prevented repair in the final patient. With a mean follow-up of 150 days (122-208), there were no instances of target vessel instability observed. One patient suffered a stroke within 30 days (11%), one patient developed pneumonia (11%), and one patient developed bowel ischemia that required laparotomy with resection of necrotic bowel (11%). No patients developed spinal cord ischemia. Four patients died within 30 days of the index intervention (44%), all presenting with acute aortic rupture. Two patients required a reintervention (22%). PMEG for total endovascular arch repair presents a possible alternative to open surgical repair or existing company manufactured arch devices in selected patients. Perioperative stroke and mortality risk and rate of reintervention with total endovascular arch repair using a physician-modified device remain significant.

Background: Extensive thoracic aortic aneurysms involving the aortic arch and descending thoracic aorta represent one of the most complex entities in cardiovascular surgery. Conventional open repair is associated with significant perioperative morbidity, especially in elderly patients with multiple comorbidities. Hybrid strategies combining open arch repair with staged endovascular treatment have emerged as a viable alternative in carefully selected patients. Case Presentation: A 64-year-old hypertensive male with a chronic smoking history and chronic obstructive pulmonary disease presented with progressive dyspnoea. Imaging revealed giant aneurysmal dilatation of the aortic arch and descending thoracic aorta, along with an associated left common iliac artery aneurysm. A staged hybrid approach was planned. Stage I involved total arch replacement with deployment of an elephant trunk graft. Stage II consisted of thoracic endovascular aortic repair to exclude the descending thoracic aortic aneurysm. The postoperative course was complicated by prolonged ventilatory requirement necessitating tracheostomy and a transient generalized tonic–clonic seizure, both of which resolved with appropriate management. The patient recovered well and was discharged in stable condition. Conclusion: This case illustrates that staged hybrid repair using the elephant trunk technique followed by TEVAR provides an effective and relatively safe treatment option for giant thoracic aortic aneurysms in high-risk patients. Careful patient selection, meticulous planning, and multidisciplinary management are essential for optimal outcomes. Keywords: Aortic arch aneurysm; Descending thoracic aortic aneurysm; Elephant trunk technique; Hybrid aortic repair; TEVAR

Aortoesophageal fistula as a late-onset complication of infected aortic arch aneurysm caused by Salmonella enterica serotype Choleraesuis: a case report.

This study compares the outcomes of endovascular repair using pre-curved fenestrated endografts and open surgery with total arch replacement for aortic arch aneurysm repair. Patients who underwent aortic arch aneurysm repair with fenestrated endograft or total arch replacement between 2009 and 2021 were retrospectively analyzed. Subjects were limited to true aortic arch aneurysms, and cases with a history of thoracic aortic surgery, connective tissue disorder, or concomitant procedure were excluded. The Kaplan-Meier method was used to calculate cumulative survival and freedom from aorta-related death, and the Fine and Grey methods were used for re-intervention rates. A total of 106 cases were included, with fenestrated endografts (F group, n=58) and total arch replacement (T group, n=48). The median follow-up times were 48.0 (25.5, 94.8) and 62.5 (46.0, 110.8) months (p=0.038) in the F and T group, respectively. The median age (76.5 [71.3, 80.0] vs 71.5 [66.0, 77.0], p<0.001) and European System for Cardiac Operative Risk Evaluation II (11.0 [10.0, 14.0] vs 8.5 [6.0, 11.0], p<0.001) were higher in the F group. Intraoperative blood transfusions (19 [32.8%] vs 48 [100%], p<0.001), operative times (145.0 [113.3, 191.0] vs 464.5 [413.8, 531.5], p<0.001), postoperative intubation times (0 [0, 0] vs 68.0 [20.0, 150.0], p<0.001), intensive care unit stays (1.0 [1.0, 2.0] vs 6.5 [5.0, 11.0], p<0.001) and in-hospital stays (10.0 [8.0, 12.0] vs 27.0 [22.0, 41.3], p<0.001) were significantly reduced in the F group. In-hospital mortality (2.0 [3.5%] vs 0 [0%], p=0.50), perioperative cerebral infarction (2 [3.5%] vs 3 [6.3%], p=0.66), and spinal cord injury (1 [1.7%] vs 0 [0%], p>1) were comparable between the 2 groups. The 5-year survival rates were 68.9% (standard error [SE]=6.85) and 81.5% (SE=6.00) in the F and T groups, respectively (p=0.003); however, freedom from aorta-related death rate (100% vs 100%, p=0.32) and the re-intervention rates (19.0% vs 6.30%, p=0.08) at 5-year showed no significant difference. Fenestrated endovascular aortic repair reduces operative time, postoperative intubation, intensive care unit and in-hospital stays, and blood transfusions. The 5-year freedom from aorta-related death and re-intervention rates were comparable to those of total arch replacement.Clinical ImpactPre-curved fenestrated endografts provide a less-invasive yet effective option for aortic arch aneurysm repair, compared to total arch replacement. They offer shorter operative and intubation times, reduced transfusion rate, and shorter ICU stays, without increasing aorta-related mortality or reintervention during follow-up. This approach expands treatment opportunities for elderly and high-risk patients who previously could not undergo conventional arch repair.

Valve-sparing aortic root replacement has increasingly been performed in Marfan patients. However, there is ongoing debate on whether the non-aneurysmal sized aortic arch should be prophylactically replaced during the index operation. The aim of our retrospective single-centre study was to investigate the long-term status of the aortic arch in these patients. Between 1993 and 2021, a total of 723 patients underwent valve-sparing aortic root replacement with a straight tube graft (David I reimplantation) at our institution; 119 patients had confirmed Marfan disease. Of these 119 Marfan patients, 67 patients had isolated aortic root aneurysm with no aortic arch pathology. These 67 patients underwent isolated David I procedure in an elective setting (only aortic root and ascending aortic replacement) without any concomitant procedures and were included in the present study. This study includes 67 patients with Marfan syndrome who underwent isolated elective valve-sparing aortic root replacement. The median age of patients was 30 years (20-41), and 47 were male (70%). The cardiopulmonary time was 157.5 (145.8-178.3) min, and aortic clamp time was 117.0 ± 19.8 min. The in-hospital mortality and stroke rates were both 0%. Follow-up was 100% complete. Survival at 1, 5, 10, 15, and 20 years were 100%, 100%, 93%, 89%, and 85%, respectively. Freedom from aortic arch reoperation due to aneurysm at 1, 5, 10, 15, and 20 years was 100%, 100%, 100%, 100%, and 95%, respectively. In follow-up, no patient required aortic arch replacement due to aortic arch aneurysm. A total of 3 patients underwent aortic arch replacement for type B aortic dissection. Of these 3 patients, 1 had chronic type B dissection with aortic aneurysm, and 2 had acute type B dissection. The long-term results after valve-sparing aortic root replacement with a straight tube graft (David I procedure) in Marfan patients are excellent. Our study shows that the risk for future aortic arch intervention after elective valve sparing aortic root replacement in Marfan patients is extremely low. Hence, our study supports the idea that concomitant prophylactic aortic arch replacement during elective valve sparing aortic root replacement in Marfan patients with non-aneurysmal aortic arch is not necessary.

Aim: to summarize the current experience in correcting complex pathology of the ascending aorta, aortic arch, and descending thoracic aorta using the frozen elephant trunk technique. Materials and methods. This study describes the technique and presents the outcomes of the first 42 operations involving prosthetic replacement of the ascending aorta, aortic arch, supra-aortic vessels, and descending thoracic aorta using the frozen elephant trunk technique. These procedures were performed by the staff of the Department of Surgical Treatment of Aortic Pathology at National M. Amosov Institute of Cardiovascular Surgery affiliated to National Academy of Medical Sciences of Ukraine, during the period from 2020 to 2025. All patients underwent a procedure involving complete replacement of the ascending aorta and arch with supra-aortic vessel reimplantation aorta using the stabilized elephant trunk technique as the first stage of reconstruction for aortic arch pathology. Results. Hospital mortality rate was 9.5 % (4 patients). Causes of death included acute cerebrovascular accident in 1 case, acute respiratory failure in 1 case, and multiple organ failure in 2 cases. Two patients required delayed re-exploration for tamponade on postoperative days 2–3 due to bleeding. Persistent lower paraplegia was observed in 3 patients; however, in 2 cases, intensive rehabilitation enabled full recovery of motor function. Renal failure requiring dialysis was observed in 5 patients. One patient underwent re-thoracotomy for postoperative bleeding. Prolonged mechanical ventilation (&gt;2 days) was necessary in 6 patients. Following the first-stage procedure, endovascular repair (TEVAR) of the aortic arch and descending thoracic aorta was performed in 3 (7.1 %) patients within a period ranging from 14 days to 3 years after the initial operation to stabilize the descending thoracic aorta and promote true lumen remodeling following dissection. All endovascular procedures were completed without complications. Conclusions. Radical surgical correction of aortic arch aneurysm or dissection involving supra-aortic vessels or disruption of the anatomical integrity of the arch is feasible using the stabilized elephant trunk technique. Advances in preoperative diagnostics, surgical techniques, optimization of cerebral, spinal, and visceral organ protection, and the availability of hybrid / endovascular approaches have enabled successful treatment of complex pathology involving the ascending aorta, arch, and descending thoracic aorta. The initial outcomes were satisfactory, with a hospital mortality rate of 9.5 % (4 out of 42).

Repair of aortic arch aneurysms is challenging whether by open surgery or endovascular techniques. The aim of this study was to analyse the midterm outcomes of an innovative endovascular thoracic aortic stent-graft with a triple branch design (Cook Medical, Bloomington, IN, USA) and to compare the outcomes in patients with a retrograde or an antegrade branch for the left common carotid artery (LCCA). All patients treated with the custom-made triple-branch arch device between October 2018 and April 2025 at a single tertiary-care hospital were enrolled. Demographics, co-morbidities, indication for the procedure, procedural details, and outcomes were recorded. The primary aim was to evaluate midterm clinical outcomes, including branch primary patency and reintervention rates. The secondary aim was to compare outcomes based on LCCA branch orientation. Some patients were treated. Indications were degenerative (49%) or post-dissection (51%) arch aneurysms. Percutaneous approach was more common in the retrograde group (74% versus 24%, P < 0.001), which also had shorter operative times (160.5 versus 234.0 min, P < 0.001). Thirty-day stroke occurred in five patients (7%; 3% retrograde versus 11% antegrade, P = 0.361). Thirty-day mortality was 3% (3% versus 3%, P = 1) and postoperative heart failure developed in three patients (6% versus 3%, P = 0.599). Median follow-up was 35.8 months (i.q.r. 17.5-62.6 months). During follow-up, 8 patients died (11%) and 14 (19%) required reintervention. Branch primary patency was 100%. Endovascular aortic arch repair with a triple-branch device is associated with favourable early outcomes. A retrograde LCCA branch orientation was associated with shorter operative times, and an increased potential for a totally percutaneous approach. Multicentre studies are required to confirm these findings and evaluate long-term outcomes.

Objective: The aim of this study was to compare clinical outcomes between total arch replacement (TAR) and thoracic endovascular aortic repair (TEVAR) using Najuta in patients with aortic arch aneurysms, based on individual risk profiles including frailty and surgical risk. Methods: From 2011 to 2024, a total of 193 patients underwent surgery for aortic arch aneurysm: 126 patients received TAR and 67 received TEVAR with Najuta. Surgical indication was determined considering frailty and comorbidities such as cancer or respiratory dysfunction (Figure). To reduce selection bias, we used inverse probability of treatment weighting (IPTW) based on age, sex, EuroSCORE II, and frailty. Postoperative stroke and overall survival were assessed using Kaplan-Meier and Cox proportional hazards analyses. Results: After adjustment with IPTW, the stroke rate was 2.7% (weighted N=167) in the TAR group and 16.3% (weighted N=164) in the TEVAR group, corresponding to 4 and 11 stroke cases, respectively. Logistic regression with IPTW showed that TEVAR was significantly associated with a higher risk of stroke (odds ratio 7.02, 95% CI: 2.52–19.57, p &lt; 0.01). In Cox regression without IPTW but adjusting for age, sex, EuroSCORE II, and frailty, TEVAR was not significantly associated with reduced survival (hazard ratio 1.02, 95% CI: 0.43–2.42, p = 0.97). Male sex and frailty showed significant or borderline associations with lower survival (HR 2.74 and 2.41, p = 0.03 and 0.05, respectively). The cumulative survival rates were 84.5%, 79.0%, and 72.9% in the TAR group and 69.0%, 65.5%, and 34.0% in the TEVAR group at 3, 5, and 10 years, respectively (Log-rank p &lt; 0.01). Conclusions: TEVAR with Najuta, selected for high-risk patients, was associated with a significantly higher incidence of stroke even after risk adjustment. Although Kaplan-Meier curves suggested poorer survival in the TEVAR group, multivariable Cox analysis did not identify treatment type as an independent predictor of survival. These findings support the importance of individualized surgical strategy based on patient risk profiles in managing aortic arch aneurysms.

Ortner's syndrome, or cardiovocal syndrome, is an uncommon cause of hoarseness resulting from left recurrent laryngeal nerve palsy due to cardiovascular pathology. We present the case of a 78-year-old male with systemic hypertension, chronic kidney disease, and a history of multiple complex aortic repairs, including Stanford type A dissection repair, thoracoabdominal aortic aneurysm reconstruction, and infrarenal endovascular repair. He developed progressive hoarseness and dysphagia over four months. Videolaryngoscopy revealed left vocal fold paresis, and computed tomography angiography demonstrated a 53-mm aortic arch aneurysm with type IA endoleak adjacent to the recurrent laryngeal nerve. The patient underwent zone 0 thoracic endovascular aortic repair with parallel stenting of the brachiocephalic trunk and left carotid artery, and left subclavian artery occlusion. Hoarseness improved significantly by postoperative day one. This case highlights the importance of considering Ortner's syndrome in patients with unexplained hoarseness and aortic disease, as prompt endovascular intervention can achieve rapid symptomatic relief, even before aneurysm sac regression occurs. To our knowledge, Ortner's syndrome occurring after three extensive aortic repairs, including open thoracoabdominal reconstruction and staged endovascular procedures, has not been previously reported. • Ortner's syndrome is a rare but clinically relevant complication of aortic arch aneurysms. • The importance of multidisciplinary collaboration for timely diagnosis and management is essential. • Rapid symptomatic improvement after advanced endovascular treatment in a high-risk/reoperative case is feasible.

Mycotic aortic arch aneurysm and floating thrombus in aspergillus aortitis in an immunocompetent patient.

Results from the Italian Nexus aRCH endovascular repair registry for endovascular aortic arch repair.

Aortic Trilogy: Aortic Intramural Haematoma between Aortic Arch and Abdominal Aortic Aneurysms.

A case report is presented of a successful hybrid treatment using combined open and endovascular techniques in a patient who developed a giant saccular aortic arch aneurysm during the late period following surgical correction of aortic coarctation in childhood. The young male patient complained of a heavy sensation in the left chest. Multislice CT (MSCT) revealed a large saccular aneurysm of the aortic arch, with a maximum diameter of 9 x 9 cm, extending to the origin of the left subclavian artery. Elective treatment included left carotid–subclavian bypass using a synthetic graft, simultaneous implantation of a stent graft in the Z1 zone of the aortic arch, intraoperative fenestration of the endograft at the left common carotid artery ostium, and subsequent stenting of the carotid origin. Intraoperative fluoroscopy with CT navigation achieved optimal outcomes: adequate perfusion through all brachiocephalic vessels, absence of endoleaks, and reduced contrast exposure. The postoperative course was uneventful, with the patient mobilized on day one and discharged in stable condition on day seven. Twelve-month follow-up MSCT demonstrated complete aneurysm thrombosis and stable stentgraft patency. This case illustrates that hybrid minimally invasive approaches complemented by CT-guided navigation may significantly enhance the safety and efficacy of treating complex aortic arch aneurysms in patients with prior vascular corrections.

ObjectivesThis study aimed to evaluate midterm outcomes and identify predictors of sac shrinkage following total arch replacement with a frozen elephant trunk (TAR-FET) for true aortic arch aneurysms.MethodsA retrospective analysis was conducted on 28 patients who underwent elective TAR-FET for true arch aneurysms between July 2014 and March 2022. Postoperative sac changes on CT were categorized as shrinkage (≥5 mm reduction), enlargement (≥5 mm increase), or no change (<5 mm change). The sphericity index, a novel morphological parameter, was calculated by dividing the average axial and sagittal sac diameters by sac length.ResultsThe median age was 74 years, and 23 were male. No operative deaths or recurrent laryngeal nerve palsy occurred. Among 28 patients, 12 experienced sac shrinkage attributable to the initial TAR-FET. Over a median follow-up of 3.6 years, 12 cases showed shrinkage, 2 enlargement, and 14 no change. Cumulative shrinkage rates at 1, 2, and 3 years were 42%, 47%, and 47%, respectively. Additional thoracic endovascular aortic repair (TEVAR) was required in 5 patients (22% at 3 years). Multivariable analysis showed that shorter preoperative sac length (subdistribution hazard ratio [SHR] 0.96; 95% CI, 0.93-0.99) and a higher sphericity index (per 0.1 increment: SHR 1.38; 95% CI, 1.21-1.57) were independently associated with sac shrinkage.ConclusionsTAR-FET resulted in sac shrinkage in a substantial proportion of patients. Aneurysms that were shorter and more protruding, as indicated by a higher sphericity index, may be more likely to exhibit postoperative sac shrinkage.Clinical Registration Number022-0242; 16 November 2022 (Ethics Committee of Hokkaido University Hospital).

Interruption of the aortic arch is a rare congenital cardiac malformation with rare cases described in adulthood. Survival in adulthood relies on developing collateral networks to maintain distal flow. CHD occurs in almost 50% of Turner syndrome and is the most frequent cause of early mortality. Also, they have an increased risk factor for thoracic aortic dilatation, and elective surgery should be considered according to body surface area. Surgical correction is the preferred treatment for the interrupted aortic arch and aortic root dilatation. We present the case of a 46-year-old patient with Turner syndrome with a diagnosis of interrupted aortic arch and aortic root aneurysm who underwent the Bentall procedure and interposition of a Dacron graft in the descending aorta. Post-procedural recovery was uneventful with a good haemodynamic response.

Duplex ultrasound-based comparative analysis of inner branch orientation for the left common carotid artery following triple-branch arch endovascular repair.

Cold agglutinin disease (CAD) is sometimes incidentally detected before cardiovascular surgery. Several methods to prevent complications associated with CAD after cardiac surgery have been reported, but there are no reports of the use of physician-modified TEVAR to date. A 76-year-old man with an arch aortic saccular aneurysm was scheduled to undergo arch aortic replacement. However, cold agglutinin syndrome was incidentally detected before open heart surgery. The safety of cardiopulmonary surgery under hypothermia for patients with cold agglutinin disease is unknown, as intravascular hemolysis is a source of concern for patients sensitive to cold stimulation. Instead, we performed physician-modified thoracic endovascular aortic repair (3 fenestrations and 1 branch), as the aneurysm in this case was suitable for thoracic endovascular aortic repair (TEVAR). As a result, the patient recovered well without any complication. The long-term prognosis of physician-modified thoracic endovascular aortic repair remains unclear, and its use is limited to high-risk patients who require open chest surgery. Also, the impact of cold agglutination on stent grafts in CAD patients has not been reported. Despite that situation, this case illustrated that physician-modified TEVAR can be safely performed without significant postoperative complications, such as coagulation-fibrinolytic abnormalities or embolic events. Further studies are needed to establish the indications for this procedure in CAD patients.