Aortic Arch Vessels Research Articles

A rare cause of dyspnea and its surgical treatment

Diagnosis of vascular anomalies of the aortic arch is often delayed in adolescents and adult patients. In the presence of dyspnea that cannot be explained through a pulmonary and/or cardiac disease, and sudden dysphagia in children and younger adult patients, a cross-sectional imaging examination of the chest is mandatory to exclude or confirm malformation or malposition of the aortic arch and/or aberrant supra-aortic vessels.

Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion Does Not Negatively Affect Donor Cardiac Function in Donation After Circulatory Death.

The hemodynamic effects of aortic arch vessel (AAV) clamping during normothermic regional perfusion (NRP) in donation after circulatory death is unknown. We investigated effects of AAV clamping during NRP compared with no clamping in a porcine model. In 16 pigs, hemodynamic parameters were recorded including biventricular pressure-volume measurements and invasive blood pressure. Additionally, blood gas parameters and inflammatory cytokines were used to assess the effect of AAV clamping. The animals were centrally cannulated for NRP, and baseline measurements were obtained before hypoxic circulatory arrest was induced by halting mechanical ventilation. During an 8-min asystole period, the animals were randomized to clamp (n = 8) or no-clamp (n = 8) of the AAV before commencement of NRP. During NRP, circulation was supported with norepinephrine (NE) and dobutamine. After 30 min of NRP, animals were weaned and observed for 180 min post-NRP. All hearts were successfully reanimated and weaned from NRP. The nonclamp groups received significantly more NE to maintain a mean arterial pressure >60 mm Hg during and after NRP compared with the clamp group. There were no between group differences in blood pressure or cardiac output. Pressure-volume measurements demonstrated preserved cardiac function' including ejection fraction and diastolic and systolic function. No between group differences in inflammatory markers were observed. AAV clamping did not negatively affect donor cardiac function or inflammation after circulatory death and NRP. Significantly less NE was used to support in the clamp group than in the nonclamp group.

Midterm Outcomes of Endovascular Repair of Aortic Arch Aneurysms with the Gore Thoracic Branch Endoprosthesis

Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported. This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported. The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement > 5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm. Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.

Separate origin of left external and internal carotid arteries directly from aortic arch in a patient with double outlet right ventricle

We report a case of a 1-year-old boy with double outlet right ventricle where computed tomography(CT) angiography incidentally demonstrated the separate origin of the left external and internal carotid arteries directly from the left-sided aortic arch with absence of a left common carotid artery. The case highlights the underlying embryological hypothesis as well as the importance of CT angiography in identifying anomalies of the aortic arch and arch vessels in the setting of complex congenital heart defects.

Adapting to transradial approach in cerebral angiography: Factors influencing successful cannulation.

To evaluate factors that influence the successful cannulation of intracranial vessels using a transradial approach. A total of 61 transradial diagnostic angiograms were evaluated in a tertiary care center from July 2020 to December 2021. We evaluated the learning curve and aortic arch vessel factors that may influence the cannulation of intracranial major vessels using a transradial approach. Learning curve for the procedure was established after 21 cases. We were successful in cannulating the supra-aortic arteries except in 4 cases where we were unable to cannulate the left VA (vertebral artery). Significant positive correlation was seen between time to Sim (Simmons curve) formation and aortic arch diameter (p = .002). Significant positive correlation was also seen between left VA take-off angle and time to cannulate left VA (p = .001) and negative correlation was noted between left CCA (common carotid artery) take-off angle and time to cannulate left CCA (p = .001). Transradial approach is a feasible and safe approach for performing cerebral angiography. Multiple factors can influence the procedure time and successful cannulation of intracranial vessels. With the availability of radial specific hardware in the future, procedural success and time taken to complete the procedure may improve.

Comparison of 2D and 4D Flow MRI in Neonates Without General Anesthesia.

Neonates with critical congenital heart disease require early intervention. Four-dimensional (4D) flow may facilitate surgical planning and improve outcome, but accuracy and precision in neonates are unknown. To 1) validate two-dimensional (2D) and 4D flow MRI in a phantom and investigate the effect of spatial and temporal resolution; 2) investigate accuracy and precision of 4D flow and internal consistency of 2D and 4D flow in neonates; and 3) compare scan time of 4D flow to multiple 2D flows. Phantom and prospective patients. A total of 17 neonates with surgically corrected aortic coarctation (age 18 days [IQR 11-20]) and a three-dimensional printed neonatal aorta phantom. 1.5T, 2D flow and 4D flow. In the phantom, 2D and 4D flow volumes (ascending and descending aorta, and aortic arch vessels) with different resolutions were compared to high-resolution reference 2D flow. In neonates, 4D flow was compared to 2D flow volumes at each vessel. Internal consistency was computed as the flow volume in the ascending aorta minus the sum of flow volumes in the aortic arch vessels and descending aorta, divided by ascending aortic flow. Bland-Altman plots, Pearson correlation coefficient (r), and Student's t-tests. In the phantom, 2D flow differed by 0.01 ± 0.02 liter/min with 1.5 mm spatial resolution and -0.01 ± 0.02 liter/min with 0.8 mm resolution; 4D flow differed by -0.05 ± 0.02 liter/min with 2.4 mm spatial and 42 msec temporal resolution, -0.01 ± 0.02 liter/min with 1.5 mm, 42 msec resolution and -0.01 ± 0.02 liter/min with 1.5 mm, 21 msec resolution. In patients, 4D flow and 2D flow differed by -0.06 ± 0.08 liter/min. Internal consistency in patients was -11% ± 17% for 2D flow and 5% ± 13% for 4D flow. Scan time was 17.1 minutes [IQR 15.5-18.5] for 2D flow and 6.2 minutes [IQR 5.3-6.9] for 4D flow, P < 0.0001. Neonatal 4D flow MRI is time efficient and can be acquired with good internal consistency without contrast agents or general anesthesia, thus potentially expanding 4D flow use to the youngest and smallest patients. 1 TECHNICAL EFFICACY: Stage 2.

Penetrating Atherosclerotic Aortic Ulcer with Pseudoaneurysm

We present a case of penetrating atherosclerotic aortic ulcer with pseudoaneurysm which was managed by a hybrid partial debranching thoracic endovascular aneurysm repair (d-TEVAR) procedure. A 68-year-old professional singer with multiple comorbidities presented with mid-chest pain radiating to the back for the past 2 months. Computed tomography aortogram revealed a penetrating atherosclerotic ulcer near the summit of the left subclavian artery (LSA) at the distal aortic arch. In view of the high risk of an open-heart surgery, TEVAR procedure with partial debranching of the aortic arch vessel was proposed. As the aneurysm was close to the origin of the LSA, an adequate proximal landing zone was not available. Hence, a bypass from the left common carotid artery to the LSA was done. Following this, an endovascular procedure was performed and the stent graft was placed covering the origin of the LSA. Check aortograms after the procedure revealed patent stent and complete obliteration of the pseudoaneurysm. There was no endoleak noted and the left carotid to subclavian artery bypass was functioning well. The postoperative period was uneventful. Follow-up over a 6-month period was satisfactory. The key elements of a successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough planning, and careful procedural execution. This case demonstrates that a hybrid procedure with partial debranching and thoracic endovascular repair of penetrating aortic ulcers is a safe and less-invasive alternative for elderly, high-risk patients.

Normothermic Regional Perfusion of Circulatory Dead Donor Hearts: Quick and Dirty or Slow and Steady?

<h3>Purpose</h3> We sought to compare two strategies for cardiac reanimation in normothermic regional perfusion (NRP) in a clinically relevant porcine model of donation after circulatory death (DCD). To this day, many different protocols for NRP have been described. <h3>Methods</h3> For NRP-strategy 1(30mProp), pigs (n=16) were anaesthetized with intravenous Propofol (3.5 mg/kg/h) and subjected to hypoxic circulatory arrest (CA) by halting mechanical ventilation. After an 8-minute warm ischemia period, donor hearts were reanimated by a 30-minute NRP-period with Propofol suspended. For NRP-strategy 2(60mSevo), pigs (n=10) were anaesthetized with inhaled Sevoflurane (3.5%) before institution of hypoxia induced CA. A 10-minute warm ischemia followed before 60 minutes NRP with Sevoflurane continued. Both groups were reperfused via central cannulation with the aortic arch vessels and infrarenal aorta occluded. NRP flow, oxygenation, and weaning were standardized between groups. We assessed hemodynamic function with invasive blood pressure and bi-ventricular pressure-volume recordings 30 minutes post-NRP. <h3>Results</h3> All hearts were successfully reanimated during NRP in both groups. During NRP, a significantly higher mean arterial blood pressure and a minor need for pressor support with norepinephrine were observed in the 60mSevo group compared to the 30mProp group. Cardiac output remained on baseline levels in both groups post-NRP. Arterial lactate was significantly lower in the 60mSevo group post-NRP compared to the 30-minProp group. Left ventricular end-systole elastance as a measure of contractility increased significantly from baseline to post-NRP by 0.5 mmHg/mL (95%CI 0.09 : 1.0) in the 60-minSevo group and increased non-significantly by 0.3 mmHg/mL (95%CI -0.04 : 0.7) in the 30minProp group, while right ventricular contractility increased non-significantly in both groups. <h3>Conclusion</h3> Hearts reperfused for 60 minutes combined with inhaled Sevoflurane showed superior contractile function compared to hearts subjected to 30-minute NRP and Propofol anaesthesia. The results indicate that longer NRP is beneficial in DCD heart donation.

Vascular anastomosis device to facilitate aortic arch vessel reconstruction.

Vascular anastomosis device to facilitate aortic arch vessel reconstruction.

"The Case of a 44 Year Old Survivor of Unrepaired Tetralogy of Fallot, Right Aortic Arch and Abdominal Aortopulmonary Collateral Vessels"

"The Case of a 44 Year Old Survivor of Unrepaired Tetralogy of Fallot, Right Aortic Arch and Abdominal Aortopulmonary Collateral Vessels"

A Combined Deep Learning System for Automatic Detection of “Bovine” Aortic Arch on Computed Tomography Scans

The “bovine” aortic arch is an anatomic variant consisting in a common origin of the innominate and left carotid artery (CILCA), associated with a greater risk of thoracic aortic diseases (aneurysms and dissections), stroke, and complications after endovascular procedures. CILCA can be detected by visual assessment of computed tomography (CT) chest scans, but it is rarely reported. We developed a deep learning (DL) segmentation-plus-classification system to automatically detect CILCA based on 302 CT studies acquired at 2 centers. One model (3D U-Net) was trained from scratch (supervised by manual segmentation), validated, and tested for the automatic segmentation of the aortic arch and supra-aortic vessels. Three DL architectures (ResNet50, DenseNet-201, and SqueezeNet), pre-trained over millions of common images, were trained, validated, and tested for the automatic classification of CILCA versus non-CILCA, supervised by radiologist’s classification. The 3D U-Net-plus-DenseNet-201 was found to be the best system (Dice index 0.912); its classification performance obtained from internal, independent testing on 126 patients gave a receiver operating characteristic area under the curve of 87.0%, sensitivity 66.7%, specificity 90.5%, positive predictive value 87.5%, negative predictive value 73.1%, positive likelihood ratio 7.0, and negative likelihood ratio 0.4. In conclusion, a combined DL system applied to chest CT scans was developed and proven to be an effective tool to detect individuals with “bovine” aortic arch with a low rate of false-positive findings.

A single-center experience in the use of hybrid techniques for thoracic aortic pathology

The hybrid method of treating thoracic aortic pathology is devoid of the disadvantages of traditional open surgery and, at the same time, has a broader range of applications than the endovascular method. From 2014 to 2019, we researched 122 patients with thoracic aortic pathology treated with the hybrid method (open surgery with thoracic endovascular aortic repair (TEVAR) at the National M. Amosov Institute of Cardiovascular Surgery National Academy of Medical Science of Ukraine. In the general group, 34 patients had a descending aortic aneurysm without dissection or rupture; 71 patients had an aortic dissection (10 – acute, 9 – subacute, 52 – chronic), penetrating aortic ulcer (PAU) – 7, thoracoabdominal aneurysm (Crawford I-II) – 4, isolated aortic arch aneurysm – 2, residual enlargement aorta after previous ascending aortic grafting causing type A acute aortic dissection (TAAD) – 3, primary aortic thrombosis – 1. Patients admitted as elective surgery candidates had switched aortic arch vessels (debranching) in the first stage and TEVAR in the second stage. For emergencies (aortic rupture with uncontrolled bleeding, malperfusion syndrome), TEVAR operation was performed first. Long-term results of treatment after three and six months are satisfactory. The hybrid technique of aortic arch treatment using modern minimally invasive technologies can eliminate the pathology in the most dangerous segment of the main artery of the body, providing a reasonable level of hospital mortality – 4.2%, and a small number of neurological complications.

Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion After Circulatory Death Prevents the Return of Brain Activity in a Porcine Model.

The cerebral effect of clamping following normothermic regional perfusion (NRP) in donation after circulatory death (DCD) remains unknown. We investigated the effect of cerebral reperfusion during NRP and the preventive effect of clamping on brain function in a porcine model. In 16 pigs, intracranial physiological parameters were recorded, including pressure, cerebral blood perfusion (CBF), temperature, and oxygen. Additionally, electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) were used to assess brain function. The animals were cannulated for the heart-lung machine, and baseline measurements were performed before withdrawal from life support. After 8 min of mechanical asystole, the animals were randomly allocated to clamp (n = 8) or nonclamp (n = 8) of the aortic arch vessels. After 30 min of NRP, the animals were monitored for 3 h after weaning (AW). Intracranial measurements of CBF, oxygen, and temperature indicated successful occlusion of the arch vessels following NRP and AW in the clamp group versus the nonclamp group. In the clamp group, EEG was isoelectric and SSEPs were absent AW in all pigs. In the nonclamp group, EEG activity was observed in all 8 pigs, whereas SSEPs were observed in 6 of 8 pigs. Additionally, agonal respiratory movements in the form of gasping were observed in 6 of 8 pigs in the nonclamp group. Reperfusion of the brain during NRP led to a return of brain activity. Conversely, clamping of the arch vessels halted cerebral circulation, ensuring the permanent cessation of brain function and maintaining the determination of death in DCD.

Surgical treatment of aneurysms of aortic arch branches and vessels of the upper extremities

Aneurysms of theaortic arch branches and vessels of the upper extremities are dangerous and there is a high probability of mortality due to rupture of the aneurysm or stroke. The indication is surgical treatment, regardless of the age and size of the aneurysms. The frequency of deaths and strokes that occurred during operations for carotid artery aneurysms is about 2%, which is associated with distal embolism of intracerebral vessels and the contents of the aneurysm cavity. One of the most common causes of aneurysms of the branches of the aortic arch and vessels of the upper extremities are atherosclerosis, nonspecific aortoarteritis and posttraumatic aneurysms. The study included 38 patients with aneurysms of the branches of the aortic arch and arteries of the upper extremities operated in the vascular surgery department over the past 10 years, whose total age ranged from 19 to 76 years. There were 84% men, 16% women. Aneurysms of the carotid arteries and its branches (temporal artery) were diagnosed in 58%, subclavian arteries in 16%, arteries of the upper extremities in 26%. The size of aneurysms of the branches of the aortic arch and arteries of the upper extremities ranged from 2.5 cm to 10 cm. The average size is 6.3±1.8 cm. When choosing the method of treatment of aneurysms of the branches of the aortic arch and arteries of the upper extremities, preference was given to performing reconstructive operations without the use of additional materials, which were performed in 52% cases), in 13 of these cases, excision of a false aneurysm with stitching of the defect was performed, in 6 of these cases, resections of aneurysms with end-to-end anastomosis were performed. In 48% cases, operations with the use of synthetic materials and autovenous plastic surgery were performed, and endovascular interventions were also performed in 4 cases. The most frequent type of surgery performed is resection of an aneurysm with a lateral suture – 34% cases. Resection of the anastomosis aneurysm at the end of the arteries – 16%, and prosthetics – in 8% cases (synthetic alloprosthetics in one and with autovenous prosthetics in two cases). After resection of subclavian artery aneurysm due to large diastasis of blood flow, reconstruction was performed by bypass surgery or prosthetics. Arterial aneurysm resection with autovenous patch was performed in 13% cases, and with allosunting – in 8% cases. Excision of an aneurysm of the axillary artery on the left with the restoration of a synthetic patch – in 5% cases. Ligation of an aneurysm in the temporal artery was performed in 2 cases (5%), this type of operation was performed with an aneurysm of non-main vessels, as well as in vessels with collateral blood flow in the distal area of the vessels. Implantation of a stentgraft into the right subclavian artery – in 3 cases (8%). X-ray endovascular embolization of aneurysm – in 3% case. Positive results in the postoperative period were observed in 92% patients. One (3%) patient developed complications in the form of hematomas after aneurysm resection. In 5% cases - lymphorrhea after excision of a false aneurysm

Experience with Thoracic EndoVascular Aortic Repair (TEVAR) treatment of uncomplicated Stanford type B aortic dissection, 2022 Updates

There have been significant advances in the technique and application of endovascular repair of thoracic aortic pathology over the past 20 years. The Stanford type A and the complicated type B dissection patients require urgent/emergent intervention. In the last decade, earlier intervention has been pursued for uncomplicated type B dissections. The INvestigation of STent-grafts in Aortic Dissection (INSTEAD) Long term (XL) study showed that there was significant crossover from medical management to Thoracic EndoVascular Aortic Repair (TEVAR) at year 3, suggesting TEVAR might benefit this population long term. Today, the application of TEVAR, which was initially designed to address aneurysmal disease, has become a standard and Food and Drug Administrative (FDA) approved management option in dissections. Currently there are four FDA approved TEVAR devices in the United States for the treatment of the thoracic dissections, namely Gore, Medtronic, Cook, and Terumo. With each iteration, there are increased opportunities for customization and widespread use in individualized patient’s pathology. As the technology improves and the feasibility of the grafts expands, the complication rates continue to decline cementing the safety and efficacy of these thoracic aortic grafts. Two rare but catastrophic complications in spinal ischemia and retrograde Stanford type A aortic dissection are further discussed. With the success of the TEVAR, a new frontier of hybrid aortic surgery has developed. The debranching of the aortic arch vessels in order to advance the TEVAR proximal landing zones has been aggressively pursued. With the widespread growth of TEVAR technology it is apparent that complex aortic pathology can be safely repaired endovascularly. Article Details

Predictors of the multiwire technique use in carotid artery stenting

ObjectivesThe multiwire technique (MWT) in carotid artery stenting (CAS), characterized by the use of more than one guidewire to support guiding catheter in patients with hostile neck anatomy, increases procedural time, enhancing the risk of periprocedural stroke. The aim of the present study was to identify which factors are predictors of the MWT use in CAS, in order to stratify patients with longer procedure at potential higher risk of periprocedural stroke. MethodsThe study retrospectively included patients who underwent CAS for stenotic plaque between January 2015 and December 2019. Exclusion criteria was incomplete clinical data. For each patients were registered clinical data, main aortic arch and supra-aortic vessel anatomical features, carotid plaque characteristics, and procedural details. The sample was divided in two group on the basis of the number of guides used during the stenting procedure: one guide (standard technique, ST) or more than one guidewire (MWT) to support the guiding catheter. Differences between groups were tested by Chi-square text or Fisher’s exact test and Mann-Whitney U test. Logistic regression analysis was used to identify predictors for the use of the MWT. The area under the ROC (AUC) curve was used to assess performance of the model to predict the use of the multiwire technique. ResultsThe final sample included 146 of the 204 (71%) patients who underwent CAS during the study period. The median age of the patients was 79 years (IQR 71–83 years) with 47/146 (32%) females. CAS was performed with MWT in 17/146 (12%) of the cases. MWT was used more likely in patients with aortic arch type II or III as compared to ST (71% vs 37%, P = 0.02) while plaques with heavy concentric calcifications were more frequent in ST as compared to MWT (38% vs 12%, P = 0.03). At multivariable analysis aortic arch type II or III (OR 5.08, 95% CI 1.48–17.93, P < 0.01), plaque stenosis > 79% (OR 4.13, 95% CI 1.03–16.61, P = 0.04), and plaque heavy concentric calcifications (OR 0.19, 95% CI 0.04–0.94, P = 0.04) were independent predictors of MWT use. The model showed an AUC of 0.827 (95% CI 0.756–0.884) for the prediction of the MWT use during CAS. ConclusionsAortic arch type II or III, carotid plaque with stenosis higher than 79% of the lumen or without heavy concentric calcifications were predictors for the use of the MWT during CAS. These features should be considered during planning of CAS as hallmark of vascular stiffness and therefore of higher procedure complexity.

Double Barreled Graft (Chimney) as a Strategy to Preserve Supraortic Branches in Contained Ruptured Thoracic Aneurysm Thoraco Endovascular Aortic Aneurysmal Repair- A Case Report

Out of many strategies that are used to treat aortic arch disease, including open surgery, branched techniques, and hybrid repair with Thoracic Endovascular Aortic Aneurysmal Repair (TEVAR) and supra-aortic branch reconstruction and fenestration, Thoracic Endovascular Aortic Aneurysmal Repair (TEVAR) incorporating chimney is frequently used in unstable and morbid patients not suitable for other procedures. We describe here a case of contained rupture of a thoracic aortic aneurysm, which was treated with TEVAR incorporating a double chimney to the left common carotid and left subclavian arteries. There was an uncomplicated course of the procedure with complete coverage of aneurysm with stent-graft and open aortic arch vessels when followed up to 6 months. There were no complications noted as well. In this case we took the precaution to upsize the stent-graft by 20% to 30% also for adequate coverage of aneurysm we had to adopt to the chimney technique. To prevent complications like gutter and endoleaks, the kissing technique was used during deployment. In addition, there was adequate coverage of chimney-grafts with adequate proximal projection.

Integrated Care Systems and the Aortovascular Hub.

Aortovascular medicine and surgery in relation to vascular health of the population requires input from a broad range of specialists and institutions throughout a patient life as well as integration with allied health care providers. This paper presents the essence of the novel clinical concept of the 'Aortovascular Hub' .

342 SURGICAL TREATMENT OF ESOPHAGEAL CANCER WITH VARIATIONS OF THE AORTIC ARCH AND ITS BRANCHES

Abstract The variations of the aortic arch and its branches are rare. The surgical treatment of esophageal cancer would be challenged for combination with this anomaly. This study intends to review significant group cases to analyze the influence of this variation on esophagectomy. Methods From 2013 to 2019, 19 patients with aortic arch and brachiocephalic vessels variations underwent esophagectomy, accounting for 0.3% during the same period. The abnormalities were distributed as follows: left-sided aortic arch combined with aberrant right subclavian artery (LAA + ARSA) occurred 13 cases, right-sided aortic arch anomalies with mirror image arch branches (RAA + MIAB) in 1 case, and right-sided aortic arch combined with aberrant left subclavian artery (RAA + ALSA) in 5 case. Of the patients with LAA + ARSA, 11 patients underwent the McKeown esophagectomy, and 2 patients via transhiatal. All patients with RAA underwent left thoracotomy approach.Perioperative outcomes and long-term survival were analyzed. Results The tumors were mostly located in the upper and middle thorax (47.4% and 42.1%). The R0 resection rate was 89.5% (17/19). Recurrent laryngeal nerve injury occurred in 2 patients, anastomotic fistula in 1 patient. Two patients died within 30 days postoperatively. The yield of lymph nodes was 21.8 ± 9.4. The sampling rate of lymph nodes along the recurrent laryngeal nerve was 61.5% in LAA + ARSA group, while 16.7% in RAA group. Recurrence happened in 5 cases (29.4%), including 2 regional relapse. Four patients died after recurrence, with a median time to death of 20 months (range: 10–48 months). Conclusion For aortic arch and brachiocephalic artery variations in esophageal cancer, aberrant right subclavian artery and right-sided aortic arch are the most common types. The surgical strategy is closely related to the aortic arch position. Due to the combined variation of the recurrent laryngeal nerve, the upper mediastinal lymph nodes dissection would be conservative, but with acceptable oncologic results.

Early experience with donation after circulatory death heart transplantation using normothermic regional perfusion in the United States

ObjectiveThis pilot study sought to evaluate the feasibility of our donation after circulatory death (DCD) heart transplantation protocol using cardiopulmonary bypass (CPB) for normothermic regional reperfusion (NRP). MethodsSuitable local DCD candidates were transferred to our institution. Life support was withdrawn in the operating room (OR). On declaration of circulatory death, sternotomy was performed, and the aortic arch vessels were ligated. CPB was initiated with left ventricular venting. The heart was reperfused, with correction of any metabolic abnormalities. CPB was weaned, and cardiac function was assessed at 30-minute intervals. If accepted, the heart was procured with cold preservation and transplanted into recipients in a nearby OR. ResultsBetween January 2020 and January 2021, a total of 8 DCD heart transplants were performed: 6 isolated hearts, 1 heart-lung, and 1 combined heart and kidney. All donor hearts were successfully resuscitated and weaned from CPB without inotropic support. Average lactate and potassium levels decreased from 9.39 ± 1.47 mmol/L to 7.20 ± 0.13 mmol/L and 7.49 ± 1.32 mmol/L to 4.36 ± 0.67 mmol/L, respectively. Post-transplantation, the heart-lung transplant recipient required venoarterial extracorporeal membrane oxygenation for primary lung graft dysfunction but was decannulated on postoperative day 3 and recovered uneventfully. All other recipients required minimal inotropic support without mechanical circulatory support. Survival was 100% with a median follow-up of 304 days (interquartile range, 105-371 days). ConclusionsDCD heart transplantation outcomes have been excellent. Our DCD protocol is adoptable for more widespread use and will increase donor heart availability in the United States.