Aortic Research Articles

Head-to-Head Comparison and Temporal Trends of Cardiac MRI Recommendations in ESC versus ACC/AHA Guidelines: A Systematic Review and Meta-Analysis.

Purpose To provide a comprehensive head-to-head comparison and temporal analysis of cardiac MRI indications between the European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines to identify areas of consensus and divergence. Materials and Methods A systematic review and meta-analysis was conducted. ESC and ACC/AHA guidelines published until May 2023 were systematically screened for recommendations related to cardiac MRI. The class of recommendation (COR) and level of evidence (LOE) for cardiac MRI recommendations were compared between the two guidelines and between newer versus older versions of each guideline using χ2 or Fisher exact tests. Results ESC guidelines included 109 recommendations regarding cardiac MRI, and ACC/AHA guidelines included 90 recommendations. The proportion of COR I and LOE B was higher in ACC/AHA versus ESC guidelines (60% [54 of 90] vs 46.8% [51 of 109]; P = .06 and 53% [48 of 90] vs 35.8% [39 of 109], respectively; P = .01). The increase in the number of cardiac MRI recommendations over time was significantly higher in ESC guidelines (from 63 to 109 for ESC vs from 65 to 90 for ACC/AHA; P = .03). The main areas of consensus were found in heart failure and hypertrophic cardiomyopathy, while the main divergences were in valvular heart disease, arrhythmias, and aortic disease. Conclusion ESC guidelines included more recommendations related to cardiac MRI use, whereas the ACC/AHA recommendations had higher COR and LOE. The number of cardiac MRI recommendations increased significantly over time in both guidelines, indicating the increasing role of cardiac MRI evaluation and management of cardiovascular disease. Keywords: Cardiovascular Magnetic Resonance, Guideline, European Society of Cardiology, ESC, American College of Cardiology/American Heart Association, ACC/AHA Supplemental material is available for this article. © RSNA, 2024.

Do Rapid-Deployment Surgical Aortic Valve Replacements Offer an Effective and Safe Treatment for Patients with Isolated Aortic Disease? A Decade's Experience from a Single Centre

Do Rapid-Deployment Surgical Aortic Valve Replacements Offer an Effective and Safe Treatment for Patients with Isolated Aortic Disease? A Decade's Experience from a Single Centre

Effect of statins on thoracic aortic disease: results from a meta-analysis and experimental data

Effect of statins on thoracic aortic disease: results from a meta-analysis and experimental data

Long-Term Outcomes of Endovascular Repair of Thoracic Aortic Aneurysms.

The thoracic aorta is a dynamic structure composed of the aortic root, ascending aorta, aortic arch, and descending aorta. It is subject to the pressure and volume of the cardiac cycle and susceptible to atherosclerotic and aneurysmal changes. With these changes, the risk for acute aortic syndromes increases, thus creating the impetus for earlier interventions. The previous standard of open surgical repair has undergone a transition in recent years toward endovascular repair being favored in the descending and abdominal aortas with ongoing investigation into approaches for the ascending and aortic arch. These therapies have been shown to improve early mortality and morbidity outcomes with the caveat of more interventions compared with open surgery. We undertook this review to analyze the current data available regarding long-term outcomes in patients undergoing endovascular repair for thoracic aortic disease. The data support long-term benefit of endovascular repair for thoracic aortic disease. The primary indications identified for reintervention are endoleak and further aneurysmal degeneration. As the devices available for endovascular repair evolve, ongoing review of these outcomes will be necessary. It will also be important to trend the results as further techniques become available for endovascular repair of the ascending aorta and aortic arch.

A Free-Floating Aortic Thrombus: An Uncommon Approach to Handle a Rare Clinical Entity.

Thrombotic material in the non-aneurysmatic and non-atherosclerotic aorta is a rare entity without any recommended standard treatment so far. We present a successful treatment strategy for patients who do not fit into any of the common approaches. A free-floating thrombus in the descending aorta was found as source of embolism in an 82-year-old female patient with lower limb ischemia. After initial heparinization of the patient without relevant reduction of the thrombotic mass, the thrombus was removed using an interdisciplinary approach. Under echocardiographic guidance to locate the thrombus, the AngioVac device, usually licensed to remove floating thrombi from the venous system, was used off-label to remove the thrombus by a transfemoral approach. To avoid rebuilding of a new thrombus, the attachment point with an exulcerated plaque in the descending aorta was covered by a stent graft via the same femoral access. The patient did not experience any further embolic events, and the postoperative course was uncomplicated. Patients with uncommon aortic diseases, such as the reported free-floating thrombus, should be treated by an individualized, interdisciplinary approach. Besides the recommended treatment options, there are other uncommon approaches that might offer an alternative in complex cases. Evidence is rare for the treatment of a free-floating thrombus in the descending aorta and the treatment strategy remains discussed controversially. We present a rather uncommon approach of successful off-label treatment for patients who do not fit into any of the common approaches (operative, endovascular, or conservative treatment based on patient's comorbidities). The AngioVac System has already been successfully used off-label in the arterial system but not in the above presented way of treating a free-floating thrombus in a patient with high embolization risk and treatment-limiting comorbidities.

Inhibition of alphaV integrins with cilengitide downregulates in vitro pro-fibrotic events in aortic smooth muscle cells and limits in vivo thoracic aortic aneurysm progression

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health "Ricerca Finalizzata - Giovani Ricercatori" Background The ‘greatest artery’, i.e., the aorta, can be affected by either acute conditions or chronic disorders, such as the aneurysm, which is the segmental aortic dilation with at least 50% increase in the normal diameter. Aortic dilation can often lead to lethal events, such as aortic dissection and/or vessel rupture. The aneurysms occurring in the thoracic trait of the aorta (TAA) may depend on comorbidities, such as hypertension (i.e., sporadic non-syndromic TAA, sTAA), or on genetically determined conditions, such as Marfan syndrome (MFS). To date, the surgical replacement of aorta represents the most effective therapeutic approach in all TAA patients, since an etiologic pharmacological treatment is still lacking. Thus, the identification of novel disease targets is mandatory. Integrin receptors are key players in cellular mechanotransduction responses. Specifically, integrins containing αV subunit have been described as important mechanotransduction mediators and responsible for pro-fibrotic molecular events. Recently, it has been reported the effectiveness of a broad αV integrin inhibitor in limiting the TAA progression by acting on FAK/AKT/mTORC signaling pathway in a MFS in vivo model. However, the specific αV integrin subgroup directly involved in this detrimental process is yet not known. Purpose We evaluated the effectiveness of a specific αVβ3 and αVβ5 integrin inhibitor (i.e., cilengitide) in downregulating pro-fibrotic in vitro events on vascular smooth muscle cells (VSMC) isolated from TAA patients’ aortic wall, and in limiting in vivo thoracic aortic dilation on a MFS mice model. Results By comparison with healthy control (HC)-VSMC, both sTAA-VSMC and MFS-VSMC showed higher levels of αVβ3 and αVβ5 integrins as well as pro-fibrotic collagen I. The in vitro inhibition of these two αV integrins mediated by cilengitide resulted more effective in collagen I downregulation when compared with GLPG0187 (pan αV inhibitor). Noteworthy, the cilengitide-mediated αV integrin inhibition consistently tempered pro-fibrotic phenotype of sTAA- and MFS-VSMC by directly acting on both canonical (p-SMAD2/3) and non-canonical (p-ERK1/2) TGF-β downstream pathways and by downregulating mechanotransduction mediators (e.g., RhoA GTPase, ROCK1, talin-1). The 2D-echocardiographic results on MFS mice treated with cilengitide confirmed the greater effectiveness of this drug in limiting the TAA progression, in comparison not only with vehicle but also with the broad integrin inhibitor GLPG0187. Conclusion Altogether, our results improve the know-how on αV integrin inhibition, highlighting the role of cilengitide as potential target for future therapeutic approaches to limit TAA progression, both in sporadic and in MFS patients.

Are telocytes related to maintenance of vascular homeostasis in normal and pathological aorta?

Abstract Funding Acknowledgements None. The telocyte (TC) is a new interstitial cell type described in a wide variety of organs and loose connective tissues around small vessels, but its presence in large arteries remains unexplored. TCs have small cell bodies and remarkably thin, long, moniliform processes called telopods (Tps). Using transmission electron microscopy and immunofluorescence, we identified TCs in normal human thoracic aortas and in those with aneurysm and acute dissection (TAAD). In normal aortas the TCs were distributed throughout the connective tissue of the adventitial layer, in its innermost portion and at the zone of transition with the medial layer, with their long axes oriented parallel to the external elastic lamellae, forming a three-dimensional network, without prevalence in the media layer. In contrast, TAAD TCs were present in the medial layer and in regions of neovascularization. The most important feature of the adventitia of diseased aortas was the presence of numerous contacts between TCs and stem cells, including vascular progenitor cells. Although the biologically functional correlations need to be elucidated, the morphological observations presented here provide strong evidence of the involvement of TCs in maintaining vascular homeostasis in pathological situations of tissue injury.

An Eye into the Aorta: The Role of Extracellular Matrix Regulatory Genes ZNF469 and PRDM5, from Their Previous Association with Brittle Cornea Syndrome to Their Novel Association with Aortic and Arterial Aneurysmal Diseases.

The extracellular matrix is a complex network of proteins and other molecules that are essential for the support, integrity, and structure of cells and tissues within the human body. The genes ZNF469 and PRDM5 each produce extracellular-matrix-related proteins that, when mutated, have been shown to result in the development of brittle cornea syndrome. This dysfunction results from aberrant protein function resulting in extracellular matrix disruption. Our group recently identified and published the first known associations between variants in these genes and aortic/arterial aneurysms and dissection diseases. This paper delineates the proposed effects of mutated ZNF469 and PRDM5 on various essential extracellular matrix components, including various collagens, TGF-B, clusterin, thrombospondin, and HAPLN-1, and reviews our recent reports associating single-nucleotide variants to these genes' development of aneurysmal and dissection diseases.

Increased indexed proximal aortic diameter is a predictor of poor prognosis in maintenance hemodialysis patients

Background: Recent studies have shown that the baseline values of absolute aortic root diameter (ARD) and indexed diameter are associated with all-cause mortality and cardiovascular events in the general population, even in the absence of aneurysmal aortic disease. However, there is limited available data on the association between ARD and prognosis in end-stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD). Accordingly, the purpose of this study is to investigate the predictive value of ARD for all-cause mortality and cardiovascular events in this specific population.Methods: ARD was measured by echocardiography at the level of the sinuses of Valsalva at end diastole and indexed to body surface area (BSA). The primary endpoint was all-cause mortality. The secondary endpoint was major adverse cardiovascular events (MACE), including cardiovascular mortality, myocardial infarction and stroke. Cox proportional hazards models were conducted to evaluate the association between baseline ARD/BSA and clinical outcomes.Results: A total of 391 patients were included in this study. The primary endpoint occurred in 95 (24.3%) patients while the secondary endpoint occurred in 71 (18.2%) patients. Multivariate Cox regression analysis showed that ARD/BSA was an independent prognostic factor for all-cause mortality (HR, per 1-SD increase, 1.403; 95% CI, 1.118–1.761; p = 0.003) as well as MACE (HR, per 1-SD increase, 1.356; 95% CI, 1.037–1.772; p = 0.026).Conclusions: Our results show that ARD/BSA is predictive of all-cause mortality and MACE in MHD patients with ESRD and support the view that assessment of ARD/BSA may refine risk stratification and preventive strategies in this population.

The transcriptome profiling of diseased mouse aortas discloses a dysregulation of the sympathetic neurotransmission in atherosclerosis

Previous reports suggest an association between the development of atherosclerosis and alterations in the aortic sympathetic nervous system, but there is no agreement on whether atherosclerotic plaques are accompanied by increased or decreased sympathetic innervation in the arterial wall.In the present study, the aortic transcriptional profile of mice with different predisposition to atherosclerosis was investigated to clarify how the expression of genes involved in sympathetic neurotransmission varied.Eight-week-old C57Bl/6J control mice, Apoe knockout mice (EKO), EKO mice overexpressing human apoA-I (EKO/hA-I) and double Apoe/Apoa1 knockout mice (DKO) mice were fed either a standard rodent diet or a Western-type diet for 22 weeks. Atherosclerosis was quantified, and the aortic transcriptome was analyzed by RNAseq. Western-type diet administration deeply modified the aortic transcriptome. In the genetically modified atherosclerosis-prone mouse lines, an upregulated expression of genes associated with the immunomodulatory response was observed, paralleled by a downregulated expression of the genes related to sympathetic nervous system. Functional enrichment analysis indicated that the presence of advanced atherosclerosis was accompanied by reduced neuronal generation, modulation of synapse chemical transmission, and catecholamine biosynthesis, supporting a relationship between atherosclerosis, dyslipidemia, and sympathetic neurotransmission.

Diagnostic value of uric acid to high-density lipoprotein cholesterol ratio in abdominal aortic aneurysms

Background Abdominal aortic aneurysm (AAA) is highly lethal upon onset of acute aortic diseases (AAD) or rupture. Dyslipidaemia and hyperuricaemia are important risk factors for the development of AAA and AAD as well as aortic disease-related death. The aim of this study was to explore whether uric acid (UA) to high-density lipoprotein cholesterol (HDL-C) ratio (UHR) can be used as an independent predictor of the presence of AAA or AAD. Methods Three hundred subjects, including 100 AAA patients (AAA group), 100 AAD patients (AAD group) and 100 controls (CON group), were recruited in this study. UHR and other serum samples were obtained upon the patients’ admission before any medical treatment. The optimal cut-off points of UHR were determined using receiver operating characteristic (ROC) curve analysis. Results The UHR in AAA group was significantly higher than that in CON group, but there was no significant difference between AAD group and CON group. The optimal cut-off point of UHR for AAA was 7.78 (sensitivity 84.7%, specificity 62.4%, and AUC 0.811; p < 0.001), and UHR (OR: 1.122, 95%CI: 1.064-1.184; p < 0.001) was found to be an independent factor for predicting AAA after adjusting for traditional AAA risk factor. Conclusion UHR can be widely used in clinical practice as an auxiliary tool for screening AAA. The optimal cut-off point for UHR to AAA was determined for the first time in Chinese subjects.

A formative mixed methods evaluation of a new Ross program: why context matters

BackgroundThe Ross procedure is a technically complex operation to address the pathology of the aortic valve. Prior attempts at widespread implementation have been plagued with variations in effectiveness. We report our initial programmatic outcomes using dissemination and implementation (D&I) science frameworks, with an aim to define both programmatic efficacy and effectiveness. The study design was a single center, explanatory sequential mixed methods evaluation of a Ross surgery program from June 2020 to April 2023. Quantitative measures for baseline patient characteristics and postoperative outcomes were summarized. Qualitative measures were obtained using semi-structured interviews and characterized using implementation science frameworks.ResultsA total of 71 patients underwent the Ross procedure at a single academic center. Mean age was 40 years (± 13). There were no perioperative deaths or valve-related reinterventions (0%). During the follow-up period, 2 (2.8%) patients required re-operation and 2 (2.8%) required balloon dilation of the pulmonary homograft. Qualitative measures noted communication and prospective self-audit facilitated measures of effectiveness, as dichotomy within expected vs. observed outcomes led to program modifications. Collaboration across hospital systems promoted adoption and implementation, which led to the incorporation of the Ross procedure into accepted organizational practice.ConclusionsIn this formative evaluation, limited-efficacy outcomes demonstrated similar programmatic success to data from other established centers. With the prerequisite center volume and case selection, the Ross procedure is a safe and efficacious treatment for aortic valvular disease. Implementation science can be used both in real-time and retrospectively to guide organizational efforts to improve outcomes and to improve the translation of results across centers.

Untargeted 16s rRNA Survey Of Microbial Communities In The Patient With Aneurysmal And Occlusive Aortic Disease

Untargeted 16s rRNA Survey Of Microbial Communities In The Patient With Aneurysmal And Occlusive Aortic Disease

Outcomes Of Fenestrated-Branched Endovascular Aortic Repair In Patients With Genetically Triggered Aortic Diseases

Outcomes Of Fenestrated-Branched Endovascular Aortic Repair In Patients With Genetically Triggered Aortic Diseases

Comprehensive analysis of gene signatures associated with aging in human aortic dissection

BackgroundAortic dissection (AD) is a lethal aortic disease with limited effective therapeutic strategies. Aging increases the risk of AD, yet the underlying mechanisms remain unclear. This study aims to analyze the association of aging-related genes (Args) and AD using bioinformatic analysis. This helps provide novel insights into AD pathogenesis and contributes to developing novel therapeutic strategies. MethodsmRNA (GSE52093, GSE153434), miRNA (GSE98770) and single-cell RNA-sequencing (scRNA-seq, GSE213740) datasets of AD were downloaded from GEO database. Args were downloaded from Aging Atlas database. Differentially-expressed Args were determined by intersecting Args and differentially-expressed mRNAs of two mRNA datasets. Cytoscape was used to identify hub genes and construct hub gene regulatory networks related to miRNAs. Seurat and clusterProfiler R package were used for investigating expression patterns of hub genes at single-cell level, and functional analysis, respectively. To validate the cellular expression pattern of hub genes, the same analysis was applied to our own scRNA-seq data. Drugs targeting hub Args were determined using the DGIdb database. ResultsHGF, CXCL8, SERPINE1, HIF1A, TIMP1, ESR1 and PLAUR were identified as aging-related hub genes in AD. miR-221-3p was predicted to interact with ESR1. A decreased ESR1 expression in smooth muscle cell subpopulation 4 (SMC4) was observed in AD versus normal aortic tissues, which was validated by sequencing 197,605 aortic cells from 13 AD patients. Additionally, upregulated genes of SMC4 in AD tissues were enriched in the “cellular senescence” pathway. These data indicated that decreased ESR1 might promote SMC4 aging during AD formation. Eleven existing drugs targeting hub genes were identified, including ruxolitinib and filgrastim, which are associated with AD. ConclusionsBy sequencing transcriptomic data, this study revealed aging-related hub genes and regulatory network involved in AD formation. Additionally, this study proposed a noteworthy hypothesis that downregulated ESR1 may exacerbate AD by promoting SMC aging, which requires further investigation.

SURGERY OF TYPE A AORTIC DISSECTIONS: WHAT HAS CHANGED? SINGLE CENTER EXPERIENCE

Abstract Introduction Our knowledge on type A aortic dissection (ATAAD) has evolved, and there are some differences in surgical approach. In this paper, we focused on what changed in the surgical treatment of ATAAD and on the impact of these changes on patients’ survival, analyzing our center experience and comparing it with literature latest evidences. Materials and Methods From 2010 to 2022, 342 consecutive patients underwent surgery for Acute Type A Aortic dissection at our institution. In order to identify changes in these patients’ management over time, we divided our population in two groups according to the year of surgery: Group A before 2016 (146 patients) and Group B after 2016 (196 patients). Results Patients from Group B (after 2016) showed more comorbidities and a worse clinical presentation than patients from Group A (chronic kidney disease 9.2% vs 2.1% p=0.006, neurological deficit on admission 8.7% vs 0% p &amp;lt; 0.001, cardiac tamponade 12.2% vs 0.7% p &amp;lt; 0.001, and pre–operative catecholamine support 4.1% vs 0% p=0.012). Also of pre–operative malperfusion was more frequent (coronary 6.6% vs 0% p &amp;lt; 0.001 and peripheral 6.6% vs 0% p &amp;lt; 0.001). In Group B in 70.4% of the population the circulatory arrest with antegrade selective cerebral perfusion was used vs 30.8% in Group A (p &amp;lt; 0.001) and we find a bigger percentage of emiarch replacement (43.4% vs 23.3% P=0.008) and total arch replacement (27% vs 13.7% p=0.017) than in Group A. In–hospital mortality resulted to be 10.2% with no differences between the groups. Neurological events (p&amp;lt;0.001) and post–operative dialysis (p=0.036) were more frequent in Group B. On the other hand, in Group A post–operative cardiac tamponade (9.65 vs 3.1% p=0.007) and red blood cells transfusions were higher. Conclusions Nowadays surgery is performed on more critical patients with higher surgical risk and the tendency is to perform more complex operations with replacement of a largest portion of the diseased aorta in order to reduce reintervention rate. Recently, clinical studies and guidelines highlighted the importance of creating a multidisciplinary aortic team to discuss and manage these patients in order to assure the best treatment options to each patient and to reduce mortality and morbidity.

Ankylosing spondylitis and atrial fibrillation: a contemporary overview.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and it is associated with increased morbidity and mortality. AF is linked with inflammatory signalling while inflammation and oxidative stress promote atrial remodelling, favouring the development and perpetuation of the arrhythmia. On the other hand, ankylosing spondylitis (AS) is considered a chronic inflammatory rheumatic condition with flares and remissions that affects the axial skeleton and mainly young people. AS has been associated with an increased risk of valvular and aorta disease but its relationship with AF has not been studied well. Recent epidemiological evidence indicates an association between AS and AF. This brief review provides a concise overview of all available data regarding the association between AS and AF including the predictive role of electrocardiographic and echocardiographic markers. Several unresolved issues including the thromboembolic risk in this setting and the potential role of anti-inflammatory interventions are also discussed.

Intravascular lithotripsy to address calcific aortic disease

Intravascular Lithotripsy (IVL) is a relatively modern endovascular tool accepted for use to address vascular calcification in the iliac arterial system and below. This case study shows evidence of successful application of IVL followed by stent placement to calcific disease present within the aorta as well. A 78-year-old female with numerous comorbidities and a history of an aorto right femoral left iliac bypass graft in 1998 presented with severe lifestyle limiting claudication secondary to high-grade atherosclerotic stenosis of her infrarenal abdominal aorta at the level of the proximal anastomosis of her bypass graft. Initial ABIs were 0.54 and 0.55 on the right and left respectively. Initially the operative plan was to conduct a retroperitoneal aortic endarterectomy. However, after the surgical optimization center deemed the patient intermediate risk and her pulmonary function decreased prior to the procedure, the decision was made to proceed with IVL followed by angioplasty and aortic stent placement. The patient tolerated the procedure well without complication and she was discharged home the following day. At follow up appointment 6 weeks later, the patient's repeat ABIs were significantly improved to 0.77 in the right and 0.86 in the left with a coinciding improvement in symptoms. In conclusion, IVL is safe and effective in calcific aortic disease and should be considered in patients who are not optimal open surgical candidates.

Targeting the smooth muscle cell KEAP1-Nrf2-STING axis with pterostilbene attenuates abdominal aortic aneurysm

BackgroundAbdominal aortic aneurysm (AAA) is a life-threatening aortic disease, and to date, there are currently no effective pharmacological treatments to address this condition. Activation of cytosolic DNA sensing adaptor stimulator of interferon genes (STING) signaling is a crucial mechanism in AAA formation. PurposeThis study investigated pterostilbene (Pt), a naturally occurring polyphenol and resveratrol analogue, as a STING inhibitor for preventing AAA. MethodsWe evaluated the effect of Pt on AAA formation in angiotensin II (AngII)-infused apolipoprotein E-deficient (ApoE−/−) mice. We used histological analysis, MMP activity measurement, western blot, and immunohistochemistry to detect AAA formation and development. We applied RNA sequencing, molecular docking, cellular thermal shift assay (CETSA) and functional studies to dissect the molecular mechanism of Pt-regulating KEAP1-Nrf2-STING signaling. We conditionally knocked down Nrf2 in vascular smooth muscle cells (VSMCs) in vivo to investigate its role in Pt-mediated protective effects on AAA. ResultsPt effectively blocked the formation of AAA in AngII-infused ApoE−/− mice. Whole transcriptome sequencing analysis revealed that nuclear factor erythroid 2-related factor 2 (Nrf2) and STING pathway in VSMCs were linked to the anti-AAA effects of pterostilbene. Mechanistically, Pt upregulated Nrf2 target genes (e.g., HO-1 and NQO1) through activation of the KEAP1/Nrf2 signaling, which restricted the immunostimulatory axis of mtDNA-STING-TBK1-NF-κB, thereby alleviating VSMC inflammation and preserving the VSMC contractile phenotype. Subsequently, molecular docking and CETSA revealed a binding mode between Pt and KEAP1/Nrf2. Intriguingly, the inhibitory effect of Pt on STING signaling and the protective role of Pt in AAA were largely abrogated by VSMC-specific Nrf2 knockdown in mice. ConclusionCollectively, naturally derived Pt shows promising efficacy for the treatment of AAA by targeting the KEAP1-Nrf2-STING axis in VSMCs.

Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options.

The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article. Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease. It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.