Dissection Repair Research Articles

Aortoesophageal fistula as a rare cause of upper gastrointestinal hemorrhage.

An aortoesophageal fistula (AEF) is an exceedingly rare and life-threatening cause of upper gastrointestinal bleeding, particularly in patients with vascular prostheses. Endoscopic findings in such cases are scarcely described. We describe a 73-year-old male admitted to the emergency department with hematemesis and altered consciousness. His history included ascending thoracic aortic dissection repair with endovascular prosthesis placement 25 years prior. Upon admission, he presented with signs of hypovolemic shock and hemoglobin of 6.5 g/dL. Following hemodynamic stabilization, upper gastrointestinal endoscopy revealed a mid-esophageal rupture, characterized by a pulsatile, violaceous, firm protrusion, without active bleeding.

The benefit of early acupuncture within 7 days for neurological outcomes in ischemic stroke patients after cardiac surgery

BackgroundStroke is a critical complication of cardiac surgery that results in increased mortality and morbidity. Limited treatment options are available for patients with severe neurological deficits, such as impaired consciousness. Acupuncture is a well-known integrative management method for stroke patients. However, there are no extensive reports discussing the benefit of acupuncture in stroke patients after cardiac surgery. The aim of this study was to demonstrate the role of acupuncture in the neurological recovery of these patients and to identify the factors that provide greater benefit.MethodsThis self-controlled case series utilized inpatient data from stroke patients after cardiac surgery who received acupuncture in a single center from 2013 to 2019. The primary outcomes included the Glasgow Coma Scale, muscle strength grading scale, and Barthel Index. Wilcoxon signed-rank test was used to compare the neurological differences between pre-acupuncture and post-acupuncture.ResultsFifty-one patients who met the criteria showed significant improvement of the severity of neurological impairment, including the Glasgow Coma Scale, muscle strength grading scale, and Barthel Index (p < 0.05). The group that underwent aortic dissection repair and the group that started acupuncture within 7 days after stroke showed greater improvement (p < 0.01). No adverse events were reported. Three patients with profound neurological impairment who received acupuncture intervention were described.ConclusionsAcupuncture has a potential benefit in improving neurological impairment and reducing mortality in stroke patients after cardiac surgery, especially within 7 days of the event. Further larger prospective studies with control groups are needed to provide convincing evidence.

False Lumen Patency After Occlusion With Physician-Modified Candy-Plug in Aortic Dissections: A 2-Center Experience.

To evaluate the early and mid-term results of physician-modified candy-plug (pmCP) in patients with type-B or residual type-A aortic dissection (TBRAD). All patients with TBRAD who received false lumen (FL) occlusion with pmCP between September 2018 and May 2024 were analyzed. Primary outcomes were technical and clinical success, and overall mortality. Secondary outcomes were postoperative aortic remodeling and aortic reintervention. Seventeen patients (88% male; mean age 69±12 years) underwent FL occlusion with a pmCP. Nine patients (53%) were emergently treated. The technical and clinical successes were 100% and 82%, respectively. One patient (6%) died postoperatively. Early complete FL occlusion was observed in 82% of the patients. One patient (6%) required an early pmCP-related reintervention. During a mean follow-up of 15±5 months, 75% of the patients had complete thoracic FL thrombosis while 13% of them aortic remodeling in the last computed tomography (CT) scan. Aneurysm size remained stable in 69% of the cases. There were no aortic-related re-interventions during follow-up. The pmCP technique is a feasible and promising alternative technique, with high primary technical and clinical success rate. Stable aortic diameters can be expected during follow-up, thus reducing the need for further aortic reintervention. Persistence of false lumen (FL) patency after thoracic endovascular aortic repair (TEVAR) for thoracic aortic dissection (TBAD) remains a significant challenge for physicians. Various strategies have been developed to address retrograde FL patency, including the candy-plug technique. This technique involves modifying thoracic stent grafts and placing an additional plug to occlude the reduced stent graft waist.Since its introduction, three generations of custom-made candy-plug devices (Cook Medical, Bloomington, IN, USA) have been developed. However, delivery times vary across countries and vascular surgery services, complicating procedural planning, particularly in symptomatic patients or cases of rapid FL diameter progression.In this study, we provide a step-by-step description of the physician-modified candy-plug technique and present our preliminary results.

Chronic Mesenteric Ischemia after a Type A Aortic Dissection Repair.

A 57-year-old male patient who underwent an open hemiarch repair with a femoral-femoral crossover bypass and right lower extremity fasciotomies for an acute Type A aortic dissection with limb ischemia presented 5 weeks' postrepair with a 20-pound weight loss due to intermittent hemodynamic collapse of the dissection flap over the origin of the superior mesenteric artery. This case highlights the challenges a dissection flap can cause after an urgent Type A aortic dissection repair.

Multicentre frozen elephant trunk technique experience as redo surgery to treat residual type A aortic dissections following ascending aortic replacement.

To assess the efficacy of reoperative frozen elephant trunk (FET) surgery for treating residual type A aortic dissections. Between 04/2015 and 10/2023, 237 patients underwent elective redo surgical aortic arch replacement via the FET technique to treat residual type A aortic dissection in eleven European aortic centres. Data were pooled and analysed retrospectively. The time between an acute type A dissection repair to FET implantation was 5 [1, 9] years. More than half of all patients (54%) presented with an entry within the aortic arch, and 174 patients (73%) presented residual dissections of supra-aortic vessels During FET repair, the axillary artery was cannulated in 181 patients (76%), while 83 patients (35%) underwent additional cardiac procedures including 39 root replacements (16%) and 15 coronary bypass procedures (6%). Zone 2 was the most common arch anastomosis site (n = 163, 69%) and bilateral antegrade cerebral perfusion was most frequent (n = 159, 67%). Fifteen patients (6%) suffered in-hospital mortality. Age in years (p < 0.001, OR: 1.069) proved to be predictive for overall mortality in our COX regression model. Elective redo surgical aortic arch replacement using the FET technique for treating residual type A aortic dissection following ascending aortic replacement revealed a favourable outcome. The decision to undertake stage-two therapy of a residually dissected aortic arch should be made by an aortic team on a patient-by-patient basis.

Polytetrafluoroethylene Felt Inlay Neomedia and Tissue Glue Do Not Prevent Reoperation in Type A Aortic Dissection.

Background/Objectives: Type A aortic dissection repair using Polytetrafluorethylene (PTFE) felt inlay and tissue glue has been proposed as a treatment modality. It remains unclear, if this method performs superiorly to tissue glue only. Methods: Between January 2011 and December 2015, 139 patients underwent surgical repair for type A aortic dissection, and 48 patients were excluded (n = 29 after receiving a composite graft, n = 18 in which no tissue glue was used, and n = 1 due to missing data). In the remaining patients, proximal aortic repair was performed either using PTFE felt inlay and tissue glue or tissue glue only. We analyzed the need for repeated surgery on the aorta during follow-up as a primary endpoint. The secondary endpoint was all-cause mortality at follow-up. Inverse probability of treatment weighting was used to balance the distribution of measured baseline covariates. Results: Sixty-six patients (73%) were treated with a tissue-glue-only approach-the Control Group. Twenty-five patients (27%) underwent proximal PTFE felt inlay and tissue glue-the Intervention Group. In the Intervention Group, 40% (n = 10) underwent reoperation due to re-dissection or pseudoaneurysm vs. 12% (n = 8) in the Control Group. The felt inlay increased the hazard of re-operation by 8.38 (1.63 to 43.0) after IPTW with death modeled as competing risk. Conclusions: Reoperation due to aortic complications was 10 times higher in patients treated with a combination of gluing and PTFE felt inlay vs. gluing only. These results are potentially caused by an interaction of PTFE, tissue glue, and aortic tissue.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis.

Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilization for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection. A systematic literature search on PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science until March 2024 was performed for studies on open aortic arch replacement with or without frozen elephant technique procedure in adult patients after previous acute aortic dissection repair. Early and late postoperative mortality were primary, while postoperative complications were secondary outcomes of interest. Additionally, a meta-analysis was performed to pool the early and late postoperative mortality. A total of 574 studies were identified, of which 9 studies including a total of 677 patients met the eligibility criteria. In-hospital or 30-day postoperative mortality and stroke were 0-17.5% and 0-7.7%, respectively. Duration of follow-up across all studies varied from 1.1 to 5.1 years. All-cause late mortality rate ranges from 5.9% to 30.5%. Aortic reintervention rate was 4.8-38.7%. The pooled early and late mortality rate were 8.7% [95% confidence interval (CI) 5.7-13%; I2 = 52%] and 24.9% (95% CI 19.5-31.1%; I2 = 54%), respectively. Current evidence suggest that relatively younger patients with chronic post-dissection aneurysm or residual aortic dissection after acute aortic dissection repair can undergo an aortic arch replacement by a dedicated aortic team with acceptable mortality risk. However, postoperative neurological deficit remains an issue.

Distal Anastomotic New Entry Tears and Aortic Remodeling Following Type A Dissection Repair: A Systematic Review

Distal Anastomotic New Entry Tears and Aortic Remodeling Following Type A Dissection Repair: A Systematic Review

Association of intraoperative transfusion of blood products with postoperative outcomes and midterm survival in acute type A aortic dissection repair

ObjectiveThe study objective was to evaluate the impact of intraoperative blood product on postoperative outcomes and midterm survival in acute type A aortic dissection repair. MethodsPatients undergoing open acute type A aortic dissection repair from January 2010 to April 2020 were divided into 2 groups: patients receiving intraoperative blood products and no intraoperative blood products, with a final propensity-matched cohort of 90 matched pairs by matching sex, age, body mass index, preoperative hemoglobin, coronary artery disease, renal failure, stroke, prior cardiac surgery, cardiogenic shock, cardiopulmonary bypass time, crossclamp time, peripheral vascular disease, and aortic insufficiency. ResultsPatients were similar in demographic and preoperative characteristics. The complexity of the surgery, including the extent of aortic root and arch repair, was similar between the groups. The intraoperative blood product group had longer intubation time (77 hours vs 44 hours, P = .023), longer postoperative (14 vs 10 days, P = .0001) and total (15 vs 10 days, P < .0001) length of stays, and a higher rate of acute renal failure postoperatively (16.7% vs 6.7%, P = .037). The 6-year survival was similar between the intraoperative blood product group and no intraoperative blood product group (76.5% vs 83.3%, P = .48). The multivariate Cox proportional hazard model showed a statistically insignificant hazard ratio of 1.27 in the intraoperative blood product group for midterm mortality (95% CI, 0.64-2.54, P = .50). ConclusionsIntraoperative blood product use during acute type A aortic dissection repair did not impact midterm survival but increased postoperative complications. Intraoperative blood product transfusion can be safely and cautiously used during acute type A aortic dissection repair.

Clinical, Preclinical, and Educational Applications of Robotic-Assisted Flap Reconstruction and Microsurgery: A Systematic Review.

Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field. We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation. A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included. One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery. Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.

Preoperative Depression is Associated With a Higher Risk of Bleeding in Type a Aortic Dissection Repair: A Population Study of National Inpatient Sample From 2015-2020.

Depression is highly prevalent in patients with aortic diseases. While depression has been shown to predispose patients to adverse outcomes after surgery, its impact on postoperative outcomes in Stanford Type A Aortic Dissection (TAAD) has not been established. This study aimed to conduct a population-based examination of the effect of preoperative depression on in-hospital outcomes after TAAD using the National/Nationwide Inpatient Sample (NIS) database, the largest all-layer database in the US. Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without preoperative depression, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status. There were 321 (7.50%) patients with depression and 3961 (92.50%) non-depressive patients who underwent TAAD repair. Patients with and without depression had comparable in-hospital mortality (11.84% vs 15.37%, P = 0.35). However, Patients with depression had a higher risk of hemorrhage/hematoma (83.49% vs 76.6%, aOR 1.593, 95 CI 1.161-2.184, P < 0.01) and a higher rate of transfer out (40.81% vs 32.62%, aOR 1.396, 95 CI 1.077-1.81, P = 0.01). All other in-hospital complications, hospital length of stay (LOS), and total hospital charge were comparable between patients with and without depression. Preoperative depression is associated with a higher risk of bleeding after TAAD repair. This may be due to anti-depression treatment, such as Selective Serotonin Reuptake Inhibitors (SSRIs), that can disrupt platelet function and lead to abnormal bleeding. While depression is not associated with other major outcomes, preoperative depression screening, as well as hemostatic monitoring and appropriate blood management in patients with depression may be crucial in preventing bleeding complications in TAAD repair.

Time critical diagnoses and transfers of patients with acute type A aortic dissection in the UK: national audit of current practice*

SummaryBackgroundType A aortic dissection repair is one of the most common emergency cardiac surgical procedures undertaken in the UK and has a high mortality. Early diagnosis and prompt surgery by an expert cardiac surgical team is crucial. Little is known about the patient's journey from first symptoms until surgery.MethodsThe Association for Cardiothoracic Anaesthesia and Critical Care undertook a prospective national audit of the management of type A aortic dissection in the UK.ResultsThe details of 334 patients with type A aortic dissection were reported by 28 UK cardiac centres over 12 months. Median (IQR [range]) time from onset of symptoms until arrival in an emergency department was 2.3 (1.4–4.7 [0.1–491.6]) h. Median (IQR [range]) time between arrival in the emergency department and the start of surgery was 9.5 (6.1–18.2 [0.8–363.5]) h. Delays in diagnosis and transfers were reported in 158 (47.3%) patients. Fifty‐two patients (15.6%) had an initial misdiagnosis. The condition of 56 patients (16.8%) deteriorated clinically before arrival in the operating theatre. A medical doctor accompanied 50 patients (15.0%) during transfer. Sixty‐four patients (19.2%) died in hospital with 41 (12.3%) dying within the first 5 days after surgery.ConclusionsThis audit provides a snapshot of current practice for patients with type A aortic dissection in the UK. Our findings show the acuity, clinical severity and vulnerability of patients with type A aortic dissection, and the deficits in the process of diagnosis and the quality of transfer. This audit demonstrates the need for the implementation of comprehensive, regionally governed, interdisciplinary medical management for every patient with type A aortic dissection.

False lumen communications predict aortic remodelling in acute type I dissection repair: measure twice, cut once.

False lumen communications predict aortic remodelling in acute type I dissection repair: measure twice, cut once.

Rate of Ascending Aortic Enlargement in a Large Echocardiographic Cohort: Associated Risk Factors and Adverse Aortic Events

Understanding ascending aortic aneurysm growth and associated risk factors is critical to advising appropriate echocardiographic follow-up intervals for patients. This study aimed to identify aortic aneurysm growth rate on serial echocardiograms as well as the clinical and demographic variables that contribute to baseline aortic size and subsequent aortic growth. Patients identified with ascending aortic aneurysm and undergoing serial echocardiograms within five years were evaluated. Ascending aortic size was measured as part of routine echocardiogram exams. Clinical and demographic variables including aortic valve type (trileaflet, bicuspid or prosthetic) were evaluated for association with baseline aortic size as well as with aortic progression rate. Clinical events including aortic dissection, elective or emergent surgical repair were recorded. 3639 patients were identified, (78% males, median age of 69 years, 175 (4.8%) with bicuspid valve, and 206 (5.6%) with prior aortic valve replacement (AVR). Patients with larger aorta at baseline were older with higher tobacco use and prior prosthetic valves. Over a mean of 2.4 years, aortic growth was observed and differed by valve type (trileaflet valve: 0.08 mm/year , bicuspid valve: 0.4 mm/year , p<0.001). In six patients who developed aortic dissection the estimated average annual growth rate was 0.98 mm/year. In a large echo cohort, aortic aneurysm growth rate was 0.08 mm/year though higher in those with bicuspid valves ( 0.4 mm/ year), but initial aortic size did not correlate with change in the aortic progression rate. This data may help inform recommended echocardiographic surveillance intervals.

Prevalence and Influence of Genetic Variants on Follow-Up Results in Patients Surviving Thoracic Aortic Therapy.

Background/Objective: To investigate the prevalence and effects of genetic variants (GVs) in survivors of thoracic aortic dissection/aneurysm repair. Methods: Patients aged 18-80 years who survived follow-up after cardiosurgical or endovascular repair of thoracic aortic aneurysm or dissection at a single tertiary center between 2008 and 2019 and underwent genetic testing were enrolled. The exclusion criteria were age >60 years, no offspring, and inflammatory- or trauma-related pathogenesis. Follow-up entailed computed tomography-angiography at 3 and 9 months and annually thereafter. All patients underwent genetic analyses of nine genes using next-generation sequencing. In cases of specific suspicion, the analysis was expanded to include 32 genes. Results: The study included 95 patients. The follow-up period was 3 ± 2.5 years. GVs were detected in 40% of patients. Correlation analysis according to primary diagnosis showed no significant correlation in disease persistence, progression, or in reintervention rates in aneurysm patients and a correlation of disease persistence with genetic variants according to variant class in dissection patients (p = 0.037). Correlation analysis according to follow-up CD finding revealed that patients with detected dissection, irrespective of original pathology, showed a strong correlation with genetic variants regarding disease progression and reintervention rates (p = 0.012 and p = 0.047, respectively). Conclusions: The prevalence of VUS is high in patients with aortic pathology. In patients with dissected aorta in the follow-up, irrespective of original pathology, genetic variants correlate with higher reintervention rates, warranting extended-spectrum genetic testing. The role of VUS may be greater than is currently known.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians.

The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. This was a single-centre retrospective study (2007-2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan-Meier and Cox proportional hazards methods were used to compare long-term survival. Fifty octogenarian patients were included (median age-82 years; closed distal-22; open distal-28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76-130 min). Median circulatory arrest time was 26 min (IQR; 20-39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5-11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Elective root replacement increases the risk of type B dissection in patients with Marfan syndrome

ObjectiveMarfan syndrome is a genetic disorder with increased risk of aortic dissection. Currently, type A aortic dissection risk is mitigated by aortic root replacement with Dacron. It is unclear if root replacement increases the risk of distal aortic disease given the noncompliant nature of Dacron. MethodsAll adult patients with a diagnosis of Marfan syndrome at a single academic center, excluding those with history of dissection or concomitant arch repair, were studied (n = 322). Student t test or Wilcoxon Mann–Whitney test was used for continuous variables; chi-square or Fisher exact test was used for categorical variables. Propensity matching used age, sex, hypertension, race, body mass index, family history of Marfan syndrome, and genetic mutational class. Differences in freedom from type B aortic dissection were determined using the log-rank test. ResultsA total of 124 patients underwent root replacement compared with 198 patients with no prior aortic surgery. Median follow-up time was 9.90 years. Male sex, weight, and hypertension prevalence were higher in the root replacement group (P < .05). Distribution of fibrillin-1 mutations was homogenous (P > .9). Type B aortic dissection frequency in the root replacement group was higher (21% [n = 20] vs 4.2% [n = 4], P < .001). Aortic-related mortality was higher in the root replacement group (11% [n = 14] vs 3.5% [n = 7], P < .01). Distal aortic intervention frequency was higher in the root replacement group (P = .009). ConclusionsPatients with Marfan syndrome who undergo elective aortic root replacement appear to have a higher incidence of subsequent type B aortic dissection, independent of other risk factors. Careful consideration must be made to the management of the distal aorta in patients with Marfan syndrome who undergo root replacement.

Early surgical outcomes in the composite-valve root replacement with bioprosthesis after surgery for acute type A aortic dissection.

This study aimed to evaluate the surgical outcomes of composite-valve root replacement with bioprosthesis (b-CVRR) after acute type A aortic dissection (AAAD) repair. We included 41 patients who underwent b-CVRR after surgery for AAAD from 2007 to 2022. We excluded seven patients with VSRR, three with mechanical valve use, one with mycotic aneurysm, and one with cardiopulmonary resuscitation. The overlapping surgical indications for b-CVRR were pseudoaneurysm in 21 patients (51.2%), severe AI in 19 (46.3%), re-dissection in 15 (36.6%), root dilatation (> 50mm) in 12 (41.5%), and rupture in 3 (7.3%). The coronary artery reconstruction methods were bilateral Carrel patch in 13 patients (32%), Carrel patch with Piehler in 16 patients (38%), bilateral Piehler in six patients (15%), and Piehler with coronary artery bypass (CABG) in six patients (15%). Four patients who underwent the Carrel patch technique required additional intraoperative CABG. Three hospital mortality occurred (7.3%; myonephropathic metabolic syndrome, heart failure, bleeding from the thyroid carotid artery without injury). No thrombosis of the reconstructed site was observed with the Piehler procedure. Surgical outcomes for patients treated with b-CVRR after AAAD repair were acceptable. Intraoperative coronary artery events occurred due to stenosis caused by traction on the reconstructed coronary artery due to adhesions.

Morphology of true lumen and surgical outcomes of acute type A aortic dissection repair with superior mesenteric artery malperfusion

BackgroundAcute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair. MethodsOpen surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods. ResultsA total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059). ConclusionsCentral repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.

Outcomes after open repair of aortic aneurysms and dissections in cannabis consumers

ObjectiveTo investigate the influence of cannabis consumption on the mid- and long-term surgical outcomes of patients with aortic aneurysms or dissections. MethodsAll individuals aged 18 years and older with more than 6 months of cannabis use at the time of surgical repair for cardiovascular disease (aortic aneurysms or aortic dissection) between 2007 and 2023 were eligible. Patients were stratified into 2 groups based on their preoperative history of cannabis use: cannabis users and noncannabis users. The primary end point was complications or death within 30 days of intervention. Secondary outcomes included late complications and reinterventions. Data were combined from our institution and inpatient hospital records. ResultsWe identified 134 patients who met the inclusion criteria out of 1543 treated patients (9%). Compared with the nonusing cannabis group, individuals in the cannabis group were significantly younger (cannabis: 48.3 ± 11.8 years vs noncannabis: 58.5 ± 14.9 years; P < .001). The cannabis group included significantly higher patients with Marfan syndrome (cannabis: 11.2% vs noncannabis: 4.4%; P < .001). Furthermore, the cannabis group showed significantly higher history of recreational drug use, including cocaine (25.4% vs 1.6%; P < .001), amphetamines (3.7% vs 0.6%; P < .001), opioids (8.2% vs 0.5%; P < .001), and intravenous drugs (6.7% vs 0.6%; P < .001). Emergency surgeries were significantly more frequent in the cannabis group (cannabis: 56.7% vs noncannabis: 36.2%; P < .001). Surgical mortality was comparable between both groups (cannabis: 9.7% vs noncannabis: 8.6%; P = .662). Postoperative stroke was significantly higher in the cannabis group (cannabis: 14.9% vs noncannabis: 8.2%; P = .009), and the rate of postoperative respiratory complications was also significantly higher in the cannabis group (cannabis: 32.1% vs noncannabis: 19.0%; P < .001). ConclusionsThe increased rates of postoperative cerebrovascular accidents and respiratory complications suggest that cannabis use is a significant risk factor in aortic surgery. Our study showed that young, healthy patients with prolonged cannabis use might be at a higher risk of requiring more emergency surgeries due to their background.