The azygos vein (AV) is typically described as ascending vertically to the right of the vertebral column before arching anteriorly to drain into the superior vena cava. However, a small number of studies suggest that it is found leftward in older adults. A retrospective analysis of the contrast-enhanced thoracic computed tomography studies from 291 individuals was conducted with ethical approval (158 females; ages 0-100). The vertebral level (VL) of the AV arch was designated "V0" with subsequent caudal VLs designated V1-V5. At each VL, the position of the AV and thoracic aorta (TA) relative to the vertebral midpoint was recorded in degrees. A significant correlation was found between increasing age and leftward shift of the AV and aorta between V0 and V4 (Spearman's ρ correlation between 0.31 and 0.68, p < 0.001). At V5, while AV position no longer changed with age (ρ = -0.03, p > 0.05), TA shift persisted (ρ = 0.39, p < 0.001). Increased positional variability of AV with age was also observed at V1-V5 (ρ between 0.17 and 0.38, p < 0.05). This leftward shift of AV and TA could reflect age-related laxity of the posterior mediastinum or relative reduction in the VC height. Understanding of this age-related anatomical change is important for reducing the risk of vascular injury during thoracic procedures. As inclusion of age-related changes is becoming increasingly important in undergraduate anatomy teaching, our findings suggest that it may be necessary to update current texts.

Understanding injury patterns and temporal dynamics of traumatic haemorrhagic death is essential for developing targeted interventions. This study characterized anatomic bleeding locations, specific vascular injuries, and survival times in patients who died from traumatic haemorrhage. Retrospective single centre study of trauma patients who died in hospital from traumatic haemorrhage during index admission between 2007 and 2023. Data were extracted from systematic mortality reviews, trauma registries, medical records, and autopsy reports. Survival times were analyzed in relation to bleeding location and specific vascular injuries. In the overall cohort (n = 226), the median age was 33 years (IQR 23-51); male patients 85% (191/226). Penetrating trauma (58%, 130/226) dominated over blunt trauma (42%, 96/226) (p = 0.013). Thorax (n = 94, 42%) was the most common region for haemorrhage death followed by multiple locations (n = 89, 39%), abdomen (n = 33, 15%), extremities (n = 6, 2.7%), and neck (n = 4, 1.8%). Time-to-death categorization revealed that most deaths (40%) occurred between 60 and 120min after injury, with 21% dying within the first 60min. Thoracic fatal haemorrhage caused the shortest survival times (median 77min, IQR 55-197), while abdominal haemorrhage had the longest survival time (127min, IQR 93-251). The survival probability after 90min for abdominal bleeding region was OR 3.89, 95% CI 1.27-11.9, p = 0.018. Thoracic aorta was the most frequent (42%, 47/113) identified vascular injury with the shortest survival (75min, IQR 55-189). Thoracic haemorrhage, particularly when involving major vessels, represented the most lethal bleeding source with the shortest survival duration; in contrast, abdominal haemorrhage was associated with a comparatively longer survival window. These findings emphasize the critical importance of minimizing time to definitive haemorrhage control through expeditious surgical management strategies.

Amlodipine improves aortic dysfunction in atherosclerotic mice.

Pediatric aortic trauma: A review of the literature.

Tyrosine kinase inhibitors (TKIs) have revolutionised chronic myeloid leukaemia treatment but cause cardiovascular toxicities through incompletely understood mechanisms. This study characterised the pharmacokinetics of imatinib, nilotinib and ponatinib, focusing on perivascular adipose tissue (PVAT) accumulation and vascular toxicity in C57BL/6 mice. Ponatinib showed unique pharmacokinetics with high apparent mean residence time (5.22 h vs. 1.51 h for imatinib, and 3.20 h for nilotinib) and high apparent distribution volume (2891.33 mL/kg vs. 683.75 mL/kg for imatinib, and 74.84 mL/kg for nilotinib). Importantly, ponatinib had exceptionally high tissue-to-plasma ratio in aorta with PVAT (8.44 vs. 0.37 for imatinib, and 0.14 for nilotinib). Chronic ponatinib treatment (10 mg/kg, 4 weeks) severely impaired endothelium-dependent vasodilation assessed by magnetic resonance imaging invivo (thoracic aorta -7.4 ± 1.1% vs. controls 5.1 ± 1.3%). Ponatinib accumulated in aorta with PVAT after chronic treatment and directly impaired adipocyte maturation in invitro experiments. In isolated aorta, ponatinib reduced vascular nitric oxide (NO) release. In conclusion, endothelial dysfunction and impaired NO-dependent function induced by ponatinib were related to a unique profile of ponatinib distribution compared with other TKIs, along with direct effects on adipocyte maturation. Our results suggest that after chronic treatment, ponatinib accumulation in PVAT leads to the impairment of the vasoprotective function of PVAT, contributing to endothelial dysfunction induced by ponatinib.

SCD1 deficiency alters the perivascular secretory function of adipocytes and induces phenotypic changes in vascular smooth muscle cells.

Nationwide outcomes of early thoracic endovascular aortic repair for type B aortic dissection.

Thoracic aortic disease poses a significant threat due to its high mortality rates and genetic. underpinnings. While gene therapy holds promise for cures, the challenge lies in achieving. effective and safe gene delivery to the thoracic aorta. Tail vein injection (TI), is hindered by. off-target effects and hepatotoxicity, and traditional blinded percutaneous left heart injection. (TLI) carries a heightened risk of bleeding and mortality. To address these limitations. ultrasound-guided techniques present a viable solution. Adeno-associated virus (AAV) vectors. were delivered into the thoracic aorta of mice through TI, TLI, and ultrasound-guided. percutaneous left heart injection(ULI). While all three injection methods can achieve gene transduction in the thoracic aorta, the ULI approach provides the optimal balance between. high transduction efficiency and safety. The ULI method represents an efficient and safe. strategy for targeted gene delivery to the mouse thoracic aorta, providing a powerful tool for preclinical aortic gene therapy research that warrants broader application.

Despite advances in antihypertensive therapies, uncontrolled hypertension remains a major global health challenge, particularly among older adults. Ferroptosis, an iron-dependent programmed cell death, has been implicated in age-related vascular dysfunction, but its regulatory mechanisms in hypertension are unclear. This study investigates Sestrin2, a highly conserved stress-induced protein linked to cellular senescence, in regulating ferroptosis in hypertension. Angiotensin II (Ang II)-induced hypertensive mouse model and human umbilical vein endothelial cells (HUVECs) were established. Blood pressure was measured via the tail-cuff system, and vascular injury was assessed by H&E staining. Ferroptosis markers (ROS, Fe2⁺, MDA, and GSH) and mitochondrial morphology were analyzed. Co-immunoprecipitation assays (Co-IP) were used to analyze the interaction between Sestrin2 and AMPK in HUVECs cells. Sestrin2 and ferroptosis were elevated in hypertensive mice and HUVECs. Inhibition of ferroptosis using ferrostatin-1 (Fer-1) improved angiotensin II-induced hypertension. Furthermore, Sestrin2 colocalized with the endothelial cell marker CD31 in the thoracic aortas. Overexpression of Sestrin2 inhibited, whereas its knockdown promoted, ferroptosis in Ang II-induced HUVECs. Additionally, Sestrin2 overexpression partially restored normal mitochondrial morphology. Co-IP experiments revealed that Sestrin2 interacts with AMP-activated protein kinase (AMPK). Moreover, the AMPK inhibitor Compound C significantly downregulated nuclear factor erythroid 2-related factor 2 (Nrf2), glutathione peroxidase 4 (GPX4), and FTH1 expression, and upregulated Fe2+ levels. In vivo, Sestrin2 overexpression prevented Ang II-induced ferroptosis and hypertension. Sestrin2 inhibits ferroptosis to prevent hypertension by activating the AMPK/Nrf2/GPX4 pathway, suggesting its potential as a therapeutic target for hypertension.

Latent Growth of the Non-Dilated Descending Thoracic Aorta as a Marker of Genetic Aortopathy.

Arterial stenosis produces nonlinear changes in vascular impedance that are challenging to investigate in real time using either benchtop flow phantoms or high-fidelity computational fluid dynamics (CFD) models. This study aimed to develop and evaluate a low-cost printed circuit board (PCB) analog capable of reproducing the hemodynamic effects of progressive arterial stenosis through an R-L-C mapping of vascular mechanics. A lumped-parameter (0D) electrical network was constructed in which voltage represented pressure, current represented flow, resistance modeled viscous losses, capacitance corresponded to vessel compliance, and inductance represented fluid inertance. A variable resistor simulated focal stenosis and was adjusted incrementally to represent progressive narrowing. Input Uin, output Uout, peak-to-peak Vpp, and mean Vavg voltages were recorded at a driving frequency of 50 Hz. Physiological correspondence was established using the canonical relationships. R=8μlπr4, L=plπr2, C=3πr32Eh, where μ is blood viscosity, ρ is density, E is Young's modulus, and h is wall thickness. A calibration constant was applied to convert measured voltage differences into pressure differences. As simulated stenosis increased, the circuit exhibited a monotonic rise in Uout and Vpp, with a precise inflection beyond mid-range narrowing-consistent with the nonlinear growth in pressure loss predicted by fluid dynamic theory. Replicate measurements yielded stable, repeatable traces with no outliers under nominal test conditions. Qualitative trends matched those of surrogate 0D and CFD analyses, showing minimal changes for mild narrowing (≤25%) and a sharp increase in pressure loss for moderate to severe stenoses (≥50%). The PCB analog uses a simplified, lumped-parameter representation driven by a fixed-frequency sinusoidal excitation and therefore does not reproduce fully characterized physiological systolic-diastolic waveforms or heart-arterial coupling. In addition, the present configuration is intended for relatively straight peripheral arterial segments and is not designed to capture the complex geometry and branching of specialized vascular beds (e.g., intracranial circulation) or strongly curved elastic vessels (e.g., the thoracic aorta). The PCB analog successfully reproduces the characteristic hemodynamic signatures of arterial stenosis in real time and at low cost. The model provides a valuable tool for educational and research applications, offering rapid and intuitive visualization of vascular behavior. Current accuracy reflects assumptions of Newtonian, laminar, and lumped flow; future work will refine calibration, quantify uncertainty, and benchmark results against physiological measurements and full CFD simulations.

Management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) in zone 2 remains debated, as intentional coverage without revascularization increases the risk of cerebrovascular accident and spinal cord ischemia. Among available strategies, physician-modified endografts (PMEGs) have emerged as a practical, fully endovascular option for LSA preservation. The study reports the single-center experience at San Raffaele University Hospital, Milan, with PMEGs for TEVAR involving the distal aortic arch and the proximal descending thoracic aorta. In addition, a review of the current literature on PMEG-based LSA revascularization was conducted, including studies published between 2016 and 2024 addressing technical success, neurologic events, and mid-term patency. Fourteen consecutive patients operated between February 2023 and October 2024, all in urgent or emergent settings, were included in this study. PMEG implantation achieved 93% technical success with no 30-day mortality, stroke, or spinal cord ischemia. At a mean follow-up of 18.4 months, LSA patency was 92.3%, with a single reintervention for branch occlusion. Consistently, literature data demonstrate >90-95% technical success, stroke rates of 0-5%, and durable (>95%) LSA patency up to 3 years. Initial experience with PMEG-based LSA revascularization seems to offer a valuable, fully endovascular alternative for Zone-2 TEVAR in urgent or emergent cases that can't wait for standard custom-made device manufacturing. Meticulous imaging-guided planning and standardized modification protocols are essential for durable outcomes. While long-term data remain limited, accumulating evidence supports PMEGs as an effective bridge between conventional hybrid approaches and dedicated branched endografts.

Regional mechanical and microstructural variations in ascending thoracic aortic aneurysms influenced by tricuspid and bicuspid aortic valves.

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique for the treatment of thoracic aortic aneurysms (TAA). We hypothesized that alteration of blood hemodynamics in the thoracic aorta caused by stent implantation can possibly lead to hypertension and reduced coronary flow leading to the induction of heart failure (HF). The search in PubMed, Web of Science, Scopus, and the Cochrane library for studies containing data about the occurrence of HF after TEVAR resulted in 1231 articles of which 11 fulfilled the inclusion criteria. A meta-analysis was undertaken with the raw incidence of HF post-implantation as the primary endpoint. This occurred, in the first 30 days, to 684 out of 30,680 total patients (2.23%), and the raw incidence rate of HF was 0.03 [0.02-0.04], p<0.001. The random effects model was used because the examined studies had significant heterogeneity (I2=99.999%, τ2=3.905×10-4, p<0.001. In addition, significant publication bias was observed (Egger's test z=2.156, p=0.031). HF may develop in 30 days post-TEVAR possibly because of the increased aortic stiffness and the subsequent heamodynamic alterations which reduce the coronary blood supply. Thus, it may be necessary to initiate early pharmacological intervention while further research with randomized controlled trials with longer follow-up is warranted for the evaluation of the incidence of HF in the long term after TEVAR.Clinical ImpactOur meta-analysis shows that heart failure (HF) can occur in approximately 3% of patients within 30 days after TEVAR, indicating that HF is a clinically relevant but often under-recognized complication. Increased aortic stiffness and subsequent heamodynamic alterations which reduce the coronary blood supply may contribute to the development of HF. Our findings highlight the need for careful peri- and post-operative cardiac monitoring, particularly in patients with pre-existing cardiovascular risk and the need for hemodynamic optimization after stent-graft implantation.

BackgroundThe purpose of this descriptive study was to characterize the utilization and outcomes of CPB after trauma.MethodsThis is an AAST-sponsored retrospective (2011-2021) multicenter (32 centers) study of all adult trauma patients undergoing CPB. Univariate analysis comparing demographics, clinical characteristics and the study outcomes were performed between those who required CPB≤2hours, >2-24hours, and >24hours from the arrival. The primary outcome was mortality.ResultsThere were 113 patients, 63% sustained blunt trauma. The most common injuries were cardiac (42%), thoracic aorta (42%), and pericardial tamponade (25%). The three most common reasons to use CPB were aortic repair (32%), cardiopulmonary resuscitation (20%), and cardiac repair (15%). CPB was performed within 2hours in 44(39%), and 21(19%) underwent CPB after 24-hours. Penetrating mechanisms of injury 24 (55%) (P = .009), higher rate of hypotension (SBP <80mmHg) 15 (71%) (P = .002) were more common in CPB≤2-hours. Septal (P = .001) and valvular (P = .002) injuries were more frequent in CPB >24hours, otherwise there were no differences in injury patterns among CPB ≤2hours, >2-24hours, and >24hours. Cardiac repair was the most common indications for CPB ≤2hours (P = .002), aorta repair was more common in CPB 2-24hours (P = .03). Complications were not different between CPB ≤2hours, >2-24hours, and >24hours. Among survivors, no differences in terms of discharge disposition, hospital LOS were found (all P > .05). Mortality was 22% with 96% of them undergoing CPB in the first 24hours (P < .001).ConclusionsCPB is rarely used for traumatic injuries. The true impact of CPB is unknown and should be studied in comparison to patients with cardiovascular injuries that are repaired without CPB.Level of EvidenceLevel IV; Therapeutic/Care Management.

To identify principal components that characterize cardiovascular structure across age groups. Cross-sectional analysis of a secondary database including 3,215 individuals under 18 years. Measurements encompassed left ventricular parameters (diameters, areas, lengths, and wall thicknesses), thoracic aorta (annulus, root, sinotubular junction, ascending aorta, and arch), atrioventricular valves, pulmonary arteries, and coronary arteries. The population was classified into three age strata. Multivariate statistics assessed suitability for factor analysis with KMO and Bartlett tests; principal component analysis using the Kaiser criterion and Varimax rotation identified latent patterns and age-specific sentinel variables. Sampling adequacy was high in all groups (KMO > 0.86; Bartlett p < 0.001). In children aged 0-5 years, a single component explained > 83% of the variance. In school-age children (6-12 years), five factors explained 71% of the variance. In adolescents (13-17 years), seven independent components accounted for 72%, with high loadings across multiple indicators, indicating progressive complexity and independence among cardiovascular domains with maturation. The pediatric heart progresses from uniform growth to a differentiated architecture; adolescence marks anatomical specialization of chambers, walls, aorta, pulmonary circulation, and coronary arteries.

Most patients with ascending thoracic aortic aneurysms (ATAA) remain asymptomatic until they develop fatal complications, including aortic dissection and rupture. We aimed to develop and validate machine-learning models for predicting ATAA risk. We developed a predictive model for the risk of ATAA based on data from 18,382 participants from the Kangbuk Samsung Health Study between January 1, 2010, and December 31, 2018. In the screening context, an ATAA was defined as an ascending thoracic aorta with a diameter ≥ 3.7 cm. For the model inputs, we used 16 variables from medical records, including basic patient information, physical indices, baseline medical conditions, and laboratory data at an early stage. A feature importance analysis was performed to analyze the factors related to the risk of ATAA in healthy adults. A machine learning model for predicting the risk of ATAA was developed using a 5-layer deep neural network (DNN) with the 15 key features. The performance of this model was evaluated in terms of accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Age was the most important factor in predicting the risk of ATAA, followed by hypertension, waist circumference, creatinine level, smoking, and body mass index. The AUROC and accuracy of our 5-layer DNN with the 15 key features are 80.4% and 83.5%, respectively. The sensitivity and specificity of the DNN were 69.4% and 81.1%, respectively. We developed and validated a machine learning model that can be used to assess the risk of ATAA. This model has potential applications in disease screening for ATAA at an early stage.

Redo coronary artery bypass grafting (CABG) is arguably one of the most technically demanding procedures in cardiac surgery due to the presence of dense mediastinal/pericardial adhesions making target vessel identification challenging, limited conduit availability and the risk of injury to the heart and patent grafts. Resternotomy, in particular with the right ventricle and/or previous grafts adjacent/adherent to the posterior sternal table, could result in catastrophic complications. In selected patients, alternative strategies can be used to reduce these hazards and increase procedural safety. This video tutorial presents the surgical technique performed in a 77-year-old gentleman with a prior history of CABG, who underwent successful off-pump revascularization of the obtuse marginal branch with a radial artery graft anastomosed to the descending thoracic aorta through a left thoracotomy approach. The step-by-step video demonstrates conduit harvesting, patient positioning, descending aorta exposure and key technical nuances associated with both, proximal and distal anastomoses. This approach exemplifies how 'thinking outside the sternum' can transform a high-risk redo operation into a safe, reproducible procedure, thereby eliminating the above-mentioned risks associated with a resternotomy. The tutorial aims to provide practical guidance for experienced coronary teams seeking to expand their surgical armamentarium and improve outcomes of complex redo CABG procedures.

Degraded mechanical properties in the aortic wall can lead to the formation of aortic aneurysms, potentially resulting in life-threatening ruptures. Current diagnostic criteria using maximum aortic diameter often fail to predict this critical moment, underscoring the need for more accurate patient-based prediction methods. A hospital-compatible experimental apparatus was designed for quasi-static ex vivo inflation testing of intact Ascending Thoracic Aortic Aneurysm (ATAA) specimens with 360° full-field three-dimensional digital image correlation (3D-DIC). Given hospital handling constraints, liquid pressurization was not feasible; instead, pressure was applied via a balloon-driven pneumatic system, and synchronized stereo imaging was used to measure surface displacement fields between 80 and 120 mmHg. The system was validated using a CT-derived ATAA silicone phantom. Full-field displacement measurements showed close agreement with finite element simulations, supporting the mechanical reliability of the apparatus and the repeatability of the measurement workflow. In addition, a frozen-thawed healthy porcine thoracic aorta was tested to demonstrate biological feasibility, particularly regarding the speckle application and DIC tracking, without aiming to extract tissue constitutive parameters. Overall, the setup provides a practical framework for acquiring full-field inflation-induced deformation data from intact aortic specimens in a hospital setting, enabling future studies on resected human ATAA tissue and model calibration that may contribute to more accurate methods for rupture prediction.

The Thoracoflo hybridgraft was developed for treatment of thoracoabdominal aortic pathologies in selective patients, avoiding thoracotomy, thoracic cross-clamping, and extracorporeal circulation (ECC). In the following manuscript, criteria for patient selection as well as pitfalls and bailouts after first clinical experience are summarised.Since September 2021, worldwide a total of 50 Thoracoflo implantations have been performed in centres with high experience in open and endovascular treatment of thoracoabdominal aortic pathologies. All patients were selected by interdisciplinary board decision. Conventional open or solely endovascular repair was not feasible or at high risk due to comorbidities or for anatomical reasons. Simulator team training was performed prior to surgery and the procedure was supervised by a proctor. All procedures were evaluated postoperatively for technical and surgical pitfalls, and consecutive bailouts were elaborated and summarised.Requirements for graft implantation are a safe landing zone in the descending thoracic aorta, which can also be created by TEVAR implantation, and possibility for retrograde visceral perfusion (access to visceral arteries in dissection, low thrombus load). The Thoracoflo hybridgraft was successfully implanted in 49 out of 50 patients, but in one procedure intraoperative conversion with thoracotomy and extracorporeal circulation was necessary. During debriefing pitfalls and bailouts were summarised.The Thoracoflo hybridgraft offers an alternative treatment option for complex aortic pathologies, if perioperative requirements are followed. Accurate patient selection and verification of treatment indication are mandatory.