Thoracic Aortic Aneurysm Surgery Research Articles

Sex-related differences in outcome of thoracic aortic surgery.

Sex-related dissimilarities' influence on outcomes following thoracic aortic surgery is poorly understood. Our aim is to examine sex-related disparities in patients undergoing thoracic aortic aneurysm (TAA). A total of 455 cases undergoing thoracic aortic aneurysm (TAA) surgery were consecutively enrolled between December 2009 and December 2015 in a Chinese hospital. Primary outcomes, including overall mortality and related risk factors, were evaluated. Cox regression is utilized to recognize the independent risk factor of these consequences. Females, compared to males, had greater indexed aortic diameters and higher aortic transvalvular pressure differences. For the location of aortic aneurysms, females had a higher rate of aortic arch involvement, while males had a higher rate of root involvement. Females underwent less frequent complex proximal aortic operations compared with males (29.5% versus 46.9%; p < 0.001). Women and men both had a lower rate of aortic transvalvular pressure difference and LV volume index 7 days after thoracic aortic surgery. The overall mortality for the women's groups (11%) was suggestively greater compared to 4.9% for the men's groups (p = 0.026). Renal failure and aortic arch involvement were the main risk factors associated with males' survival, while maximum indexed aortic diameter and cross-clamp time were the risk factors associated with females' survival. The outcome after TAA surgery was less favorable in women with significantly increased overall mortality. It highlights the need to focus on implementing personalized surgery strategies and gender-specific guidelines in treating female patients following TAA surgery.

Experience of surgery for thoracic and abdominal thoracic aortic aneurysms by direct approach: Lack of CSF drainage does not alter the neurologic prognosis

Experience of surgery for thoracic and abdominal thoracic aortic aneurysms by direct approach: Lack of CSF drainage does not alter the neurologic prognosis

Elective Thoracic Aortic Aneurysm Surgery: A Tertiary Center Experience.

Background A thoracic aortic aneurysm (TAA) is a diseased expansion of the thoracic aorta. There is morbidity associated with a dilated aorta, as well as significant mortality. Open thoracic surgery is the fundamental management for proximal lesions, offering definitive treatment with excellent results. This study aimed to summarize preoperative data and operative outcomes of patients who underwent TAA repair at our institution. Methods Data were retrospectively collected from 234 patients that underwent elective open thoracic surgery at University Hospital Southampton for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures, were gathered. Results There were 166 males and 68 females, with an overall mean age of 66 years. The breakdown of operations comprised 105 aortic roots, 171 ascending aorta, 20 aortic arch, and 12 descending aorta cases. The mean follow-up was 370 days. 30-day mortality was 5.13%. Mortality was associated with female gender, aortic root surgery, and prosthetic valves. Mean aortic diameters at the time of surgery for the non-genetic aortopathy and genetic aortopathy groups were respectively 4.93cm and 4.63cm in the aortic root, 5.56cm and 4.88cm in the ascending aorta, 5.08cm and 3.87cm in the aortic arch, and 6.63cm and 5.50cm in the descending aorta. Conclusion Several factors are associated with complications and morbidity, which should be considered when discussing the risks of intervention with patients. There were no neuroprotective strategies that altered post-operative neurological function. Current practice in our unit fits in with current international guidance.

The epidemiology of pathologically confirmed clinically isolated aortitis: a North American population-based study.

Clinically isolated aortitis (CIA) refers to inflammation of the aorta without signs of systemic vasculitis or infection. Population-based data on the epidemiology of CIA in North America is lacking. We aimed to investigate the epidemiology of pathologically confirmed CIA. Residents of Olmsted County, Minnesota were screened for thoracic aortic aneurysm procedures with current procedural terminology codes between January 1, 2000, and December 31, 2021, using the resources of the Rochester Epidemiology Project. The medical records of all patients were manually reviewed. CIA was defined as histopathologically confirmed active aortitis diagnosed by evaluation of aortic tissue obtained during thoracic aortic aneurysm surgery in the absence of any infection, rheumatic disease, or systemic vasculitis. Incidence rates were age and sex adjusted to the 2020 United States total population. Eight incident cases of CIA were diagnosed during the study period; 6 (75%) of them were female. Median (IQR) age at diagnosis of CIA was 78.3 (70.2-78.9) years; all were diagnosed following ascending aortic aneurysm repair. The overall age and sex adjusted annual incidence rate of CIA was 8.9 (95% CI, 2.7-15.1) per 1,000,000 individuals over age 50 years. The median (IQR) duration of follow-up was 8.7 (1.2-12.0) years. The overall mortality compared to the age and sex matched general population did not differ (standardised mortality ratio: 1.58; 95% CI, 0.51-3.68). This is the first population-based epidemiologic study of pathologically confirmed CIA in North America. CIA predominantly affects women in their eighth decade and is quite rare.

Pro: Fluoroscopic Guidance Should Be Routinely Used to Place Cerebrospinal Fluid Drains for Patients Undergoing Aortic Surgery

PER THE SOCIETY for Vascular Surgery clinical guidelines, use of cerebrospinal fluid drains (CSFDs) should be considered for appropriately-selected patients undergoing extensive aortic repair. 1 Upchurch GR Escobar GA Azizzadeh A et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021; 73: 55S-83S Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Use of CSFDs enhances spinal cord perfusion pressure, thus ameliorating the detrimental effects in vulnerable watershed regions caused by the surgical reduction in blood supply, and thereby preventing devastating spinal cord ischemia (SCI). It is important to note that patients who experience SCI after aortic repairs have significantly worse long-term survival than those without this complication. More importantly, patients who have a return of neurologic function after SCI can anticipate similar life expectancy compared to those without SCI. There is plenty of evidence suggesting that prophylactic use of CSFDs in selected high-risk patients undergoing aortic repairs reduces the incidence of postoperative SCI. 2 DeSart K Scali ST Feezor RJ et al. Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair. J Vasc Surg. 2013; 58 (e2): 635-642 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar A recent meta-analysis that included 3,561 patients from 34 studies, demonstrated a lower incidence of SCI when CSFDs were placed routinely, as opposed to use only in patients meeting specified criteria. 3 Zhang Z Zhou Y Lin S et al. Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg. 2022; 75 (e5): 1478-1489 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Hence, the use of CSFDs will be warranted in selected patients undergoing aortic repairs who are at a high risk of SCI. 4 Arora H Ullery BW Kumar PA et al. Pro: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1376-1380 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Although CSFDs are an essential tool in the prevention of SCI caused by the surgery, CSFD placement is not without risk. Rong et al. published a meta-analysis that included 4,714 patients across 34 studies who underwent open and endovascular aortic repairs with CSFDs. 5 Rong LQ Kamel MK Rahouma M et al. Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis. Br J Anaesth. 2018; 120: 904-913 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar This analysis focused on CSFD-related complications, with a 6.5% rate of pooled events, 2.5% of which represented severe complications, including epidural hematoma, intracranial hemorrhage, subarachnoid hemorrhage, meningitis, and/or catheter-related neurologic deficit. Risk factors for increased technical difficulty or even failed CSFD placement included atypical anatomy, such as from prior lumbar spine surgery, osteoarthritis or scoliosis, and poor surface landmarks, as can occur with a higher body mass index. 6 Awad H Ramadan ME Tili E et al. Fluoroscopic-guided lumbar spinal drain insertion for thoracic aortic aneurysm surgery. Anesth Analg. 2017; 125: 1219-1222 Crossref PubMed Scopus (4) Google Scholar

Comparative Risks of Initial Aortic Events Associated With Genetic Thoracic Aortic Disease

BackgroundPathogenic variants in 11 genes predispose individuals to heritable thoracic aortic disease (HTAD), but limited data are available to stratify the risk for aortic events associated with these genes. ObjectivesThis study sought to compare the risk of first aortic event, specifically thoracic aortic aneurysm surgery or an aortic dissection, among 7 HTAD genes and variant types within each gene. MethodsA retrospective cohort of probands and relatives with rare variants in 7 genes for HTAD (n = 1,028) was assessed for the risk of first aortic events based on the gene altered, pathogenic variant type, sex, proband status, and location of recruitment. ResultsSignificant differences in aortic event risk were identified among the smooth muscle contraction genes (ACTA2, MYLK, and PRKG1; P = 0.002) and among the genes for Loeys-Dietz syndrome, which encode proteins in the transforming growth factor (TGF)-β pathway (SMAD3, TGFB2, TGFBR1, and TGFBR2;P < 0.0001). Cumulative incidence of type A aortic dissection was higher than elective aneurysm surgery in patients with variants in ACTA2, MYLK, PRKG1, and SMAD3; in contrast, patients with TGFBR2 variants had lower cumulative incidence of type A aortic dissection than elective aneurysm surgery. Cumulative incidence of type B aortic dissection was higher for ACTA2, PRKG1, and TGFBR2 than other genes. After adjusting for proband status, sex, and recruitment location, specific variants in ACTA2 and TGFBR2 were associated with substantially higher risk of aortic event with childhood onset. ConclusionsGene- and variant-specific data on aortic events in individuals with HTAD support personalized aortic surveillance and clinical management.

Preoperative and postoperative complications of cerebrospinal fluid drainage in descending thoracic and thoraco-abdominal aortic aneurysm surgery: a single-center retrospective study.

Cerebrospinal-fluid drainage (CSFD) has been performed to prevent paraplegia in descending thoracic or thoraco-abdominal aortic aneurysm (DTA/TAAA) surgery; however, CSFD itself has a risk of severe complications. We retrospectively investigated the incidence rates of CSFD-related preoperative and postoperative complications. Patients who underwent DTA/TAAA surgery with a CSFD catheter that was inserted on the day before surgery were enrolled. The incidence rates of complications from spinal puncture until DTA/TAAA surgery were investigated as preoperative CSFD complications, and the incidence rates from DTA/TAAA surgery to postoperative day 7 were investigated as CSFD-related postoperative complications. Preoperative CSFD complications were analyzed in 123 cases. DTA/TAAA surgery was postponed due to bloody cerebrospinal fluid (2.5%) and due to meningitis (1.7%). The incidence rate of mild preoperative complications was 32.4%. Postoperative CSFD complications were analyzed in 108 cases. Intracranial hemorrhage occurred in 3.9% of cases in open surgery and other postoperative severe CSFD complications did not occur. The incidence rates of moderate/mild complications in open surgery were 2.6%/14.3% and those in TEVAR were 3.2%/19.4%. Bloody cerebrospinal fluid and meningitis, which are severe complications associated with spinal puncture, occurred within 1 day after spinal puncture. The incidence rates of moderate/mild complications were high in both the preoperative and postoperative periods. These results showed that CSFD catheter insertion and management should be performed carefully with consideration given to the risks and benefits of CSFD.

Creation of an Analytical Model of Spinal Cord Cooling by Epidural Catheter for Preventing Paraplegia.

IntroductionParaplegia is a serious complication after thoracic and thoracoabdominal aortic aneurysm surgery. The aortic cross-clamp blocks blood flow to the intercostal artery as a feeding blood vessel, so the spinal cord is at risk of being exposed to ischemia. Hypothermia with systemic cooling is a useful means of avoiding spinal ischemia caused by aortic blockade but has various side effects. Theoretically, local cooling by epidural cooling catheter is an effective method to reduce the side effects. However, the use of needle sensors to measure the temperature of the human spinal cord is not ethically applicable in the real clinical field. The purpose of the study is to build computer modeling of human-sized spinal cords and a basic platform for simulating spinal cord cooling. This is being done to prove that local cooling can cool the human spinal cord in the same way, even in human spinal cords larger than laboratory animals.MethodsWe tried to model a horizontal cross-section of tissue near the spinal cord at a size equivalent to that of an adult human. The tissue around the spinal cord was decomposed into many small matrices for analysis using the finite element method. Next, the analysis was performed using a high-speed computer on the assumption that the matrix exchanges heat with the adjacent matrix over time according to Pennes' bio-heat equation. Repeated calculations were performed on a high-speed computer to calculate temperature changes in the central part of the spinal cord.ResultBy setting the temperature of the cooling catheter to 20°C, temperatures at the center of the spinal cord after 5, 10, 15, 20 and 25 minutes were 34.08°C, 33.64°C, 33.48°C, 33.40°C, and 33.36°C, respectively. After stopping the cooling, the temperature at the center of the spinal cord recovered to baseline temperature within 10 minutes.ConclusionResults were similar to those of previous animal studies using our local cooling system, suggesting that evaluation of cooling catheter's performance by computational simulation (CS) is effective.

Statin Therapy in Patients Undergoing Thoracic Aorta Replacement for Aortic Aneurysms.

Background Patients undergoing surgery for thoracic aortic aneurysms receive statin therapy out of proportion to cardiovascular comorbidity. We sought to determine the prevalence of statin use among patients presenting for thoracic aortic aneurysm surgery and investigate its effect on outcomes. Methods From January 1, 2005 to January 1, 2011, 1,839 consecutive patients underwent aortic replacement for degenerative thoracic aortic aneurysm at Cleveland Clinic. Of these, 771 (42%) were on statins preoperatively. Statin users (vs. nonstatin users) were older (65 ± 11 vs. 56 ± 16 years) and had more hypertension (78 vs. 59%). Propensity matching based on 56 preoperative variables other than lipid levels was used to compare outcomes among 570 matched patient pairs (74% of possible pairs). Results Propensity-matched statin and nonstatin users were aged 64 ± 11 years, 394 (69%) versus 387 (68%) were male, and 437 (77%) versus 442 (78%) had ascending aortic aneurysms, respectively. Overall, 25% of patients were followed for more than 8.2 years and 10% for more than 10 years. Perioperative outcomes were similar, including hospital mortality (11 [1.9%] vs. 5 [0.88%]) and stroke (22 [3.9%] vs. 13 [2.3%]), but 16 statin users (2.8%) versus 5 nonstatin users (0.88%) required temporary dialysis after surgery ( p = 0.02). At 6 years, 3.7% of statin users versus 5.1% of nonstatin users ( p [log-rank] = 0.5) underwent further aortic surgery, and at 10 years, mortality was 25% in both groups ( p > 0.5). Conclusion Patients presenting for thoracic aortic aneurysm surgery frequently receive unnecessary statins. Additionally, statin use was associated with more postoperative renal failure, but not less intermediate-term risk for aortic reintervention or all-cause mortality after surgery. Therefore, presence of a thoracic aortic aneurysm should not be considered an indication for statin therapy in the absence of well-established indications.

Exploring the potential of rapid evaporative ionization mass spectrometry (Intelligent Knife) for point-of-care testing in aortic surgery.

OBJECTIVESMany intraoperative decisions regarding the extent of thoracic aortic surgery are subjective and are based on the appearance of the aorta, perceived surgical risks and likelihood of early recurrent disease. Our objective in this work was to carry out a cross-sectional study to demonstrate that rapid evaporative ionization mass spectrometry (REIMS) of electrosurgical aerosol is able to empirically discriminate ex vivo aneurysmal human thoracic aorta from normal aorta, thus providing supportive evidence for the development of the technique as a point-of-care test guiding intraoperative surgical decision-making.METHODSHuman aortic tissue was obtained from patients undergoing surgery for thoracic aortic aneurysms (n = 44). Normal aorta was obtained from a mixture of post-mortem and punch biopsies from patients undergoing coronary surgery (n = 13). Monopolar electrocautery was applied to samples and surgical aerosol aspirated and analysed by REIMS to produce mass spectral data.RESULTSModels generated from REIMS data can discriminate aneurysmal from normal aorta with accuracy and precision of 88.7% and 85.1%, respectively. In addition, further analysis investigating aneurysmal tissue from patients with bicuspid and tricuspid aortic valves was discriminated from normal tissue and each other with accuracies and precision of 93.5% and 91.4% for control, 83.8% and 76.7% for bicuspid aortic valve and 89.3% and 86.0% for tricuspid aortic valve, respectively.CONCLUSIONSAnalysis of electrosurgical aerosol from ex vivo aortic tissue using REIMS allowed us to discriminate aneurysmal from normal aorta, supporting its development as a point-of-care test (Intelligent Knife) for guiding surgical intraoperative decision-making.

Pre- and postoperative left atrial and ventricular volumetric and deformation analyses in severe aortic regurgitation

BackgroundThe impact of volume overload due to aortic regurgitation (AR) on systolic and diastolic left ventricular (LV) indices and left atrial remodeling is unclear. We assessed the structural and functional effects of severe AR on LV and left atrium before and after aortic valve replacement.MethodsPatients with severe AR scheduled for aortic valve replacement (n = 65) underwent two- and three-dimensional echocardiography, including left atrial strain imaging, before and 1 year after surgery. A control group was selected, and comprised patients undergoing surgery for thoracic aortic aneurysm without aortic valve replacement (n = 20). Logistic regression analysis was used to assess predictors of impaired left ventricular functional and structural recovery, defined as a composite variable of diastolic dysfunction grade ≥ 2, EF < 50%, or left ventricular end-diastolic volume index above the gender-specific normal range.ResultsDiastolic dysfunction was present in 32% of patients with AR at baseline. Diastolic LV function indices and left atrial strain improved, and both left atrial and LV volumes decreased in the AR group following aortic valve replacement. Preoperative left atrial strain during the conduit phase added to left ventricular end-systolic volume index for the prediction of impaired LV functional and structural recovery after aortic valve replacement (model p < 0.001, accuracy 70%; addition of left atrial strain during the conduit phase to end-systolic volume index p = 0.006).ConclusionsOne-third of patients with severe AR had signs of diastolic dysfunction. Aortic valve surgery reduced LV and left atrial volumes and improved diastolic indices. Left atrial strain during the conduit phase added to the well-established left ventricular end-diastolic dimension for the prediction of impaired left ventricular functional and structural recovery at follow-up. However, long-term follow-up studies with hard endpoints are needed to assess the value of left atrial strain as predictor of myocardial recovery in aortic regurgitation.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Increase of urinary TIMP-2 and IGFBP7 as potential predictor of acute kidney injury requiring renal replacement therapy and patients' outcome following complex endovascular and open thoracic abdominal aortic aneurysm surgery - a prospective observational study.

Background: Acute kidney injury (AKI) as complication after open and endovascular repair of thoracoabdominal aortic aneurysm (TAAA) is one major predictor of mortality and postoperative complications. We evaluated tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) as combined early biomarker for AKI detection and predictor of patients' outcome. Patients and methods: Between 2014 and 2015, 52 patients have been enrolled in this observational study, of whom 29 (55.8%) underwent elective open repair and 23 (44.2%) endovascular repair. TIMP2×IGFBP7 were measured until 48 hours after admission on intensive-care unit (ICU) and were analyzed regarding their predictive ability for AKI (defined according to the KDIGO criteria) requiring temporary renal replacement therapy (RRT) and 90-day mortality using ROC curves. Results: Mean patient age was 64.5 years (Min: 43, Max: 85), endovascular treated patients were older (p <0.0001). 40.4% (n = 21) developed AKI, and 21.2% (n = 11) required renal replacement therapy. In-hospital and total mortality rates were 7.7% (n = 4) and 9.6% (n = 5), respectively. At no time a significant difference in TIMP2×IGFB7 levels between patients undergoing open or endovascular surgery was observed. The predictive quality of the TIMP2×IGFBP7 value on ICU admission was sound regarding AKI requiring temporary renal replacement therapy (sensitivity: 55.56% [38.1-72.1%], specificity: 90.91% [58.7-99.8%] with an area under the curve [AUC]: 0.694 [0.543-0.820]). Mean follow-up was 13.2 months (Min: 2, Max: 20), regarding the 90-day mortality, the predictive property of the TIMP2×IGFBP7 value was not sufficient (sensitivity: 80% [28.4-99.5%], specificity: 52.38% [36.4-68%], and AUC: 0.607 [0.454-0.746]). Conclusions: TIMP2×IGFBP7 level measured 6-12 hrs postoperatively may be useful as an early detectable biomarker for AKI requiring temporary renal replacement therapy. It seems not suited to predict patients' outcome following complex thoracoabdominal aortic surgery, regardless if performed by open or endovascular repair.

International study on impact of COVID‐19 on cardiac and thoracic aortic aneurysm surgery

BackgroundThe coronavirus disease‐2019 (COVID‐19) pandemic gripped every nation's health care system and provisions on all levels. In cardiac and aortic surgery, as it is with most specialities, elective surgeries were halted.Aims of the studyWe captured reflections, contingencies, and current practices across of high‐volume centers in cardiac and aortic surgery globally. We also aimed this study to assess decision on prioritization of the surgical patients, the need for personal protection equipment, and the choice of preoperative investigations in current dynamic and fluid climate.MethodsA validated web‐based questionnaire was constructed and was circulated to the international surgeons amongst high volume cardiac and aortic surgery centers. Their intrinsic feedback on decision making, the impact of the lockdown, and perspectives for the future ahead of us all were noted. A mixed‐method approach was constructed. Qualitative data analysis was introduced to signify the impact globally.ResultsOverall, 23 centers from 18 countries participated in this international study. About 91.7% of the respondents stopped operating on elective patients during the pandemic. The majority of the surgeons agreed that acute aortic dissection (87.1%) should be operated as an emergency procedure and stable triple vessel disease (87.1%) to be considered as an elective procedure. Three‐fifth (60%) of the respondents relied on computerized tomography chest as a preoperative screening modality.ConclusionIn the present climate where there is a paucity of evidence, this will give an interim consensus for the cardiac surgeons. With the increase in the cumulative number of patients with COVID‐19, careful utilization of the resources regarding hospital beds and manpower is of paramount importance.

An evaluation of the long-term patency of the aortocoronary bypass graft anastomosed to a vascular prosthesis.

Although concomitant surgery for coronary artery disease (CAD) and thoracic aortic aneurysm is performed often, the long-term patency of the coronary artery bypass grafting (CABG) anastomosed to a vascular prosthesis has not been fully investigated. Here, we explored the long-term patency of the graft in comparison with the proximal anastomosis site on the native ascending aorta or vascular prosthesis. A total of 84 patients with concomitant CABG who underwent surgery for thoracic aortic aneurysm at 3 Osaka Cardiovascular Research Group institutes were retrospectively investigated for this study. The patency of 109 aortocoronary bypasses using saphenous vein grafts was evaluated with computed tomography angiography or coronary angiography, comparing the grafts anastomosed on the vascular prosthesis (group P, n = 75) to those anastomosed on the native ascending aorta (group N, n = 34). During 45.9 ± 39.7 months follow-up, significantly worse patency of the grafts in group P was revealed when compared with those in group N (100% vs 77.6% in 12 months, 100% vs 52.7% in 36 months and 100% vs 31.6% in 57 months, log rank P < 0.001). The poor patency of the grafts was confirmed in each target lesions (left anterior descending artery: P = 0.050, right coronary artery: P = 0.045, left circumflex artery: P = 0.051) and regardless of the severities of the target coronary vessels (severe stenosis: P = 0.013, mild-to-moderate stenosis: P = 0.029). Furthermore, an analysis of graft occlusion risk factors using the univariate Cox proportional hazards model revealed that the proximal anastomosis site on the vascular prosthesis was the sole risk factor for graft occlusion (P < 0.001). In the simultaneous surgery for CAD and thoracic aortic aneurysm, CABG design from vascular prosthesis to coronary artery should be avoided if possible, although further studies are warranted.

Incidence and characteristics of hospitalization for proximal aortic surgery for acute syndromes and for aneurysms in the USA from 2005 to 2014.

The effectiveness of proximal thoracic aortic aneurysm (TAA) surgery in preventing acute aortic syndromes, such as dissection and rupture, is unknown at the populational level. This study evaluated trends in acute aortic syndrome operation incidence relative to proximal aortic surgical volume in the USA. A retrospective analysis of the National Inpatient Sample in 2005-2014 was performed. Acute aortic syndrome and TAA were identified with International Classification of Diseases, 9th edition diagnosis codes. Proximal aortic surgery was defined as the diagnosis of acute aortic syndrome or TAA with an aortic procedure and either cardioplegia, cardiopulmonary bypass or other cardiac operation. Annual rates of acute aortic syndrome surgery and proximal thoracic aneurysm surgery were adjusted for US population. Trends were evaluated using linear regression. We identified 38 442 operations for acute aortic diagnoses and 74 953 operations for TAAs. Case volume for acute aortic syndromes increased from 0.93 to 1.63 per 100 000 (P = 0.001), and aneurysm surgery increased from 1.75 to 3.19 per 100 000 (P < 0.001). Patient and hospital characteristics differed between acute aortic and aneurysm operations, with black patients being most notably underrepresented in the aneurysm population (4.9% vs 17.0%, P < 0.001). Acute aortic syndrome operative volume increased from 2005 to 2014 despite increasing rates of proximal aortic aneurysm surgery. Patient characteristic discrepancies were observed between the 2 groups of hospitalizations, highlighting the need for continued efforts to minimize sociodemographic disparities.

Thoracic Aortic Aneurysm Surgery in Marfan Patients: a Perspective from the UK.

ObjectiveCardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes.MethodsA total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival.ResultsRoot and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%.ConclusionThe outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.

Which is the Optimal Frozen Elephant Trunk? A Systematic Review and Meta-Analysis of Outcomes in 2161 Patients Undergoing Thoracic Aortic Aneurysm Surgery Using E-vita OPEN PLUS Hybrid Stent Graft versus Thoraflex™ Hybrid Prosthesis.

ObjectiveTo systematically review the rate of morbidity and mortality associated with the use of E-vita hybrid stent graft and ThoraflexTM in patients undergoing complex aortic surgery.MethodsA comprehensive search was undertaken among the four major databases to identify published data about E-vita or Thoraflex™ in patients undergoing repair of thoracic aortic aneurysms.ResultsIn total, 28 papers were included in the study, encompassing a total of 2,161 patients (1,919 E-vita and 242 Thoraflex™). Patients undergoing surgery with E-vita or Thoraflex™ were of similar age and sex. The number of patients undergoing non-elective repair with Thoraflex™ was higher than with E-vita (35.2% vs. 28.7%, respectively). Cardiopulmonary bypass time was associated with increasing mortality in E-vita patients, however a meta-analysis of proportions showed higher 30-day mortality, permanent neurological deficit, and one-year mortality for Thoraflex™ patients. Direct statistical comparisons between E-vita and Thoraflex™ was not possible due to heterogeneity of studies.ConclusionAlthough there are limited studies available, the available data suggests that mortality and morbidity are lower for the E-vita device in thoracic aortic aneurysm surgery than for Thoraflex™. Long-term data of comparative studies do not yet exist to assess viability of these procedures.

Surgical treatment for secondary aortoesophageal fistula after prosthetic aortic replacement: A report of four cases

IntroductionWith the increase of thoracic aortic aneurysm surgery and thoracic endovascular aortic repair, secondary aortoesophageal fistula (AEF) has been reported. However, the treatment strategy for AEF remains controversial. Presentation of casesFour patients who had undergone prosthetic aortic replacement for thoracic aortic aneurysm 4–36 months previously, were hospitalized with sepsis-like symptoms. They were diagnosed with aortic prosthetic graft infection after computed tomography revealed ectopic gas around the prosthesis. After that, esophagogastroduodenoscopy revealed an esophageal perforation, so we diagnosed AEF. They received medication and stepwise surgery; 1 patient was discharged, 2 remain hospitalized, and 1 died. DiscussionSome reports have suggested that combined surgery provides better outcomes for AEF. Infection may be controlled by esophagectomy and antibiotic treatment, so prosthesis replacement is not always necessary. However, we should note that infection between a prosthetic graft and the native aorta brings a danger of pseudoaneurysm of the anastomosis. ConclusionBased on our experience we conclude that surgery performed stepwise along with infection control and general health improvement is a valid treatment strategy for secondary AEF after prosthetic aortic replacement.

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery.

In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined. Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C. The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days. Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.