Thoracic Aortic Repair Research Articles

Thoracic aortic endovascular repair or open surgery after frozen elephant trunk?—the last word has not been spoken yet!

Thoracic aortic endovascular repair or open surgery after frozen elephant trunk?—the last word has not been spoken yet!

THE ANESTHETIC MANAGEMENT OF EXTENSIVE AORTIC THORACIC ANEURYSM REPAIR WITH CLAMSHELL INCISION

Introduction Surgical repair of extensive thoracic aorta disease represents an interesting challenge, both surgical and anesthetic. We describe the surgical repair of an acute aortic dissection beginning in the aortic arch in relation with aortic coartation and a post coartation aneurism, and the aspects related to planning, management and perioperative care. The clamshell incision is associated with respiratory complications, bleeding and post-operative severe pain. Interruption of spinal cord blood supply is one of the causes of spinal cord injury after thoracic aortic aneurism repair. Aortic arch surgery requiring circulatory arrest bears significant risk of brain injury. Methods Descending aorta cannulation and perfusion, preservation of its posterior wall, lumbar paravertebral NIRS and femoral arterial invasive pressure monitoring were used as spinal cord protective strategies. Cerebral antegrade perfusion, initially unilateral and then bilateral, with BIS and cerebral NIRS monitoring were the key components of the cerebral protection strategy. A bilateral erector spinae plane block (BESPB) was performed to allow good pain control in the postoperative period, early extubation and rehabilitation. Intravenous antifibrinolytic, goal directed transfusion therapy and maintaining a coagulation friendly environment were the mainstays of the non-surgical hemostasis strategy. Results The patient was successfully extubated in the operating room presenting no neurological deficits. The surgical drains were removed on the fifth day; on the following day it was necessary to surgically remove part of the left thoracic drain, under combined anesthesia with the ipsilateral ESPB catheter. The remaining postoperative period was uneventful and the patient was discharged home in the 10th postoperative day. Discussion No subarachnoid catheter was placed (to drain cerebrospinal fluid to protect the spinal cord from ischemia), after discussing it in advance with the surgical team, given the risks associated with it and the protective strategy to be adopted: direct perfusion of the descending aorta, preservation of its posterior wall, lumbar paravertebral NIRS ant femoral arterial invasive pressure monitoring., in the intraoperative period, on table extubation and direct neurological monitoring, together with adequate systemic arterial pressures, in the immediate postoperative period. Good pain control with BESPB and on table extubation allowed for early rehabilitation

One-Stage Hybrid Total Aortic Arch and Descending Thoracic Aortic Repair is a Safe and Secure Procedure With Less Postoperative Complications for Extended Aortic Arch Aneurysms

Purpose Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. Materials and Methods From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. Results The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (p<0.01). The rate of 6 year freedom from all-cause death in type II-1 HAR (83.1%) was numerically higher than that in TAR (74.7%), and the rate of 6 year freedom from surgery-related complications in type II-1 HAR (90.3%) was numerically lower than that in TAR (96.9%) due to the occurrence of TEVAR-related complications, and the rate of 6 year freedom from reintervention to the descending thoracic aorta in type II-1 HAR (100%) seemed to be better than that in TAR (83.7%). However, Cox regression analysis did not reveal any statistical difference between the 2 procedures. Conclusions HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

Trends in operative case volumes of Canadian vascular surgery trainees

ObjectiveVascular surgery has evolved with increasing use of endovascular therapies and a decline in open surgery. The influence of these changes, in addition to a new vascular surgery training program introduced in 2012, on case volumes of vascular trainees is not known. We sought to evaluate trends in operative case volumes of Canadian vascular surgery trainees. MethodsA survey was administered to graduates of the Canadian Royal College-accredited Vascular Fellowships (VFs) and Integrated Vascular Surgery Residency (IVSR) programs (2007-2019) to record cases performed during their final 2 years of training. Procedures of interest were open abdominal aortic aneurysm (oAAA) repair, open thoracic/thoracoabdominal aortic (oTAA/TAAA) repair, lower extremity bypass (LEB), carotid endarterectomy (CEA), lower extremity endovascular intervention (LEEI), and endovascular abdominal, advanced, and thoracic aortic repair (EVAR, aEVAR, and TEVAR). Case volumes were analyzed overall, and by graduation year, type of training program, and resident demographics. ResultsA total of 60 participants (10% female) from all the 10 Canadian training institutions responded (response rate, 63%). There was a declining trend in overall procedures performed since the introduction of IVSR in 2012 (median, 427 [interquartile range (IQR), 304-496] in 2007-2012 vs median, 342 [IQR, 279-405] in 2013-2019; P = .055), driven by a significant decline in open vascular surgery cases (median, 273 [IQR, 221-339] in 2007-2012 vs median, 156 [IQR, 128-181] in 2013-2019; P = .001). Case volumes of oAAA, LEB, and CEA declined by 44%, 40%, and 45%, respectively. Compared with vascular fellows, IVSR residents logged ∼2.5 times more aEVARs (median, 8; IQR, 2-11 vs median, 19; IQR, 8-27; P = .001) and ∼1.5 times more LEEIs (median, 60; IQR, 40-99 vs median, 93; IQR, 69-120; P = .018). Trainees were most confident (range, 90%-100%) in performing oAAA, EVAR, LEB, LEEI, and CEA after training, and least confident in performing oTAA/TAAA and aEVAR (20% and 49% confidence, respectively). ConclusionsOperative case volumes of Canadian vascular surgery trainees since the introduction of IVSR program in 2012 have decreased, driven by declining exposure to open cases. However, trainees continue to receive adequate operative exposure to perform most standard vascular procedures confidently upon graduation.

Effects of acute normovolemic hemodilution on post‐cardiopulmonary bypass coagulation tests and allogeneic blood transfusion in thoracic aortic repair surgery: An observational cohort study

Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair with cardiopulmonary bypass (CPB) from 2019 to 2021. A total of 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p < 0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH versus control group: FFP 1.1 ± 1.6 versus 1.9 ± 2.3 (p = 0.003), platelets 0.6 ± 0.8 versus 1.2 ± 1.3 (p = 0.0008), and cryoprecipitate 0.3 ± 0.7 versus 0.7 ± 1.1 (p = 0.008). Reduction in red blood cell transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p = 0.42). There was no significant difference in major adverse outcomes. ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests ANH can improve some coagulation values after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.

Temporal Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Aortic Syndromes in Bicuspid Aortic Valves: Insights from a National Database

IntroductionThere is paucity of data on the outcomes of hospitalization for bicuspid aortic valve (BAV)-related aortopathies.MethodsWe queried the NIS database (2012–2016) for hospitalizations for elective thoracic aortic repair or acute aortic syndrome (AAS) among those with BAV versus trileaflet aortic valve (TAV).ResultsOur analysis yielded 38,010 hospitalizations for elective aortic repair, of whom 34.4% had BAV, as well as 81,875 hospitalizations for thoracic AAS, of whom 1.1% had BAV. Hospitalizations for BAV were younger and had fewer comorbidities compared with their TAV counterparts. The number of hospitalizations for BAV during the observational period was unchanged. After propensity matching, elective aortic repair for BAV was associated with lower mortality (0.5% versus 1.7%, odds ratio = 0.28; 95% CI 1.5–0.50, p < 0.001), use of mechanical circulatory support, acute stroke, and shorter length of hospital stay compared with TAV. After propensity matching, AAS among those with BAV had a greater incidence of bleeding events, blood transfusion, cardiac tamponade, ventricular arrhythmias, and a longer length of hospital stay compared with TAV. Among those with BAV, predictors of lower mortality if undergoing elective aortic repair included larger hospitals and teaching hospitals. Predictors of higher mortality in patients with AAS included heart failure, chronic kidney disease, and coronary artery disease.ConclusionData from a national database showed no change in the number of hospitalizations for BAV-related aortopathy, with relatively lower incidence of AAS. Compared with TAV, elective aortic repair for BAV is associated with lower mortality, while BAV-related AAS is associated with higher in-hospital complications.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-021-00237-3.

Video of Thoracic Endovascular Aortic Repair With Subclavian Artery Laser Fenestration

We present a case of laser fenestration to the left subclavian artery during thoracic aortic endovascular repair in a patient not well-suited to left carotid to subclavian bypass to maintain a previously placed left brachiocephalic dialysis access. We have outlined a stepwise approach, including details of the technique and clear intraoperative imaging and decision-making.

A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery

ObjectiveThe objective was to develop a novel scoring system that would be predictive of postoperative pulmonary complications in critically ill patients after cardiac and major vascular surgery. MethodsA total of 17,433 postoperative patients after coronary artery bypass graft, valve, or thoracic aorta repair surgery admitted to the cardiovascular intensive care units at Cleveland Clinic Main Campus from 2009 to 2015. The primary outcome was the composite of postoperative pulmonary complications, including pneumonia, prolonged postoperative mechanical ventilation (>48 hours), or reintubation occurring during the hospital stay. Elastic net logistic regression was used on the training subset to build a prediction model that included perioperative predictors. Five-fold cross-validation was used to select an appropriate subset of the predictors. The predictive efficacy was assessed with calibration and discrimination statistics. Post hoc, of 13,353 adult patients, we tested the clinical usefulness of our risk prediction model on 12,956 patients who underwent surgery from 2015 to 2019. ResultsPostoperative pulmonary complications were observed in 1669 patients (9.6%). A prediction model that included baseline and demographic risk factors along with perioperative predictors had a C-statistic of 0.87 (95% confidence interval, 0.86-0.88), with a corrected Brier score of 0.06. Our prediction model maintains satisfactory discrimination (C-statistics of 0.87) and calibration (Brier score of 0.07) abilities when evaluated on an independent dataset of 12,843 recent adult patients who underwent cardiovascular surgery. ConclusionsA novel prediction nomogram accurately predicted postoperative pulmonary complications after major cardiac and vascular surgery. Intensivists may use these predictors to allow for proactive and preventative interventions in this patient population.

Progress in Diagnosis and Endoscopic Treatment of Stanford B Penetrating Aortic Ulcers

Penetrating aortic ulcers is rare in clinical practice, and it is necessary to intervene in this type of aortic perforating ulcer because it can be accompanied by major arterial dissection and intermural hematoma. With the widespread application and technical advancement of follow-up thoracic aortic endovascular repair (TEVAR), endovascular treatment has become the first choice for symptomatic aortic perforating ulcers. In this review, we will review the diagnosis, diagnosis and endovascular treatment of aortic perforating ulcer.

Analysis of diagnosis, treatment and risk classification of blunt thoracic aortic injury

Objective: Propose a new risk classification system for blunt thoracic aortic injury and explore its treatment strategies. Methods: After the retrospective analysis of clinical data from 68 patients with blunt thoracic aortic injury in the First Affiliated Hospital of Zhengzhou University from November 2016 to October 2020, there were 56 males and 12 females, among these patients, the median age was 45(21-69). According to the degree of aortic injury and the combined injury, the patients were scored for aortic injury, and the risk of the patients were graded into following three types: low-risk group (score ≤ 2 points) 12 cases, intermediate-risk group (3 points ≤ score ≤ 5 points) 41 cases, high-risk group (score ≥ 6 points) 15 cases. Analyzing the effects of treatments received by patients in different grades on the prognosis. Patients were followed up through hospitalization or outpatient clinics at 1, 3, 6, 12 months after surgery and every year thereafter. Results: Of the 68 patients, 21 received non-surgical treatment and 47 received surgical repair, including 6 open surgery and 41 thoracic aortic endovascular repair. There were 16 cases of emergency operation and 31 cases of delayed operation. Twelve low-risk patients were treated with non-surgical treatment, and only 1 patient died of lung infection, with a mortality rate of 8.3% (1/12). There were 8 deaths in 41 moderate-risk patients, with a mortality rate of 19.5% (8/41), and the aortic-related mortality rate was 9.8% (4/41), and the operative mortality rate was 10.8% (4/37). The total mortality of 15 high-risk patients was 40% (6/15), and the aortic-related mortality rate was 30.0% (5/15), and the mortality rate of surgical patients was 10% (1/10). During the follow-up period of 5 to 52 months, no deaths occurred outside the hospital. According to the risk grading, there were significant differences in the aortic-related mortality of each grade (χ²=7.840, P=0.020). During the follow-up of 5-52 months, 1 case had type Ⅰ endoleak, 1 case of cerebral infarction, and 1 case of acute renal failure. Conclusion: According to the patient's degree of aortic injury and combined injury, the risk classification helps to choose the appropriate treatment.

Postoperative complications of endovascular blunt thoracic aortic injury repair

BackgroundThoracic endovascular aortic repair (TEVAR) has become the standard of care for thoracic aortic aneurysms and increasingly for blunt thoracic aortic injury (BTAI). Postoperative complications, including spinal cord ischemia and...

Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: Single-Center Experience in a Developing Country

Background: Blunt thoracic aortic injury (BTAI) is a lethal condition. The most common intervention is no longer open aortic repair (OAR), it has been almost entirely replaced by thoracic aortic endovascular repair (TEVAR). Objectives: In the present study, we aimed to share our experience in emergency TEVAR and address some difficulties that have been encountered. Methods: In this retrospective study, all patients with blunt chest trauma between July 2014 and April 2020 were identified. Only patients with BTAI who were treated by emergency TEVAR were included. Demographic and clinical data were collected and analyzed. Results:A total of 657 cases of blunt chest trauma were identified. Only 7 cases were found to have BTAI who underwent emergency TEVAR; six patients (85.7%) were males, with a mean age (±SD) of 29.5±8.5 years and one as a 39-year-old female. Motor vehicle accident (MVA) was the mechanism of injury (100%). Two patients (27.6%) had grade-II, 4 patients (57.1%) had grade-III, and 1 patient (14.2%) had grade IV aortic injuries. Technical success was achieved in all cases (100%). No peri-procedural-related mortality and morbidity. No graft-related complications or re-interventions during the average follow-up of 23.3±8.6 months. Conclusions: Despite our lack of experience in OAR for BTAI, TEVAR has provided us with an alternative treatment option for this life-threatening condition. Considering the challenges that may be encountered in developing countries, our results were similar to what has been reported in the literature.

Spinal drainage complications after aortic surgery

Objective/BackgroundSpinal drain (SD) placement is an adjunct used in open and endovascular aortic surgery to mitigate the risk of spinal cord injury. SD placement can lead to subdural hematoma and intracranial hemorrhage (SDH/ICH). Previous studies have highlighted a correlation between incidence of SDH/ICH and amount of cerebrospinal fluid (CSF) drained. We have two philosophies of SD management in our institution. One protocol allows fluid removal for pressure >10 cm H2O with no volume restriction. A second, similar protocol restricts CSF drainage to <25 mL/h. We examined SD complications and the influence of volume restriction. MethodsPatients were identified according to the Current Procedure Terminology codes for SD placement, thoracic endovascular aortic repair, fenestrated/branched endovascular aortic repair, endovascular abdominal aortic repair, and open thoracic or thoracoabdominal aortic repair between January 1, 2012, and December 31, 2015. Patients' demographics included age, gender, race, body mass index, and comorbidities such as hypertension, chronic obstructive pulmonary disease, stroke, transient ischemic attack, diabetes mellitus, bleeding disorder, and connective tissue disorders. Management protocol was classified as volume independent (VI) or volume dependent (VD) by physician order. Postoperative complications related to the SD were noted. ResultsWe identified 948 patients who had an SD placed during the study period; 473 were done before aortic surgeries. A total of 364 patients (77%) underwent endovascular aortic surgery. The mean age at the time of procedure was 67.2 years, and 66% of patients were male. Thirty-nine patients (8.3%) were noted to have connective tissue disorders. Bloody SD placement occurred in 14 patients (3.1%) requiring rescheduling of the operation. SDH/ICH occurred in 11 patients (2.3%), postoperative blood tinged SD output in 94 patients (19.9 %), and 22 patients (4.7 %) had a CSF leak after SD removal. The incidence of SDH/ICH was not affected by the management protocol (2.6% VI vs 2.0% VD, P = .66), whereas the incidence of postoperative blood tinged SD output was significantly higher in the VI group (25.1% VI vs 15.0% VD, P = .006). Perioperative low-dose aspirin (81 mg) and prophylactic subcutaneous heparin did not increase the incidence of SDH/ICH. Postoperative thrombocytopenia was found to be associated with higher incidence of SDH/ICH (median 86,000 vs 113,000, P = .002). ConclusionsSevere complications of SD placement (SDH/ICH) occur in 2.3% of SD patients undergoing aortic surgery, and the risk is higher in the setting of postoperative thrombocytopenia. SD volume limitation, blood tinged drainage, antiplatelet medication, and low-dose heparin do not affect the risk of SDH/ICH. The risks of spinal drains for aortic surgery should be balanced against potential benefits.

Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion.

Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure. Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis. DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment. Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.

Sizing of the hybrid stent-graft for the frozen elephant trunk procedure

Objective . The aim of study was to determine the tactics of choosing the optimal diameter of stent-graft in open hybrid repair of thoracic aorta based on the analysis of literature and the experience of Petrovsky National Research Centre of Surgery. Material and Methods. A hybrid approach using the frozen elephant trunk (FET) technique is currently the safest and most optimal approach for thoracic aorta repair in case of extended pathology of all thoracic aorta segments, including the arch and descending thoracic aorta. Despite this technique has been used for over 15 years, there is no agreement in the current literature regarding the algorithm for choosing the optimal stent-graft diameter. A total of 135 FET procedures were performed at our centre from 2013 to 2020. The average age of patients was 52.8 ± 11.5 years. We analyzed our own experience and current literature to determine the optimal tactics for sizing the hybrid stent-graft for FET procedure. Results. One of the main factors influencing the tactics of selecting the stent-graft diameter is the nature of pathology. The experience of most surgeons suggests that the size of stent-graft should not excessively exceed the diameter of a true canal in chronic dissection and the overall diameter in case of acute aortic dissection. In case of aneurysms, most authors use stent-grafts with the diameters exceeding distal landing zone diameter by 10–20%. Some authors consider it necessary to preoperatively measure the calculated diameter based on multislice computed tomography (CT) data, whereas many other authors prefer intraoperative measurements. Conclusion. The use of a stent-graft, which is too large, can result in a high risk of new fenestration at the distal end level during the postoperative period and follow-up complications, whereas stent-graft, which is too small, would not allow the adequate fit in the distal part. Therefore, the choice of optimal stent-graft size remains one of the key issues in hybrid thoracic aortic surgery.

Balloon Endoclamping for Postdissection Infrarenal Aorto-Iliac Aneurysm Repair

Isolated post dissection infrarenal and iliac aneurysm is a rare condition that often requires surgical treatment. Surgical repair should involve the replacement of the aneurysmal segments and a wide fenestration in the residual proximal untreated abdominal aorta. However, in these patients proximal aortic clamping may be challenging. Indeed, infrarenal clamping may hamper an appropriate fenestration in the proximal dissecting lamella, and suprarenal or supraceliac clamping can be dangerous and highly demanding, especially in acute and subacute patients. Here we report our initial experience with a balloon endoclamping technique. Our technique includes 1) direct aortic true lumen catheterization, 2) balloon endoclamping of the proximal thoracic aorta, 3) wide fenestration of the infrarenal aorta followed by external clamp positioning, 4) infrarenal aorta and iliac artery reconstruction. Between October 2018 and November 2019, 4 patients (male n = 4, median age 57 years) underwent postdissection iliac aneurysm repair in our institution. All patients had previously undergone emergent thoracic aorta repair. Postoperative courses were uneventful in all cases. At a median FU of 13 months, all patients remain well, with stable diameters in visceral aorta. In our initial experience, proximal aortic endoclamping appeared to be a safe technique associated with promising results. This approach may facilitate proximal aortic clamping and allow for a wide aortic fenestration. Further larger clinical trials are needed to validate our preliminary observations.

Hospitalization Cost and In-hospital Outcomes Following Type B Thoracic Aortic Dissection Repair

Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States. A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes. Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P < 1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P < 0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P < 0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P < 0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P < 0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P < 0.001. The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.

Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States

BackgroundThere is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. MethodsWe queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality. ResultsThe analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (Ptrend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (Ptrend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome. ConclusionContemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.

Implications of different definitions for aortic arch classification provided by contemporary guidelines on thoracic aortic repair.

Contemporary guidelines on thoracic aortic repair provide inconsistent reporting standards for the definition of aortic arch classification in Types I, II and III. The different reported criteria cannot be used interchangeably, due to a very low level of concordance, and this finding has relevant implications for the comparisons between studies using different classifications, and between different datasets of multicentre trials, which are not consistently analyzed with the same criteria. Also, the reported definitions, which were originally proposed for predicting difficult carotid stenting and therefore were conceived for healthy aortic arches, can be influenced by the pathological derangements of the aortic wall, including aneurysms and dissections. In this respect, the Madhwal's classification, which is based on the diameter of the left common carotid artery, appears to be the more suitable one for aortic arch classification in patients with thoracic aortic disease because it provides relevant clinical information along with an adequate reproducibility.

Perfusion and cannulation techniques in minimally invasive thoracic aortic repair

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Определить универсальный алгоритм выбора тактики канюляции при малоинвазивных вмешательствах на грудной аорте и оценить его безопасность для пациента. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Для ретроспективного когортного анализа с 2016 г. отобраны 189 пациентов с патологией грудной аорты, подвергшихся малоинвазивному хирургическому лечению. Всем пациентам вмешательство выполнялось из J-мини-стернотомии в четвертом межреберье. Среди вмешательств на корне аорты операция Bentall—DeBono выполнялась в 56 случаях, David — в 45, раздельное протезирование — в 37, протезирование восходящей аорты с пластикой корня аорты — в 36. Замена дуги аорты выполнялась 39 пациентам: полная замена дуги — 18, операция Hemiarch — 21. Во всех случаях выбор методики канюляции осуществлялся после предоперационной оценки данных МСКТ согласно разработанному персонифицированному протоколу. Центральная артериальная канюляция стала применяться с октября 2019 г. при отсутствии расширения/аневризмы дуги аорты и первичном характере вмешательств (14 (7,5%) случаев). Канюляция правой подключичной артерии использована в 32 (16,9%) случаях, общей бедренной артерии — в 143 (75,6%). Центральная венозная канюляция также выполнялась в 14 (7,5%) случаях, периферическая — в 175 (92,5%). В случае сочетанных вмешательств на митральном клапане и правых отделах сердца выполнялась установка двухуровневой канюли Carpentier. Были проанализированы послеоперационные результаты, а также выполнен факторный анализ влияния методики канюляции. <h3>РЕЗУЛЬТАТЫ</h3> Средний возраст пациентов составил 44,4±14,5 года. Частота конверсий в полную стернотомию составила 1,6% (<i>n</i>=3) по причине необходимости экстренной реваскуляризации миокарда у пациентов с периферической канюляцией (<i>p</i>&gt;0,05). Случаев интраоперационного расслоения аорты, а также неврологических осложнений не отмечено. Лимфорея в зоне периферического доступа была отмечена в 5 (2,6%) случаях (<i>p</i>&gt;0,05). Госпитальная летальность составила 2 (1,1%) случая. При анализе влияния методики канюляции на серьезные осложнения и летальность значимых различий получено не было. <h3>ВЫВОД</h3> В настоящее время существует множество вариантов канюляции в малоинвазивной хирургии грудной аорты. Тип вмешательства, предоперационное планирование, а также опыт хирургической бригады являются определяющими при выборе конкретной стратегии перфузии. Таким образом, использование персонифицированного алгоритма выбора методики канюляции в сочетании с взаимодействием аортальной команды позволяет обеспечить безопасность малоинвазивных вмешательств.