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Acquired coarctation of the aorta (CoA) following total aortic arch replacement (TAR) is a rare complication inducing left ventricular (LV) dysfunction probably due to increased LV afterload and secondary hypertension caused by increased upper body and decreased renal blood flow. We describe a case of a 35-year-old male who developed atypical CoA with severe LV dysfunction with LV ejection fraction of 10%, but without secondary hypertension after TAR using conventional elephant trunk (ET) technique for acute aortic dissection. Computed tomography revealed near-occlusive CoA due to narrowed distal ET. Because the myocardial histological findings were mild, and he had no cardiac failure history, we determined that LV function might be reversible. He underwent thoracic endovascular aortic repair (TEVAR), resulting in restored LV function. However, as the descending aortic false lumen distally to the end of ET was rapidly dilated, probably due to increased cardiac output and lower body blood flow, he underwent descending aortic replacement 3 months after TEVAR. In conclusion, a narrowed distal ET may cause LV dysfunction early after TAR, even without secondary hypertension. TEVAR may be a useful therapeutic option for a narrowed distant ET but can induce distal aortic dilatation. < Learning objective: A 35-year-old male demonstrated that acquired coarctation of the aorta due to a narrowed distant elephant trunk led to left ventricular (LV) dysfunction with comparable severity of dilated cardiomyopathy even with normal blood pressure. Thoracic endovascular aortic repair is an effective treatment option to restore LV function by decreasing LV afterload. However, a narrowed distal ET relief with an increased cardiac output might cause distal aortic dilatation.> [ABSTRACT FROM AUTHOR]

The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary resuscitation (CPR) were evaluated. Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events. The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 [61.8%]), followed by coronary malperfusion (n = 12 [35.3%]) and acute aortic valve regurgitation (n = 3 [8.8%]). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P =.039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P =.045). Although the duration from onset or arrival to the operating room was similar (P =.35 and P =.49, respectively), overall duration of CPR was shorter in survivors (10 minutes [range, 7.5-16 minutes] vs 16.5 minutes [range, 15-20 minutes]; P =.044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P =.0040). CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy. [ABSTRACT FROM AUTHOR]

Abstract Objective Total arch replacement (TAR) is an established standard surgical procedure. We report >1000 cases of TAR using a 4-branched graft with antegrade cerebral perfusion (ACP) during a 15-year period. Methods Since May 2001, 1005 patients who underwent total aortic replacement (mean age 69.8 ± 11.2 years; range, 9-92 years; 744 male) underwent TAR with a 4-branched graft. All surgeries were performed under hypothermia with ACP. There were 252 emergent operations for acute aortic dissection or aneurysm rupture. Concomitant operations included coronary arterial bypass grafting in 196 patients, aortic valve repair or replacement in 64, and aortic root replacements in 38. Results The operation time was 482 ± 171 minutes, cardiopulmonary time was 254 ± 94 minutes, cardiac ischemia time was 145 ± 51 minutes, ACP time was 160 ± 47 minutes, and lower body circulatory arrest time was 62 ± 16 minutes. The hospital mortality rate was 5.2%. The permanent neurological dysfunction rate was 3.6% and temporary neurological dysfunction rate was 6.4%. There were no spinal cord complications. The 5-year survival rate was 80.7% and 10-year survival rate was 63.1%. Fifteen patients (1.5%) underwent reoperation for the arch grafts because of a pseudoaneurysm (11 patients), hemolysis (3 patients), and infection (1 patient). Conclusions TAR using a 4-branched graft with ACP could be accomplished with acceptable short- and long-term results. [ABSTRACT FROM AUTHOR]

Objective Anastomosis in dissected aorta management remains challenging. The patent false lumen of remnant aorta influences the growth of the residual aorta after hemiarch replacement. We evaluated the beneficial effect of adventitial inversion technique for distal anastomotic reinforcement of hemiarch replacement in acute type A aortic dissection. Methods From 2006 to 2014, 90 patients with DeBakey type I aortic dissection who underwent hemiarch replacement for acute type A aortic dissection management at the National Cerebral and Cardiovascular Center were retrospectively analyzed. Patients were divided according to the technique used: the adventitial inversion technique in group A and the original Sandwich method with Teflon felt in group S. Surgical variables and aortic morphology from distal aortic anastomosis were evaluated by computed tomography after surgery. Results The mean follow-up time was 2.2 ± 2.1 years with a follow-up rate of 91.1%. Cardiopulmonary bypass time was 208.2 ± 93.9 minutes in group A and 220.6 ± 93.9 minutes in group S; lower body circulatory arrest time was 51.6 ± 10.2 minutes in group A and 54.5 ± 17.8 minutes in group S. No significant differences were observed between groups. The overall hospital mortality rate was 10.0%. Postoperative false lumen thrombosis rate at proximal descending aorta on enhanced delayed phase computed tomography was significantly higher in group A than in group S. Conclusions The adventitial inversion technique may facilitate thrombotic closure of the distal false lumen in acute type A aortic dissection management by hemiarch replacement. [ABSTRACT FROM AUTHOR]

Loeys-Dietz syndrome (LDS) is a recently identified rare connective tissue disorder caused by mutations of the transforming growth factor-β receptors and first described in 2005. It is an autosomal dominant syndrome with 2 different phenotypic expressions—LDS I and II. LDS is characterized by the triad of arterial tortuosity and aneurysm, hypertelorism, and a bifid uvula or cleft palate. We present a case of a 9-year-old boy diagnosed with LDS who underwent urgent thoracoabdominal aortic aneurysm repair followed by total arch replacement and aortic valve–sparing root replacement (AVSRR). [ABSTRACT FROM AUTHOR]

Background Although thoracic endovascular aortic repair has advantages in elderly patients, it is not always applicable, and some elderly patients require open surgical repair. Methods Between 2008 and 2014, 157 patients (11 men) older then 75 years (mean age, 79.3 ± 3.3 years) underwent conventional total arch replacement, of which 39 were emergency operations. Coexisting diseases included remote stroke in 54 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in 25, and chronic kidney disease in 112. Concomitant procedures were performed in 46 patients. Results Mean follow-up time was 2.9 ± 1.8 years. Mean cardiopulmonary bypass time was 251.1 ± 68.4 minutes. Mean lowest nasopharyngeal temperature was 23.2° ± 3.4°C. The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% in elective cases, and 15.4% in emergency cases. Postoperative complications included permanent neurologic dysfunction in 5.7% of patients and prolonged ventilation time exceeding 72 hours in 13.4%. No spinal cord complications occurred. The 1-year and 5-year survival rates were 88.2% and 69.2% in all cases and 91.3% and 77.0% in elective cases, respectively. Univariate analysis demonstrated that risk factors for hospital death in elective cases were chronic kidney disease (odds ratio, 4.00; p = 0.028) and ventilation time exceeding 72 hours (odds ratio, 13.3; p = 0.001). Conclusions Even in patients older than 75 years, recent surgical results of conventional open arch repair were acceptable, especially in elective cases. Thus, conventional open surgical aortic arch replacement remains a good option, especially in patients with preserved renal function. [ABSTRACT FROM AUTHOR]

The aim of this study was to disclose the differences of surgical outcomes between Marfan syndrome with mutations in fibrillin-1 gene and Loeys–Dietz syndrome with mutations in transforming growth factor-beta receptor 1 and 2. We reviewed 368 patients aged less than 50 years who underwent surgery for thoracic aortic diseases between 1988 and 2019, and enrolled 99 patients with Marfan syndrome (26.9%; 57 men, 33 ± 7.5 years) and 24 patients with Loeys–Dietz syndrome (6.5%; 13 men, 28 ± 11 years). Freedom from all causes of mortality was similar between the 2 groups (P =. 40, log-rank). The cumulative incidence of reintervention was significantly lower in the Marfan syndrome group than in the Loeys–Dietz syndrome group (P =. 016, Gray). The cumulative incidence of first aortic arch reoperation for aortic arch aneurysm was significantly lower in the Marfan syndrome group than in the Loeys–Dietz syndrome group (P <. 001, Gray). The cumulative incidence of first aortic root reoperation for aortic root aneurysm (P =. 57, Gray) and first descending aorta reoperation for descending aortic aneurysm (P =. 76, Gray) was similar between the 2 groups. The cumulative incidence of aortic dissection after initial surgery was significantly lower in Marfan syndrome than in Loeys–Dietz syndrome (P =. 0059, Gray). Loeys-Dietz syndrome with mutations in transforming growth factor-beta receptor 1 and 2 revealed higher rates of reoperation, and more specifically the arch reoperation was higher in those with Loeys–Dietz syndrome than those with Marfan syndrome. Aggressive arch surgery in the initial operation on the proximal aorta is recommendable in Loeys–Dietz syndrome to avoid additional aortic events. In Marfan syndrome, this is controversial in patients without dissection because of a low possibility to expand. [Display omitted] [ABSTRACT FROM AUTHOR]

We describe a previously unreported case of abscess formation around the right internal iliac artery (IIA) after coil embolization prior to endovascular aneurysm repair (EVAR). A 75-year-old man was admitted for elective repair of a right common iliac aneurysm. The right IIA coil embolization and EVAR procedures were uncomplicated and assessment by postoperative computed tomography (CT) was satisfactory. The patient was readmitted 2 weeks after EVAR with right buttock pain and pyrexia. CT indicated an isolated abscess around the coil-embolized IIA. The patient was successfully treated with CT-guided percutaneous drainage. [Copyright &y& Elsevier]

Andersen-Tawil syndrome is an uncommon inherited autosomal disorder characterized by a prolonged QT interval, periodic paralysis, and dysmorphic features. The deleterious effects of cardioplegia on periodic paralysis and cardiac arrhythmia are unknown, and no studies have reported the performance of cardiac surgery in patients with Andersen-Tawil syndrome. We present a case of successful cardiac surgery in a patient with Andersen-Tawil syndrome, without using cardioplegia. [Copyright &y& Elsevier]

This study aimed to review the clinical results of young adult patients with aortic disease associated with mutations in the fibrillin-1 gene (FBN1) and disclose the histologic differences between the ascending and descending aortas. Between 2012 and 2015, 94 patients aged less than 50 years underwent surgery for thoracic aortic diseases. Forty-two patients (44.7%) had FBN-1 mutations. Of these, 40 patients (42.5%) with surgical specimens for histologic evaluation were included in the study. With the histologic results including the specimen sampled at their previous operations, cystic medial necrosis was classified into 3 grades according to the degree of the cystic area. Thirty-nine patients (97.5%) had aortic root dilatation (Z ≥2), and 13 patients (32.5%) had ectopia lentis. Thirty-nine patients (97.5%) fulfilled the diagnostic criteria for Marfan syndrome. There were no in-hospital deaths. The majority (27/29: 93.1%) of the specimens of the ascending aorta revealed cystic medial necrosis pattern. With grade III being the most severe condition, these cases were classified into grade I (n = 2), grade II (n = 5), and grade III (n = 20). In contrast, only 6 specimens (6/17: 35.3%) of the descending aorta showed a cystic medial necrosis pattern that was classified into grade I (n = 2) and grade III (n = 4), (P <.00001). Fewer specimens of the descending aorta revealed cystic medial necrosis compared with those of the ascending aorta. This difference might influence the characteristic aortic disease in Marfan syndrome associated with FBN-1 mutations. [ABSTRACT FROM AUTHOR]

Abstract Objectives Since 2012, we have routinely applied balloon protection of the proximal left subclavian artery to prevent embolic events through the left vertebral artery during debranching thoracic endovascular aortic repair. This study aimed to study the effectiveness of balloon protection of the proximal left subclavian artery. Methods We reviewed the medical records of 157 patients who underwent debranching thoracic endovascular aortic repair between 2007 and 2017. Of these, 71 patients for whom balloon protection of the proximal left subclavian artery was used were assigned to the balloon protection of the proximal left subclavian artery group (58 men; age: 78 ± 6.7 years), and 86 patients were assigned to the control group (66 men; age: 78 ± 8.9 years). A total of 51 patients from each group were matched by their propensity scores to adjust for differences in the patients' characteristics. Results Perioperative stroke was significantly lower in the balloon protection of the proximal left subclavian artery group than in the control group (0%: 0/71 vs 7.9%: 7/86, P =.014). Freedom from all causes of mortality at 2 and 4 years was significantly higher in the balloon protection of the proximal left subclavian artery group compared with the control group (93%/76% vs 77%/59%, P =.015). Freedom from aortic death at 2 and 4 years was similar in both groups (97%/97% vs 91%/86%, P =.094). Propensity score matching yielded similar results of better freedom from all causes of mortality in the balloon protection of the proximal left subclavian artery group (93%/93% vs 81%/63%, P =.017) and equivalent aortic death in both groups (95%/95% vs 92%/88%, P =.30). Conclusions Debranching thoracic endovascular aortic repair using balloon protection of the proximal left subclavian artery demonstrated more appropriate early and late outcomes. Evaluation using propensity score matching enhanced the efficacy of balloon protection of the proximal left subclavian artery. [ABSTRACT FROM AUTHOR]

Spinal cord injury remains a major adverse event of extended thoracic and thoracoabdominal aortic surgical procedures. Preoperative identification of the Adamkiewicz artery and prompt reattachment of the targeted intercostal arteries during operation should contribute to preventing spinal cord injury. In this report, we describe a simple and definite identification of the critical intercostal artery during extended descending and thoracoabdominal aortic surgical procedures. [ABSTRACT FROM AUTHOR]

Proximal anastomosis is an important operative procedure in type A acute aortic dissection. We report our experience with the proximal stepwise technique, which is widely used during distal anastomosis in total arch replacement, in a series of 53 patients. We treated 53 patients for aortic dissection using this technique in our center. There were no bleeding adverse events during the operations and no early death caused by bleeding. This hemostatic technique was simple to use and demonstrated excellent early and midterm operative results. [ABSTRACT FROM AUTHOR]