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Open in new tab Download slide OBJECTIVES The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement. METHODS Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years. RESULTS The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P  < 0.001). Positive aortic remodelling was observed in the proximal descending (P  < 0.001) to mid-descending (P  < 0.001) aorta exclusively in patients with acute aortic dissection. CONCLUSIONS The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia. Methods: The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data. Results: The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia. Conclusions: The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion. [Copyright &y& Elsevier]