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Background: Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts., Methods: Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity., Results: Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively., Conclusions: Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Arterial involvement in Behçet disease (BD) is rare, and its surgical management is a major concern because of its high recurrence rate. This study evaluated the influence of the surgical technique, device, and immunosuppressive treatment used on the postoperative recurrence in patients with non-pulmonary arterial BD., Methods: A single-center, retrospective study was conducted of 23 patients meeting the international criteria for BD who underwent surgery for arterial involvement between May 1996 and September 2015. Recurrence was defined as the occurrence of arterial aneurysm or thrombosis during follow-up. Perioperative medical treatment and surgical technique used were reported., Results: There were 47 surgical procedures performed in 23 patients. Mean follow-up was 8.4 ± 7.5 years. Initial arterial lesions were aneurysms and thrombosis in 85% and 15% of cases, respectively. Arterial lesions were aortic and peripheral in 48% and 52% of cases. Recurrence rate was 51%. Recurrences developed within <1 year in 24% of cases and at the same anatomic site in 92% of cases. Among the 24 recurrences, 17 were false aneurysms, 6 were thrombosis, and 1 was a true aneurysm in a different arterial site. To treat the arterial lesion, direct anastomosis was performed in 6 cases; bypass using the saphenous vein, graft, or allograft was performed in 6, 27, and 5 cases, respectively; and stent graft was used in 3 cases. Vascular lesions involved the aorta in 19 cases and a peripheral artery in 28 cases. Preoperative medical treatments, including colchicine, steroids, and immunosuppressants, significantly decreased recurrence rate: 28% (7/25) vs 75% (15/20) in untreated patients (P = .002). The recurrence rate was 42.5% (17/40) in patients treated postoperatively vs 80% (4/5) in untreated patients. The nature of the device used (vein, prosthetic graft, allograft, stent graft, or direct anastomosis) did not change the risk of recurrence. When anastomoses were protected using the prosthetic sleeving technique, the recurrence rate was three times lower (P = .08)., Conclusions: Relapse is a main concern after surgical repair of arterial BD. This study suggests the need for targeted perioperative medical management to reduce the risk of arterial recurrence in BD patients. To this end, a multidisciplinary approach is mandatory. The use of sleeve anastomosis is associated with a numerically lower risk of recurrence. However, further studies are needed to confirm this efficacy., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Carotid endarterectomy and carotid artery stenting are both valid therapeutic options for the treatment of radiation-induced carotid stenosis (RICS). The second has the advantage of being less invasive, although it seems to result in more restenosis than the first. Meanwhile, progress in radiation therapy and head and neck surgery has significantly increased the survival of these patients. As a result, treatment of RICS should be considered from a long-term perspective. This works presents perioperative and follow-up outcomes of surgical treatment of RICS., Methods: This single-center retrospective study included all patients who underwent carotid endarterectomy for RICS from January 1998 to June 2017. Clinical and duplex ultrasound examination-based follow-up was performed postoperatively, at 1 month, 6 months, 12 months, and yearly thereafter. Kaplan-Meier curves were used for survival plots based on a log-rank test. Any abnormal finding led to angio-computed tomography scan and specialized neurovascular examination., Results: Between 1998 and 2017, 128 patients (162 lesions) were treated. The median interval between radiation therapy and surgery was 16 years. Forty-five patients (35%) were symptomatic. The eversion technique was performed in 79 cases (49%), and the patch was favored in 24 cases (15%), prosthetic bypass graft in 51 cases (31%), and a venous bypass graft in 8 cases (5%). Two postoperative deaths (1.5%) (one secondary to massive stroke) were noted. The primary end point of early postoperative cerebrovascular event was 2.5%. Two cervical hematomas (1.2%) required surgical revision and seven cases of permanent cranial nerve injury were recorded. The median follow-up was 29 months (range, 2-199 months). There were no additional strokes. The 3-year primary patency rate was 96% and the 3-year freedom from neurologic event was 98%., Conclusions: Open surgical treatment of RICS lesions is a safe and durable option. Our results suggest that the outcomes of such treatment are good and in particular that rates of cerebrovascular event and restenosis are low and that cranial nerve injury should not be a concern. As a result, we consider that open surgery for RICS lesions should be offered as a first-line treatment. However, comparative data are mandated to address this issue., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to assess outcomes of a hybrid technique for treatment of abdominal aortic aneurysm (AAA) associated with iliac aneurysm without distal neck by combining an AAA endovascular repair approach with open surgery for preservation of the internal iliac artery (IIA)., Methods: The files of 51 patients operated on between 1998 and 2017 in a single vascular surgery department were retrospectively analyzed. Inclusion criteria were patients with AAA associated with uni-iliac or bi-iliac aneurysm without suitable distal sealing zone. Surgery consisted of deployment of an aortouni-iliac stent graft combined with an extra-anatomic crossover prosthetic bypass. With use of a limited retroperitoneal approach, the contralateral proximal common iliac aneurysm was surgically excluded and the IIA revascularized by direct ilioiliac anastomosis or terminal common iliac suture, preserving the iliac bifurcation., Results: The patients' mean age was 74 years (58-88 years), and 92% were men. The mean follow-up was 5.8 years (0.1-18 years). Twenty-nine patients (57%) had one or more high-risk criteria for open surgery. Nineteen patients (37.3%) had aortouni-iliac aneurysms, 19 (37.3%) aortobi-iliac aneurysms, 5 (10%) isolated iliac aneurysms, and 8 (15.7%) bi-iliac aneurysms without aortic location. Four patients (7.8%) also had IIA aneurysms. Surgery was successful in all cases. Two patients (4%) died during the 30 days after surgery. One surgically preserved IIA occluded within the first month, resulting in buttock claudication. The 5-year IIA primary patency rate was 96%. Type I proximal endoleaks occurred in two patients, requiring additional surgery 3 years and 13 years after the initial surgery, respectively., Conclusions: This hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV., Methods: Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought., Results: From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively., Conclusions: These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to describe large-vessel vasculitis (LVV) in patients with human immunodeficiency virus (HIV) infection. It is a retrospective single-center study conducted between 2000 and 2015 through a university hospital of 11 HIV-infected patients with LVV., Methods: The characteristics and outcome of 11 HIV-infected patients with LVV (7 patients fulfilled international criteria for Takayasu arteritis, 5 patients had histologic findings of vasculitis, and 5 patients had imaging features of aortitis) were analyzed and compared with those of 82 patients with LVV but without HIV infection., Results: Concerning the HIV-infected patients with LVV (n = 11), the mean age was 40 years (range, 36-56 years), and 55% of patients were female. At diagnosis of LLV, the mean initial CD4 cell count was 455 cells/mm 3 (range, 166-837 cells/mm 3 ), and the median HIV viral load was 9241 copies. Vascular lesions were located in the aorta (n = 7), in supra-aortic trunks (n = 7), and in digestive arteries (n = 3). Inflammatory aorta infiltrates showed a strong expression of interferon-γ and interleukin 6. In HIV-negative LVV patients (n = 82), the median age was 42 years, and 88% of the patients were women. Thirty patients had an inflammatory syndrome. Seventy patients had been treated with glucocorticosteroids and 57 with immunosuppressive treatments. Compared with their negative counterparts, HIV-positive patients with LVV were more frequently male (P = .014), had more vascular complications (ie, Ishikawa score; P = .017), and had more frequent revascularization (P = .047). After a mean follow-up of 96 months, four relapses of vasculitis were reported, and one patient died. Regardless of the HIV virologic response, antiretroviral therapy improved LVV in only one case., Conclusions: LVV in HIV-infected patients is a rare and severe entity., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The choice between open surgery (OS) and transluminal carotid angioplasty with stenting (CAS) for the treatment of primary carotid stenosis remains controversial. However, CAS is considered a valid option for selected cases, such as recurrent carotid stenosis (RCS). Tertiary RCS seems to be a concerning issue after CAS but few large reports focused on the durability of CAS and OS. We report our early and long-term results with OS for RCS., Methods: From 1989 to 2006, perioperative data regarding 4245 consecutive surgical carotid reconstructions was prospectively collected. Patients whose indication was RCS were subjected to further analysis. Indications for surgery were symptomatic RCS >50% or asymptomatic RCS >80%. Freedom from neurologic event was defined as the absence of any ipsilateral symptom at any time after the procedure. Kaplan-Meier analysis was used to estimate freedom from reintervention, freedom from restenosis >50% and occlusion, freedom from neurologic event and survival., Results: A total of 119 patients (2.8%) with RCS underwent OS. The average time from the primary OS was 59.4 +/- 54.5 months (range, 2-204). Forty-nine patients (41%) were symptomatic. In 103 patients (87%), the technique did not differ from a primary approach. Postoperative (<30 days) combined stroke and death rate was 3.3%. Cranial nerve injury occurred in 5 cases (4.2%). With a mean follow-up of 53 +/- 48 months (range, 1-204), 3 patients had an ipsilateral stroke (including one hemorrhagic stroke) and 7 were diagnosed with a tertiary RCS >50%. At 5 years, Kaplan-Meier estimates of freedom from reintervention, freedom from restenosis and occlusion, freedom from neurologic event, and survival were 99%, 91%, 89%, and 91%, respectively., Conclusion: OS for RCS is not a high-risk procedure and provides excellent long-term results, with low rates of tertiary RCS and reinterventions. The comparison between OS and CAS in this indication suffers from the absence of standardized follow-up paradigms after primary OS and the lack of prospective randomized trial comparing the two techniques. Despite these limitations in the available data, we conclude that OS should remain the first line therapy when treatment of RCS is indicated., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

This report describes the development of recurrent spinal cord ischemia in a patient after insertion of a stent graft into the upper segment of the descending thoracic aorta for the treatment of a chronic traumatic aneurysm of the aortic isthmus. Intraoperatively, the stent covered the ostium of the left T7 artery, which was shown to give rise to a middle dorsal artery by postoperative spinal cord arteriography.

Purpose: This report presents our experience with open repair of post-traumatic aneurysms of the aortic isthmus using recent surgical techniques, including distal aortic perfusion and the preferential use of direct aortoaortic anastomosis without interposition of prosthetic material., Methods: From 1990 to 2004, the senior author (EK) patients (21 men; mean age, 40.3 years) who presented with post-traumatic aneurysms of the aortic isthmus were treated operatively, either with (20 patients) or without (3 patients) distal aortic perfusion, or endovascularly with a stent graft (3 patients). In 15 (75 %) of the 20 patients treated with distal aortic perfusion, the technique consisted of resection followed by direct aortoaortic anastomosis. Eight patients, including the three patients treated with simple clamping, had prosthetic replacement., Results: No postoperative deaths or permanent spinal cord complications occurred. One patient required reoperation to control hemorrhage. Aortography or computed tomography angiography was performed on 12 of the 15 patients treated by direct aortoaortic anastomosis, with a mean follow-up of 58.7 +/- 8.9 months. No morphologic abnormality was found., Conclusion: This study shows that low-risk patients with a chronic post-traumatic aneurysm of the aortic isthmus can be successfully treated with excellent long-term results by resection and direct aortoaortic anastomosis without prosthetic interposition. In our opinion, endovascular repair should only be used in patients who present with absolute contraindications for open surgical repair.

Purpose: Surgical revascularization of intestinal arteries is an effective long-term treatment for chronic intestinal ischemia (CII) regardless of the technique used. Conventional antegrade or retrograde bypass techniques are the most common modalities for extensive lesions that cannot be treated by endarterectomy or transposition. In this report, we describe our experience with an antegrade bypass technique from the ascending aorta in patients with no other available inflow., Methods: From April 1990 to May 2004, we performed antegrade bypass from the ascending aorta to the celiac artery, superior mesenteric artery (SMA), or both in five patients. These cases accounted for 2.4% of the 211 patients who underwent surgery on intestinal arteries during the study period., Results: Four patients presented with symptomatic CII, and one patient had no intestinal ischemic symptoms. The underlying disease was Takayasu disease in two cases, Erdheim-Chester disease in one case, chronic aortic dissection in one case, and atherosclerosis in one case. Two patients had already undergone an unsuccessful revascularization attempt with another technique. Bypass was performed alone in three cases in association with revascularization of the ascending aorta, aortic arch, and proximal descending thoracic aorta in one case and in association with revascularization of the ascending aorta and proximal aortic arch and renal autotransplantation in one case. Recovery was uneventful in all cases. One venous graft occluded because of technical defects and required reoperation for prosthetic graft replacement on the 10th postoperative day. Symptoms of CII resolved in all cases. Four months after the procedure, one patient underwent dilatation of an asymptomatic stenosis of the SMA distal to the bypass. During the 50th month after the procedure, a new re-stenosis of the SMA appeared. Left untreated, this stenosis led to asymptomatic occlusion of the mesenteric segment of a sequential aortoceliomesenteric bypass 13 months later. This aortoceliac bypass and the other four bypasses were patent after 4, 31, 46, 52, and 120 months of follow-up., Conclusion: Antegrade intestinal artery bypass from the ascending aorta is an effective alternative for patients who have no other available inflow for conventional antegrade or retrograde bypass and for patients in whom major technical difficulties are likely after multiple exposures of the thoracoabdominal aorta. Although indications are uncommon, antegrade intestinal artery bypass can provide durable revascularization of the intestine.

Objectives: We evaluated early and late results of allograft replacement to treat infrarenal aortic graft infection in a large number of patients and compared the results in patients who received fresh allografts versus patients who received cryopreserved allografts., Methods: From 1988 to 2002 we operated on 179 consecutive patients (mean age, 64.6 +/- 9.0 years; 88.8% men). One hundred twenty-five patients (69.8%) had primary graft infections, and 54 patients (30.2%) had secondary aortoenteric fistulas (AEFs). Fresh allografts were used in 111 patients (62.0%) until 1996, and cryopreserved allografts were used in 68 patients (38.0%) thereafter., Results: Early postoperative mortality was 20.1% (36 patients), including four (2.2%) allograft-related deaths from rupture of the allograft (recurrent AEF, n = 3), all in patients with fresh allografts. Thirty-two deaths were not allograft related. Significant risk factors for early mortality were septic shock (P <.001), presence of AEF (P =.04), emergency operation (P =.003), emergency allograft replacement (P =.0075), surgical complication (P =.003) or medical complication (P <.0001), and need for repeat operation (P =.04). There were five (2.8%) nonlethal allograft complications (rupture, n = 2; thromboses, which were successfully treated at repeat operation, n = 2; and amputation, n = 1), all in patients with fresh allografts. Four patients (2.2%) were lost to follow-up. Mean follow-up was 46.0 +/- 42.1 months (range, 1-148 months). Late mortality was 25.9% (37 patients). There were three (2.1%) allograft-related late deaths from rupture of the allograft, at 9, 10, and 27 months, respectively, all in patients with fresh allografts. Actuarial survival was 73.2% +/- 6.8% at 1 year, 55.0% +/- 8.8% at 5 years, and 49.4% +/- 9.6% at 7 years. Late nonlethal aortic events occurred in 10 patients (7.2%; occlusion, n = 4; dilatation < 4 cm, n = 5; aneurysm, n = 1), at a mean of 28.3 +/- 28.2 months, all but two in patients with fresh allografts. The only significant risk factor for late aortic events was use of an allograft obtained from the descending thoracic aorta (P =.03). Actuarial freedom from late aortic events was 96.6% +/- 3.4% at 1 year, 89.3% +/- 6.6% at 3 years, and 89.3% +/- 6.6% at 5 years. There were 63 late, mostly occlusive, iliofemoral events, which occurred at a mean of 34.9 +/- 33.7 months in 38 patients (26.6%), 28 of whom (73.7%) had received fresh allografts. The only significant risk factor for late iliofemoral events was use of fresh allografts versus cryopreserved allografts (P =.03). Actuarial freedom from late iliofemoral events was 84.6% +/- 7.0% at 1 year, 72.5% +/- 9.0% at 3 years, and 66.4% +/- 10.2% at 5 years., Conclusions: Early and long-term results of allograft replacement are at least similar to those of other methods to manage infrarenal aortic graft infections. Rare specific complications include early or late allograft rupture and late aortic dilatation. The more frequent late iliofemoral complications may be easily managed through the groin. These complications are significantly reduced by using cryopreserved allografts rather than fresh allografts and by not using allografts obtained from the descending thoracic aorta.

Purpose: The purpose of this article was to report our long-term results of distal vertebral artery (DVA) reconstruction., Method: From 1978 to 2001 we performed 352 DVA reconstructions on 323 patients (177 men, 148 women; mean age, 60.0 +/- 12.1 years). Symptoms of vertebrobasilar insufficiency were present in 332 cases (94.3%). Bypass grafting using mostly saphenous vein graft was performed in 240 cases (68.2%). In 102 cases (29.0%) the DVA was transposed into the internal carotid artery (ICA). Other techniques were used in 10 cases., Results: Stroke caused all 7 deaths (2.0%) in the early postoperative period. There were 5 nonfatal strokes (1.4%). Strokes were hemispheric in 7 cases (6 ipsilateral, 1 contralateral) and vertebrobasilar in 5 cases. There were 6 strokes (2.3%) in the subgroup of 264 isolated DVA reconstruction and 6 strokes (6.8%) in the subgroup of 88 procedures involving combined ICA and DVA reconstruction (P <.04). Temporary paralysis of the spinal accessory nerve occurred in 26 cases (7.4%). Intraoperative or early postoperative angiography findings were available in 341 of 345 cases (98.8%). Early postoperative occlusion occurred after 25 procedures (7.1%). Complete clinical follow-up was available for 313 (99.1%) of the postoperative survivors. Mean duration of follow-up was 99.5 +/- 62.5 months. Assessment of late patency was performed in 343 (99.4%) of 345 cases by angiography (21.2%) or duplex scanning (78.8%). A total of 65 (23.7%) patients died during follow-up. No deaths resulted from vertebrobasilar or hemispheric stroke. Cumulative Kaplan-Meier survival rate was 89.0% +/- 3.9% at 5 years and 75.4% +/- 7.1% at 10 years. Significant vertebrobasilar symptom-free rate was 94.0% +/- 3.5% at 5 years and 92.8% +/- 3.8% at 10 years. Primary patency rate was 89.3% +/- 3.6% at 5 years and 88.1% +/- 4.0% at 10 years., Conclusions: This study clearly establishes the excellent long-term results of DVA reconstruction for the treatment of extracranial lesions of the vertebral artery. However, every effort should be made to reduce the rate of early postoperative occlusions. The subgroup of patients involving combined ICA and DVA reconstruction remains at high risk of postoperative stroke.

Purpose: Aneurysms of the innominate artery (AIA) are widely considered to be a rare entity. We describe our experience with AIAs in the last three decades., Methods: From October 1973 to October 2000, we operated on 27 patients with an AIA. The underlying cause of aneurysm was Takayasu's disease in 7 patients, degenerative disease in 6 patients, syphilis in 5 patients, chronic dissection in 3 patients, trauma in 2 patients, infection in 2 patients, a postoperative complication in 1 patient, and Marfan syndrome in 1 patient. AIA was associated with an aortic aneurysm in 17 patients. Fourteen patients had no symptoms. The remaining patients had symptoms, with thromboembolic complications in 7 patients, pain without rupture in 3 patients, and a ruptured aneurysm in 3 patients. In two patients at high risk for surgery who had a small AIA with embolic complications, a cervical approach was used as a means of performing distal exclusion and crossover bypass. In the remaining 25 patients, a midline sternotomy was used. One patient with a ruptured AIA exsanguinated during sternotomy. Ten patients underwent a prosthetic replacement of the ascending aorta and/or aortic arch with a separate prosthetic branch to the innominate artery (IA). Thirteen patients underwent ascending aorta-to-IA prosthetic bypass in association with lateral suture (8 patients) or prosthetic patching (5 patients) of the aorta. One patient with an infected aneurysm was treated by means of resection of the aneurysm, proximal ligation of the IA, and transposition of the right into the left common carotid artery. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in 10 patients., Results: Three perioperative deaths occurred (2 of 4 in association with emergency treatment and 1 of 23 with elective treatment). Respiratory complications requiring prolonged artificial ventilation developed in five patients. Two patients had transient worsening of preoperative neurologic deficits. Late results, with a mean follow-up of 85 months, were good., Conclusion: The etiology and presentation of AIAs are variable. Surgical management with current cardiovascular techniques achieves excellent results.