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Minimization of end-organ ischemia is a key tenet in successful thoracoabdominal aortic aneurysm (TAAA) surgery. During these reattachments, antegrade pulsatile blood flow to the spinal cord was guaranteed not only via the Adamkiewicz artery but also the collateral network, which ultimately minimizes spinal cord ischemia. Therefore, the question remains whether the incidence of spinal cord ischemia in patients with atherothrombotic aorta could be reduced by the current technique. [Extracted from the article]

OBJECTIVE Impact of the decrease of regional cerebral oxygen saturation (rSO2) on postoperative delayed awakening after total aortic arch replacement (TAR) was validated. METHODS From 2008 to 2013, 143 consecutive patients underwent TAR using selective antegrade cerebral perfusion. rSO2 was monitored using near-infrared spectroscopy. We calculated a percent decrease of rSO2 (%-D) immediately after rewarming according to the following formula: %-D = rSO2 (X1) − rSO2 (X2)/rSO2 (X1) × 100 (%), where rSO2 (X1) was measured at the beginning of rewarming, and rSO2 (X2) was measured 10 min later. Delayed awakening was defined as patients not waking up for more than 6 h after the termination of anaesthesia. RESULTS The average time to wake up was 3.6 ± 2.0 h. Fourteen patients showed delayed awakening. %-D showed a positive linear relationship to awakening time (y = 0.67x − 0.7, r = 0.23, P = 0.007) and receiver operating characteristic analysis showed %-D had a good predictive value for delayed awakening (area under the curve = 0.84). %-D was significantly different between the delayed awakening and the normal group (7.1 ± 5.1 vs 1.3 ± 6.6%, P = 0.002). Two patients (1.4%) who had multicomorbidity with higher %-D died in the hospital due to colon necrosis and sepsis. There were significant differences between patients with normal and delayed awakening in hospital mortality (P = 0.04) and transient neurological deficit (TND, P = 0.007). CONCLUSION The maintenance of rSO2 at the early phase of rewarming may be important to avoid delayed awakening or TND after TAR. [ABSTRACT FROM PUBLISHER]

OBJECTIVES We present our experience of total aortic arch replacement. METHODS Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years. CONCLUSIONS Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS). METHODS From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2. RESULTS Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified. CONCLUSIONS The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results. [ABSTRACT FROM AUTHOR]

A 59-year-old male underwent Bio-Bentall + total arch replacement with a frozen elephant trunk for acute type A aortic dissection before at another hospital. He was diagnosed as mediastinitis and previous graft infection, followed by wound closure with omental flap installation. However, the recurrent graft infection from the aortic root to the FET in the descending aorta was diagnosed by 18-fluorodeoxyglucose positron emission tomography. Redo modified Bio-Bentall procedure, total arch replacement, and descending aortic replacement for previous graft infection using anterolateral thoracotomy with partial sternotomy was successfully performed. Anterolateral thoracotomy with partial sternotomy provided not only the excellent exposure from the aortic root to the descending aorta but also sure myocardial protection with antegrade and selective delivery of cold crystalloid cardioplegia and stable brain protection with antegrade selective cerebral perfusion. The patient is doing well without recurrent of infection after 2 years of the operation. [ABSTRACT FROM AUTHOR]

Objectives: Synchrotron radiation-based X-ray phase-contrast tomography (XPCT) has proven innovative modality for analyzing 3D morphology and is useful for understanding the pathophysiology of various cardiovascular disease. To elucidate mechanisms of aneurysmal wall enlargement after endovascular aortic repair (TEVAR or EVAR), we evaluated aortic wall samples after TEVAR and EVAR with XPCT. Methods: Human aortic samples of the descending aorta or abdominal aorta were obtained during open aortic repair for aortic aneurysm (Group-A; n=5),and for aneurysm expansion after endovascular repairs (Group-E: n=7). Normal aorta (Group-N: n=10), obtained from autopsy, were also investigated. Effective resolution of XPCT in Japan Synchrotron Radiation Research Institute / SPring-8 is 11.7 μm. Pathological analysis was performed, subsequently. Results: Age of patients was 76.8 ± 5.4 years old in Group-A, 83.4 ± 5.2 in Group-E, and 57.5 ± 9.5 in Group-N. In Group-E, time from endovascular repair to open aortic repair was 64.2 ± 7.2 months, and initial endovascular repair included TEVAR (n=2) and EVAR (n=5). Representative findings of three groups were demonstrated in figures, including XPCT findings (Fig.A), changes of wall density (B), and pathological findings (C). In Group-N, density of the tunica media was not different within tunica media and average of medial density was 1.085 ± 0.003g/cm3. In Group-A, thickness of aortic wall was lower than Group-N, but density of the tunica media was unchanged (1.079 ± 0.022g/cm3). On contrast, in Group-E, density of the tunica media was significantly lower than Group-N (1.063 ± 0.008; p < 0.005), and differences in density within tunica media were well correlated with distribution of elastic fibers and existence of medial necrosis in pathological analysis. Conclusions: X-ray phase-contrast tomography was a cutting-edge modality to understand aortic structures and degeneration of tunica media in aneurysm expansion after endovascular repair was clearly demonstrated. [ABSTRACT FROM AUTHOR]

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]

Aortic angiosarcoma is an exceedingly rare clinical entity. A significant delay in diagnosis can occur due to its rareness and lack of specific clinical manifestation. A 71-year-old woman was admitted to the emergency department owing to an acute episode of abdominal pain. A computed tomography (CT) scan showed thoraco-abdominal aortic occlusion and splenic infarction. The patient was initially treated with descending aortic replacement for degenerative atherothrombotic aneurysm. An FDG-positron emission tomography-CT scan and biopsy ultimately confirmed the diagnosis of aortic angiosarcoma. This case highlights the difficulties of making an early diagnosis of aortic angiosarcoma. [ABSTRACT FROM AUTHOR]