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A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The aim of this study was to investigate the early and long-term outcomes after total arch replacement (TAR) and frozen elephant trunk (FET) implantation in adult patients ≤30 years with acute type A aortic dissection (ATAAD)., Methods: All young adult patients (≤30 years) with ATAAD who underwent TAR and FET between 2009 and 2017 were enrolled. The end points were major organ morbidity and mortality, aortic-related events and reoperation., Results: The mean age of all 83 patients was 25.9 (standard deviation, 3.3) years. The in-hospital mortality was 9.64% (8/83), and 9 (10.8%) patients required re-exploration for bleeding. The aortic-related events risk was 42.7% (32/75) and the aortic reoperation risk was 17.3% (13/75). Overall survival was 85.5% [95% confidence interval (CI), 75.9-91.5%] at 5 years and 75.9% (95% CI, 63.3-84.7%) at 10 years. The cumulative incidence of aortic-related events was 35% (95% CI, 24-47%) at 5 years and 58% (95% CI, 36-75%) at 10 years; the cumulative reoperation rate was 15% (95% CI, 7.9-24%) at 5 years and 17% (95% CI, 9.2-27%) at 10 years. Marfan syndrome significantly increased the aortic-related events (P = 0.036) and reoperation (P = 0.041) risks., Conclusions: Despite extensive repair in young ATAAD patients, the late aortic dilatation and reoperation risk remain high. The TAR and FET procedures achieved satisfactory early outcomes and reduced late aortic dilatation and reoperation in young patients compared with other records. Close follow-up and aggressive early reintervention are essential for patients with aortic-related risk factors early in life., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To analyze the effect of sex on the short-time prognosis in two different age subgroups (≤55 years old and >55 years old)., Methods: From January 2009 to 2019, 1522 patients with DeBakey I acute aortic dissection (AAD) underwent frozen elephant trunk and total arch replacement at a Tertiary Center in China were divided into female group ( n = 324) and male group ( n = 1198). The demographic characteristics, clinical presentation, management, short-term outcomes were described in the different sex groups. The risk factors of 30-days mortality for females and males were identified by univariate and multivariable logistic regression analysis. Then, random Forest regression was used to analyze the association between age and 30-days mortality in the different sexes groups. The cut-off age for 30-days mortality in females was then identified as 55 years. The patients were divided into two subgroups: young patients (≤55 years old) and elderly patients (>55 years old). Clinical prognosis between different sex groups was further compared in the age subgroups., Results: Approximately four-fifths of the patients were males. Males with DeBakey I AAD were younger than females (47 vs 52 years; p < 0.01). The proportion of males gradually declined with age. The cut-off age for 30-days mortality in females and males was identified as 55 years old and 63 years old, respectively. In young patients (≤55 years old), the 30-days mortality rate for females was lower than males (hazard ratio [HR, 2.02, p < 0.05). Following adjustment using the multivariable Cox regression analysis, females were identified as an independent protective factor for 30-days mortality (HR, 2.24, p = 0.03)., Conclusions: Our study showed that females present with DeBakey I AAD less frequently than males and they tend to present with DeBakey AAD later in life. In young patients, females had better early outcomes despite similar time for symptom onset to diagnosis and surgical technique than males., Competing Interests: Declaration Conflict of interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The open anastomosis technique has become more popular since it was first used in hemiarch replacement; however, hypothermic circulatory arrest is unavoidable. This institution performed a novel surgical technique called the arch-clamping technique. It has been used in the treatment of patients with ascending aortic aneurysm extending to the proximal aortic arch and avoids the use of hypothermic circulatory arrest. Thirty patients had a hemiarch replacement with the arch-clamping technique from 2021 to 2022; all of them were discharged uneventfully., (Copyright © 2023. Published by Elsevier B.V.)

Background: Stanford type A acute aortic dissection (TAAAD) is often accompanied by preoperative disorders of coagulation. The study aimed to evaluate the relationship between computed tomography angiography imaging features and preoperative coagulopathy in TAAAD patients., Methods: This was a single-center retrospective review of adult patients undergoing TAAAD surgery from January 2015 to January 2019 in the Beijing Anzhen Hospital (Beijing, China). Images were obtained using preoperative enhanced computed tomography in 174 patients with TAAAD. Preoperative coagulopathy was defined as the disseminated intravascular coagulation score greater than 5. The patients were divided into coagulopathy and non-coagulopathy groups. Circumferential arc lengths of the false lumen (Fx) and true lumen (Tx) were measured at four planes (ascending aorta, thoracic-descending aorta, descending aorta and abdominal aorta). We define the value of Fx/(Tx+Fx) × 100% as tear index (TI) and take the four planes' averages to weighed the false lumen's size. By analyzing the two groups of clinical data and computed tomography angiography imaging data, potentially related factors were detected by univariate analysis and multivariate binary logistic regression analysis., Results: The incidence of preoperative coagulopathy for TAAAD patients was 12.07%. In adjusted multivariate binary logistic regression analysis, white blood cell count (odds ratio [OR]: 1.204, 95% confidence interval [CI]: 1.035-1.400, P = 0.016); longitude length of aortic dissection (OR: 1.076, 95% CI: 1.016-1.139, P = 0.012); and Tear index (OR = 1.177, 95% CI: 1.075-1.289, P < 0.001) were significant factors related to the occurrence of preoperative coagulopathy for TAAAD., Conclusions: The incidence of preoperative coagulopathy in TAAAD patients was 12.07%. The longitude length of AD, TI and white blood cell count were significant factors related to preoperative coagulopathy in patients with TAAAD. The significance of imaging and anatomic changes related to coagulopathy are worth further study in TAAAD patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF., Methods: From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision., Results: In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up., Conclusions: ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF., (© 2020 Wiley Periodicals LLC.)

Several novel technological developments and surgical approaches have characterized the field of aortic surgery in the recent decade. The progressive introduction of endovascular procedures, minimally invasive surgical techniques and hybrid approaches have changed the practice in aortic surgery and generated new trends and questions. Also, the advancements in the manufacturing of tissue engineered vascular grafts as substitutes for aortic replacements are enlightening new avenues in the treatment of aortic disease. This review will provide an overview of the current novel perspectives, debates and trends in major thoracic aortic surgery.

Background: Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during aortic arch surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP., Methods: From January 2009 to January 2016, 1691 patients who underwent aortic arch surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients., Results: The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P for interaction < 0.05). The high temperature group had a significant protective effect in the UACP ≤ 40 minutes subgroup (HR, 0.30; 95% CI, 0.12-0.74; P = 0.01) but not in the UACP > 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99)., Conclusions: This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

A 39-year-old man with Stanford B aortic dissection was treated by thoracic endovascular aortic repair (TEVAR) and experienced an aortoesophageal fistula (AEF). After repeated TEVAR and esophageal stent implantation, the hematemesis did not cease although the whole thoracic descending aorta was covered by stents. A three-stage operation was performed, and an AEF 9 cm long was found during the operation. To our knowledge, this may be the largest AEF ever reported. The patient survived without adverse events., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: EuroSCORE is a widely used objective risk scoring model., Objective: The aim of this study was to evaluate the validation of EuroSCORE II for predicting in-hospital mortality and length of intensive care unit (ICU) stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey Type I aortic dissection., Patients and Methods: Between February 2009 and February 2012, data from 384 consecutive patients, who underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation, were collected retrospectively. EuroSCORE II was applied to predict mortality and length of ICU stay. The C-statistic was used to test discrimination of the model. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic., Results: The in-hospital mortality was 8.07%. The mean length of ICU stay was 3.06 days. A total of 75 patients remained at ICU for 5 days or more and 42 patients for 7 days or more. EuroSCORE II did not show good discriminatory ability in predicting mortality and length of ICU stay. The C-statistic of predicting mortality, ICU stay for 5 days or more, and ICU stay for 7 days or more were 0.49, 0.56, and 0.52, respectively. The calibration was poor for predicting mortality (p < 0.001), ICU stay for 5 days or more (p < 0.001), and ICU stay for 7 days or more (p < 0.001)., Conclusion: Although EuroSCORE II is the newest risk model for cardiac surgery, it is not accurate when it is applied for thoracic aortic surgery. A new risk evaluating system specially designed for aortic surgery should be developed in the future., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The presence of an isolated left vertebral artery requires changes in the aortic arch reconstruction techniques and cerebral protection methods in patients with total arch replacement. The best method for surgical repair of the isolated left vertebral artery is controversial. We retrospectively reviewed our experience of total arch replacement in patients with aortic dissection with this vessel anomaly., Methods: Between August 2003 and December 2008, 21 patients with aortic dissection (type A dissection, n = 20; type B dissection, n = 1) with an isolated left vertebral artery underwent total arch replacement under hypothermic cardiopulmonary bypass combined with selective cerebral perfusion. Concomitant stented elephant trunk was implanted in 20 patients., Results: There was no in-hospital death. Injury to the spinal cord occurred in 2 patients with chronic dissection using stented elephant trunk implantation. One had weakness in the left lower extremity, and the other patient had paraparesis: both recovered during the follow-up period. One patient experienced transient neurologic deficit, and acute renal failure was observed in 1 patient: both recovered completely before hospital discharge., Conclusions: Acceptable results were obtained in patients with aortic dissection with an isolated left vertebral artery. Although there was no clear evidence that the spinal cord injury was related to the isolated left vertebral artery using stented elephant trunk implantation, the isolated left vertebral artery was constructed as soon as possible in patients with this vessel anomaly., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We evaluated an open stented elephant trunk (sET) technique combined with cardiac operations for a one-stage treatment of patients with complicated Stanford type B aortic dissection (AoD) and cardiac diseases., Methods: Between April 2007 and March 2010, 16 patients with Stanford B AoD and cardiac diseases (mean age 49.75 ± 13.42 years) underwent sET combined with cardiac operations. Under deep hypothermic cardiac arrest (DHCA), a stented graft was directly delivered via the incision of aortic arch and the proximal graft was sutured on the normal distal aortic arch wall in a continuous circumferential full-thickness fashion. The combined cardiac operations (Bentall procedure, etc.) were performed before sET implantation while cooling., Results: Average time of cardiopulmonary bypass, aortic cross clamping durance, and DHCA was 131.62 ± 23.85, 64.69 ± 9.72, and 21.94 ± 3.60 minutes, respectively. There were no early deaths and no neurological complications. During a follow-up of 18.69 ± 9.94 months, computed tomographic angiography was performed in all patients. Neither endoleak nor stent shifting was observed. Retrograde type A AoD was not found during follow-up. Thrombus was formed in the false lumen from the proximal descending aorta to the diaphragmatic section., Conclusions: The open sET technique combined cardiac procedures can reliably treat Stanford type B AoD concomitant with surgical cardiac disease in a single stage., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: The optimal surgical repair for patients with Marfan syndrome with type A dissection involving the aortic arch is controversial. We retrospectively reviewed our experience of total arch replacement combined with stented elephant trunk implantation for patients with Marfan syndrome with type A dissection., Methods: Between April 2003 and September 2008, 44 patients with Marfan syndrome (acute = 19, chronic = 25) with type A dissection underwent this procedure. Postoperative computed tomography was used to evaluate thrombosis and absorption of the residual false lumen., Results: In-hospital mortality was 4.55% (2/44) (acute = 0%, 0/19; chronic = 8.00%, 2/25) and follow-up death rate was 4.76% (2/42) (acute = 5.26%, 1/19; chronic = 4.35%, 1/23) during a mean follow-up of 38 ± 17 months. One patient (5.26%, 1/19) with chronic dissection underwent thoracoabdominal aortic replacement 7 months after surgery. Injury to the spinal cord and visceral ischemia were not observed during follow-up. Obliteration of the false lumen around the stented elephant trunk was observed in 76.2% of patients (32/42) (acute = 84.2%, 16/19; chronic = 69.6%, 16/23) as demonstrated by postoperative computed tomography. The distal end of the stent-graft entering the false lumen was observed in 4 patients (21.1%, 4/19) with acute dissection., Conclusions: The procedure was a suitable alternative to patients with Marfan syndrome with chronic type A dissection. However, more attention should be paid to patients with Marfan syndrome with acute dissection caused by the fragile dissecting membrane. If this procedure was adopted in patients with Marfan syndrome with acute type A dissection, an entry adjacent to the distal end of the surgical stent-graft, a small true lumen, or an extremely tortuous morphology of the false lumen aorta should be excluded., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Appropriate surgical management of type A dissection is a critical factor for achieving satisfactory outcome, but the choice of optimal procedure is controversial. We retrospectively reviewed our experience with aortic arch replacement for type A dissection involving the arch., Methods and Results: Excluding 14 cases of subtotal or total aortic replacement, 411 of 544 patients with type A dissection (stented elephant trunk=291, conventional surgical repair=120) underwent aortic arch replacement between January 2003 and September 2008. In-hospital mortality was 3.09% (9 of 291) for stented (acute=4.73%, 7 of 148; chronic=1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acute=6.06%, 4 of 66; chronic=3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stented=2.41%, 7 of 291; conventional=0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stented=1 and conventional=4; P=0.031) and 3.05% (6 of 197) for chronic dissection (stented=4 and conventional=2; P=0.661) during follow-up. Obliteration of the false lumen around the stented elephant trunk occurred in 94.2% (130 of 138) of patients with acute dissection and in 92.0% (126 of 137) of patients with chronic dissection., Conclusions: Total arch replacement combined with stented elephant trunk implantation demonstrated the superiority of the combination of the surgical and interventional approaches while avoiding the weaknesses associated with the individual methods. The encouraging surgical results could enable this procedure to become the new "standard" therapy for type A dissection involving repair of the aortic arch.

Background: A conventional single-stage procedure, staged procedures, or debranching of the supraaortic vessels, followed by immediate transfemoral stenting of the aortic arch, have been introduced to treat chronic type B dissection with aortic arch involvement. The best method for surgical repair of chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions is not known., Methods: Between October 2003 and December 2008, 19 patients underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion through a median sternotomy. Thirteen patients had proximal aortic lesions. Postoperative computed tomography was used to evaluate thrombosis and absorption of the false lumen., Results: Concomitant proximal aortic lesions were repaired in all patients. Thirty-day mortality was 5.26% (1/19). There was one late death at a mean follow-up of 36 +/- 12 months. There was no spinal cord injury or visceral malperfusion. One patient with Marfan syndrome with chronic dissection underwent thoracoabdominal aortic replacement 6 months later. Obliteration of the false lumen around the stented elephant trunk was observed in 16 patients (94.1%, 16/17) during follow-up., Conclusions: This technique is safe, effective, and economical. Replacement of aortic arch dissection and thrombosis of the dissected descending aorta was achieved simultaneously. Concomitant proximal aortic lesions were repaired. Favorable surgical outcomes and postoperative results using this technique were obtained in patients with chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of the study was to assess the efficacy of total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute Stanford type A aortic dissection involving the aortic arch., Methods: Between January 2004 and April 2006, 13 consecutive Marfan patients (4 female, 9 male) with acute type A aortic dissection involving the aortic arch underwent total arch replacement combined with implantation of a stented elephant trunk. Aortic dissection extending to the iliac artery was seen in 10 patients, and to the abdominal aorta in 3 patients. Ages ranged from 17 to 65 years (mean, 39 +/- 13). Computed tomography was done to evaluate the residual false lumen in the descending aorta., Results: All patients survived and were discharged from hospital. One patient with thrombosis of the innominate artery suffered cerebral infarction and recovered during follow-up. One patient had ischemia of the left upper limb postoperatively, but recovered after axillary to axillary artery bypass. There was 1 death during the mean follow-up period of 27 +/- 10 months. Complete thrombus formation was observed in 84.6% of patients (11 of 13) around the stented elephant trunk, and in 69.2% of patients (9 of 13) at the diaphragmatic level., Conclusions: Total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute type A aortic dissection involving the aortic arch results in less late dilatation of the dissected descending aorta. That prolongs the reoperation interval or reduces the number of late thoracoabdominal aortic replacements, unless there is a patent false lumen around the stented elephant trunk.