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Objective The reversed elephant trunk technique permits staged repair of extensive thoracic aortic aneurysm in patients whose distal (ie, descending thoracic and thoracoabdominal) aorta is symptomatic or disproportionately large compared with their proximal aorta (ie, ascending aorta and transverse aortic arch). We present our 23-year experience with the reversed elephant trunk approach. Methods Between 1994 and 2017, 94 patients (median age 62 [46-69] years) underwent stage 1 reversed elephant trunk repair of the distal aorta. Fifty-three patients (56%) had aortic dissection, and 31 patients (33%) had heritable thoracic aortic disease. Eighty-eight operations (94%) were Crawford extent I or II thoracoabdominal aortic repairs. Twenty-seven patients (29%) underwent subsequent stage 2 repair of the proximal aorta; 14 patients (52%) required redo median sternotomy. The median time between the stage 1 and 2 operations was 18.8 (4.8-69.3) months. Results The operative mortality was 10% (9/94) for stage 1 repairs and 4% (1/27) for stage 2 repairs; 1 patient with heritable thoracic aortic disease died after stage 1 repair (1/31, 3%), and 1 patient died after stage 2 repair (1/13, 8%). Two patients (2%) had ruptures after stage 1 repair; 1 resulted in death, and 1 precipitated emergency stage 2 repair. In total, 36 patients (38%) who survived stage 1 repair died before stage 2 reversed elephant trunk completion repair could be performed. Conclusions Managing extensive aortic aneurysm with the 2-stage reversed elephant trunk technique yields acceptable short-term outcomes. This technique is useful for the reversed elephant trunk in patients who require distal aortic repair before proximal repair and is particularly effective in patients with heritable thoracic aortic disease. The low number of patients returning for completion repair is concerning. Rigorous surveillance is needed.

Background Midaortic syndrome (MAS) is a rare congenital or acquired condition marked by segmental or diffuse stenosis of the distal thoracic and/or abdominal aorta and its branches. The optimal approach to medical or interventional management of MAS and long-term outcomes in adults are not well defined. We reviewed MAS cases to characterize the natural history of aortic disease, identify prognostic factors, and evaluate the durability of invasive interventions. Methods We conducted a retrospective review of patients with MAS who presented to Memorial Hermann Hospital and Baylor College of Medicine between 1997 and 2018. We categorized cases according to demographic and clinical manifestations, etiologies, the extent of aortic involvement, interventions, and vascular outcomes. Results We identified a cohort of 13 patients with MAS. The etiology of MAS was identified in 6 cases, including genetic syndromes (neurofibromatosis type 1 (2/13), Williams syndrome (1/13), fibromuscular dysplasia (2/13), and Takayasu arteritis (1/13)). Mean age at first documented clinical event was 25.2 (2–67) years, but cases with genetic etiologies presented significantly younger (18.2 years). The most common primary anatomic site was the suprarenal and infrarenal aorta (zones 5–8). Extra-aortic locations involved the renal (4/13), celiac (3/13), and superior mesenteric (3/13) arteries. Clinical manifestations included hypertension (13/13), claudication (9/13), and postprandial abdominal pain (5/13). All patients with available follow-up data underwent at least one surgical or endovascular intervention (range: 1–8). Postoperative complications included renal failure requiring postdischarge hemodialysis and respiratory failure. There were no deaths in long-term follow-up. Conclusions MAS is a complex vasculopathy with substantial variability in clinical presentation and anatomic distribution. Extensive disease frequently requires multiple invasive interventions and results in refractory hypertension, which may predict subsequent clinical events. A multidisciplinary approach with long-term monitoring is essential for preservation of end-organ function and quality of life in this debilitating disease.

Objective We determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. Methods Outcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. Results The stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P = .41), persistent stroke (6.3% vs 5.3%, P = .75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P = .059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P = .66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P = .18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P = .0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P = .13). Stented patients also had fewer subsequent procedures (P = .25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P = .015 for overall survival). Conclusions In the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients.

Background Acute kidney injury (AKI) necessitating renal replacement therapy adversely affects outcomes after thoracoabdominal aortic aneurysm (TAAA) repair. The effects of earlier stages of AKI are less known. We hypothesized that earlier stages of AKI would reduce early survival after TAAA repair. Methods We analyzed prospectively collected data from 1,056 consecutive TAAA repairs from our institution (2006 to 2016). We excluded patients less than 18 years of age, those with preexisting renal disease, and three patients who died intraoperatively, resulting in 873 patients. The Kidney Disease Improving Global Outcomes criteria grouped patients into three AKI stages; stage 3 necessitated initiation of renal replacement therapy. Multivariable modeling identified operative mortality predictors. Kaplan-Meier analysis assessed 1-year survival. Results Of 873 patients, 642 (73.5%) had no AKI and 231 (26.5%) had postoperative AKI (mild/stage 1, n = 92 [10.5%]; moderate/stage 2, n = 44 [5%]; severe/stage 3, n = 95 [10.9%]). Operative death occurred in 65 patients (7.4%): 14 (2.2%) with no AKI, 5 (5.4%) with mild AKI (p = 0.07 versus no AKI), 8 (18.2%) with moderate AKI (p = 0.02 versus mild), and 38 (40%) with severe AKI (p = 0.01 versus moderate). In multivariable analysis, moderate AKI independently predicted death (relative risk ratio: 9.4, 95% confidence interval: 3.4 to 25.9). Kaplan-Meier 1-year survival was 91.1% ± 1.2% for no AKI, 84.6% ± 3.9% for mild AKI (p = 0.07 versus no AKI), 67.4% ± 7.6% for moderate AKI (p = 0.01 versus mild), and 46.6% ± 5.3% for severe AKI (p = 0.02 versus moderate; p Conclusions Moderate/stage 2 AKI reduced early survival after TAAA repair. Prevention, earlier detection, and optimal medical management of AKI may improve survival.

Introduction fishing communities in Uganda are key populations for HIV, with persistently higher prevalence and incidence than the general population. Methods between March and August 2014, a cross sectional survey was conducted in 10 fishing communities of Lake Victoria in Uganda. Data was collected on socio-behavioural characteristics using interviewer administered questionnaires and venous blood collected for HIV testing. Prevalent HIV infections among adolescents and young people aged 13 to 24 years was estimated and the factors associated with those infections determined using multi variable logistic regression modelling. Results HIV prevalence was 10.8% among the 630 (96.5%) who provided a blood sample. Females were 3.5 times as likely to have HIV infection as males (aOR=3.52, 95% CI: 1.34-9.22). Young people aged 20-24 years were twice as likely to be HIV infected as those aged 13-19 years (aOR=1.77, 95% CI: 0.05-2.10), participants without formal education or those who had studied up to primary level were more likely to be HIV infected than those who had post primary education ((aOR=2.45, 95% CI: 1.19-5.07) or (5.29 (1.35-20.71) respectively). Reporting more than one sexual partner in the past 6 months was associated with HIV prevalent infection than those reporting no sexual partners (aOR=6.44, 95% CI: 1.27-32.83). Conclusion adolescents and young people aged 13-24 years in fishing communities around Lake Victoria, Uganda, have a high HIV prevalence, with females having a three-fold higher level than males. These findings highlight-the need to improve HIV prevention among young females living in these fishing communities.

OBJECTIVES To compare short-term outcomes, long-term survival and reinterventions in patients requiring surgery after chronic Type I and chronic primary Type III aortic dissections. METHODS Over an 11-year period, 466 patients underwent thoraco-abdominal aortic aneurysm repair for chronic Type III (n = 239) and Type I (n = 227) aortic dissections. Short-term outcomes and reinterventions were evaluated by multivariable regression analysis for the entire group; propensity matching produced 169 pairs. RESULTS Mortality was 6% (n = 28) in the overall cohort and 6.2% (n = 14) and 5.9% (n = 14) in those with chronic Type I and Type III aortic dissections, respectively. Overall stroke and persistent spinal cord deficit rates were 4.0% and 2.6%, respectively, in the Type I group and 1.3% and 3.8% in the Type III group. In the propensity-matched patients, analysis showed no neurological differences between the 2 groups, but respiratory failure was significantly more frequent in the chronic Type I group (30.2% vs 15.4%; P = 0.001). Multivariable analysis identified chronic Type I dissection as an independent risk factor for postoperative pulmonary complications (odds ratio 1.612; 95% confidence interval 1.060-2.452; P = 0.026) and an association between chronic Type I dissection and stroke (odds ratio 4.013; 95% confidence interval 1.026-15.698; P = 0.046). Six-year survival was 74.4% ± 4.1% and 74.4% ± 4.6% in the chronic Type I and Type III groups, respectively (P = 0.87). CONCLUSIONS Short- and long-term mortality and reintervention rates were comparable after open repair for chronic Type I and primary chronic Type III aortic dissections. Respiratory failure was more frequent in the chronic Type I aortic dissection group.

Chylothorax is a potentially deadly complication that can occur after thoracoabdominal aortic aneurysm (TAAA) repair. We describe our contemporary experience (2005-2014) with this complication, our efforts to identify perioperative variables associated with it, and our attempts to assess treatment outcomes. We reviewed the records of 1092 consecutive patients who underwent TAAA repair between 2005 and 2014. Standard bivariate analysis was used to test for between-group differences. Eleven patients (0.9%) developed postoperative chylothorax. Nonoperative management was used in 8 of these patients (73%); 1 patient died after a lengthy hospital stay (297 days). The other 3 patients required thoracotomy with direct ligation; 1 of these patients required a second operation. Patients who developed chylothorax appeared to be similar to other patients in age, sex, extent of aneurysm, and metabolic or cardiovascular comorbidities. Patients who developed postoperative chylothorax were more likely to require drainage of a pleural effusion (P = 0.005), tracheostomy (P = 0.02), and longer stays in the intensive care unit (median, 6 [2-24] days, P 0.001) and the hospital (median, 35 [24-88] days, P = 0.001), and these patients were more likely to develop a graft infection (n = 2, P 0.001). The extent of TAAA repair (Crawford I-IV), reoperation, and clamping proximal to the left subclavian artery were not significantly associated with postoperative chylothorax. Chylothorax after TAAA repair can often be managed nonoperatively. Development of postoperative chylothorax may lead to significant morbidity, longer hospitalization, and increased likelihood of graft infection.

Background Although reducing the incidence of unplanned readmission after thoracoabdominal aortic aneurysm (TAAA) repair represents an important opportunity to improve outcomes, predictors of readmissions are not known. We sought to characterize and identify factors associated with unplanned readmission after discharge in survivors of open TAAA repair. Methods Through prospective phone contact and retrospective record review, we determined the frequency and characteristics of unplanned readmissions within 30 days of discharge in 363 patients who were discharged after open TAAA repair. We used univariate and multivariable analyses to identify factors associated with readmission. Results There were 44 unplanned readmissions in 40 patients (11%). After readmission, 11 patients underwent operations, and 17 underwent nonsurgical procedures, the most common of which was thoracentesis (n = 9). Readmitted patients tended to have lower preoperative estimated glomerular filtration rates ( p = 0.045), higher frequencies of preoperative sleep apnea ( p = 0.009) and postoperative pulmonary ( p = 0.04) and infection ( p = 0.02) complications, and longer hospital stays ( p = 0.01) than patients without readmissions. Patient age, urgency of operation, and extent of TAAA repair were similar in patients with and without readmissions. Multivariable analysis identified sleep apnea (relative risk ratio [RRR] 3.21, 95% confidence interval [CI]: 1.51 to 6.82, p = 0.002), postoperative infection (RRR 4.34, 95% CI: 1.32 to 14.25, p = 0.02), renal failure necessitating dialysis (RRR 3.14, 95% CI: 1.04 to 9.46, p = 0.04), and visceral artery stenting (RRR 2.43, 95% CI: 1.09 to 5.44, p = 0.03) as significant predictors of readmission. Conclusions Patients with renal dysfunction, sleep apnea, or postoperative infection were particularly likely to be readmitted; optimizing the management of these factors may reduce early readmission after TAAA repair.

Background We analyzed trends, assessed outcomes and lessons learned, and investigated whether using a simplified US version of the frozen elephant trunk (FET) technique to treat complex arch pathology poses additional risk. Methods From 2010 to 2015, we performed 129 consecutive ET procedures (traditional ET [t-ET], n = 92 [71.3%]; FET, n = 37 [28.7%]) for chronic dissecting (n = 62 [48.1%]) and atherosclerotic aneurysms (n = 67 [51.9%]). A stepwise logistic regression model using preoperative and intraoperative variables was created to analyze the outcomes. Results Thirty-day mortality was 12.4% (t-ET, n = 9 [9.8%]; FET, n = 7 [18.9%]; p = 0.24). The rate of persistent (at the time of discharge) stroke was 5.4% (t-ET, n = 5 [5.4%]; FET, n = 2 [5.4%]; p =1.00). The rate of persistent spinal cord deficit was 3.9% (t-ET, n = 3 [3.3%]; FET, n = 2 [5.4%]; p = 0.62). In the multivariable analyses, the addition of FET was not an independent predictor of mortality, permanent stroke, or spinal cord deficit. Conclusions With the advent of endovascular technology, there is a clinical shift toward increased use of FET to eliminate or facilitate the second surgical stage in treating patients with extensive aortic pathology. The addition of FET to the surgical armamentarium does not seem to pose additional risk (although larger studies are needed), but judicious use is advised nonetheless. A single-piece endoprosthesis for FET instead of a customized one should be considered.

Cardiac arrhythmias commonly arise after cardiac surgery and are associated with poor prognosis. In thoracoabdominal aortic aneurysm (TAAA) repair, these complications are poorly understood. We assessed characteristics, incidence, outcomes, and potential predictors of postoperative arrhythmia (PA) after open TAAA repair.From 2010 to 2014, 403 consecutive open TAAA replacement operations were performed in patients without preoperative cardiac rhythm abnormalities at a single tertiary center. We compared preoperative characteristics, operative factors, and postoperative outcomes in patients with and without PA, and we used multivariable logistic regression to identify predictors of PA.PA occurred after 107 (26.5%) procedures. Atrial fibrillation (23%) was the most common type of PA. Length of hospital stay and operative mortality were greater in patients with PA than in patients without it (p 0.01 for both). Kaplan-Meier cumulative survival for patients with PA was lower than for patients without PA: 69.2% ± 4.6% versus 88.3% ± 2.0% at 1 year and 59.0% ± 5.3% versus 85.0% ± 2.3% at 3 years (p0.001 for both). The odds of PA increased with advancing age (1.07 per year; p0.001). In addition, the odds of developing PA were higher in patients who received visceral perfusion (odds ratio, 2.58; p = 0.001) and were lower in patients who underwent extent IV repair (odds ratio, 0.44; p = 0.01).Postoperative cardiac arrhythmia was common after open TAAA repair. Older patients and patients who underwent visceral perfusion were more likely to develop PA. Cardiac arrhythmia after TAAA repair was associated with prolonged hospital stay, higher early mortality, and lower midterm survival.

Objective We examined the early outcomes and the long-term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for >30 minutes. Methods During a 10-year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C-20°C; n = 116 [21.3%]), low-moderate (20.1°C-23.9°C; n = 262 [48.2%]), and high-moderate (24°C-28°C; n = 166 [30.5%]). A variable called "predicted temperature" was used in propensity-score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. Results The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low-moderate, and high-moderate hypothermia patients, respectively ( P = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively ( P = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity-matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87-1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87-1.15) than the patients with predicted moderate hypothermia. On long-term follow-up (mean duration, 5.12 years), 4- and 8-year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group ( P = .0015). Conclusions In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long-term survival was better in the moderate hypothermia group.

Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery.During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not.Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support48 hours (P .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028).In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.

The frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality.We searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage.Thirty-five studies (total N = 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P .001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P = .46), stroke 9.3% versus 6.6% (P = .51), and overall adverse events 22.0% versus 16.5% (P = .41).As the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided.

Objectives To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. Methods Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). Results The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. Conclusions Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.

Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes.We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 [59-73] years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes.There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P.0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years.Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.

Background Pathologic conditions of the aorta remain a major source of morbidity and mortality for patients with Marfan syndrome (MFS). Extensive thoracoabdominal aortic aneurysm (TAAA) repair can prevent aortic catastrophe but carries substantial risk of perioperative adverse events. We evaluated midterm survival and quality of life (QoL) after contemporary Crawford extent II TAAA repair in patients with MFS. Methods From 2004 to 2010, 49 consecutive patients with MFS (mean age, 43.4 ± 12.0 years) underwent extent II TAAA repair (41 elective and 8 urgent/emergent procedures) with intercostal reimplantation. Thirty-six patients (73%) had aorta-related symptoms, and 45 (92%) had distal aortic dissection. Operative adjuncts included cerebrospinal fluid drainage (n = 47 [96%]), left heart bypass (n = 46 [94%]), and cold renal perfusion (n = 47 [96%]). Kaplan-Meier survival analysis was performed. QoL was assessed in 24 patients with a 12-item survey (12-Item Short Form Health Survey version 2 [SF-12v2]) a median of 5.3 (interquartile range [IQR], 4.0-7.9) years postoperatively. QoL data were normalized and compared with data from the general population. Results There were no operative deaths, strokes, paraparesis, or paraplegia. Two patients (4%) had permanent renal failure necessitating hemodialysis. The most frequent complication was vocal cord paralysis (n = 21 [43%]). Six-year Kaplan-Meier survival was 84% ± 6%. The 24 patients with QoL data had slightly worse physical component scores (46.0 ± 10.6) and slightly better mental component scores (51.4 ± 10.4) than the general population (50 ± 10 for both scores). Conclusions Operative treatment of extensive TAAA in patients with MFS enables excellent midterm survival and QoL. Cerebrospinal fluid drainage, left heart bypass, and cold renal perfusion probably aid in achieving excellent outcomes.

Respiratory failure, the most frequent complication after thoracoabdominal aortic aneurysm (TAAA) repair, necessitates tracheostomy in severe cases. We examined risk factors for and outcomes of tracheostomy after TAAA repair.We reviewed the records of 1267 consecutive patients who underwent TAAA repair. Patients with a preexisting tracheostomy were excluded. Extensive repairs (Crawford extent I or II) were performed in 716 patients (56.6%). Stepwise logistic regression analysis was used to identify risk factors for postrepair tracheostomy.Tracheostomy was necessary in 140 patients (11.1%). Operative mortality was significantly higher in patients with tracheostomy (27.9%) than in those without (5.8%; p0.001). As expected, tracheostomy patients had longer intensive care unit stays (24 vs 4 days, p0.001) and hospital stays (57 vs 10 days, p0.001) than nontracheostomy patients. Patients with tracheostomy were frequently transferred for additional long-term acute care or hospitalization (107, 76.4%), and many died after transfer (24/107, 22.4%). Kaplan-Meier curves showed markedly poorer late survival in patients with tracheostomy than in those without (47.9% ± 4.3% vs 87.3% ± 1.0% at 1 year; 27.8% ± 4.8% vs 68.6% ± 1.6% at 5 years). Independent predictors of post-TAAA repair tracheostomy included acute aortic dissection, chronic renal insufficiency, underweight body mass index, hypertension, history of stroke, extent II repair, diabetes, age at least 70 years, and greater platelet transfusion volume.Patients who undergo tracheostomy after TAAA repair have a high risk of early and late mortality as well as prolonged hospitalization. Strategies for improving survival outcomes in tracheostomy patients warrant investigation.

The data supporting performing elective aortic arch surgery in patients aged 75 years or older are equivocal. We evaluated short- and long-term outcomes after elective arch surgery in patients aged ≥75 years to determine whether complex arch operations are justified in such patients.Over a 10-year period, 805 patients aged 50 to 89 years underwent elective proximal or total arch surgery. Composite adverse outcome was defined as operative mortality, persistent (ie, present at discharge) neurologic event, or persistent hemodialysis. Multivariable logistic regression was performed in the entire group.Multivariable analysis showed that age at admission independently predicted composite adverse outcome, operative mortality, and prolonged (48 hours) ventilator support (P .0001 for all), but not stroke. The same results were shown in a subgroup analysis in which older age (80-89 years) was associated with composite adverse outcome, operative mortality, and prolonged ventilator support. In a Cox proportional hazards regression model adjusted for antegrade cerebral perfusion time and prior history of renal disease, patients aged 50 to 74 years had significantly better overall survival than patients aged ≥75 years (P .001).As endovascular technology evolves, having benchmark data from likely endovascular-therapy candidates is critical. This study, among the few to focus on elective aortic arch surgery in elderly patients, suggests that surgical intervention carries risk and that novel endovascular therapies are needed.

Objective The effect of incidental splenectomy during thoracoabdominal aortic aneurysm repair is unknown. We hypothesized incidental splenectomy was associated with decreased late survival. Methods We studied 1056 thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Exclusion criteria were age less than 18 years (n = 9), prior splenectomy (n = 2), and intraoperative death (n = 3). This left 1042 thoracoabdominal aortic aneurysm repairs for analysis (median age, 65 years; interquartile range, 56-72), including 221 (21%) that were reoperations. Multivariable modeling identified predictors of operative mortality in the total cohort. Moreover, to adjust for baseline differences, propensity score matching was performed to examine the frequency of these outcomes in the total cohort (n = 132 pairs) and the early survivors (n = 110 pairs). Late survival was estimated by the Kaplan–Meier method, and risk of late mortality was assessed by Cox proportional hazards regression. Results Incidental splenectomy was performed in 135 patients (13%), 36% of whom underwent reoperation. Operative mortality rates of the incidental splenectomy and nonincidental splenectomy groups were 16% versus 8% in both the overall study (P = .005) and the propensity score–matched (P = .07) cohorts. In multivariable analysis, incidental splenectomy independently predicted operative mortality (odds ratio, 2.2; 95% confidence interval, 1.21-3.94; P = .008). For early survivors, incidental splenectomy did not increase the risk of late mortality. Survival estimates of matched early survivors did not differ between the incidental splenectomy and nonincidental splenectomy groups (P = .29). Conclusions Incidental splenectomy during thoracoabdominal aortic aneurysm repair was associated with increased operative mortality but not reduced late survival. Splenic preservation is encouraged when feasible.

Vocal fold movement impairment (VFMI) secondary to neuronal injury is a known risk after aortic surgery. Total arch replacement is technically challenging, and the incidence of vocal fold movement impairment secondary to neuronal injury after this surgery is unknown. This study examined the incidence of VFMI after total arch replacement and medialization treatment outcomes.Retrospective cohort study.All patients who underwent total arch replacement at a tertiary care center over 11 years (2006-2017) were identified through an institutional database. End points included evidence of VFMI on flexible laryngoscopy, time to diagnosis, time to treatment, need for reintubation, and intensive care unit (ICU) and hospital length of stay.Of the 358 patients who underwent total arch replacement, 63 (20%) were diagnosed with VFMI during their initial inpatient stay. Fifty patients (79%) VFMIs were left-sided, nine (14%) were right-sided, and four (6%) were bilateral. Thirty-nine patients (62%) underwent inpatient vocal fold medialization: 28 (72%) by injection laryngoplasty and 11 (28%) by type 1 thyroplasty. Those with unilateral VFMI had longer ICU (8.9 days) and hospital (19.4 days) than those with no VFMI (5.7 and 16.1 days). Among patients with unilateral VFMI, those who underwent inpatient vocal fold medialization trended toward shorter ICU (6.2 vs. 14.4 days, P = .03) and hospital stays (20.1 vs. 23.3 days, P = .4) than patients who did not have a medialization procedure.The overall incidence of VFMI after total arch replacement in our series was 20%. Both the right and left vocal folds are potentially at risk from a total arch replacement; consequently, the distribution of injury in our cohort was more heterogeneous than in other series.3 Laryngoscope, 129:699-703, 2019.

Background We examined our contemporary experience with hemiarch and total arch replacement in patients with previous acute type I aortic dissection. Methods Over an 8.5-year period, 137 consecutive patients (median age 58 years, interquartile range, 50 to 67) underwent hemiarch or total transverse aortic arch replacement a median of 7.7 years (range, 67 days to 32 years; interquartile range, 2.8 to 12.3 years) after previous acute type I aortic dissection repair. Interventions involving only the aortic root, aortic valve, descending aorta, or thoracoabdominal aorta were excluded. Multivariate analysis of 20 potential preoperative and intraoperative risk factors was performed to examine early death, neurologic deficit, composite endpoint (operative death, permanent neurologic deficit, or hemodialysis at discharge), and long-term mortality. Results Total arch replacement was performed in 103 patients (75.2%), hemiarch replacement in 34 (24.8%), and elephant trunk procedures in 77 (56.2%). Thirty-one repairs (22.6%) were emergent or urgent. There were 16 operative deaths (11.7%), 4 permanent strokes (3.6%), and 21 (15.3%) instances of the composite endpoint. In the multivariate analysis, congestive heart failure and cardiopulmonary bypass time independently predicted operative mortality ( p = 0.0027, p = 0.018). Emergency operation approached significance for stroke ( p = 0.088). Predictors of long-term mortality (during a median follow-up period of 5.1 years, 95% confidence interval: 4.4 to 5.8) were female sex ( p = 0.0036), congestive heart failure ( p = 0.0045), and circulatory arrest time ( p = 0.0013); preoperative pulmonary disease approached significance ( p = 0.074). Five-year survival was 73.2%. Conclusions In patients with previous acute type I aortic dissection repair, hemiarch and total arch operations have respectable morbidity and survival rates. Congestive heart failure predicts operative death, long-term mortality, and our adverse event endpoint. Cardiopulmonary bypass time predicts operative mortality, and female sex and circulatory arrest time predict long-term mortality.

Objective The preferred arterial cannulation site for elective proximal aortic procedures requiring circulatory arrest varies, and different sites have been tried. We evaluated the relationships between arterial cannulation site and adverse outcomes, including stroke, in patients undergoing elective aortic arch surgery. Methods We reviewed the records of 938 patients who underwent elective hemiarch or total arch surgery with circulatory arrest between 2006 and 2016. Five cannulation sites were used: the right axillary (n = 515; 54.9%), innominate (n = 376; 40.1%), and right common carotid arteries (n = 15; 1.6%), each with a side graft; the ascending aorta (n = 19; 2.0%); and the femoral artery (n = 13; 1.4%). Multivariable logistic regression analysis was used to model the effects of cannulation site on adverse outcomes for the entire cohort and for a subcohort of 891 patients who underwent innominate or axillary artery cannulation. Propensity-matching yielded 564 patients (282 pairs) from the right axillary and innominate artery groups. Results For the entire cohort, mortality, stroke, and composite adverse outcome (operative death or persistent stroke or renal failure at hospital discharge) rates were 7.0%, 4.1%, and 9.8%. In the multivariable analysis of the axillary/innominate subcohort, cannulation site did not independently predict operative mortality, persistent stroke, or composite adverse event. These results were confirmed with the propensity-matched analysis, where both axillary and innominate artery cannulation provided equivalent composite adverse event rates, operative death rates, and overall stroke rates. Conclusions During elective arch surgery, right axillary artery cannulation and innominate artery cannulation (both via a side graft) produce excellent results and can be used interchangeably.

Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery.A 5-year review (2011-2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY).All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI -0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy.Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed.4. Laryngoscope, 128:144-147, 2018.

Background Valve-sparing aortic root replacement (VSARR) is an alternative to traditional composite valve graft (CVG) root replacement. We examined early and midterm outcomes after VSARR. Methods A combined retrospective/prospective study was performed in 83 patients who underwent VSARR (16%) among 515 patients who underwent aortic root replacement during a nearly 12-year period. Thirty-six patients (43%) had a connective tissue disorder, 3 patients (4%) had acute aortic dissection, and 40 (48%) patients had at least moderate aortic regurgitation (AR). Twenty-eight patients (34%) had left ventricular hypertrophy or dilatation. The reimplantation VSARR technique was used in 82 patients (99%), and the Florida sleeve technique was used in 1 patient. Thirty-two patients (39%) underwent concomitant aortic arch replacement. For early survivors, the median duration of follow-up was 3.5 years (range, 5 days–12.2 years). Results One patient had severe AR after VSARR that necessitated intraoperative conversion to a mechanical CVG. The 1 operative death and 1 stroke occurred in a patient with acute dissection. Actuarial survival was 96.4% ± 2.0% at 2 years and 86.9% ± 5.6% at 8 years. Six patients (7%) had late valve-related complications: 1 died of endocarditis, 4 underwent reoperation for severe AR and received replacement valves, and 1 had severe AR and is being monitored. Freedom from repair failure (reoperation, endocarditis, or severe AR) was 94.8% ± 2.6% at 2 years and 87.3% ± 5.7% at 8 years. Conclusions Valve-sparing aortic root replacement can have excellent early and respectable midterm outcomes, even when combined with arch repair. Further follow-up remains necessary to evaluate the long-term durability of VSARR.

Objective To determine whether preoperative chronic kidney disease (CKD) is predictive of poor outcomes in patients who undergo Crawford extent II thoracoabdominal aortic aneurysm (TAAA) repair. Methods Data were collected from patients with CKD (defined as a preoperative estimated glomerular filtration rate Results Compared with patients without CKD, patients who presented with CKD were older and had greater rates of comorbidities, including coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Patients with CKD had higher rates of operative mortality and adverse events. After propensity analysis, patients with CKD had greater rates of adverse event and renal failure necessitating dialysis, but had comparable rates of operative death to patients without CKD. Multivariable modeling indicated that CKD independently predicted adverse event (relative risk ratio [RRR] = 1.61; P = .01) and renal failure (RRR = 1.86; P = .02) after repair. After adjustment for median age, patients with CKD had substantially worse mid-term survival than those without (23.9 ± 2.4% vs 48.5 ± 2.5% at 10 years; P Conclusions In patients who present with CKD, extent II open TAAA repair carries considerable risks of operative death and adverse events. Further investigation is needed to improve renal protection during such repair.

Since the advent of endovascular repair for aortic aneurysms, many centers have justified the use of endovascular approaches in patients with previous open distal aortic repair by deeming these patients "high risk" because of their previous operation. We sought to determine whether patients who undergo reoperative repair for thoracoabdominal aortic aneurysm (TAAA) have worse outcomes than patients who undergo non-reoperative repair.We reviewed our data on 3379 TAAA repairs from 1986 to 2016. We compared patients' preoperative characteristics, surgical variables, and outcomes among reoperative (n = 726) and non-reoperative (n = 2653) cases. Furthermore, we examined reoperative indications to identify repairs performed because of repair failure (n = 93) and reoperations performed as an adjacent extension of repair (n = 633). A multivariable analysis was conducted to identify predictors of adverse events by using relevant preoperative and intraoperative factors.The operative mortality rate did not significantly differ between groups (8.1% for reoperative vs 7.3% for non-reoperative; P = .5); in addition, reoperative repair was not associated with an increased risk of adverse event. However, Kaplan-Meier survival analysis showed that over the first 10 years, the reoperative groups fared significantly worse than the non-reoperative group (P .001) (survival estimates at 10 years: 23.9% ± 4.9% for patients with repair failure, 28.4% ± 2.0% for those with extension of repair, and 40.1% ± 1.1% for non-reoperative repairs).We were unable to detect noteworthy differences in early outcomes between reoperative and non-reoperative TAAA repair. However, mid-term results indicate worse survival for patients who undergo reoperative surgery.

Objectives Endovascular aortic repair is increasingly being used to treat aneurysms, dissections, and traumatic injuries, despite its unknown long-term durability. We describe our 19-year experience with open descending thoracic and thoracoabdominal aortic repair after endovascular aortic repair. Methods Between 1996 and 2015, 67 patients were treated with open distal arch, descending thoracic, or thoracoabdominal aortic repair, or extra-anatomic bypass repair with aortic extirpation for complications after endovascular repair of the thoracic (n = 45, 67%) or abdominal (n = 22, 33%) aorta. The median interval between procedures was 18.0 months (interquartile range, 3.9-44.9). Indications for open repair included expanding aneurysm (n = 56), infection (n = 11), fistula (n = 8), aneurysm rupture (n = 5), pseudoaneurysm (n = 2), and restenosis (n = 1). Open repair involved partial (n = 9, 13%) or complete (n = 56, 84%) device removal or device salvage (n = 2, 3%) through a thoracoabdominal (n = 58, 87%) or thoracotomy (n = 9, 13%) incision. Eight patients (12%) underwent emergency procedures. Results There were 3 early (operative) deaths (2 with preoperative device infection) and 19 late deaths during a median follow-up of 35.8 months (interquartile range, 16.8-52.8 months). Overall 1- and 5-year survivals were 85% ± 4% and 60% ± 8%, respectively. Four patients had open repair failures necessitating reoperation; 2 patients had preoperative infection, and both died (1 early and 1 late). Conclusions Open repair for complications after endovascular procedures is not uncommon. Experienced centers can yield acceptable outcomes, especially in patients without infection. Close surveillance is mandatory after endovascular aortic repair.

Objective To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C-28.0°C vs 20.1°C-23.9°C) within the wide range of moderate hypothermia. Methods Over a 9-year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower-temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher-temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, "predicted temperature," was analyzed to eliminate surgeon bias. We used this variable in a propensity score–matching analysis to validate the multivariate analysis results. Results A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower– and higher–predicted temperature groups within the moderate hypothermia range in the propensity score–matching analysis. The higher–actual temperature group had a lower rate of ventilator support at >48 hours ( P = .036) and less need for tracheostomy ( P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome ( P = .0053 and .0002, respectively), operative mortality ( P = .0051 and .0041), and postoperative stroke ( P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome ( P = .0005), operative mortality ( P 48 hours ( P P = .0005). Conclusions In elective proximal or total arch surgery, higher temperatures (≥24.0°C-28.0°C) within the wide range of moderate hypothermia (20.1°C-28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.

Objective Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery. Methods Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs. Results There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group ( P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect. Conclusions In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement.

Evolving endovascular approaches to thoracoabdominal aortic aneurysm (TAAA) repair are attractive alternatives to the "gold standard" of conventional open TAAA repair. However, open repair may be more suitable for younger patients. We compared the outcomes of open TAAA repair in younger (≤50 years) and older (50 years) patients to evaluate operative risk in younger patients.We analyzed retrospective and prospective data from 3,346 cases of open TAAA repair performed between 1986 and 2015. Of those patients, 445 (13.3%) were 50 years old or younger and 2,901 (86.7%) were older than 50 years at the time of repair. In the younger cohort, 237 patients (53.3%) had connective tissue disorder, and many (n = 359, 80.7%) had aortic dissection. Younger patients tended to be in good health, and rupture was uncommon (n = 11, 2.5%). The outcomes examined included adverse event, a composite endpoint that comprised operative death or persistent stroke, paraplegia, paraparesis, or renal failure requiring dialysis.Comparisons between the two age groups showed that younger patients underwent more extent II repairs, urgent/emergent repairs, and visceral artery bypass procedures and had longer aortic clamp times. Nevertheless, younger patients had better early outcomes than did older patients, including lower rates of operative death (3.2% vs 8.2%, p = 0.002) and adverse events (5.2% vs 15.9%, p0.001). Multivariable analyses determined age 50 years old or younger to be an independent predictor of reduced adverse events (relative risk ratio = 0.29, p0.001).Early outcomes of open TAAA repair were excellent for patients 50 years old or younger, despite the fact that these patients typically required extensive repairs.

Background Aortic arch replacement remains among the most technically challenging cardiovascular operations, incurring considerable risk for perioperative death and stroke. The trifurcated graft technique, in which a double Y-graft is used to connect brachiocephalic branches to the main aortic graft, was recently developed to simplify arch reconstruction, reduce embolization, and minimize related cerebral ischemia. We examined early outcomes of aortic arch replacement performed by using single or double Y-graft variations of this technique. Methods Between December 2006 and May 2009, the Y-graft technique was used to perform aortic arch replacement in 55 patients. Thirty-three patients had prior median sternotomy (60%), and 34 (62%) had ascending aortic dissection. Axillary cannulation was used in 52 patients (95%), and hypothermic circulatory arrest and antegrade cerebral perfusion were used in all patients. Median systemic and cerebral circulatory arrest times were 65 minutes and 0 minutes, respectively. A first-stage elephant trunk repair was performed in 46 patients (84%). Follow-up data were obtained for all patients. Results There were no in-hospital deaths and one 30-day death (2%). Three patients (5%) had strokes, 1 of which was transient. Actuarial 1-year and 2-year survival rates were 80.0% ± 5.4% and 77.6% ± 5.7%, respectively. Thirty-one of the elephant trunk patients (67%) subsequently underwent second-stage completion procedures, 5 (16%) of them endovascular. Conclusions Early results of aortic arch replacement by the Y-graft technique compare favorably with those of traditional approaches. The technique enables effective delivery of antegrade cerebral perfusion during complex arch procedures and incurs only a low risk of neurologic sequelae.

Objective We attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. Methods We performed multivariable analysis using 16 variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. Results Operative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group ( P = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional [5.5%] vs 4 hybrid [8.9%]; P = .32), and 2 patients (both traditional) had permanent paraplegia ( P = 1.00). The hybrid group had more total neurologic events ( P = .051) but not more permanent strokes ( P = .32). Prior cardiac disease unrelated to the aorta ( P = .0033) and congestive heart failure ( P = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke ( P = .032), as did previous cerebrovascular disease ( P = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke ( P = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference ( P = .14). Conclusions Among contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.

In patients with Marfan syndrome (MFS), distal aortic dissection can necessitate thoracoabdominal aortic aneurysm (TAAA) repair in survivors of acute DeBakey type I dissection and those with DeBakey type III dissection. We examined outcomes of surgical repair of TAAA in patients with MFS with distal aortic dissection.Data were analyzed for 127 consecutive TAAA repairs performed between January 2004 and June 2014 in patients with MFS and distal aortic dissection-DeBakey types I (n = 73) and III (n = 54). The median time from dissection onset to TAAA repair was 5.2 years (interquartile range [IQR]: 2.1 to 9.8 years) for the overall group and was longer in patients with DeBakey I (6.5 years, IQR: 3.5 to 13.9 years) than patients with DeBakey III (2.9 years, IQR: 0.6 to 6.0 years, p0.001). Eleven patients (9%) had acute or subacute dissection at the time of repair. Sixty-six patients (52%) underwent Crawford extent II TAAA repair. A composite end point, adverse event, was defined as operative death or permanent stroke, renal failure, paraplegia, or paraparesis.Eight patients had adverse events (6%), including 5 operative deaths (4%). There was no permanent stroke and 1 case each of permanent paraplegia and paraparesis. At discharge, 2 early survivors (2%) had renal failure. Extent II repairs did not have substantially different outcomes from other repairs.In these patients with MFS with aortic dissection, open TAAA repair incurred reasonable operative risk, but improvements are needed to reduce rates of renal failure. Extent II TAAA repair does not appear to increase operative risk in patients with MFS.

Women fare worse than men after many cardiovascular operations, including coronary artery bypass grafting and valve surgery. We sought to determine whether sex affects outcomes after open thoracoabdominal aortic aneurysm repair.We evaluated data on 3353 consecutive patients (1281 women, 38.2%) who underwent open thoracoabdominal aortic aneurysm repair between October 1986 and July 2015. We compared preoperative characteristics, surgical variables, and outcomes between men and women in the overall group. A propensity-matching analysis was performed to adjust for preoperative and intraoperative differences. A multivariable analysis was conducted to identify predictors of poor outcomes using relevant preoperative and intraoperative factors.Men had a significantly higher prevalence of comorbid conditions, including coronary artery disease, and presented more often with dissection; women were slightly older than men (median age, 69 [62-74] years vs 67 [57-73] years; P .001) and more often symptomatic. Men underwent extent II and IV repairs more often, whereas women more often had extent I and III repairs. The propensity analysis resulted in 958 matched pairs. Overall, women and men had similar early mortality (7.9% vs 7.2%, P = .5) and adverse event rates (14.8% vs 14.1%, P = .6), which were similar in propensity-matched groups. Multivariable analysis showed that predictors of operative death and adverse event differed between the sexes. Survival and freedom from repair failure were similar between the overall and matched groups.Men and women who undergo thoracoabdominal aortic aneurysm repair have similar outcomes, but there are important differences in several perioperative factors and predictors of poor outcomes.

We sought to evaluate our contemporary outcomes with open thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians to determine whether open TAAA repair is a viable option, with acceptable risk, in this elderly cohort.We analyzed clinical data from 1267 enrolled patients who underwent open TAAA repair between 2003 and 2013. Eighty-eight patients (7%) were octogenarians (median age, 82 years; range, 80-92 years) and 1179 were 79 years of age or less.Aneurysm rupture was more common in octogenarians (14% vs 4.7%, P = .001), whereas aortic dissections predominated in younger patients (43.9% vs 13%, P .001). Octogenarians had higher rates of visceral-branch endarterectomy/stenting (58% vs 33.5%, P .001), adverse postoperative outcomes (36% vs 15.3%, P .001), operative mortality (26% vs 6.9%, P .001), and prolonged hospital stay (P = .004). Among octogenarians, preoperative aortic dissection was most commonly associated with extent I repair (42% vs10% for other extents, P .001). Extent II repairs most frequently necessitated concomitant visceral-branch procedures and carried the highest risk of mortality (62%). Extent I and III repairs carried intermediate operative risk, and extent IV repairs posed the least risk (11%). Multivariate modeling analysis identified extent II TAAA (P = .001; odds ratio, 11.6), presence of concomitant dissection (P = .02; odds ratio, 5.6), and aneurysm rupture (P = .02; odds ratio, 5.7) as independent predictors of operative mortality in octogenarians.Open extent II TAAA repair carries significant risk for octogenarians; extent I, III, and IV repairs incur more reasonable postoperative risk. Although TAAA repair should not be denied to octogenarians based solely on age, extensive TAAA repair should be performed with caution.

ObjectivesIn patients with acute DeBakey type I dissection, endovascular repair of the descending thoracic aorta during proximal aortic repair is an increasingly popular approach to preventing distal aortic sequelae and subsequent repair. To better define the risks and outcomes associated with these secondary operations, we examined our contemporary experience with open distal aortic repair in patients with chronic type I aortic dissection.MethodsData were collected between January 2005 and June 2013 regarding 198 consecutive open descending thoracic (n = 27) or thoracoabdominal (n = 171) aortic repairs performed in patients with chronic type I dissection. The median interval between the dissection onset and the subsequent distal operation was 5.0 years (interquartile range, 2.4-10.5 years). A total of 110 repairs (56%) were performed in patients with genetic disorders.ResultsThere were 14 early deaths (7%). Permanent paraplegia developed in 2 patients (1%), 5 patients (3%) had permanent stroke, and 9 patients (5%) had permanent renal failure. Factors associated with early death included greater age (P = .01), chronic obstructive pulmonary disease (P = .01), clamping proximal to the left subclavian artery (P = .004), and use of hypothermic circulatory arrest (P = .002). The use of cold renal perfusion (P

ObjectiveSelective antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) provides cerebral protection during aortic arch surgery. However, the ideal temperature for HCA during ACP remains unknown. Clinical outcomes were compared in patients who underwent moderate (nasopharyngeal temperature, ≥20°C) versus deep (nasopharyngeal temperature