Search

OBJECTIVE: Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair. METHODS: From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database. RESULTS: Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged more than 80 years being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes. CONCLUSIONS: Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.

Various surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum.Between 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed.No mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection.The treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.

Background The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. Methods Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. Results C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. Conclusions New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bail-out maneuvers are sparse in the literature. Herein, we describe seven patients with errant endoprosthesis re-routed with minimally invasive intervention into the true lumen.

Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.

Background Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature. Methods Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed. Results Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P Conclusions ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.

Background Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), there are scant data regarding aortic valve reintervention after initial TAVR. Methods Between 2011 and 2019, 1487 patients underwent a TAVR at the University of Michigan. Among these, 24 (1.6%) patients required an aortic valve reintervention. Additionally, 4 patients who received a TAVR at another institution underwent a valve reintervention at our institution. We retrospectively reviewed these 28 patients. Results The median age was 72 years, 36% were female and 86% of implanted TAVR devices were self-expandable. The leading indications for reintervention were structural valve degeneration (39%) and paravalvular leak (36%). The cumulative incidence of aortic valve reintervention was 4.6% at 8 years. Most (71%) were deemed unsuitable for repeat TAVR because of the need for concurrent cardiac procedures (50%), unfavorable anatomy (45%), or endocarditis (10%). TAVR valve explant was associated with frequent concurrent procedures, consisting of aortic repair (35%), mitral repair/replacement (35%), tricuspid repair (25%), and coronary artery bypass graft (20%). Seventy-one percent of aortic procedures were unplanned but proved necessary because of severe adhesion of the devices to the contacting tissue. There were 3 (15%) in-hospital mortalities in the TAVR valve explant group, whereas there was no mortality in the repeat TAVR group. Conclusions Repeat TAVR procedure was frequently not feasible because of unfavorable anatomy and/or the need for concurrent cardiac procedures. Careful assessment of TAVR procedure repeatability should be weighed at the initial TAVR workup especially in younger patients who are expected to require a valve reintervention.

BACKGROUND. Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS. From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS. Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%) and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .0001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS. Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.

It is controversial if extension of aortic dissection into arch branches should be an indication for replacement of the arch and its branches in acute type A aortic dissection.From 2008 to April 2018, 399 patients underwent open repair for an acute type A aortic dissection, and 190 patients had known innominate and/or left common carotid artery dissection without malperfusion syndrome, including no arch procedure (n = 1)/hemiarch replacement (n = 109) and zone 1/2/3 arch replacement (n = 80) with replacement of 1 to 4 arch branch vessels.Median patient age was 58 years. Preoperative comorbidities were similar between groups, except the hemiarch group had more coronary artery disease (22% vs 3%, P = .0002). Both groups underwent similar aortic root procedures and other concomitant procedures with equivalent cardiopulmonary bypass and aortic cross-clamp times. The zone 1/2/3 group had longer hypothermic circulatory arrest times with greater use of antegrade cerebral perfusion (all P.05). The perioperative and midterm outcomes were similar between the hemiarch and zone 1/2/3 arch groups, including 30-day mortality (7% vs 5%), rates of transient ischemic attack and stroke, incidence rates of reoperation for distal aortic pathology with a mean follow-up time of 3.5 years, and 5-year survival (79% [95% confidence interval, 69%-87%] vs 85% [95% confidence interval, 71%-93%]). However the hemiarch group had a trend of increased cumulative incidence of reoperation (8-year, 23% vs 9%; P = .33).In acute type A aortic dissection, dissection of arch branches alone should not be an indication for routine zone 1/2/3 arch replacement; however zone 1/2/3 arch replacement could be considered to prevent future reoperations in select patients.

Objective To determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). Methods Between 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. Results Compared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P Conclusions BAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.

As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend.001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P.001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P.001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P.001).This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.

Mechanisms contributing to acute kidney injury (AKI) after acute type B aortic dissection (ABAD) include renal malperfusion or underlying renal dysfunction. We characterized AKI after ABAD and evaluated its potential for adverse clinical and aortic outcomes.Between 1995 and 2016, 478 patients without prior dialysis requirement (mean age, 62.1 years; 60.5% male) presented with ABAD. Renal malperfusion was identified in 87 (18.2%). AKI was assessed by the Kidney Disease: Improving Global Outcomes criteria.AKI was seen in 252 (52.7%; stage 1 in 130, stage 2 in 71, stage 3 in 51) and was associated with increased hospitalization (11 days vs 7 days with no AKI, p = 0.008). Independent predictors of AKI included hypertension (odds ratio [OR], 1.69), chronic kidney disease (OR, 3.98), congestive heart failure (OR, 2.36), and visceral (OR, 2.19), renal (OR, 3.18), or limb malperfusion (OR, 2.18, all p0.05). Early mortality occurred in 44 (9.2%) and was independently predicted by stages 2 (OR, 4.38) and 3 AKI (OR, 6.30; both p0.03). The 10-year survival was 46.5%, and independent predictors of late death included aortic diameter (OR, 1.02), chronic obstructive pulmonary disease (OR, 2.02), chronic kidney disease (OR, 3.51), and stages 2 (OR, 2.74) and 3 AKI (OR, 2.26, all p0.01). The 10-year freedom from aortic rupture, repeat dissection, or need for reintervention was 39.8%. Independent predictors of late aortic events included hyperlipidemia (OR, 1.55), diabetes (OR, 0.38), aortic diameter (OR, 1.03), and connective tissue disease (OR, 2.54, all p0.03), but not AKI (p = 0.149).AKI is common after ABAD and increases early mortality and hospital stay and diminishes late survival. Despite its adverse effect on survival, AKI is not associated with late aortic events.

The role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair.Between 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair.Aortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P .001).Stand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.

Introduction: It’s unknown if patients with Bicuspid Aortic Valve (BAV) endocarditis behave differently compared to Tricuspid Aortic Valve (TAV), and if BAV patients are more susceptible to aortic valve endocarditis. Hypothesis: We aimed to distinguish BAV and TAV infectious endocarditis, including the short and long-term outcomes after surgical treatment. Methods: From 1997-2017, 336 patients underwent surgical treatment for aortic valve endocarditis, including 63(19%) BAV, which is 10-20 times higher than the BAV incidence in the general population (1-2%), and 273(81%) TAV endocarditis. Results: Postoperatively, the BAV group had significant shorter intubation time, and less renal failure on dialysis compared to TAV group. There was no compelling difference in postoperative stroke, sepsis, pacemaker requirement and in-hospital mortality [3/65(4.6%) vs. 19/283(6.7%)] between groups. The 10-year survival was better in the BAV group than the TAV group (62% vs. 33%, p=0.004) (Figure). The significant risk factors for late mortality were renal failure on dialysis [hazard ratio (HR)=2], intravenous drug user (HR=2.4), congestive heart failure (HR=1.6), previous coronary artery bypass (HR=1.8) and liver disease (HR=2.4), all p Conclusions: In conclusion, BAV patients have a higher likelihood of infectious endocarditis requiring surgery at a younger age than TAV patients, but similar outcomes. Strong consideration of utilizing prophylactic antibiotics and early surgical treatment for BAV patients, to lower the likelihood of aortic valve endocarditis.

Objective The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis. Methods From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n = 97, 37%) or a stentless valve (n = 168, 63%) with further breakdown into inclusion technique (n = 142, 85%) or total root replacement (n = 26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data. Results The median age of patients was 53 years (43-56) in the stented group and 57 years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups. Conclusions Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P.05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P.05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P.001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, while largely ignored thus far, will be key to the value proposition for payers. METHODS: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n=1,655) or SAVR (33 hospitals, n=4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. RESULTS: Payments (± standard deviation) were higher for TAVR than SAVR ($69,388 ± $22,259 vs. $66,683 ± $27,377, p

Aortoenteric fistulae are life-threatening conditions characterized by abnormal communications between the aorta and gastrointestinal tract. Aortoenteric fistulae may be characterized by the triad of bleeding, abdominal pain, or a pulsatile abdominal mass. Although hemorrhage is the most common presentation, it does not always occur; thus, patients may present with nonspecific symptoms. Computed tomography angiography findings suggestive of aortoenteric fistulae include ectopic gas within or adjacent to the aorta, discontinuity of the aortic wall, bowel wall thickening, and extravasation of contrast into the bowel. Endovascular treatments include retrograde balloon occlusion of the aorta and stent-graft deployment as well as coil, fibrin, and glue embolization of the fistulous tract. This report describes 3 cases of aortoenteric fistulae temporized and treated by interventional radiology and vascular and cardiac surgery at a single institution in an effort to increase awareness of this important clinical condition.

To improve surgical pain control through cryoablation of intercostal nerves and reduce narcotic usage in patients undergoing open thoracic or thoracoabdominal aortic aneurysm (TAA or TAAA) repair. From 2012 to 2018, 117 patients underwent open repair of TAA or TAAA. Of those patients, 25 (21%) received cryoablation (2016-2018) of their intercostal nerves and 92 (79%) did not (2012-2018). The primary outcome was pain scores and narcotic usage from extubation day 1 to 10 or the day of discharge. The median age (57 years), demographics, and preoperative comorbidities were not significantly different between the 2 groups. The cryoablation group had significantly more incidences of thoracoabdominal incisions (52% vs 28%), urgent operations (32% vs 11%), and longer duration of chest tubes compared to the noncryoablation group (all P0.05). T9-T12 intercostal arteries were selectively reimplanted. Left intercostal nerves were cryoablated from T3 to T9 if 2 thoracotomies were used; or 2 intercostal spaces above and below the thoracotomy if 1 thoracotomy was used. There were no significant differences between the noncryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was significantly reduced in the cryoablation group by 28 measured morphine equivalents (equal to four 5 mg Oxycodone)/patient/day in 10 days after extubation, P = 0.005. With cryoablation of intercostal nerves, the postoperative surgical pain was well controlled and narcotic usage was significantly decreased after TAA or TAAA repair. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.

Background: We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Methods: Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Results: Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs . 1%, P

Triggering events for acute aortic dissections are incompletely understood. We sought to investigate whether there is an association between admission for acute type A aortic dissection (ATAAD) to the University of Michigan Medical Center and the reported annual influenza activity by the Michigan Department of Health and Human Services. From 1996–2019 we had 758 patients admitted for ATAAD with 3.1 admissions per month during November-March and 2.5 admissions per month during April-October (p = 0.01). Influenza reporting data by the Michigan Department of Health and Human Services became available in 2009. ATAAD admissions for the period 2009–2019 (n = 455) were 4.8 cases/month during peak influenza months compared to 3.5 cases/month during non-peak influenza months (p = 0.001). ATAAD patients admitted during influenza season had increased in-hospital mortality (11.0% vs. 5.8%, p = 0.024) and increased 30-day mortality (9.7 vs. 5.4%, p = 0.048). The results point to higher admission rates for ATAAD during months with above average influenza rates. Future studies need to investigate whether influenza virus infection affects susceptibility for aortic dissection, and whether this risk can be attenuated with the annual influenza vaccine in this patient population.

Objectives To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically. Methods From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data. Results Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%). Conclusions Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.

Background The use of transcatheter aortic valve replacement (TAVR) has grown rapidly. The purpose of this study was to assess whether hospital market competition was associated with the use of TAVR. Methods We used 5 Healthcare Cost and Utilization Project state inpatient databases (Arizona, Florida, Iowa, Massachusetts, Washington) to identify patients undergoing TAVR (n = 5563) or surgical aortic valve replacement (n = 30,672) across 154 hospitals from 2011 to 2014. Using the Herfindahl-Hirschman Index (HHI) to calculate market competition, hospitals were categorized into commonly used categories of low (HHI >0.25), moderate (HHI 0.15-0.25), and high (HHI Results After adjustment, patients treated at high-competition hospitals had higher odds of receiving TAVR, relative to patients at low-competition hospitals (adjusted odds ratio [ORadj], 5.31; 95% confidence interval [CI], 2.10-13.4). TAVR use increased each year (ORadj, 1.73; 95% CI, 1.38-2.17) but was similar across HHI categories. Competition was not associated with in-hospital mortality or length of stay. Patients at high-competition hospitals were more likely to be discharged home (ORadj, 2.39; 95% CI, 1.23-4.66) compared with patients at low-competition hospitals. Conclusions Market competition was positively associated with a hospital's adoption of TAVR. Future studies should further examine the impact of competition on quality and appropriateness.

Objective The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion. Methods From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143). Results The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30). Conclusions Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Objective To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair. Methods From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database. Results The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46. Conclusions In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.

The study objective was to determine the optimal treatment for patients with acute type A aortic dissection and previous cardiac surgery.A total of 545 patients underwent open repair of an acute type A aortic dissection (July 1996 to January 2017), including patients with (n = 50) and without previous cardiac surgery (n = 495). Data were collected through the University of Michigan Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.Compared with patients without previous cardiac surgery, patients with previous cardiac surgery were older (62 vs 59 years, P = .24) and had significantly more coronary artery disease (48% vs 14%, P .001), peripheral arterial disease (24% vs 11%, P = .01), connective tissue disorders (15% vs 4.5%, P = .004), and acute renal failure on presentation (28% vs 15%, P = .02); and significantly more concomitant mitral or tricuspid procedures, longer cardiopulmonary bypass time, and more intraoperative blood transfusions. There were no statistically significant differences in postoperative major complications between previous cardiac surgery and no previous cardiac surgery groups, including stroke, myocardial infarction, new-onset dialysis, and 30-day mortality (8.9% vs 6.3%, P = .55). Multivariable logistic model showed the significant risk factors for operative mortality were cardiogenic shock (odds ratio, 9.6; P .0001) and male gender (odds ratio, 3.7; P = .006). The 5- and 10-year unadjusted survivals were significantly lower in the previous cardiac surgery group compared with the no previous cardiac surgery group (66% vs 80% and 42% vs 66%, respectively, P = .02). However, previous cardiac surgery itself was not a significant risk factor for operative mortality (odds ratio, 1.6; P = .36) or all-time mortality (hazard ratio, 1.3; P = .33).Acute type A aortic dissection in patients with previous cardiac surgery can be repaired with favorable operative mortality and long-term survival, and should be treated surgically.

Objective The study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection. Methods From 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology. Results Patients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group. Conclusions Aortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.

Background: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. Methods: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an “upfront OR for every patient” approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). Results: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P P =0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5–29; P =0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P ≤0.03). Conclusions: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Objective To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD). Methods From 1996 to 2017, we compared outcomes of hemiarch (n = 322) versus aggressive arch replacements (zones 2 and 3 arch replacement with implantation of 2-4 arch branches, n = 150) in ATAAD. Indications for aggressive arch were arch aneurysm >4 cm or intimal tear in the aortic arch that was not resectable by hemiarch replacement, or dissection of arch branches with malperfusion. Results Patients in the aggressive arch group were significantly younger (mean age: 57 vs 61 years old) and had significantly longer hypothermic circulatory arrest, cardiopulmonary bypass, and aortic crossclamp times. There were no significant differences in perioperative outcomes between hemiarch and aggressive arch groups, including 30-day mortality (5.3% vs 7.3%, P = .38) and postoperative stroke rate (7% vs 7%, P = .96). Over 15 years, Kaplan–Meier survival was similar between hemiarch and aggressive arch groups (log-rank P = .55, 10-year survival 70% vs 72%). Given death as a competing factor, incidence rates of reoperation over 15 years (2.1% vs 2.0% per year, P = 1) and 10-year cumulative incidence of reoperation (14% vs 12%, P = .89) for arch and distal aorta pathology were similar between the 2 groups. Conclusions Both hemiarch and aggressive arch replacement are appropriate approaches for select patients with ATAAD. Aggressive arch replacement should be considered for an arch aneurysm >4 cm or an intimal tear at the arch unable to be resected by hemiarch replacement, or dissection of the arch branches with malperfusion.

Objective To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS). Methods Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n = 419) served as controls. Results In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008-2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P = .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P = .016), and serum lactate ≥6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P = .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P = .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome. Conclusions In patients with acute type A aortic dissection with mesMPS, endovascular fenestration/stenting, and delayed open aortic repair achieved favorable short- and long-term outcomes. Surgeons should consider correcting mesenteric malperfusion before undertaking open aortic repair in patients with mesMPS, especially those with acute stroke, gross bowel necrosis at laparotomy, or serum lactate ≥6 mmol/L.

The aim was to compare computed tomography (CT) features in acute and chronic aortic dissections (AADs and CADs) and determine if a certain combination of imaging features was reliably predictive of the acute versus chronic nature of disease in individual patients. Consecutive patients with aortic dissection and a chest CT scan were identified, and 120 CT scans corresponding to 105 patients were reviewed for a variety of imaging features. Statistical tests assessed for differences in the frequency of these features. A predictive model was created and tested on an additional 120 CT scans from 115 patients. Statistically significant features of AAD included periaortic confluent soft tissue opacity, curved dissection flap, and highly mobile dissection flap, and features of CAD included thick dissection flap, false lumen (FL) outer wall calcification, FL thrombus, dilated FL, and tear edges curling into the FL. The model predicted the chronicity of a dissection with an area under the curve of 0.98 (CI 0.98-1.00). AADs and CADs demonstrated significantly different CT imaging features.

Background Surgery in patients with Kommerell diverticulum (KD) is controversial. Although the presence of symptoms is an accepted indication, the KD itself may be a risk factor for dissection and rupture, although size criteria for operation are undefined. Methods A retrospective review of 19 adult patients who underwent surgical treatment of KD between March 2004 and June 2013 was performed. Mean age was 48 years (range, 32 to 68 years). Fifteen patients were female, 15 were symptomatic, and 13 had a right aortic arch. Sixteen patients with aberrant subclavian artery underwent a two-stage procedure involving subclavian–common carotid artery transposition or bypass followed by aortic resection, including origin of the KD, with interposition graft reconstruction. Aortic resection was performed with left heart bypass (n = 10) or deep hypothermic circulatory arrest (n = 9). Results There were no deaths or strokes. Complications after aberrant subclavian artery revascularization were transient ptosis (n = 3), graft occlusion (n = 1), recurrent laryngeal nerve injury (n = 1),phrenic nerve injury (n = 1), and reintubation (n = 1). Complications after aortic resection were intraoperative type A dissection (n = 1), phrenic nerve injury (n = 1), chylothorax (n = 1), and transient neurologic dysfunction (n = 1). Mean hospital stay after aberrant subclavian artery revascularization was 2 ± 2 days and after aortic resection, 6.4 ± 2.4 days. Of 18 available pathology specimens, all 18 showed medial degeneration. Mean follow-up was 3.3 years. Conclusions This is the largest reported single-center experience with the surgical management of KD in adults, verifying its safety and efficacy. The high percentage of KD with medial degeneration suggests asymptomatic patients with an enlarged KD also may benefit from resection.

Background— Acute coronary syndrome is the leading cause of mortality worldwide. However, treatment of acute coronary occlusion inevitably results in ischemia-reperfusion injury. Circulating natural IgM has been shown to play a significant role in mouse models of ischemia-reperfusion injury. A highly conserved self-antigen, nonmuscle myosin heavy chain II, has been identified as a target of pathogenic IgM. We hypothesized that a monoclonal antibody (m21G6) directed against nonmuscle myosin heavy chain II may inhibit IgM binding and reduce injury in a preclinical model of myocardial infarction. Thus, our objective was to evaluate the efficacy of intravenous m21G6 treatment in limiting infarct expansion, troponin release, and left ventricular dysfunction in a swine myocardial infarction model. Methods and Results— Massachusetts General Hospital miniature swine underwent occlusion of the midleft anterior descending coronary artery for 60 minutes, followed by 1 hour, 5-day, or 21-day reperfusion. Specificity and localization of m21G6 to injured myocardium were confirmed using fluorescently labeled m21G6. Treatment with m21G6 before reperfusion resulted in a 49% reduction in infarct size ( P P P Conclusions— Treatment with m21G6 significantly reduced infarct size and troponin-T release, and led to marked preservation of cardiac function in our study. Overall, these findings suggest that pathogenic IgM blockade represents a valid therapeutic strategy in mitigating myocardial ischemia-reperfusion injury.

Objective Structural changes within the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B thoracic aortic dissections (ABAD) remain unknown. This study reviewed and analyzed morphologic changes, volumetric data, and clinical outcomes of patients with ABAD. Methods Forty-one consecutive patients with ABAD, all with the volumetric analysis of aortic luminal changes and ≥1 year of follow-up, were treated as a part of a single-center U.S. Food and Drug Administration (FDA)-approved investigational device exemption (IDE) trial from 2002 to 2009. Indications were malperfusion in 17, rupture in 12, chest pain in 6, acute enlargement in 4, and uncontrolled hypertension in 2. Duration of symptoms was ≤14 days. Three-dimensional M2S computed tomography reconstructions (Medical MetRx Solutions, West Lebanon, NH) were analyzed for aortic volume and diameter changes, regression of the false lumen, and expansion of the true lumen. Results Emergent surgery was required in 17 (42%) patients, excluding one death at induction. Procedural success rate was 92.5%. The 30-day mortality was 4.9% for malperfusion, 4.9% for rupture, and 0% for all others, with late mortality of 0%, 9.8%, and 7.3%, respectively. Mean follow-up was 12.4 months. Permanent stroke and paraplegia rates were 4.9% (n = 2) and 0%. Ten of 12 secondary interventions were performed for 6 proximal endoleaks, 1 distal cuff endoleak, and 3 distal reperfusions. For the 33 patients without endoleaks, the true lumen volume increased by 29% at 1 month, 51% at 1 year, and 80% at 5 years. Volume regression of the false lumen was 69%, 76%, and 86%, respectively. The true lumen volume did not change at 1 month or 1 year in the endoleak group (n = 7) but increased 50% at 2 years after secondary intervention. A 10% reduction of abdominal aortic volume distal to endograft occurred over 5 years in the absence of endoleaks. Conclusions TEVAR offers a promising solution to patients with ABAD. Aortic morphologic changes occur shortly after TEVAR and remain predictable up to 5 years with continuous expansion of the true lumen and regression of the false lumen. A lack of increase in the true lumen volume is associated with endoleaks or distal reperfusion.

The transplantation of allogeneic organs triggers a massive inflammatory immune response mediated by recipient T lymphocytes recognizing donor major histocompatibility complex (MHC) molecules. Allorecognition takes place primarily in the recipient’s secondary lymphoid organs where T cells interact with intact allo-MHC molecules present on donor dendritic cells (direct allorecognition) and with donor MHC peptides processed and presented by recipient antigen presenting cells (indirect allorecognition) (1). In addition, minor histocompatibility antigens, defined as peptides derived from non-MHC donor polymorphic proteins, are presented directly or indirectly, and can trigger an alloimmune response (2). The activation of alloreactive CD4+ and CD8+ T cells triggers a cascade of events including cytotoxic T-cell differentiation, delayed type hypersensitivity (DTH) reactions, and anti-donor antibody production that lead to the rejection of allografts. On the other hand, the involvement of tissue-specific antigens in anti-graft immunity has long been postulated (3). Although some of these antigens have been identified, little is known regarding their contribution to the rejection of allografts. Recent studies in our laboratory and others’ have demonstrated that rodents receiving allogeneic heart or lung transplants mount an autoimmune response to graft tissue-specific antigens (4–6). In a mouse heart transplant model, we have reported that the T-cell response to donor MHC class I molecules is followed by an autoimmune response to cardiac myosin (CM), a contractile protein expressed by cardiomyocytes (4). CM also represents the target autoantigen in experimental autoimmune myocarditis (EAM), a mouse model of autoimmune heart disease (7). These findings suggest that anti-CM immunity may cause damage to the transplanted heart, thereby contributing to its rejection by the host. There is a report supporting this view that induction of an autoimmune response to CM in mouse recipients before transplantation accelerates the rejection of allogeneic heart transplants (4). In this case, the anti-CM autoimmune response was mediated by activated MHC class II-restricted CM-specific CD4+ TH1 cells (4). In addition, high titers of IgG1 anti-CM autoantibodies were detected in the serum of transplanted mice (4). Most importantly, tolerance induction to CM and collagen type V has been shown to significantly prolong the survival of heart and lung transplants, respectively (8, 9). Finally, several studies have provided evidence suggesting the relevance of CM autoimmunity in clinical cardiac transplantation (10–13). Collectively, these studies suggest that secondary immunity to tissue-specific antigens may represent an essential component of allograft rejection. However, the actual relevance of this phenomenon to the rejection of minor antigen-mismatched allografts in a large-animal model remains to be established. In this study, we investigated the influence of CM autoimmunity on the rejection of minor antigen-mismatched cardiac allografts performed in a swine model. We observed that the induction of an anti-CM response led to the rejection of minor antigen-mismatched cardiac allografts. The implications of these findings for the design of novel diagnostic tools and therapies in transplantation are discussed.

In this small series, Hosoyama and colleagues 1 have described their use of negative pressure wound therapy and delayed sternal closure after resection and replacement of infected ascending aortic grafts to decrease the risk of recurrent infection. They performed daily dressing changes at the intensive care unit (ICU) bedside for 9 days, without hemorrhagic complications. All 4 patients survived, with follow-up ranging from 1 to 5 years. For 1 patient, they were evenable toeradicateCandidainfection,a difficult organism to treat in the mediastinum. The mortality from ascending aortic graft infection can be as high as 35%. Approaches to this difficult problem have led to variable success in treating the infection without significant morbidity and mortality, and more importantly, preventing recurrent infection. Antibiotic therapy alone is rarely successful without other measures to debride infected tissue. Mediastinal debridement without graft resection, followed by coverage with an omental or muscle flap, avoids the morbidity of graft replacement, but patients may need to continue lifelong, suppression antibiotic therapy for the remaining graft itself. Replacing infected Dacron graft with new Dacron or homograft may be more effective, but this is a fairly major operation, especially in older patients with multiple comorbidities, complications from sepsis, and decreased nutritional reserve. This group’s approach, of performing graft resection and replacement, using omental coverage, leaving the chest open, performing daily dressing changes in the ICU until cultures cleared, and delaying sternal closure, was aggressive but successful. The materials used are available in any hospital, and although the process is labor intensive, performing dressing changes in the ICU obviates the need for daily transport to the operating room and the use of operating room time.

Purpose We aim to assess the effect of regional block anesthesia on vein diameter, type of AVF placement, and fistula size and flow volume. Methods 30 patients presenting for AV access procedures were followed prospectively. Vein diameters via venous ultrasound and planned location for AV access were documented. Supraclavicular brachial plexus block was followed by repeat ultrasound and alterations in operative plan were noted. Patients returned to clinic for duplex ultrasound assessment. Results Average increase from baseline vein diameter with regional block was most pronounced in the lower cephalic (34%), upper cephalic (24.2%), and basilic veins (31.3%) and less in the brachial vein (8.7%). Type of AVF was modified following regional block in 14%. The rate of native AVF placement improved from 89% to 93% with regional block. Twenty-three AVF patients were available for follow-up (mean 24 weeks). Average fistula size was 7.9 mm (CI 6.9–8.9) and all patent fistulas developed flow volume >600 mL/min. Primary patency was attained in 83%. One thrombosis occurred after a basilic artery was lacerated during dialysis access. The average fistula increased 0.33 cm from post-block diameter (SD 0.22, PConclusions Vein diameter increases significantly in the basilic and cephalic veins following regional block anesthesia and may improve the rate of native fistula placement. Propensity to dilate after regional block anesthesia does not predict size of the fistula.

Traumatic rupture of the aorta in the rare setting of the aberrant right subclavian artery (ARSA) requires special consideration to prevent the occurrence of a devastating posterior cerebral circulation stroke. We present three cases managed by using an endovascular approach, with a discussion of important preoperative and operative issues. Three patients involved in motor vehicle collisions with multiple injuries were managed at two institutions. Computed tomography revealed transection of the aorta with incidental ARSA. All three cases were managed with a different approach. One patient did not undergo a preoperative bypass because imaging confirmed an adequate landing zone distal to the origin of the left subclavian artery. Two patients received preoperative right carotid-to-subclavian bypass for anticipated endograft coverage of both subclavian arteries to preserve single vertebral arterial flow. In one patient, an endovascular occlusion device was deployed in the ARSA before aortic endograft deployment. In the other, ARSA occlusion was performed 4 days later for a persistent type II endoleak. The patient who underwent bypass and preoperative ARSA occlusion suffered a fatal posterior circulation stroke shortly after surgery. The other two patients had no procedural complications and have not required any reinterventions at follow-up after 2 and 5 years. One patient is still undergoing rehabilitation after 5 years of follow-up for traumatic brain injury unrelated to the endograft repair. Although the incidence of ARSA is very low, preoperative imaging and assessment of cerebral blood flow are critical to prevent a perioperative stroke. Revascularization, if required to achieve a secure proximal landing zone, must be performed before endograft deployment. Bilateral subclavian revascularization is indicated if anomalies of the cerebral circulation are present.

Inadequately regulated proteolytic activity is responsible for the chronic lung tissue degeneration and irreversible loss of pulmonary function that define emphysema. In this study, we show that an inhaled broad-spectrum matrix metalloprotease inhibitor, ilomastat, can provide protection against the development of emphysema in cigarette smoke-treated mice. Control animals were exposed to daily cigarette smoke for 6 months. As has been reported previously, cigarette smoke was seen to increase significantly the recruitment of macrophages into the lungs of these animals, leading to concomitant alveolar airspace enlargement and emphysema. In animals treated daily with nebulized ilomastat for 6 months, lung macrophage levels were greatly reduced, and neutrophil accumulation was also inhibited. Corresponding reductions in airspace enlargement of up to 96% were observed. These striking observations suggest that delivery of ilomastat directly into the lungs of smoke-treated mice can not only inhibit lung tissue damage mediated by metalloproteases, but may also reduce that component of tissue degeneration mediated by excess neutrophil-derived products. Our data also suggest that the matrix metalloprotease inhibitors may represent a class of drugs that, when delivered by inhalation, could be used practically to treat cigarette smoking-related chronic obstructive pulmonary disease by modifying the course of the disease.