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OBJECTIVES Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients. METHODS This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis. RESULTS In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31–3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22–7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76–2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80–3.66; P = 0.14). CONCLUSIONS In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.

Background The aim of this study is to test if the newly proposed 45 mm size criterion for ascending aortic replacement (AAR) in bicuspid aortic valve (BAV) patients undergoing aortic valve replacement (AVR) is predictive of improved early outcomes. Methods Data of 306 BAV patients with an aortic diameter of ≥45 mm undergoing AVR alone or with AAR were retrospectively analyzed. Patients were divided into groups of AVR + AAR (n = 220) and AVR only (n = 86) based on if surgery was performed according to the 45 mm criterion. End point was early adverse events, including 30-day and in-hospital mortality, cardiac events, acute renal failure, stroke, and reoperation for bleeding. Cox regression was used to assess if conformance to 45 mm criterion could predict fewer early adverse events. Results AVR + AAR group had significantly higher postoperative left ventricular ejection fraction (LVEF) (0.59 ± 0.09 vs. 0.55 ± 0.11, p = 0.006) and longer cardiopulmonary bypass (CPB) time (128 vs. 111 minutes, p = 0.002). Early adverse events occurred in 45 patients (14.7%), which was more prevalent in the AVR-only group (22.1% vs. 11.8%, p = 0.020). Conformance to the 45 mm criterion predicted lower rate of early adverse events (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.28–0.98, p = 0.042). After adjustment for gender, age, AAo diameter, sinuses of Valsalva diameter, preoperative LVEF, Sievers subtypes, BAV valvulopathy, and CPB and cross-clamp times, conformance to the 45 mm size criterion still predicted lower incidence of early adverse events (HR: 0.37, 95% CI: 0.15–0.90, p = 0.028). Conclusions This study shows that conformance to 45 mm size cutoff for preemptive AAR during aortic valve replacement in patients with BAV was not associated with increased risk for adverse events and may improve early surgical outcomes.

The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P.01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = -0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.

Background: Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS. Methods: The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed. Results: Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death. Conclusions: This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.

OBJECTIVES Pregnancy-related aortic dissection (AoD) in Marfan syndrome is a lethal catastrophe. Due to its rarity and limited clinical experience, there is no consensus regarding the optimal management strategy. We seek to present our 21-year experience in such patients , focusing on management strategies and early and late outcomes. METHODS Between 1998 and 2019, we managed 30 pregnant women with Marfan syndrome (mean age 30.7 ± 4.3 years) who sustained AoD at a mean of 28.3 ± 8.8 weeks of gestation (GWs). AoD was acute in 21 (70%), type A (TAAD) in 24 (80%) and type B (TBAD) in 6 (20%). Fourteen TAADs (58.3%, 14/24) and 2 TBADs (33.3%, 2/6) occurred in the third trimester or postpartum. The maximal aortic size was < 45 mm in 26.7% (8/30; 3 TAADs, 5 TBADs). Management strategy was based on the types of dissection and GWs (i.e. surgical versus medical treatment, surgery or delivery first). RESULTS TAADs were treated medically in 1 and surgically in 23. The timing of delivery and surgery were caesarean first at 35.4 ± 6.1 GWs in 7 (29.2%), followed by surgery after mean 46 days; single-stage C-section and surgery at 32.0 ± 5.0 GWs in 10 (41.7%); and surgery first at 18.0 ± 5.8 GWs in 6 (25%), followed by C-section after 20 days. Maternal and foetal mortality were 28.6% (2/7) and 14.3% (1/7), 10.0% (1/10) and 20.0% (2/10) and 16.7% (1/6) and 83.3% (5/6), respectively. Five TBADs (83.3%) were managed with C-section followed by surgery in 2 and medical treatment in 3. The respective maternal and foetal mortality were 50% (1/2) and 100% (2/2) and 33.3% (1/3) and 33.3% (1/3), respectively. One TBAD was managed surgically first followed by C-section, resulting in maternal survival and foetal death. Follow-up was complete in 95.8% (23/24) at 3.7 ± 2.9 years. Four late deaths occurred and reoperation was performed in 1 patient. Maternal and foetal survival were 64.3% and 54.1% at 6 years, respectively. CONCLUSIONS Management of AoD in pregnant women with Marfan syndrome should be based on types of dissection (surgical versus medical) and gestational age (delivery or surgery first), which largely determine maternal and foetal survival. Aortic repair should be considered prior to conception in women with Marfan syndrome even at diameters smaller than recommended by current guidelines.

Background Although obstructive sleep apnoea (OSA) is prevalent among patients with aortic dissection, its prognostic impact is not yet determined in patients undergoing major vascular surgery. We aimed to investigate the association of OSA with hypoxaemia and with prolonged intensive care unit (ICU) stay after type A aortic dissection (TAAD) repair. Methods This retrospective study continuously enrolled 83 patients who underwent TAAD repair from January 1 to December 31, 2018. OSA was diagnosed by sleep test and defined as an apnoea hypopnea index (AHI) of ≥ 15/h, while an AHI of > 30/h was defined severe OSA. Hypoxaemia was defined as an oxygenation index (OI) of 72 h. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of postoperative OI for prolonged ICU stay. Multivariate logistic regression was performed to assess the association of OSA with hypoxaemia and prolonged ICU stay. Results A total of 41 (49.4%) patients were diagnosed with OSA using the sleep test. Hypoxaemia occurred postoperatively in 56 patients (67.5%). Postoperatively hypoxaemia developed mostly in patients with OSA (52.4% vs. 83.0%, p = 0.003), and particularly in those with severe OSA (52.4% vs. 90.5%, p = 0.003). The postoperative OI could fairly predict a prolonged ICU stay (area under the receiver-operating characteristic curve, 0.72; 95% confidence intervals [CI] 0.60–0.84; p = 0.002). Severe OSA was associated with both postoperative hypoxaemia (odds ratio [OR] 6.65; 95% CI 1.56–46.26, p = 0.008) and prolonged ICU stay (OR 5.58; 95% CI 1.54–20.24, p = 0.009). Conclusions OSA was common in patients with TAAD. Severe OSA was associated with postoperative hypoxaemia and prolonged ICU stay following TAAD repair.

BACKGROUND: The blood pressure of cervical spondylosis (CS) patients with hypertension often returns to normal after decompressive cervical surgery (DCS). However, the effect of DCS on the blood pressure of patients with CS has not been rigorously studied. METHODS: We recruited 50 consecutive CS patients with hypertension from 2014–2017 and investigated the changes in blood pressure after DCS using a time series design. Ambulatory blood pressure monitoring (ABPM) was performed at 3 and 0 days before DCS and at 30 and 90 days after DCS. The primary outcome was mean 24-hour systolic blood pressure (SBP). Secondary outcomes included mean 24-hour diastolic blood pressure (DBP), office blood pressure, and the percentage of patients on antihypertensive medication. Paired t test was used for assessing the changes in blood pressure over time and a McNemar test was used for comparison among different medication groups. RESULTS: The mean 24-hour SBP did not vary significantly among 4 time points (134.5 ± 14.7, 132.8 ± 14.7, 131.5 ± 13.3, and 133.2 ± 14.6, respectively; P = .42). The mean 24-hour DBP showed a similar trend. However, mean office SBP/DBP decreased significantly from 142.5/82.0 mm Hg before surgery to 127.3/76.6 mm Hg after surgery (both P < .01). The corresponding percentage of patients on antihypertensive medication decreased significantly, from 84% to 54% (P < .01). CONCLUSIONS: This study confirmed previous findings of reduction in office blood pressure associated with DCS among CS patients with hypertension. However, this was not confirmed by multiple-time series of 24-hour ABPM. LEVEL OF EVIDENCE: 3.

Summary: Objective: The aim of our study was to assess how much renal malperfusion increases the risk of early and late mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair. Methods: This study included 218 patients with ATAAD undergoing surgical repair using the total arch replacement and frozen elephant trunk technique. Mean age was 47.8 ± 10.7 years and 170 were male (78.0%). Based on clinical symptoms and computed tomographic angiography (CTA) findings, 48 patients were diagnosed with preoperative renal malperfusion (22.0%). Clinical data were compared between two groups. The impact of renal malperfusion on operative and late mortality were evaluated with Cox regression. Results: Patients with renal malperfusion experienced significantly higher incidences of persistent postoperative acute kidney injury (AKI; 10/48, 20.8% vs 7/170, 4.1%; p

Graft aneurysm after ascending aorta to abdominal aorta bypass is a rare complication of repair of coarctation of the aorta. We present a case of an aneurysm measuring 75 mm in diameter at the midportion of the prosthetic graft in a 33-year-old man. To prevent aneurysm rupture, redo ascending-to-abdominal aortic bypass was performed through an upper ministernotomy and upper midline laparotomy. No postoperative complications occurred. The patient was successfully discharged on postoperative day 6. Although ascending-to-abdominal aortic bypass can achieve long-term patency, the prosthetic graft still has the rare risk of aneurysm formation, as highlighted in this case. Early diagnosis and timely management of this rare complication are essential in preventing aneurysm rupture. Keywords: Aorta/abdominal, Coarctation, Surgery, Aneurysm, Blood vessel prosthesis, Extra-anatomic bypass

Objective The risk of rupture and dissection in ascending thoracic aortic aneurysms increases as the aortic diameter exceeds 5 cm. This study evaluates the clinical effectiveness of a specific algorithm based on size and symptoms for preemptive surgery to prevent complications. Methods A total of 781 patients with nondissecting ascending thoracic aortic aneurysms who presented electively for evaluation to our institution from 2011 to 2017 were triaged to surgery (n = 607, 77%) or medical observation (n = 181, 24%) based on a specific algorithm: surgery for large (>5 cm) or symptomatic aneurysms. A total of 309 of 781 patients did not undergo surgery. Of these, 128 (16%) had been triaged to prompt repair but did not undergo surgery for a variety of reasons ("surgery noncompliant and overwhelming comorbidities" group). Another 181 patients (24%) were triaged to medical management ("medical" group). Results In the "surgery noncompliant and overwhelming comorbidities" versus the "medical" group, mean aortic diameters were 5 ± 0.5 cm versus 4.45 ± 0.4 cm and aortic events (rupture/dissection) occurred in 17 patients (13.3%) versus 3 patients (1.7%), respectively (P Conclusions Patients with ascending thoracic aortic aneurysms who did not follow surgical recommendations experienced substantially worse outcomes compared with medically triaged candidates. The specific algorithm based on size and symptoms functioned effectively in the clinical setting, correctly identifying both at-risk and safe patients.

Background: Abnormal sleep duration predicts depression and anxiety. We seek to evaluate the impact of sleep duration before stroke on the occurrence of depression and anxiety at 3 months after acute ischemic stroke (AIS).Methods: Nationally representative samples from the Third China National Stroke Registry were used to examine cognition and sleep impairment after AIS (CNSR-III-ICONS). Based on baseline sleep duration before onset of stroke as measured by using the Pittsburgh Sleep Quality Index (PSQI), 1,446 patients were divided into four groups: >7, 6–7, 5–6, and Results: The incidences of PSA and PSD were 11.2 and 17.6% at 3 months, respectively. Compared to a sleep duration of >7 h, 5–6 h, and P < 0.01 and OR, 3.41; 95% CI, 1.94–6.04; P < 0.01) and PSD (OR, 1.47; 95% CI, 1.00–2.17; P = 0.04 and OR, 3.05; 95% CI, 1.85–5.02; P < 0.01), while 6–7 h of sleep was associated with neither PSA (OR, 1.09; 95% CI, 0.71–1.67; P = 0.68) nor PSD (OR, 0.92; 95% CI, 0.64–1.30; P = 0.64). In interaction analysis, the impact of sleep duration on PSA and PSD was not affected by gender (P = 0.68 and P = 0.29, respectively).Conclusions: Sleep duration of shorter than 6 h was predictive of anxiety and depression after ischemic stroke.

Background : Although obstructive sleep apnoea (OSA) is prevalent among patients with aortic dissection, its prognostic impact is not yet determined in patients undergoing major vascular surgery. We aimed to investigate the association of OSA with hypoxemia and with prolonged intensive care unit (ICU) stay after type A aortic dissection (TAAD) repair. Methods: This study enrolled 83 patients who underwent TAAD repair. OSA diagnosis was confirmed by a preoperative STOP-BANG questionnaire and a sleep test performed within 90 days postoperatively. OSA was defined as an apnoea hypopnea index (AHI) of ≥15/h, while an AHI of >30/h was defined severe OSA. Hypoxemia was defined as an oxygenation index (OI) of 72 h. Multivariable analysis was performed to assess the association of OSA with hypoxemia and prolonged ICU stay. Results: OSA was diagnosed in 41 patients (49.4%), which was consistent with the detection by using a preoperative STOP-BANG score of ≥4 (Kappa=0.424, PConclusions: OSA was common in patients with TAAD. Severe OSA was predictive of hypoxemia and prolonged ICU stay after TAAD repair. The STOP-BANG score may offer diagnostic clues to OSA in patients with TAAD.

Background Diabetic peripheral neuropathy (DPN) is one of the most common and complex chronic complications of diabetes, but it is clinically lacking effective means for early diagnosis and early treatment. MicroRNA, in the occurrence and development of the disease, has an important regulatory role. Its role in diabetes has been reported more. However, specific research on microRNA in DPN is rare. Methods Based on the results of bioinformatics screening, miR-377 and miR-216a, their respective target molecules growth association protein 43 (GAP-43) and angiopoietin-like 4 protein (ANGPTL4), and related pathways peroxisome proliferator activated receptor gamma (PPARG) and chemerin were tested by RT-qPCR and ELISA in blood samples of DPN to analyze the correlation between these differentially expressed molecules and clinico-pathological factors of DPN. Results In this study, we found that miR-377, miR-216a, GAP-43, ANGPTL4, and PPARG were significantly differentially expressed genes for DPN. The correlation analysis showed that they were closely related to the clinical indicators of DPN suggesting that they may be involved in the development of DPN. In addition, receiver operating characteristic (ROC) curves generated for miR216a, miR377, ANGPTL4, GAP43, PPARG revealed that they can be used as new molecular diagnostic markers of DPN. Conclusions miR-216a, miR-377, ANGPTL4, GAP-43, and PPARG could potentially be biomarkers of DPN.

OBJECTIVES: We seek to report our management protocol and early outcomes of acute type A aortic dissection (ATAAD) repair during the early phase of coronavirus disease 2019 (COVID-19). METHODS: From January 23 to April 30, 2020, we performed ATAAD repair for 33 patients, including three with pregnancy-related TAADs. Confirmation of COVID-19 depended on the results of two nucleic acid tests and pulmonary computed tomography scan. Based on testing results and hemodynamic stability, patients were triaged to an isolated intensive care unit or negative pressure operating room for emergency surgery. RESULTS: Mean age 50.2 ± 13.3 years and 20 were male (60.1%) and 8 patients were febrile (>37.3°C; 24.2%) and 17 were lymphopenic (51.5%). No patient was excluded from COVID-19 infection preoperatively. Extensive aortic repair with total arch replacement (TAR) was performed in 24 (72.7%), and limited proximal repair in 9 patients (27.3%). Cardiopulmonary bypass and cross-clamp times averaged 177 ± 34 and 88 ± 20 min for TAR, and 150 ± 30 and 83 ± 18 min for hemiarch, respectively. The mean operation time was 410 ± 68.3 min. Operative mortality was 6.1% (2/33). Complications included reintubation in four (12.1%), acute kidney failure in two (6.1%), and cerebral infarction in one (3.0%). No paraplegia nor re-exploration for bleeding occurred. COVID-19 was excluded in 100% eventually. No nosocomial infection occurred. Nor did any patient/surgical staff develop fever or test positive during the study period. CONCLUSIONS: The results of this study show that our management protocol based on testing results and hemodynamic stability in patients with ATAAD during the COVID-19 pandemic was effective and achieved favorable early surgical outcomes.

During aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR), repeated delivery of cardioplegia into the coronary ostia using a routine infusion cannula may induce coronary ostial injury. This study aims to introduce a new no-touch delivery method with reduced time and similar or better outcomes. Preliminary results have shown that no-touch cardioplegia delivery method was a simple, safe, and effective approach for cardioplegia infusion during AVR in patients with severe AR.

BACKGROUND Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using the frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation. METHODS The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2±10.5 years and 426 were male (82.2%). The mean time from symptomatic onset to surgery was 4.8±3.7 days. Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass (CPB), cross-clamp and selective antegrade cerebral perfusion were 201±50, 112±34, and 26±10 minutes, respectively. RESULTS Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), re-exploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0±4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, and anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P

Background Aggressive angiomyxoma (AA) is a rare tumor that typically occurs in the pelvis and perineum, most commonly in women of reproductive age. However, no para-ureteral AA has been reported according to the literature. Case presentation We herein describe the first case of para-ureteral AA. A 62-year-old male presented to our institute in March 2017 with a para-ureteral mass that was 15 mm in diameter incidentally. No symptom was observed and laboratory analysis was unremarkable. Magnetic resonance and computed tomography imaging showed a non-enhancing mass abutting the left ureter without causing obstruction. Laparoscopic resection of the mass was performed without injury to the ureter. Pathologic and immunohistochemical results were consistent with AA. Till now, no recurrence was noticed. Conclusions We reported a rare case of para-ureteral AA, along with a literature review. Early diagnosis, proper surgical plan and long-term close follow-up is recommended for its high risk of recurrence and malignant potential.

Background: Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD). Methods: From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up. Results: In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5–6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7–95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%. Conclusions: Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.

Intraoperative aortic dissection is a very rare complication during surgical cardiac intervention with occurrence frequencies of 0.06–0.23% (1-3). However, when it does occur it is uniformly a life-threatening complication with high rates of morbidity and mortality (3-5). Despite the potentially catastrophic outcomes of intraoperative aortic dissection, no clear guidelines exist regarding optimal management.

Background: We seek to report the long-term outcomes of the total arch replacement and frozen elephant trunk (TAR + FET) technique for type A aortic dissection (TAAD) following prior Bentall procedure in patients with Marfan syndrome (MFS). Methods: Between 2003 and 2015, we performed TAR + FET for 26 patients with MFS who developed TAAD following a prior Bentall procedure. Mean age at FET 36.9±9.7 years and 24 were males. TAAD was acute in 8 (30.8%, all new dissections from precious root aneurysm) and chronic in 18 (69.2%, 15 residual and 3 new). The interval from Bentall procedure to FET averaged 6.4±5.8 years, which was significantly longer in the acute group (10.3±6.3 vs . 4.6±4.9, P=0.021). The early and long-term outcomes were compared between two groups and risk factors identified for late adverse events. Results: Operative mortality was 11.5% (3/26). Stroke, lower limb ischemia and reexploration for bleeding occurred in 1 patient each (3.8%). Follow-up was complete in 100% (23/23) at mean 5.1±2.3 years (range, 0.9–11.2 years). The maximal diameter (DMax) of distal aorta in the chronic group was significantly greater at the unstented descending aorta [DA, (56.4±15.5 vs . 35.6±12.2 mm, P=0.006)] compared to acute patients. The false lumen was obliterated in 95.7% across the FET and 56.5% in the unstented DA. Distal aortic dilation occurred in 13 patients (11 chronic, 68.8%). Of those 11 patients, 4 underwent an open thoracoabdominal aortic repair and 3 died of distal aortic rupture. Late death occurred in 7 patients at mean 3.9±2.5 years. At 6 years, the incidence was 18% for death, 11% for distal aortic reoperation, and 71% for reoperation-free survival. Survival did not differ between two groups (75.0% vs . 71.3%, P=0.851), while acute patients had significantly higher freedom from late rupture and reoperation at 6 years (100% vs . 61.9%, P=0.046). Hypertension was the sole risk factor for distal aortic dilatation [hazard ratio (HR) =7.271; 95% confidence interval (CI), 1.814–29.143; P=0.005]. Risk factors for late adverse events were hypertension (HR =6.712; 95% CI, 1.201–37.503; P=0.030) and age Conclusions: The TAR and FET technique was feasible and efficacious for TAAD following previous Bentall procedure in patients with MFS. Early and late survival did not differ with acute and chronic dissections, while freedom from late rupture and reoperation is significantly higher in patients with acute TAAD. Patients with hypertension and aged

This study sought to determine whether assessment of the renal resistive index (RRI) can predict the short-term reversibility of acute kidney injury (AKI) after repair of acute type A aortic dissection (TAAD).This prospective study included 62 patients undergoing repair of acute TAAD. Doppler-based RRIs were obtained preoperatively, immediately after the surgical procedure, and 6, 24, and 48 hours postoperatively. The occurrence of AKI was evaluated daily according to Acute Kidney Injury Network criteria. Persistent AKI was defined as AKI lasting longer than 3 days. The association between the maximum RRI level at different time points and persistent AKI was analyzed by the receiver-operating characteristic curve.Of the 62 patients, 22 (35.5%) had no AKI, 21 (33.9%) had transient AKI, and 19 (30.6%) had persistent AKI. The maximum RRI was 0.67 ± 0.03 (0.62 to 0.71), 0.71 ± 0.05 (0.59 to 0.79), and 0.78 ± 0.05 (0.70 to 0.92) in the no AKI, transient AKI, and persistent AKI groups, respectively. The maximum level of RRI was significantly correlated with that of SCr during the first 48 hours postoperatively (rho = 0.606; p0.001). RRI could predict persistent AKI with an area under the receiver-operating characteristic curve of 0.918 (95% confidence interval, 0.850 to 0.986; p0.001). A postoperative RRI of 0.725 or higher was a marker for early detection of persistent AKI with high sensitivity and specificity (94.7% and 72.1%, respectively).An elevated maximum RRI may be a predictor of persistent AKI after repair of acute TAAD. This is helpful for management decision making and improving the prognosis of patients with AKI.

Background Prolonged mechanical ventilation (PMV) after surgical repair of acute type A aortic dissection (ATAAD) is associated with increased risk for mortality and morbidity. Objective(s) The goal of this study was to evaluate the influence of PMV on early and late outcomes and to identify the risk factors for PMV after ATAAD repair. Design, Setting, and Participants This study was a retrospective analysis of prospectively collected data, which resulted from a prior clinical trial. Clinical outcomes were analyzed in 121 patients with ATAAD (mean age 46.6 ± 10.4 years; 93 men), who underwent total arch replacement and frozen elephant trunk at a mean of 3.6 days from onset. Multivariate analysis was used to identify risk factors for PMV after surgery. Main Outcome Measures The primary endpoint of this study was the occurrence of PMV following ATAAD surgery. The second endpoints were risk factors for PMV, in-hospital mortality and one-year survival. Results PMV was needed in 35 patients (28.9%). The PMV group had a longer ventilation time and length of ICU stay (129 ± 79 and 167 ± 119 hours vs. 19 ± 10 and 32 ± 23 hours, respectively, P < 0.001). Post-operative mortality was 6.6% (8/121), including 6 (17.2%) in the PMV and 2 (2.3%) in the non-PMV groups (P = 0.003). PMV was associated with increased in-hospital mortality (OR, 6.4; 95% CI, 1.1-36.0; P, 0.036). Follow-up was complete in 88.6% (98/113) of patients at a mean of 26 months (1-39). Survival at 1 year was significantly lower in the PMV group compared with the non-PMV group (77.1% vs. 95.3%, P = 0.002). Risk factors for PMV were the level of serum lactate (mmol/L) at the end of surgery (odds ratio, OR 1.189; 95% confidence interval CI 1.026-1.377; P = 0.021) and a lower preoperative platelet count (109/L) (OR 0.918; 95% CI 0.847-0.994; P = 0.034). Conclusion In this study, the occurrence of PMV was 28.9% in patients with ATAAD. A lower preoperative platelet count and a higher serum lactate level after ATAAD surgery were risk factors for PMV. Identification of risk factors may be helpful for preventing PMV and improving outcomes after surgical repair of ATAAD.

Although family members of patients with aortic dissection (AoD) are believed to be at higher risk of AoD, the prognostic value of family history (FH) of aortic dissection (FHAD) in family members of patients with AoD has not been studied rigorously. We seek examine how much a positive FHAD increases the risk of developing new aortic dissection (AoD) among first-degree relatives.Patients with AoD at our institution were analyzed for information of FHAD. Positive FHAD referred to that AoD occurred in index patient and one or more first-degree relatives. Negative FHAD was defined as the condition in which only one case of AoD (the index patient) occurred in the family. The age at AoD, exposure years in adulthood before AoD, and annual probability of AoD among first-degree relatives were compared between patients with negative and positive FHADs.FHAD was positive in 32 and negative in 68 among the 100 AoD patients with detailed family history information. Mean age at dissection was 59.9±14.7years. Compared to negative FHAD, patients with positive FHAD dissected at significantly younger age (54.7±16.8 vs 62.4±13.0years, p=0.013), had more AoD events in first-degree relatives (2.3±0.6 vs 1.0±0.0, p0.001), and shorter exposure years per AoD event (18.3±6.7 vs 43.1±8.5, p0.001). Annual probability of AoD per first-degree relative was 2.77 times higher in patients with positive than negative FHADs (0.0100±0.0057 vs 0.0036±0.0014, p0.001).A positive FHAD confers a significantly increased risk of developing aortic dissection on family members, with a higher annual probability of aortic dissection, a shorter duration of "exposure time" before dissection occurs and a lower mean age at time of dissection.

Background: To identify the risk factors for continuous renal replacement therapy (CRRT) following surgical repair of type A aortic dissection (TAAD) using the total arch replacement and frozen elephant trunk (TAR + FET) technique. Methods: The study included 330 patients with TAAD repaired using TAR + FET between January 2014 and April 2015. Mean age was 47.1±10.2 years (range, 18–73 years) and 242 were male (73.3%). Univariate and multivariate analyses were used to identify the risk factors for CRRT. Results: Postoperative CRRT was required in 38 patients (mean age 50.7±10.0 years; 27 males). Operative death occurred in 12 patients (3.6%, 12/330). The mortality rate was 23.7% (9/38) in patients with CRRT and 1.0% (3/292) in those without CRRT (P vs . 46.7±10.2 years, P=0.023), preoperative serum creatinine (sCr) (135.0±154.2 vs . 85.7±37.0 μmol/L, P vs . 73.3%, P=0.030), cardiopulmonary bypass (CPB) time (265.2±98.8 vs . 199.7±44.2 minutes, P vs . 116.3±33.2 minutes, P vs . 3.7±3.3 unit, P vs . 784.2±488.5 mL, P vs . 2,856.7 mg/L, P vs . 2.4%, P Conclusions: In this series of patients with TAAD, the time of CPB (minute), sCr level (μmol/L) and the amount of red blood cell transfused intraoperatively (unit) were risk factors for CRRT after TAR + FET.

Background Aortic dissection in pregnancy is a rare but lethal catastrophe. Clinical experiences are limited. We report our experience in 25 patients focusing on etiology, management strategies, and outcomes. Methods Between June 1998 and February 2015, we treated 25 pregnant women (mean age, 31.6 ± 4.7 years) in whom aortic dissection developed at a mean of 28 ± 10 gestational weeks (GWs). Type A aortic dissection (TAAD) was present in 20 (80%) and type B (TBAD) in 5 (20%). Marfan syndrome was seen in 17 (68%). Management strategy was based on dissection type and GWs. Results TAADs were managed surgically in 19 (95.0%) and medically in 1 (5.0%). Maternal and fetal mortalities were, respectively, 14.3% (1 of 7) and 0 (0 of 7) in the "delivery first" group (7 of 20), 16.7% (1 of 6) and 33.3% (2 of 6) in "single-stage delivery and aortic repair" group (6 of 20), 16.7% (1 of 6) and 66.7% (4 of 6) in "aortic repair first" group (6 of 20), and 100% (1 of 1) and 100% (1 of 1) in the "medical management" group (1 of 20). TBADs were managed surgically in 60% (3 of 5) and endovascularly and medically in 20% each (1 of 5). No maternal deaths occurred. Fetal mortality was 100% in the surgical group and 0% in the other groups. During late follow-up, which was complete in 95.2% (20 of 21), 3 maternal and 2 fetal deaths occurred in the TAAD group. Overall maternal survival was 68.6% at 5 years. Conclusions Marfan syndrome predominates among women with aortic dissection in pregnancy. For TAADs, after 28 GWs, delivery followed by surgical repair can achieve maternal and fetal survival adequately; before 28 GWs, maternal survival should be prioritized given the high risk of fetal death. For TBADs in pregnancy, nonsurgical management is preferred.

Background Prediction of the age at aortic dissection for family members of aortic dissection patients would enhance early detection and clinical management. We sought to determine whether these dissections tend to cluster by age in family members of the dissection patients. Methods Ages at dissection were examined, including 51 sporadic dissectors (one dissection in family) and 39 familial dissectors (two or more dissections in family) from 16 families. Differences between sporadic and familial dissectors and relationships between ages at dissection in family members were analyzed by linear regression and clustering analysis. Results Age at dissection was significantly younger in familial versus sporadic dissectors (54.1 ± 15.2 years versus 63.1±12.4 years, p = 0.002). Regression analysis of pairs of family member ages at dissection found a moderately close linear fit (R 2 = 0.35). Cluster analysis indicated that age at onset of family dissectors increases as age of proband dissector increases. More than 50% of familial dissections occurred within 10 years of the median onset age for any given age decade. For familial dissectors with onset age of 30 to 49 years, 71% of other family member dissections also occurred at age 30 to 49 years, and no dissections occurred above the age of 63 years. For familial dissectors with onset age of 60 to 79 years, 80% of other family member dissections occurred beyond the age of 50 years. Conclusions Familial dissections occur earlier than sporadic dissections. Dissections cluster by age in families, and age at onset can predict the age of other dissectors. This finding argues for consideration of prophylactic resection of an aneurysm in family members approaching the age at onset of prior thoracic aortic dissection.

OBJECTIVES Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience. METHODS From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15–40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft. RESULTS ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011–1.348; P = 0.034). CONCLUSIONS The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.

Background: Acute aorta dissection (AD) is a fatal emergency, however, studies addressing the clinical characteristics, management, and outcome of acute AD in young adult patients aged under 45 yea...

BACKGROUND Operative choices for aortic root disease include traditional root replacement with a composite valved graft as well as various valve-sparing and root repair procedures. OBJECTIVES To report our experience with traditional composite graft aortic root replacement by a single surgeon over a 25-year period in 449 patients, focusing on long-term survival and freedom from late reoperation and adverse events. METHODS The coronary button technique was used in all patients. Mean age was 56.1 ± 14.0 years (range 14-87) with 83% males (373/449). Valve prosthesis was mechanical in 343 (76%) and bioprosthetic in 106 (24%). A modified Cabrol procedure (Dacron coronary graft) was employed in 10% (45/449) and concomitant coronary artery bypass graft in 10.9% (49/449). There were 15.8% (71/449) urgent/emergent and 8.2% (37/449) redo procedures. Survival follow-up was 100%. Mean follow-up was 7.0 ± 5.1 years (range 0.1-24.8). RESULTS Operative mortality occurred in 14 patients (3.1%) and was 2.2% (9/418) in non-dissection and 1.9% (7/361) in elective first-time operations. Stroke and re-exploration for bleeding occurred in nine (2.0%) and 20 (4.5%) patients, respectively. Major late events included bleeding in 2.5% (11/435) and thromboembolism in 1.1% (5/435). At 5, 10, and 20 years, freedom from major events and reoperations on the root were 97.8, 95.4, and 94.39%, and 99.0, 99.0, and 97.9%, respectively. Survival in patients aged

This study sought to evaluate the long-term impact of frozen elephant trunk (FET) on the distal aorta of patients with Marfan syndrome (MFS) who had type I dissection confined to the thoracic aorta (above the diaphragmatic hiatus).Between 2003 and 2016, 42 patients with MFS (Ghent or revised Ghent criteria) (age 33.3 ± 8.9 years; 27 men; 64.3%) sustaining type I dissection above the diaphragmatic hiatus involving the aortic arch (22 acute; 52.4%) underwent total arch replacement and FET. Dissection extended distally to the mid-descending aorta in 32 (76%) and to above the diaphragmatic hiatus in 10 (24%) patients. Operative mortality was 4.8% (2 of 42). Follow-up was 100% at 6.3 ± 3.0 years.Maximal aortic sizes at the mid-descending aorta, diaphragmatic hiatus, renal arteries, and largest segment of abdominal aorta were 22.8, 21.1, 19.1, and 19.9 mm preoperatively and 23.1, 22.0, 19.8, and 22.4 mm on the latest computed tomographic angiography. Dilation and complete remodeling of the distal aorta occurred in 10.0% (4 of 40) and 90% (36 of 40) of patients, respectively. One late death occurred, and 3 distal reoperations were performed. Preoperative abdominal aortic maximal aortic size was predictive of distal dilatation (mm) (hazard ratio, 1.78; P = .021) and reoperation (≥25 mm vs25 mm) (hazard ratio, 12.88; P = .037). At 10 years, freedom from dilation, reoperation, and death were 69.8%, 78.1%, and 90.0%, respectively. At 8 years, the rates of death, reoperation, and reoperation-free survival were 10%, 11%, and 79%, respectively.The FET technique has a positive remodeling impact on type I dissection confined to the thoracic aorta in patients with MFS. This study adds evidence supporting the safety and durability of this extended approach for type I aortic dissection in MFS.

Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme.Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients.Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively.Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.

Summary: Objective: To compare the outcomes of the en bloc and branched graft techniques for supra-aortic vessel reconstruction in total arch replacement (TAR) for acute type A aortic dissection (ATAAD). Methods: In 53 ATAAD patients with intact supra-aortic arch vessels undergoing TAR, the arch vessels were reconstructed using the branched graft technique in 35 patients and en bloc technique in 18, i.e. reimplantation of the innominate artery and the left carotid artery (LCA) and transposition of left subclavian artery to LCA. The early and mid-term outcomes were compared between two groups. Results: The selective antegrade cerebral perfusion time in en bloc group was significantly longer (33 ± 10 vs 24 ± 7 min, p = 0.001). Operative mortality was 5.7% (3/53), including 1 and 2 in the en bloc and branched graft groups, respectively (5.6% vs 5.7%, p = 0.981). Stroke occurred in 1 patient. No spinal cord injury occurred. At mean 4.3 ± 1.6 years, clinical and CT follow-up were complete in 100% and 86% (43/50). No cerebrovascular accidents or upper extremity claudication occurred. There were 4 deaths and 1 reintervention in follow-up. Survival was 88.6% and 88.9% at 3 months, and 83.3% and 88.6% at 6 months, 3 and 5 years in the en bloc and branched graft groups, respectively (p = 0.597). The arch vessels were patent in 100% (43/43) without stenosis or aneurysm. Conclusions: The modified en bloc technique could achieve comparable early and mid-term outcomes to the branched graft technique in patients undergoing TAR for ATAAD. This approach may be an alternative technique for ATAAD patients with intact supra-aortic arch vessels. Keywords: Aortic dissection, Aortic arch, Surgery, Total arch replacement, Vascular prosthesis/frozen elephant trunk

Objective We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH). Methods The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification. Results A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03). Conclusions The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.

Background Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients. Methods Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD. Results Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7 ± 2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINE recurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8 years compared with medical therapy (88.3% vs 63.5%, p = 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p = 0.037) and chronic phase (hazard ratio, 1.725; p = 0.049). Conclusions In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.

The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test.The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test).PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.

Background A combined endovascular and debranching hybrid procedure was performed for descending aortic pathologies involving the distal aortic arch. We reviewed our results of this procedure to summarize clinical experiences. Methods From April 2009 to April 2013, 36 patients (21 males and 15 females) underwent the hybrid operation. Hospital stay and complications were closely monitored after operation. Follow-up CT scan was performed at postoperative 3 months and 12 months. Results The hospital stay ranged from 7 to 25 (15.1 ± 5.0) days. The mean age at operation was 67.6 ± 4.8 years (range: 60–79 years). In-hospital mortality and stroke rates were 2.8% (1/36) and 2.8% (1/36). At a mean follow-up of 22 months (4–52 months), the mortality was 0% (0/35). All remaining 35 patients returned to normal life. During the follow-up period, one patient required secondary endovascular reintervention for a type 1 distal endovascular leak. Conclusion Hybrid repair for descending aortic pathologies involving the distal arch proves to be effective and safe at midterm follow-up with acceptable surgical risks and satisfactory results.

With growing experience in patients with aneurysms and dissections in the arch and proximal descending aorta, the frozen elephant trunk (FET) technique has been shown to be safe and effective, and has achieved favorable short to mid-term outcomes. As the FET technique is gaining wider acceptance, there is a growing need for versatile, technically simple, and highly durable open stented grafts involving less complicated deployment mechanisms enabling use in various indications. This paper gives a brief review on the technical aspects and clinical outcomes of currently available open stented grafts used in the FET technique, including the E-vita Open Plus, Thoraflex Hybrid, Cronus, and J Graft. While none of these grafts can claim to be an ideal device, technology continues to improve towards this goal. As newer devices and systems are developed, more widespread use of the FET technique can be expected; such progress promises to improve the clinical outcomes and quality of life for patients with complex aortic diseases.

Background: Although bovine serum albumin-glutaraldehyde glue (BioGlue®) has been successfully used as a hemostatic adjunct in aortic surgical procedures, there are reports that it may lead to anastomotic pseudoaneurysm formation. We seek to examine if the use of BioGlue is associated with a high incidence of anastomotic pseudoaneurysm formation following surgical repair of thoracic aortic disease. Methods: We reviewed the medical records and follow-up computed tomography (CT) scans of patients from 2001 to 2015 in whom BioGlue was used during surgical repair of thoracic aortic disease to detect postoperative anastomotic pseudoaneurysm formation. Results: A total of 233 patients with BioGlue use were identified. Mean age was 63.5±14.0 years (median 66; range 14–88; 25–75%, IQR 54–74 years) and 149 were male (63.9%). Surgical indication was thoracic aortic aneurysm in 169 (72.5%) patients, aortic dissection in 49 (21.0%), intramural hematoma in 9 (3.9%), penetrating aortic ulcer in 3 (1.3%) and other in 3 (1.3%). Emergency/urgent surgery was performed in 68 cases (29.2%). Operative mortality was 7.3% (17/233). Re-exploration for bleeding and neurologic deficits occurred in 24 (10.3%) and 21 (9.0%) patients respectively. All operative survivors were followed (100%, 216/216) and CT follow-up was available in 81.9% (177/216) for a mean duration of 2.4 years (median 0.6; 25–75% IQR 0.2–3.6 years). Anastomotic pseudoaneurysm was detected in 1 patient (0.6%) at 3 years postoperatively. This was an elderly female with extremely frail tissues who underwent a reoperative ascending and arch replacement for dissection. Conclusions: The use of BioGlue in thoracic aortic surgery was not associated with excess incidence of anastomotic pseudoaneurysm formation following surgical repair of thoracic aortic disease. Its use need not be discouraged on this basis.

Introduction To date, clinically available expanded polytetrafluoro-ethylene (ePTFE) vascular grafts are suboptimal for reconstructing small caliber (D 165 and heparin. The short term performance was evaluated both in vitro and in vivo. Method Four-mm caliber grafts were prepared by the coaxial-elctrospun technique, which consisted of poly(l-lactide-co-caprolactone) [P(LLA-CL)] collagen and elastin. Heparin and endothelial cell growth factor-165 (VEGF 165 ) were encapsulated in the core of the fibrous. Controlled release of the heparin and VEGF 165 were evaluated for 28 days. Endothelial cells were cultured on the electrospun grafts or ePTFE grafts as controls. The cellular adhesion, proliferation and morphology were examined. Electrospun or ePTFE grafts were randomly implanted into a rabbit infrarenal aortic replacement model (n = 30) for 28 days without any antiplatelet therapy. At the termination, all grafts were examined by Doppler ultrasound and then evaluated with histology and scanning electron microscopy. Results The cumulative release amount of heparin (6.93 ± 1.03 mg) and VEGF 165 (22.17 ± 5.56 μg) during 28 days were measured. Endothelial cells cultured on electrospun grafts showed significantly higher attachment efficiency and proliferation compared to the ePTFE ones ( P P = 0.021). Correspondingly, the microscope images of electrospun implants showed little thrombus when compared with the ePTFE implants. Conclusion Biofunctionalized electrospun graft showed surgical properties, hemocompatibility and higher short-term patency compared with the ePTFE grafts. Despite good early performances, profound study should be designed for long-term evaluation.

Background In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height-based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations. Methods Aortic diameters and long-term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared. Results Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m 2 ) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five-year complication-free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications ( P P Conclusions Compared with indices including weight, the simpler height-based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.

Background: In patients with type A dissection, residual dissection and new distal entry tears following the frozen elephant trunk (FET) procedure adversely affect long-term prognosis. Management include open and endovascular repair, while clinical experience is limited. We evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in management of residual intimal tear or distal new entry tear following FET in patients with type A aortic dissection (TAAD). Methods: Between May 2003 and April 2013, we performed FET and total arch replacement for 1,003 patients with TAAD. Among these, 23 patients (2.3%) required TEVAR for distal new entry (n=2) or residual intimal tear (n=21) at a mean of 2.0±1.6 years after FET. Mean age was 50.1±11.5 years. Marfan syndrome was seen in 2 patients (8.7%). Results: Procedural success was 100%. The distal landing zone was above the 11th thoracic vertebra (T11) in 86.9% (20/23). Neither death nor any paraplegia or stroke occurred early after TEVAR. Follow-up was complete in 100% averaging 2.8±1.7 years (0.3–6.4). One non-Marfan patient died of distal aortic rupture at 4 months after TEVAR. No late stroke or paraplegia occurred. Survival was 95.7% (95% CI, 72.9–99.4%) at 3 and 5 years, respectively. CTA detected false lumen obliteration by thrombus around the endograft in the descending aorta in 91.3% (21/23) of patients. Conclusions: These early and midterm outcomes show the efficacy of TEVAR in obliterating the residual intimal tear or distal new entry after FET in patients with TAAD. TEVAR may be an alternative approach to distal new entry or residual intimal tear following FET for patients with TAAD.

EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation.Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation.The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 10⁹/L (p0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75).EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation.

ObjectiveWe seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality.MethodsWe performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure.ResultsThe operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P 180 minutes (OR, 1.01; P 180 minutes) were at greater risk of operative mortality.

Background Left circumflex coronary artery (LCX) fistula is rare, and surgical experience is limited. We report our experience with 29 patients with LCX fistula during a 25-year period in terms of clinical features, pathology, surgical procedure, and late outcomes. Methods Between June 1988 and July 2013, 29 patients (19 males, 10 females; median age, 10 years) with LCX fistula were treated surgically and followed up. Preoperative diagnosis was made echocardiographically in 29 patients and angiographically in 17. The fistula drained into the right atrium in 12, the right ventricle in 8, left atrium and left ventricle, each in 3, main pulmonary artery in 2, and coronary sinus in 1. Surgical procedure included endocardial closure in 17 patients, epicardial closure in 5, endocardial and epicardial closure in 2, suture ligation in 1, and off-pump suture ligation in 4. Postoperative anticoagulation was prescribed for at least 6 months. Results There were no operative deaths. Complications included residual shunt in 2 patients, and LCX thrombosis, pneumothorax, hemoglobinuria, and wound infection, each in 1 patient. At the latest follow-up extending to 25 years (mean, 10.1 ± 4.6 years), 17 patients were asymptomatic and in New York Heart Association functional class I, 4 in II and 2 in III. Residual shunt, myocardial infarction, and right atrial thrombosis occurred, each in 1 patient. Conclusions Surgical repair of LCX fistula is safe and effective, with low risks and favorable late outcomes. Our experience implies the necessity for postoperative anticoagulation therapy to achieve good long-term outcomes.

Background Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique. Methods Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1 ± 8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results. Results Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2 ± 13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival. Conclusions The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.

The gender difference of bicuspid aortic valve (BAV) is largely unclear. We evaluate the impact of gender on the morphology, valve function, aortopathy, outcomes of aortic valve replacement (AVR) of BAV patients. Among 992 BAV patients (mean age 50.3; 734 men; 74.0%) without aortic dissection and

Sun's procedure is a modified elephant trunk technique that integrates the advantages of open surgical and endovascular repairs as a treatment of type A aortic dissection. It is named after Dr. Li-Zhong Sun and refers to total arch replacement using a four-branched graft with implantation of a special stented endovascular graft. Since its introduction, it has produced excellent early and late clinical outcomes. We present a video of this procedure and make an overview regarding the technical aspects, surgical indications, and clinical outcomes of Sun's procedure.

BACKGROUND The aim of this study was to investigate the feasibility and safety of tubeless minimally-invasive percutaneous nephrolithotomy (MPCNL) in a randomized controlled trial. METHODS Patients receiving MPCNL from September 2014 to November 2015 were selected according to inclusion and exclusion criteria after nephrolithotomy and divided into study group (tubeless MPCNL) and control group (standard MPCNL) by random number table. A total of 62 patients were included (N.=31 each), and there was no significant difference in age, gender and calculus size between the two groups (P>0.05). All operations were carried out by the same surgeon. The evaluation indexes included postoperative pain, hemoglobin (Hb) drop, incidence of fever, perirenal leakage/hematoma incidence and length of stay, etc. Independent sample t-test was used for comparison of measurement data, and rank-sum test was adopted for comparison of skewed-distributed data. χ2 test was used for comparison of enumeration data. RESULTS Significant difference was shown in Visual Analogue Scale (VAS) of pain and average length of stay after surgery between the two groups (P